Health care providers and other providers in mental health care, including psychiatrists, psychologists, counsellors, psychotherapists, nurses, primary care physicians, social workers, occupational therapists and peer support workers

Administrators wishing to increase the uptake of digital mental health tools, such as program planners, digital health implementation specialists, information management / information technology specialists and process improvement specialists.

In addition, clients and caregivers are the audience for several of the resources on this page. We invite clients and caregivers to use the page to identify resources that might be helpful to them. The primary audience for this page will vary between organizations, depending on contextual factors such as size, policies and existing infrastructure. We encourage you to consult within your organization before implementing a resource listed here.

These types of tools remain relatively new. Much of the focus to date has been in helping users choose and integrate apps and in implementing digital mental health programs through comprehensive guides. The COVID-19 pandemic of 2020 resulted in a sharp increase in the use of telemedicine tools. However, any gaps remain.

• No resources were found that directly address tools related to virtual reality, robots, gaming or artificial intelligence.
• No resources were found that target caregivers. More explicit attention to their unique position in supporting clients (and providers) would undoubtedly promote the uptake and use of digital mental health tools.
• In general, resources seemed not to account for cultural differences. For example, no resources were found that target Indigenous people. Given their unique and diverse cultures, this gap may do a disservice to the First Nations, Inuit and Métis people of Canada.

This project is not:

• A collection of digital mental health tools (e.g., specific apps or technologies) that can be used in the client-provider interaction; rather it describes a number of resources that can support the integration of digital mental health tools into clinical practice
• An expert rating or review of the resources presented; we encourage you to assess yourself whether the resource meets your needs

Information on how to use a given resource is often provided in the resource itself. For many resources, it is self-evident. In the summary of each resource, we provide some basic information on how to use it.

When thinking about how you might use a resource in your clinical practice, consider the discussion in the next section of barriers and facilitating factors that influence the uptake of digital mental health tools.

Administrator: A person working in the mental health care sector who performs business operations roles that support the clinical care functions of an organization.

App assessment resource: A resource that provides a generic model or framework that the user follows to evaluate an app of their choice; the resource does not provide an assessment of an app but rather guidance on how to assess an app.

App rating resource: A resource that provides summaries and expert ratings of different apps; the resource offers an expert assessment of different apps.

App selection tool: An interactive tool that provides access to a collection of apps. Apps are presented based on a series of questions or filters based on specific characteristics of the app, such as audience or type of therapy.

Caregiver: An informal care provider, such as a family member, friend or other social support, whom a client calls upon for help, care and support.

Client: A person who accesses mental health services or seeks mental health care.

Health care provider: A trained health professional or allied health worker who provides care and services to people looking for mental health care.

Implementation resource: A resource that provides information and guidance on how to establish and operate a program or practice that incorporates a digital mental health tool; these resources often target larger projects that involve changes to workflow and care practices.

Resource: A website, document, poster, or other material that can help to integrate different digital mental health tools into practice; for example, a website that reviews and rates apps can help identify the right tool for a client.

Resource collection: A collection of resources curated to focus on a particular topic.

Tool: An app, website, device or other digital mental health technology that is to be used by the client or the provider, together or separately; for example, a tool could be a cognitive behavioural therapy app.

App libraries

App Library (Health Navigator New Zealand https://www.healthnavigator.org.nz/apps/

Apps Library (National Health Service, United Kingdom https://www.nhs.uk/apps-library/

Reviewed Mental Health Apps (Anxiety and Depression Association of America) https://adaa.org/finding-help/mobile-apps

App assessment frameworks

Guiding Principles for Physicians Recommending Mobile Health Applications (Canadian Medical Association) https://policybase.cma.ca/en/permalink/policy11521

Mobile Application Rating Scale (MARS) App Classification (Ministry of Health, New Zealand) https://www.health.govt.nz/system/files/documents/pages/guidance-evaluating-developing-health-app-oct17-v2.pdf

Implementation guides

Digital Health Implementation Playbook (American Medical Association) https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook

e-Mental health guide and strategic planning worksheet (ACCESS Open Minds) https://accessopenminds.ca/wp-content/uploads/dlm_uploads/2018/08/ACCESS-Open-Minds-eMental-Health-Guide-EN-vers20180723.pdf

Best Practice Guideline: Adopting eHealth Solutions: Implementation Strategies (Registered Nurses Association of Ontario) https://rnao.ca/sites/rnao-ca/files/bpg/Digital_Health_Guideline.pdf

