Kayrouz et al. BMC Psychiatry (2020) 20:111 https://doi.org/10.1186/s12888-020-02486-3 RESEARCH ARTICLE Open Access A comparison of the characteristics and treatment outcomes of migrant and Australian-born users of a national digital mental health service Rony Kayrouz1,2* , Eyal Karin1,2, Lauren G. Staples1,2, Olav Nielssen1, Blake F. Dear1,2 and Nickolai Titov1,2 Abstract Background: To explore the characteristics and compare clinical outcomes of non-Australian born (migrant) and Australian-born users of an Australian national digital mental health service. Methods: The characteristics and treatment outcomes of patients who completed online treatment at the MindSpot Clinic between January 2014 and December 2016 and reported a country of birth other than Australia were compared to Australian-born users. Data about the main language spoken at home were used to create distinct groups. Changes in symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 Item (PHQ-9), and Generalized Anxiety Disorder Scale – 7 Item (GAD-7), respectively. Results: Of 52,020 people who started assessment at MindSpot between 1st January 2014 and 22nd December 2016, 45,082 reported a country of birth, of whom 78.6% (n = 35,240) were Australian-born, and 21.4% (n = 9842) were born overseas. Of 6782 people who completed the online treatment and reported country of birth and main language spoken at home, 1631 (24%) were migrants, 960 (59%) were from English-speaking countries, and 671 (41%) were from non-English speaking countries. Treatment-seeking migrant users reported higher rates of tertiary education than Australian-born users. The baseline symptom severity, and rates of symptom reduction and remission following online treatment were similar across groups. Conclusions: Online treatment was associated with significant reductions in anxiety and depression in migrants of both English speaking and non-English speaking backgrounds, with outcomes similar to those obtained by Australian-born patients. DMHS have considerable potential to help reduce barriers to mental health care for migrants. Keywords: Migrants, Digital mental health service, Online treatment, Anxiety, Depression, iCBT, Ethnicity Background background (ESB) and those from Non-English-speaking Australia has the third highest proportion of residents background countries (NESB). Migration to most coun- born overseas of the OECD countries, with around 28% tries is associated with an increased likelihood of having of the population born elsewhere [1]. In 2016, the five or developing a mental illness [3]. However, the 2007 countries providing the most migrants were England National Survey of Mental Health and Wellbeing survey (14.7%), New Zealand (8.4%), China (8.3%), India (7·4%) found that the overall rates of anxiety and mood disor- and the Philippines (3.8%) [2], reflecting two broad ders in Australians born overseas were lower than the groups of migrants, those of English-speaking Australian-born population, although rates were higher among some refugees [4]. Equity of access to mental health services is a priority * Correspondence: [email protected] 1MindSpot Clinic, Macquarie University, Sydney, Australia for most governments. However research shows that mi- 2eCentreClinic, Department of Psychology, Macquarie University, Sydney, grants, especially those of NESB, experience barriers to New South Wales 2109, Australia © The Author(s). 2020 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. Kayrouz et al. BMC Psychiatry (2020) 20:111 Page 2 of 13 accessing treatment, including low mental health liter- STROBE methodological checklist for observational co- acy, a lack of suitable services and a lack of trust of ser- hort studies [20]. vices [5], as well as the more universal barriers of stigma and cost [6]. In Australia, there is emerging evidence of Participants increasing uptake of face-to-face treatment by migrants Interested adults completed an online screening assess- [7], but despite this trend, the use of mental health ser- ment through the MindSpot website (www.mindspot. vices by many migrant groups remains low. org.au), which provides information about common An important development in the effort to increase ac- mental health disorders and treatment of these disor- cess to mental health care for common mental disorders ders. Inclusion criteria for MindSpot were: (1) Adults has been the introduction of digital mental health ser- aged at least 18 years; (2) currently living in Australia; vices (DMHS), that is, treatment delivered via the inter- and (3) were eligible for treatment under Medicare, the net. A large number of clinical trials have demonstrated Australian national health insurance program. Inclusion the efficacy of internet-delivered cognitive behaviour criteria for this current study were: (1) reported county therapy (iCBT) for anxiety and depression [8], with some of birth; (2) reported main language spoken at home; trials indicating encouraging outcomes when interven- and (3) enrolled in the Wellbeing Course. tions are translated into other languages (e.g., [9, 10]). Between the 1 January 2014 and 22 December 2016, Furthermore, studies have shown that psychological 52,020 people completed a MindSpot assessment, of treatments are just as effective in non-Western countries whom 45,082 reported a country of birth. Of these as they are in Europe and Anglophone countries [11]. 78.6% (n = 35,240) were Australian-born, and 21.4% (n = iCBT is now available in several countries as part of 9842) were migrants, from 166 countries and jurisdic- routine care, and when administered in a systematic tions. Of the 45,082, 15% (6782) enrolled for treatment way, can achieve large clinical improvements that match with the online Wellbeing Course (see Fig. 1). Patients those of clinical trials [12]. One of these services is the provided demographic details at the time of registration, MindSpot Clinic, established as part of the Australian including country of birth and, if other than Australia, Government’s eMental Health strategy in order to im- the main language spoken at home, and completed a prove the availability of mental health services for adults series of validated symptom questionnaires relevant to with anxiety and depression, particularly for people who their presenting problems. The Wellbeing Course was may not access face-to-face care [13]. MindSpot (www. only available in English and was delivered over eight mindspot.org.au) provides free assessment and treatment, weeks, and is described in detail elsewhere. More detail offering seven iCBT treatment courses, including the about the assessment procedures, treatment courses, and Wellbeing Course [14, 15]. The Wellbeing Course is a the methods of maintaining patient safety are described transdiagnostic treatment that targets core symptoms of elsewhere [13, 21]. The MindSpot service was provided anxiety and depression, is designed for adults aged 26– at no cost to participants. All participants provided con- 65 years, and is associated with improvements in symp- sent for their data to be used for research purposes via toms of anxiety and depression of around 50%, and de- an online form, which they are presented with at their terioration rates of 2% [13, 16, 17]. Outcomes for first engagement with the service. Approval to conduct Indigenous Australians are equivalent to those of non- the study was obtained from the Macquarie University Indigenous Australians [18]. These encouraging results Human Research Ethics Committee. have influenced the Australian Government Productivity Information about the demographic characteristics, Commission’s draft report on mental health recom- previous service use, clinical symptoms and additional mending the expansion of supported online mental language and migration features of the treatment sam- health treatment to cater for migrants [19]. However, to ple, are further detailed in Table 1, illustrated graphically date, no studies have examined outcomes for migrants in Fig. 2 (the sample who continued to participate in from iCBT delivered in routine care. Wellbeing Course). The aims of the present study were (1) to compare the characteristics of those who started treatment at Mind- Spot and identified a country of birth other than Design Australia (i.e., migrants) with Australian-born patients The clinical outcomes of migrant and Australian-born and (2) to compare the treatment outcomes of migrants groups in treatment were explored in a series of steps, and Australian-born patients. (1) identifying cohorts of Australian-born, NESB and ESB migrants, (2) the comparison of demographic char- Methods acteristics, symptom scores and past and current service The study employed a retrospective uncontrolled observa- use, and (3) the comparison of clinical trajectory of these tional cohort study design, following the recommended cohorts at post-treatment. Kayrouz et al. BMC Psychiatry (2020) 20:111 Page 3 of 13 Fig. 1 Sample sizes of patients