Advancing the Evolution – Insights into the State of e-Mental Health Services in Canada

Purpose

Despite the widespread prevalence of mental health problems and illnesses, it is estimated that fewer than one-third of Canadians affected by them will seek treatment. With high rates of mental health problems and low access levels for traditional mental health services (delivered one-onone, in-person at a clinic settings), there is an urgent need for innovative approaches to service provision. This, combined with exponential growth in communication technologies and the development of effective digital interventions to address mental health, has made improving the design and application of e-health technologies a mental health priority of national concern. In fact, Canada’s first mental health strategy, Changing Directions, Changing Lives, recommends that technology be used in myriad ways, to “foster collaboration, increase access to services, and engage people in managing their mental health problems and illnesses.”

Despite the clear potential of digital technology to connect people and health services in new ways, there is plenty of evidence to suggest that this potential is not being fully realized in Canada. This environmental scan identifies current e-mental health programs and initiatives operating as part of mental health service delivery through a hospital or community-based service provider, and/or as a component of a government’s mental health strategy. It also summarizes themes that emerged through 21 in-depth key informant interviews. The analysis follows the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance Framework) which seeks to bridge the gap between research and practice by specifying key steps involved in the successful application of programs and policies in real-world settings. This framework provides critical questions to help program planners, evaluators, and policy makers maximize their chances for successful translation of evidence-based interventions.

As a result of this scan, challenges in the implementation of e-mental health in Canada are identified, along with opportunities to build on existing strengths and areas for growth in the planning of e-mental health services and programs in Canada to ensure their adoption, successful implementation, and evaluation. Notably, it is important to:

• Strengthen e-mental health research and development.
• Engage in knowledge translation across the country and across the globe.
• Ensure people with lived experience and their caregivers are engaged as partners and co-designers throughout the design, development and implementation of e-mental health innovations.
• Pursue the integration of e-mental health as part of broader – and necessary – mental health service transformations.
• Adopt an implementation science approach to enhance the likelihood of translating successful research outcomes to community practice settings.

It is imperative that research and practice communities work together to translate evidence-based programs and policies into widespread practice. A helter skelter approach is likely to be unsuccessful. The application of the RE-AIM Framework however, can facilitate successful knowledge translation efforts and make a positive difference in delivering high quality mental health care in Canada.

Methodology

Search of Current Practices in Canada

We began with an initial Internet search of government and other publicly available websites, starting with websites of Canadian health centres that are part of the Canadian Association of Pediatric Health Centres (CAPHC), Canadian Association of Community Health Centres (CACHC), First Nations and Inuit Health Branch (FNIHB) and other agencies (e.g., Canadian Mental Health Association (CMHA), Centre for Addiction and Mental Health (CAMH)). We also approached patient and non-profit organizations (e.g., eMentalHealth.ca, Clients Canada, Canadian Family Advisory Network). Our aim for the online scan was to identify e-mental health programs and initiatives, which we broadly defined as any an e-mental health program operating as part of mental health service delivery through a hospital or community-based service provider, and/or as a component of a government’s mental health strategy. We did not include initiatives related generally to e-health (e.g., electronic medical records). We used data extraction tools to identify key features of these initiatives for summary purposes, with a focus on identifying gaps in knowledge and practice which should be filled to inform the strategic planning.

Key Informant Interviews

Next, for a more in-depth view of existing practices and policies, we contacted 40 key stakeholders—including jurisdictional representatives from all provinces and territories—and invited them all to participate in a 60-minute telephone interview. Twenty-one agreed to be interviewed. Interviewees were identified by: (1) targeted Google searches for relevant government, health, and technology organizations; (2) rapid review of Canadian researchers working in relevant areas; and (3) recommendations from members of our team. We planned the interview based on a list of standardized questions designed to reveal current levels of e-mental health awareness and to gain information about existing programs and policies. Key informants received the guide via e-mail two days prior to their scheduled interview, to allow time to review the questions in advance.
After an experienced transcriptionist transcribed the digitally recorded interviews, we conducted rapid deductive thematic analyses of the transcripts using the RE-AIM Framework.

RE-AIM Framework

The RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance Framework) bridges the gap between research and practice by specifying the key steps involved in successfully applying programs and policies in real-world settings. It provides critical questions to help program planners, evaluators, and policy makers maximize their chances for successful translation of evidence-based interventions.

The RE-AIM Framework has also been used to understand the relative strengths and weaknesses of different approaches to health care services—such as in-person counselling, telephone counselling, and Internet resources. The overall goal of the RE-AIM Framework is to focus attention and critical thinking on essential program elements that can improve the sustainable adoption and implementation of effective, evidence-based programs and policies. To maximize overall impact, a program must perform well across all five RE-AIM elements. Our goal was to explore what the RE-AIM elements currently look like in relationship to e-mental health in Canada.