Telemental health

Center for Care Innovations Resource Center (USA) https://www.careinnovations.org/resources/

Telepsychiatry toolkit (American Psychiatric Association) https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit

Guidance on telemental health for mental health services and practitioners (eMEN, Ireland) https://www.mentalhealthreform.ie/wp-content/uploads/2020/04/eMEN-rapid-briefing-paper_-COVID-19_final-12.pdf

Therapy decision guides

Stepped Care Guide: A promising model to improve access to mental health care on campus (Memorial University, St. John’s, Newfoundland) https://campusmentalhealth.ca/wp-content/uploads/2019/07/Stepped-Care-Guide-V10.pdf

Therapy option guide (Anxiety and Depression Association of America) https://adaa.org/sites/default/files/final-therapygu_23840851_3ad732e6e2a37020f3ac49fcaf48f6305f631dcf_0.jpeg

Comprehensive web resources

E-Mental Health in Practice (Black Dog Institute, Australia) https://www.blackdoginstitute.org.au/education-training/health-professionals/emental-health-in-practice

Improving Patient-Centred Technology Use (iPaCT) Education and Evaluation Toolkit (University of Chicago) https://www.mededportal.org/publication/9953/

(Based on a literature search conducted in late 2019.)

Advances in technology continue to revolutionize the health care system and influence the practice of health care professionals.

The COVID-19 world pandemic of 2020 provided additional impetus to use digital mental health tools, both to provide care while adhering to public health prevention guidelines and to support people manage the stress of the pandemic. Introducing digital tools and technology into the mental health care system has the potential to shorten wait times, increase access in rural and remote communities, and provide cost-effective access to care.(1) Research has demonstrated that many mental health care providers are aware of and ready to utilize these opportunities.

Nonetheless, several factors specific to mental health care need to be considered when implementing digital tools. One overarching consideration to keep in mind is that no single tool will work for everyone.(1) Other factors to consider are described below.

Potential uses

Enthusiasm for the use of digital tools is high among mental health care providers: in one survey, 98% of respondents said they were ready to use technology to support their clients.(2) Providers see the potential for digital health tools to increase access to mental health care and support for their clients.

There are many potential ways in which digital health tools may be used in mental health care. Here are a few examples:

• A computer-assisted client assessment or survey could be created for people waiting to see their family physician. The technology could promote self-disclosure through a non-intrusive means of prompting discussion of mental health concerns.(3)
• Incorporating technology-mediated supervision, such as a digital platform that would allow mental health providers to consult with each other on their use of digital tools, may provide the necessary support for providers to incorporate digital tools and technology in their clinical practice.(4)
• Tools to enhance face-to-face therapeutic interventions could allow therapy to extend beyond the session itself, and so contribute to treatment progress.(5)
• Digital health tools could help to personalize mental health treatment by sharing individualized plans or tracking progress.

Ethical, legal, privacy and confidentiality considerations

It is important to help clients to understand the ethical, legal, privacy and confidentiality considerations of digital tools. Areas to consider include:

• understanding the detailed risks and benefits of each tool used(5)
• the security risks and security settings of different technologies and digital tools, and the increased chance of security breaches(4,5,6,7,8)
• the level of consent required(8)
• the blurred limits of duty of care, and the challenge of defining and maintaining boundaries with clients when their access to a provider may be effectively unlimited(8,9)
• the absence of clearly defined guidelines in navigating privacy, security and confidentiality.

Emergency and crisis situations

• Interviews with psychologists revealed that 52% felt they had inadequate skills to manage an emergency or crisis situation in the context of online counselling.(6)
• Providers note the difficulty in identifying a client’s mental status and changes in status, and in addressing these changes, when using a digital tool.(6,9)
• Online counselling through video conferencing, and particularly group discussion, may exacerbate stress for some clients. How best to identify and address individuals’ needs in a virtual group-based format is a concern.(10)
• Mental health care providers worry about how to manage crisis information that may be conveyed through digital mental health tools.(11)

Face-to-face contact

Research shows that mental health care providers are beginning to incorporate digital health tools in providing ongoing face-to-face services.(6) They express strong interest in the ability of these tools to extend therapy beyond each individual session.(4) However, there are also concerns about this trend:

• One study noted that clients’ potential lack of support outside of the therapy room could be exacerbated by sole reliance on digital mental health interventions.(4)
• Clinical practice relies on non-verbal cues communicated in person to develop the therapeutic alliance, so technology-based interactions may sometimes not be as effective.(9)
• Face-to-face contact can provide a valuable avenue for some clients to separate from technology and develop the social skills needed for interpersonal communication and connection(9)—so this kind of tool may not be indicated in all cases.

