 Thanks very much, Beverly. Well, when I was first invited to present this talk at this meeting, my first thought was to see what I could find on the web about translational models and activities in the field. And the first result that Google returned was the website for a translational psychiatry conference that was held last year in Austria. And what was the first keynote? A talk entitled Deep Brain Stimulation in Human Depression, How Can This Inform Animal Research? I got to say it was a bit confused. But then last week, it all became clear there was an article in the paper about the increasing rates of cats and dogs taking antidepressants. So definitely a victory for translational psychiatry there and definitely a lesson that translational psychiatry isn't only about from bench to bedside. What about the kennel? Today, Helen Christensen and I would like to tell our non-linear translational public mental health story. Perhaps the best place to start is at the beginning, or at least one of the beginnings. In 1998, the chair of our session this morning, Professor Beverly Raphael, initiated and chaired a working party to produce Australia's first national action plan for the prevention of mental disorders. And I was the executive editor of that first national action plan. And two years before Helen Christensen and I had been the writers of the NHMRC clinical practice guidelines for depression in young people, and again, Beverly was the chair and initiator of that particular initiative. And one of the big gaps and action areas that emerged from the national action plan was the need for developing means of reaching, engaging with, and providing prevention programs for young adults. And particularly young males who were at high risk of mental disorders. And at the same time I was doing this, my son was attending an alternative school which was teetering on the edge of closure. And day after day, I saw the faces of the kids at that school. And if they weren't depressed, they were at high risk of developing depression. And I wondered, how was it possible to provide a prevention program for these kids and for young adults out in the community? When, well, you know, we knew there were face-to-face group prevention programs, but they required people who were trained. They required many up to 15 weeks of delivery. They were typically delivered by health professionals and so forth. And of course, young adults wouldn't have access to them anyway when they were out in the community. So Helen and I got together and began discussing it. And the internet was really just emerging at that time. And we wondered whether the internet might not be the answer. On the other hand, everybody told us that it would never work as a mechanism. Well, 10 years later, by 2008, we had a global commercialized in the sense of being funded by government, evidence-based online e-mental health service for anxiety and depression. So today, our aim is to just briefly describe how we got from our starting point and our early population trials to this global e-mental health service for the public. To do this, I'm going to briefly just describe where we are now in terms of the usage and reach of our service. And then Helen is going to describe the key elements of how we actually got there, ranging from policy, research, trials, technology, and implementation. Then I'll talk about lessons learned. And finally, Helen will conclude with the next steps as we see it. So where are we now? Let's just briefly look at that. We have, it's a global service for anxiety and depression, but it's self-help. It's delivered via the web. And unlike most mental health services, it's provided by a university, namely ANU. It's government funded, as I said. It's free to the end user. It's anonymous. It's confidential and accessible to the world wide. And it now has its own Facebook page. Most of you, or many of you, will be familiar with Mrazak and Hagerty's spectrum of mental health care, which broadly ranges from prevention through to treatment, through to maintenance or recovery. The e-hub programs are being used at each of these levels of spectrum of care. So for example, there's universal preventive interventions going on in schools. There's indicated interventions, integrated preventive interventions going on in places that provide financial counseling for people who are having financial problems. People are self-prescribing it, general practitioners are prescribing it for treatment. And our peer-to-peer support group helps with the recovery phase of anxiety and depression. E-hub services delivers information. It delivers e-learning programs. And as I said, peer-to-peer support. And it also has a compendium of all behavioral interventions available across the world. It's underpinned by a team of mental health and IT specialists and admin support people, most of whom work both in service delivery and research. And a key and necessary element of the service is that it has very strong security and clinical protocols. And it meets the draft national guidelines for e-health services delivery. So this is a picture of the structure of the service. Basically, there are directors, Helen and myself. We have managers of development managers, IT and clinical services managers, and other IT and admin support people. And we have four consumer moderators. They are people who have lived experience of mental health problems. And in fact, a number of us, including myself, are consumers as well as academics or professionals. And that's a critical element of this particular service. So where are we now? Sorry, what are the programs that comprise this service? Well, I'm going to only briefly go through these, because there are people in the audience who will know them quite well. But the first flagship program was MUGIM, which delivers cognitive behavioral therapy for depression. It was launched in 2011. And the third version of it was launched in 2008. It currently has 400... The marks, sorry, currently has 450,000 registrants on it, 28,000 unique visitors a month. 