In this model, information is provided to service users to guide them towards high quality resources. At a minimum, providers can promote credible portal websites, which direct service users to relevant, evidence-based resources [37]. Providers can also become familiar with and promote the resources most relevant to their service - including information sites, symptom-focused treatment programs and online sources of emotional support.

Most primary health care providers can promote e-mental health resources. Those in non-clinical roles such as practice managers and administrators can arrange for promotional material to be displayed to service users in waiting rooms or on websites run by the practice. Providers in clinical roles may engage in more active forms of promotion such as briefly describing relevant resources to service users. This may occur in the course of general health consultations as well as in response to service users’ requests for mental health assistance.

For example, general practice nurses have regular contact with people experiencing chronic physical conditions, to whom they provide information, monitoring and treatment. Given the high comorbidity of these conditions with mental health problems, practice nurses are well placed to promote awareness in this at risk group, to detect changes in life circumstances that may increase risk of mental health problems and to respond to the development of symptoms in these service users [38]. Similarly, service providers such as physiotherapists, exercise physiologists, and dietitians treat conditions that are highly comorbid with mental health concerns and can provide information about e-mental health services as appropriate.

There is also enormous potential for promotion by those who provide ancillary services to people experiencing mental health concerns. Community pharmacists are highly accessible and have regular contact with people who are using psychotropic medications. Relationships with pharmacists may be particularly important for people who lack continuity of care in their relationships with other professionals. This may be critical where service users obtain repeat medication prescriptions from different doctors in walk-in clinics.

There have been calls to extend pharmacists’ role in recovery-oriented mental health care [39] and the promotion of e-mental health resources through pharmacies could be one means of facilitating this development. Pharmacists can encourage service users to explore appropriate e-mental health resources in addition to using medication. People interested in self-help interventions may also seek information about supplements such as St John’s Wort. In addition to advice provided directly by the pharmacist, these customers can be encouraged to visit sites that provide evidence-based information about supplements and other interventions.

Service providers working in clinical roles will have pre-existing knowledge about mental health, face-to-face care options, and referral processes. These providers would at least need to be familiar with key mental health portals and may also choose to learn about specific resources most relevant to their practice.

Where workers in non-clinical roles engage in promotion activities, it is expected that the clinicians employing them would oversee the selection of resources and the manner in which they were promoted.

This approach requires little specialist knowledge or change to existing practice. In Australia, there is anecdotal evidence that e-mental health resources are already being promoted by mental health service providers and by general health workers in clinical and non-clinical roles including general practice nurses, practice managers, community health outreach workers, physiotherapists, pharmacists, and osteopaths.

In this model, the practitioner provides an initial assessment, referral to an e-mental health resource and a follow-up assessment. Referrals are most commonly made to iCBT or self-guided symptom-focused programs, but can also be made to e-mental health support groups and other resources.

Prior to referral, an initial assessment is required to determine the most suitable intervention. E-mental health programs typically use automated screening tools to help guide the service user in their intervention choices. These vary in complexity, but are often focused on the symptoms treated by the particular program. In community-based practice where the service user has approached a service provider for assistance, more comprehensive assessments are required (eg, [40]). These require a relatively high level of skill and service providers engaging in assessment should be appropriately qualified. Assessment will generally occur during face-to-face or possibly video-conferenced consultations [41], although information from e-mental health tools may be incorporated into the assessment.

Once the service user has engaged with the e-mental health program, the provider is not expected to assist them to work through it. However, the provider is expected to provide additional assessment, support, and alternative referrals if the service user does not find the e-mental health program to be helpful, and/or if their condition or situation deteriorates.

When used as an intervention in the case management model, the e-mental health resource is the main psychological treatment for at least one area of concern. It may be provided as a stand-alone intervention used in addition to other interventions. For example, a general practitioner might prescribe psychotropic medication and refer the service user to an iCBT program. Similarly, a person experiencing pain and depression might be referred to a physiotherapist as well as to an e-mental health depression treatment program. E-mental health resources can also be combined with human delivered psychological treatments (see Models 4 and 5 in this paper).

This approach is particularly suitable for practitioners who provide non-specialist mental health assessment and referral such as general medical practitioners. It is also used by mental health professionals such as those working as injury / rehabilitation consultants and in community outreach services.

In the case management approach, e-mental health services are considered as referral destinations where appropriate (eg, [40]). This can be particularly useful where specialist assistance is not available in a timely manner or not available at all. For example, we are aware of a public sector mental health team that encourages general medical practitioners to consider this approach for people who have undergone specialist assessment but whose symptoms are not sufficiently acute or severe to meet specialist service admission criteria.

This approach is useful where service users have been accepted into a service but cannot immediately access face-to-face support or psychological therapy, for example where there are waiting lists (eg, [42]). This is highly relevant to services that have existing triage, internal referral, and case management processes such those catering for a particular demographic group (such as young people) or disorder (such as substance use). Workers who already provide assessment and case management in these systems such as youth workers, substance abuse counselors and community health workers, can incorporate e-mental health resources into their work with some additional training.

