Nielssen et al. BMC Psychiatry (2015) 15:304 DOI 10.1186/s12888-015-0676-6 RESEARCH ARTICLE Open Access Procedures for risk management and a review of crisis referrals from the MindSpot Clinic, a national service for the remote assessment and treatment of anxiety and depression Olav Nielssen1,2,3*, Blake F. Dear1,4, Lauren G. Staples1,4, Rebecca Dear1, Kathryn Ryan1, Carol Purtell1 and Nickolai Titov1,4 Abstract Background: The MindSpot Clinic (MindSpot) provides remote screening assessments and therapist-guided treatment for anxiety and depression to adult Australians. Most patients are self-referred. The purpose of this study was to report on the procedures followed to maintain the safety of patients and to examine the circumstances of urgent referrals to local services made by this remote mental health service. Method: A description of the procedures used to manage risk, and an audit of case summaries of patients who were urgently referred for crisis intervention. The reported measures were scores on self-report scales of psychological distress (K-10) and depression (PHQ-9), the number reporting suicidal thoughts and plans, and the number of acute referrals. Results: A total of 9061 people completed assessments and consented for analysis of their data in the year from 1 July, 2013 to 30 June, 2014. Of these, 2599 enrolled in online treatment at MindSpot, and the remainder were supported to access local mental health services. Suicidal thoughts were reported by 2366 (26.1 %) and suicidal plans were reported by 213 (2.4 %). There were 51 acute referrals, of whom 19 (37.3 %) lived in regional or remote locations. The main reason for referral was the patients’ self-report of imminent suicidal intent. The police were notified in three cases, and in another case an ambulance attended after the patient reported taking an overdose. For the remaining acute referrals, MindSpot therapists were able to identify a local mental health service or a general practitioner, confirm receipt of a written case summary, and confirm that the patient had been contacted, or that the local service intended to contact the patient. Conclusions: Around 0.6 % of the people seeking assessment or treatment by MindSpot were referred to local mental health services for urgent face to face care. The procedures for identifying and managing those patients were satisfactory, and in every case, either emergency services or local mental health services were able to take over the patient’s care. This review suggests that the uncertainty associated with taking responsibility for the remote treatment of patients who disclose active suicidal plans is not a major impediment to providing direct access online treatment for severe forms of anxiety and depression. Keywords: MindSpot, Anxiety, Depression, Risk assessment, Suicide, Online treatment, Crisis * Correspondence: [email protected] 1MindSpot Clinic, 16 University Ave, North Ryde, NSW 2019, Australia 2University of Sydney, 92 Parramatta Road, Camperdown, NSW 2050, Australia Full list of author information is available at the end of the article © 2015 Nielssen et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nielssen et al. BMC Psychiatry (2015) 15:304 Page 2 of 6 Background care to all patients, including supporting all patients to de- Community surveys have consistently identified that velop a pragmatic safety plan, referral to local services for less than half of all people with clinically significant those in acute distress and providing effective treatment levels of anxiety and depression receive any form of for depression to people who would not otherwise receive treatment [1, 2], and only a portion of those receive any treatment. evidence based care [3]. There is also a growing body Other remote services have considered the issue of of evidence showing the effectiveness of cognitive behav- how best to manage patients at risk and the liability for iour therapy delivered via the internet [4, 5]. The MindSpot adverse events among patients treated remotely. For ex- Clinic (MindSpot) was funded by the Australian Federal ample, Fitzgerald et al. [10] noted the requirement to Government as part of the eMental Health Strategy for provide competent care in a way that did not harm the Australia [6] of which one key aim was to increase access patient, and also the duty to try to protect patients in to evidence-based mental health services for Australian crisis. They recommended the development of policies to adults with anxiety and depression. manage crises, and recording all contact and treatment Supporting patient safety and identifying patients who plans. In a trial of a web based self help intervention for might go on to commit suicide is a key challenge and suicidal thoughts, van Spijker et al. reviewed the safety of major concern of all mental health services. An important patients using twice weekly enquiries regarding the pres- task of MindSpot is to identify patients who are at imme- ence of suicidal thoughts and intervention in response to diate risk of suicide and to refer them for appropriate elevated scores on scales for assessing suicidal ideation treatment or support. However, MindSpot differs from and depression [11]. A recent consensus statement on many other remote or online treatment services because defining and measuring negative effects of internet in- most referrals come directly from the public, rather than terventions by pioneering treatment providers in from a referring agency that knows the patient and can Sweden, the Netherlands, Germany and Australia [12] intervene and arrange emergency care for suicidal behav- noted the lack of research on negative effects of inter- iour if required. Moreover, MindSpot assesses and treats net provided treatment when compared to those of people from all over Australia from facilities on the face to face psychotherapy. The paper raised a number campus of Macquarie University in Sydney, between the of hypothetical reasons for negative effects, including dis- hours of 8:00 am to 8:00 pm from Monday to Saturday appointment, deficient preparation and treatment, and pa- and relies on local mental health services from all over tient and therapist characteristics. The statement Australia to provide emergency care. A major priority in recommended regular measurement of symptoms and the service planning and the development of operational outcome, and intervention in patients who deteriorate or policies and procedures has been the safety of patients, have high symptom scores and fail to progress in how best to identify patients at risk of suicide and how the treatment. service should respond to those patients. Consistent with this literature, MindSpot has devel- The risk management procedures at MindSpot have oped procedures to actively manage the risk of self-harm been developed in accordance with a best practice model, by developing Safety Plans for all patients, the use of drawing from guidelines developed by the New South weekly automated assessments of symptoms and patient Wales Ministry of Health (http://www.health.nsw.gov.au/ safety, and a framework to ensure consistent responses mhdao/publications/Pages/suicide-risk.aspx), and rely on to patients whose communication with the service indi- the self report of suicidal thoughts and plans to identify cates that they might be at risk. people who are contemplating suicide. However, a recent The aim of this paper was to describe the safety proce- meta-analysis found that expressed suicidal ideation is not dures of MindSpot and to review the characteristics and associated with subsequent suicide in patients with a diag- circumstances of patients referred for urgent face to face nosis of mood disorder [7], and several other studies have mental health assessment. shown limits in the ability of risk assessment procedures to predict which patients will commit suicide. For Methods example, studies of factors associated with the suicide of We report on the procedures developed for managing pa- inpatients [8] and patients discharged from psychiatric tient safety at Mindspot. We also conducted a retrospective hospitals [9] have shown that the base rate of suicide is observational study of the number of patients who self re- too low, even in these high risk groups, and the factors ported suicidal ideas and plans for patients who completed associated with suicide are too common, to be able to use assessments, and the circumstances and characteristics of risk algorithms to identify which patients might go on to patients who were urgently referred to local services in a commit suicide in order to intervene to prevent suicide. full year of operation of MindSpot. The alternative to attempting to predict which patients The anonymised details of all patients who, as part of will commit suicide is to provide an adequate standard of their assessment, gave written consent for the data they Nielssen et al. BMC Psychiatry (2015) 15:304 Page 3 of 6 provided to be analysed by confirming agreement