70% of them are from overseas, and 24% are from rural and remote areas. Now, if you want to think about whether there's a global service or not, you can see quite clearly there that it's accessed from 203 nation states. The bits in white are the countries where people haven't accessed MUGIM. The rest are where they have. It was originally designed for young people as per the National Action Plan strategy. But in fact, although the peak user group is 25 to 29 years old, you can see there that people of all ages use it. It continues to grow in terms of registrations. In 2008, there were 200,000. That's more than doubled to 431,000 in October 2010. The number of visits per month has grown from 40,000 visits to 50,000 visits in that period of time. Originally, users found us via links. This is the worldwide way in which users find us. It's quite interesting, as you can see, that now GPs are the major source of referral to MUGIM, whereas it would have been people individually finding it. Originally, and we think that the reason for that is that the UK has introduced almost a mandatory requirement that people with mild to moderate depression should have access to computerised cognitive behaviour therapy. The green line is the peaks for media, and they do correspond to articles, for example, in the March 2009 peak that I think was the readers' digest. This one was the New York Times, and definitely we get peaks when we get news stories of that sort. That's just to show that in Australia, the most common reason or referral is from links from another website. ECATCH is like the mother of all. It was deployed more recently. It's like a huge number of different MUGIMs. It provides depression, generalised anxiety disorder, social anxiety disorder, and it helped to specific groups, divorce and separated, and bereavement and loss. And each of those streams comprises a mental health literacy information stream, as well as evidence-based self-help tools. So, for example, for depression, the tools are the things we know work out in a face-to-face context like CBT, interpersonal therapy, applied relaxation, physical activity and problem-solving therapy, and we did the same thing for the other conditions, found evidence-based interventions that worked and put them on the web. In terms of usage, it's only been around a shorter period of time, but currently has 26,000 registered users, which is up from 2000 into 2008, so it's growing. 60% of the users are from overseas, and 22% are from rural areas. At this stage, clinical practitioners don't know about it as much as they know about MUGIM, so that's a lesser percentage of who comes. The third program is a peer-to-peer support group called Blueboard, and it incorporates forums for depression and each of the different anxiety disorders, and it's staffed by trained consumer moderators, highly trained, under the supervision of a clinical psychologist. And it was launched originally in 2003, but had to close down due to lack of resources, and is now was launched again in 2008. It has 2800 registered users, but what's really quite interesting is that, obviously, a lot of people look and read it without registering, so it has 80 to 90,000 pages accessed per month. And we also have an information website which provides evidence-based information to consumers, and it has 7000 unique visitors a month. And finally, we have a program that Helen introduced, which I think is fantastic. It's in compendium of all internet behavioral interventions on the web, and it has expert ratings on the evidence underlying those, and it also has ratings from consumers who have used those. So now I'd like to hand over to Helen, who's going to talk about how we got there. Okay, well, Cathy's already sort of described the policy environment in which we moved from, so I'll jump straight to the research trials, which I think were one of the four important components about actually ending up with a, what we're calling a global health service. I think people often think about our programs as being, you know, sort of programs just out there for the community, but Cathy's point, I think, is really relevant, and that is that we do everything from treatment through to primary prevention. So this was our first study, which was using community people with high elevated baseline symptoms of depression, and we found that mood gym relative to a placebo-controlled condition, so not a weightless-controlled condition, resulted in quite a strong effect, and that was maintained over 12 months. The effects I was there for completers were something like 0.7, and for non-completers, about 0.5. This was our first attempt to fully automatize our research system, so not only did we have an automatic delivery of a computer program, we also automized the recruitment, randomization, outcome measures, and so on, and this was published in 2006, which initially attracted 1,700 people directly, just by advertising through the web and so on, to actually come and do the website. And again, what we