The case management approach can also be used to introduce e-mental health resources as post-treatment booster or relapse prevention interventions. Anecdotal reports from service users indicate that although they may delay returning to face-to-face therapy until symptoms are relatively severe, they may access e-mental health resources when symptoms are still mild.

Service providers using this model will already have clinical roles and relevant skills in assessment and referral. To refer to e-mental health resources, they would also need to be able to locate and evaluate relevant resources and have detailed knowledge of specific resources most relevant to their practice area.

Engaging in active follow-up assessments is critical in this model to enhance safety by ensuring that services are matched to clinical need and by providing access to alternative care as required. It also helps providers to understand how service users in their particular setting respond to e-mental health resources. If outcomes and adherence are disappointing, this should be investigated so that local service users’ preferences can be understood and referral practices can be modified. However, it should be noted that people who do not complete online programs are not necessarily dissatisfied with the program (eg, [43-46]).

This model is currently promoted and supported by a range of online services. For example, Australian online clinics support referrals and case management by offering clinicians’ resources such as an online referral facility [32] and online decision-making tools and guides [45,47,48].

Some online providers have developed referral aids in the style of prescription or referral pads and distributed them to clinicians so they can direct service users to their particular programs. These aids have been distributed in printed format and in an electronic format that can be incorporated into medical practice software (eg, [47,48]).

As part of the eMHPrac project in Australia [29], referral aids have been developed to raise practitioner awareness of multiple resources. These aids are currently incorporated into a software application embedded within clinical information software, and it is hoped in the future that they will be incorporated directly into the most frequently used clinical information software packages (Personal communication by J Proudfoot and J Tennant, 2014).

In the coaching model, human support is added to a symptom-focused e-mental health program. The treatment team thus has three components—the service user, the human service provider and the e-mental health program. The online program is the primary intervention and provides the content and structure for the treatment. The coach supports the self-therapeutic activities undertaken by the service user and helps them engage with and complete the program [49].

Coaching combines the benefits of human support and Internet-delivered content. Online formats can reliably deliver material with high fidelity and may enhance learning and retention of critical material compared to traditionally delivered CBT [50,51]. On the other hand, human coaches may improve the match between service user and intervention through assessment and tailoring; support users to complete the program and enhance users’ understanding and application of program material [41,52]. Coaching may be used to reduce the amount of clinician time required to deliver an intervention, improve fidelity and support non-expert workers to deliver basic interventions.

The provision of coaching by community-based providers raises critical questions about qualifications, training, and supervision. Requirements will depend upon the service users involved, the programs used, and the degree of therapeutic skill required by particular coaching protocols.

In community-based primary health care settings, coaching is most likely to be delivered by providers with an existing clinical role. For example, in Australia, coaching is likely to be delivered by health professionals but in other countries such as the United Kingdom, coaching is likely to be delivered by para-professional workers such as the IAPT’s Psychological Wellbeing Practitioners [53].

Effectiveness studies of individual programs have demonstrated that, with appropriate training and supervision, a wide range of people can provide coaching. In one study, coaches were drawn from a mixed group of clinicians (general medical practitioners, psychologists, medical specialists, nurses, and other allied health practitioners) [45]. Other studies have included coaches who were: general medical practitioners with additional mental health training [54,55]; primary care nurses and social workers [7]; psychologists working in private practice [44] and in a non-government mental health organization [56]; community-based psychologists and social workers [46]; paraprofessional graduate mental health workers [57]; peer workers [58], and administrative staff [59].

There is great interest in incorporating the perspectives of people with lived experience of mental disorders into symptom-focused e-mental health programs. In addition to developing direct coaching roles, programs have included service user narratives in the automated content and/or hosted online peer forums within the program [59,60]. We are also aware of projects in which peer workers and advocates have developed their own coaching procedures for freely available Internet-delivered programs, in order to offer services to people living in areas that lack mental health treatment services.

Providers already in clinical roles will have mental health knowledge and skills appropriate to their role and are able to provide mental health assessment, support, and referrals. Coaching that requires psychotherapeutic skills is likely to be delivered by providers who have therapy qualifications and already provide psychological services. In addition, they will need sufficient familiarity with e-mental health programs to match them with individual service users and skills relevant to providing coaching for the particular programs they use.

Coaches will also need to use their existing clinical skills, their understanding of particular programs, and service user preferences to decide whether to offer a coached intervention to an individual service user. Many protocols have excluded people who are psychotic, acutely suicidal, engaging in substance abuse, or have other conditions that may impair learning. Other factors to be considered include service users’ Internet access; comfort and proficiency in using text-based material and computer programs, and their capacity to work independently [61-63].

In this model, the therapist provides an individualized assessment, formulation, and intervention that incorporates traditional therapeutic activities as well as e-mental health resources.

The relative contributions of electronic resources and traditional therapy will vary across therapists and service users. E-mental health resources can be used to assist with standard therapeutic tasks such as assessment, psycho-education, self-monitoring, cognitive restructuring and the development of skills such as relaxation and mindfulness. Online peer groups can provide opportunities for behavioral experiments and social skills practice exercises.