found here was that the number of modules that people did made a difference to the level of effect that they got, and this study determined that maybe two modules, or two or three of the modules, were an efficient clinical effect. So it's really a dose-response study. We've done a study in general practice with Ian Hickey, where we introduced mood gym in as an adjunct to what was already being delivered by a sphere-trained general practitioner, so they had training in mental health, and found that mood gym added to the intervention already provided by the general practitioner. This is one of our recent trials, where we took the advantage of the fact that there are so many lifeline counselors out there delivering services directly to people who are what people have called repeat callers, who have anxiety and depression. And what we did was introduce our e-health programs into the Lifeline Call Center so that people took the telephone call, people gave up their anonymity and undertook an online web program. And what we demonstrated in this study, as you can see, is that the internet was the effective component of the intervention. It wasn't tracking by the Lifeline counselor that led to improvements, they were improvements, but they went to the same extent, and that the addition of the tracking by the Lifeline counselor didn't add. Now, again, we were getting effect sizes here in an intention to treat a 0.8, so in a way it was a treatment trial directed at people who do call Lifeline and in fact do not have access to other interventions. This was a universal prevention program in schools. Again, we showed that by giving people mood gym, it reduced their levels of anxiety relative to a control condition. And we did the same effect looking at depression and this worked for boys, but not for girls. The number needed to treat was 14. So a classroom of boys given mood gym, the number needed to treat is one in 14. So a classroom, two kids might have reduced their depression incidence over a six month period. These were quite exciting to us because even though the effect sizes are small, I should appreciate it's a universal prevention program done in schools by teachers. This is another trial that was just completed, an NH and MRC funded one where we looked at the contribution of the bulletin board in conjunction with the web programs. As you can see there, when we looked at initially post-test, it looked like the intervention using the couch intervention here for anxiety and depression was effective and that it was the component that was effective. But as you can see, looking at the yellow line across the 12 month follow up, the board actually ended up having quite a strong effect by itself. And again, I think this is about the dynamics of support groups and boards. And of course, the interaction of a web based program plus a board was in this case effective. This is a study that was done by US collaborators. What it was, it was a selective prevention trial. It's known that 25% of doctors going out into the field developed depression over the first six to 12 months. And it was designed to prevent the development of depression in those interns. And the results were quite surprising to me. This is mean PHQ9. The green line is the weightless control group. The red line is the intervention which was giving them mood gym over four weeks. And the blue line is the intervention for those who completed the program. So this study, which I mean, I was just the odds ratio there is 3.9. Giving a program like mood gym to medical interns is highly effective in reducing the development of depression in this group. And I have to say this was done outside of our center. So we were quite pleased to see an independent replication. This is a study that's currently just finished on the UK National Health Service portal where people go to looking for information. This is a study to see if people going onto the website looking for help would use an intervention like mood gym and whether that would lead to increased well-being compared to not being randomized, being weight listed to the condition. And as you can see there, this is fully automatized. So there's no involvement by health professionals at all. There was a significant increase in a positive mental health outcome, well-being over the course of the 12 week period. So that is the sort of population based trials that we've been doing. The technology really was how we got to being able to do these population based trials. So just to explain the system here, anyone can go to mood gym for example. We upload new information if required but basically it's just an internet program with the software application behind it. But we can run community trials directly, recruiting people directly from the community or by inviting them through the normal recruitment stages. So you can run open access for everybody plus a number of different trials at the same time. You can also run specific dedicated trials. So currently we might be running four or five research trials at once and it allows the research managers from the institutions that we collaborate with to download and develop their own research protocols in conjunction with us but they have access to the data and it's a collaborative experience. So I'm just flicking through a number of the trials that are currently underway, some of them are finished now but I think there's something like 25 trials that are happening around, well in Australia and also internationally and doing treatment, early intervention, prevention