Symptom focused programs can also be incorporated into therapy by presenting material in both electronic and face-to-face formats. In one study, participants received face-to-face CBT therapy in the first half of the sessions and worked independently through an online program in the second half. Outcomes for anxiety, distress, and depression in the combined (face-to-face and online) intervention were as good or better than outcomes in the traditionally delivered (face-to-face only) intervention [83]. The combined intervention thus reduced therapist time and maintained or improved outcomes.

e-mental health and therapist-delivered material can also be delivered sequentially. For example, a service user could meet with a therapist for a series of face-to-face sessions and then complete a symptom-focused e-program before returning to the therapist for a follow-up assessment (cf [34]).

There is also potential to develop symptom-focused group therapy interventions using e-mental health programs. This could occur in a similar manner to that reported for a primary-care mood-disorders group based on a computerized (but not Internet-delivered) CBT program [84]. This group was hosted by a general medical practice that provided a meeting room and a computer for each participant. The facilitators set a module for each session and in the first part of the session each participant used their computer to work through the module. After a tea break, facilitators led a group session on the topic of the module that had been completed by the group members.

This model is likely to be used by therapists already providing discrete symptom-focused psychological interventions such as manual-based CBT to relieve specific symptoms and disorders. In the Australian primary health care system for example, this model is particularly relevant to providers delivering Focused Psychological Strategies interventions under the Medicare Better Access program [85]. These providers include psychologists, social workers, occupational therapists, and general medical practitioners with relevant therapy training. It would also be relevant to mental health nurses and other mental health workers delivering therapy in other primary care services.

In order to use the symptom-focused model, providers require existing qualifications and experience in providing face-to-face symptom-focused therapies. In addition, they would need to be sufficiently familiar with specific e-mental health resources to choose relevant elements and integrate them into bespoke interventions for individual service users.

Although there are anecdotal reports of this model’s use and some promising research data, more ecologically valid research is needed to evaluate whether it delivers improved effectiveness and efficiency in routine care.

In this practice model, e-mental health resources are used in a comprehensive intervention designed and structured by the human therapist. The e-mental health resource is one element of a multi-modal approach that uses a range of interventions to treat a presenting problem or simultaneously addresses a number of presenting problems.

The therapist’s role will include both traditional therapeutic activities and activities related to the service users’ interaction with e-mental health resources. Therapists’ roles in relation to e-mental health will vary from case to case and may resemble activities in described Models 2, 3, or 4. Thus the therapist may encourage the service user to use an information site, online support group or symptom-focused program in a relatively independent manner and monitor the service users’ response to the resource. In other cases, the therapist will be more directly involved in supporting the service user’s interaction with the electronic resource. For example, they may provide some coaching for an online CBT program or integrate the program into a symptom-focused intervention.

This integrated comprehensive model can be used where multiple therapeutic approaches are required to tackle one presenting problem, particularly where first line interventions have been unsuccessful or where some components of therapy require an emphasis on interpersonal processes occurring in the therapeutic relationship. For example, the early stages of treating complex trauma may require a strong focus on building the therapeutic relationship and engagement. Concurrent use of e-mental health programs at this stage could help lay the foundation for challenging activities such as exposure work. For example, working through a symptom-focused program could help provide some initial symptom relief, improve skills for managing arousal and enhance stability and resilience.

This approach can also be helpful where there is more than one presenting problem, or where there are comorbidities and secondary disorders that require treatment. Given that the number of funded sessions is likely to be limited, augmenting human delivered therapy with e-mental health resources may reduce the risks associated with incomplete or inadequate treatment of complex issues.

This model will be most relevant to therapists who already provide comprehensive individualized therapies in their existing practice. In the Australian primary care system for example, this would include clinical psychologists providing psychological therapies under the Medicare Better Access program and other therapists whose work involves tackling complex problems. It would also be relevant to providers whose primary role is to treat very specific concerns and who may need an additional resource to tackle comorbid problems such as anxiety, depression, and substance abuse. For example, in relationship interventions where one or more of the participants is experiencing a high prevalence disorder such as depression, the therapist can focus on interpersonal processes during sessions and refer the symptomatic partner(s) to an online service that treats depression.

Service providers who are engaging in comprehensive individualized assessment and therapy will already have extensive knowledge of psychological processes and diverse therapies as well as skills in developing multi-modal assessment and treatment plans. Those who provide therapy for specific issues such as relationship problems will have existing skills in screening for comorbid problems that require treatment. In addition, providers need to have familiarity with the e-mental health resources they intend to integrate into their therapies.

At this stage, individual therapists are integrating e-mental health idiosyncratically into comprehensive therapies. Anecdotal evidence indicates that uptake of this model may be aided by its conceptual similarity to the use of face to face delivered CBT-based skills groups traditionally provided alongside individual specialist therapy in secondary care psychiatric services.