in a range of settings in I think six to eight countries. We also have a translation interface and it's currently, we've translated into Norwegian, one of the world's great languages, I always have to say that. Then also we're doing Spanish, Portuguese, Cantonese and Mandarin currently. So how we got there, a final kind of key point, I think we've talked about policy, research trials, technology. The final key point was that we implemented the service before we developed the evidence around the service. So it's an interesting idea about the non-linear nature of translation. We didn't think the service would provide harm but on the other hand, we implemented it and started it before it actually was evaluated. Cathy's gonna do lessons learned now, so. Well, one of the lessons we felt that had been learned was that technology is a key to fast translation and fast science. If you think about it, seven years after the product was completed and four years after the first randomized controlled trial of Mergem, the e-hubs service was funded by Doha and that's really quite a big reduction on what is often claimed as the typical 17-year period to incorporate new knowledge into clinical practice. So we think that's an important point. The second lesson that we feel we've learned is that a funding, we need some way of funding R&D technology-based intervention in Australia. Our original applications for funding for our R&D effort were unsuccessful. We applied to the NHMRC, we applied to Rotary. Obviously people thought this was never going to work and those bodies are not really set up to fund this type of research which includes a development as well as a research component. We were very fortunate, I think Scott Henderson is here at the moment. He was the director of our centre at the time and he gave us some money for a server and to develop a little bit of a prototype for which we'll always be grateful. And the other thing is that we went begging to the ACT Health Minister who fortunately had a master's degree in public health. He had a vision about what he thought health could be in the future and he had some experience personally with contact with young people with depression and he actually gave us the money we needed to do the development of Mergem. But you know that's a very hit and miss way of approaching these things. Other countries have funding bodies that will fund this sort of development of technology-based interventions. A lot of them have this to a sort of proof of concept research approach. And I think we need the same thing or we think we need the same thing in Australia. In fact, we need the same thing globally. After all, it's people benefit globally from these interventions. The world is the beneficiary. The other thing we feel is that new organisations might well be a key to implementation. In some ways, the degree of uptake of the technology by individuals within organisations like general practitioners is surprisingly high. But on the other hand, it's very difficult to effect change at a whole of organisational level. And we found that, for example, working with a tele-counseling environment where we know the intervention works in that environment but you need to actually get it implemented in the environment in the long term. So we do need to work out ways of identifying these, the barriers that are stopping this implementation and moving forward with that. But it's also our view that we think that we need... We need to think of outside the old space, basically, and establish funding mechanisms that will allow the establishment of new organisations, of cutting-edge organisations which deliver these new services. Well, another lesson that's very clear from our experience is that translation in public health at least is a non-linear process. I think we think there's a concept of translation as being a linear process, as evidenced by the phrase from bench to bedside. But...and this process sees researchers at one end and policy makers at the other end of the spectrum. But that's not how this development occurred. The research process has occurred at all points along that the spectrum and it continues. Similarly, the impetus for the development was policy and we wrote another policy document in 2002 about the policy implications of e-mental health in... Sorry, of e-health in mental health domain. And Helen has just written another policy document about the vision of e-health in Australia. We need better ways to conceptualise this non-linear process and to describe what public health translation really means so that what is being done is understood, valued and funded. Most of all, there's a need for us to recognise that translation involves the continued interplay between research, between policy and implementation, all of which are important at different times and all of which are not the sole province of any one particular group of people. Researchers can prepare policy documents and we do and you only have to look at Beverly Raphael to see an example of that. And researchers can provide services, we do, and many others do, and policy makers can undertake research and I'm engaged with some work where I'm involved with policy makers doing research. So what I'd like to do now is to hand over to Helen to describe the next steps. Oh yeah, the easy part, the easy part. No, I think Julia's really described a problem which is that despite the success of our service, which I think is successful, it's clear that providing, implementing and disseminating our programs does not automatically result in uptake by those who might need them or use them. And this means, the means by which we get people to take up known effective treatments or interventions is probably the biggest translation gap. And in the public health space, I think that's also something that hasn't really been very well considered so far. So we've got these programs that are out there but they're not necessarily being taken up. And when you're in the area of health promotion and prevention, the idea that you're making people do something that they don't even know they have to do in order to prevent something that's going to happen into the future is very different from telling somebody who's smoking even that they have to stop smoking because they're pretty clear, it's a similar idea that essentially prevention is about actually preventing something that isn't already causing them some distress. So how do we, what are we going to do next? And I think the next agenda is developing and testing methods to increase uptake of these sorts of programs. And again, I've sort of got four ideas about what might be required for those steps. The first is the consumer input. We really need to know what views and perceptions people have about doing prevention and in particular areas. And to fully engage with the consumer because as in most technology projects, you can have great technology and people won't use them. I mean, the second thing is the technology. I think technology is the key to us being able to do really good public health because of the mass capacity of people to be able to use computers. I mean, when you get a computer that's face-to-face with you, then it's highly interactive and has many, many features that make it much more likely that you want to engage with it. But I think we have to start thinking outside the box as other people have been doing, not just us, which is how we investigate the use of web too, which is essentially using other individuals in a sort of mass persuasion way to start engaging in health behaviors or improving their mental health behaviors. So that's one thing. The use of the web too, crowd-sourcing the way and mass into personal persuasion is one thing that we haven't really, really moved into and yet is probably going to be key. But just using technology by itself is not going to be the answer. And what we need to do is use our knowledge of behavioral change to create the technology solutions. So we do have models about how behavior changes. We just have not really had very good tools about how to actually make that happen. And the work of BJ Fogg from Stanford is particularly interesting in this. He's written a book called Mobile Persuasion, which was very persuasive in its views about how the mobile phone application can do a lot of things. The ways in which texts can be used in order to change behavior. And of course, there's always the robots and the personal coaching kind of mechanism. I mean, I've just heard about this robot who resides Shakespeare. I think that sounds rather nice. Better than a friend, really, can reside Shakespeare at you. And this lovely little robot who's got quite a cute face, if you can see him there, perches on the user's shoulder. And the person who this person's talking to through the robot is Skyping into that robot. So they're having a little conversation as they're walking along. And I mean, the parallels with what could be done in terms of health promotion. You know, persuading the person not to eat that McDonald's. You know, the whole idea of actually using technology in this broader way is kind of potentially interesting area, I think. Now, I couldn't help but put up this picture, which goes 2008 iPhone, 2010 iPad, 2012 I-Board, 2014 IMAT, which is kind of a joke. But actually, we may be going that way. We may be having the whole environment being sensitive to what we do and how we act. And, I mean, I know that IMAT is probably not going to do it for us, but it's that idea that there is a whole world of technology that can be used to shape our behavior in this space where we're trying to get people promote healthy behavior. Okay, final two other areas, I think, that need to be investigated that we can develop. And that is the concept of financial incentives for public health. I think if you pay people to do prevention programs, they will do them. If you pay $50 to do a six-month prevention program, and that actually works, that's very useful money being spent by the government, I think, in changing people and preventing payers. And then there's the prescribing and legislation, which is another idea where you actually do prescribe people, say, in the workforce, one of Kathy's concepts is that people come into a workforce and they have to do a prevention program for mental health. So you're actually prescribing, the organization makes them do it, because we know from the evidence that we've got that that actually prevents the development of depression in your workforce. So it seems to make sense as well. Okay, so just to conclude, sort of gathering together what we've been talking about, which is this idea, what is public health translation still lost in translation? I know that's a bit of a kind of everyone saying translation, lost in translation. Actually, Julia's called it found in translation. But I think our point is that public health translation is lost in translation on many people who don't understand that from public health research, you still have to move into the translation of it. So thank you very much.