Reliability of digital tools and technologies

Providers may need to discuss the reliability of digital tools and technologies with clients. This may include discussing the challenges in choosing the most appropriate tool, especially for clients with complex and comorbid clinical presentations, or presentations that change over time.(2,7,11,12) It is possible that unintended consequences may arise from using digital mental health tools that lack empirical support.(7)

Not all providers may be open to using technology-based interventions, leading to additional skepticism about reliability.(11)

Logistical factors

Three logistical factors to consider are training, time, and the interaction between new tools and existing policy and procedures:

• Barriers reported in the literature include inadequate training for staff on how to work with and navigate digital mental health tools.(2,6,9)
• The time needed to learn some of the tools may also be a barrier,(2,9,11) particularly given the full caseloads of many mental health care providers.
• In implementing a tool, the impact on billing, malpractice insurance and coverage, liability, licensure and cost need to be addressed.(6,7,11)

Additional considerations

• Digital health interventions can perpetuate the “digital divide,” whereby not all clients have the access or the technological skills needed to engage in digital mental health services.(11,13) In these cases, health care providers can support clients in obtaining access to technology, if appropriate, or in seeking support through a different source.
• There is the potential in some people for overreliance on technology. For example, one study commented on the possibility of technology use becoming a maladaptive safety behaviour for some clients, increasing distress when access to the technology is unavailable, and thus creating dependence rather than promoting autonomy.(8)
• Language may be a barrier to technology use in cases where the client is using a tool in a language they are not comfortable with.(3)

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References

1. Mental Health Commission of Canada. E-mental health in Canada: Transforming the mental health system using technology Internet. Ottawa, ON: MHCC. 2014 cited 2019 Sep. Available from https://www.mentalhealthcommission.ca/sites/default/files/MHCC_E-Mental_Health-Briefing_Document_ENG_0.pdf
2. Clarke AM, Chambers D, Barry MM. Bridging the digital disconnect: Exploring the views of professionals on using technology to promote young people’s mental health. Sch Psychol Int. 2017;38:380–97.
3. Ferrari M, Ahmad F, Shakya Y, Ledwos C, McKenzie K. Computer-assisted client assessment survey for mental health: Patient and health provider perspectives. BMC Health Serv Res. 2016;16:516.
4. Schueller SM, Washburn JJ, Price M. Exploring mental health providers’ interest in using web and mobile-based tools in their practices. Internet Interv. 2016;4:145–51.
5. Eonta AM, Christon L, Hourigan S, Ravindran N, Vrana S, Southam-Gerow M. Using everyday technology to enhance evidence-based treatments. Prof Psychol Res Pract. 2011;42:513–20.
6. Glueckauf RL, Mahue MM, Drude KP, Wells BA, Wang Y, Gustafson DJ, et al. Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Prof Psychol Res Pract. 2018;49:205–19.
7. Hatch A, Hoffman JE, Ross R, Docherty JP. Expert consensus survey on digital health tools for patients with serious mental illness: Optimizing for user characteristics and user support. JMIR Ment Health. 2018;5:e46.
8. Ignatowicz A, Slowther AM, Elder P, Bryce C, Hamilton K, Huxley C, et al. Ethical implications of digital communication for the patient-clinician relationship: Analysis of interviews with clinicians and young adults with long term conditions (the LYNC study). BMC Med Ethics. 2018;19:11.
9. Orlowski S, Lawn S, Matthews, B, Venning A, Wyld K, Jones G, et al. The promise and the reality: A mental health workforce perspective on technology-enhanced youth mental health service delivery. BMC Health Serv Res. 2016;16:562.
10. Sansom‐Daly UM, Wakefield CE, McGill BC, Patterson P. Ethical and clinical challenges delivering group‐based cognitive‐behavioural therapy to adolescents and young adults with cancer using videoconferencing technology. Aust Psychol. 2015;50:271–8.
11. Lattie EG, Nicholas J, Knapp AA, Skerl JJ, Kaiser SM, Mohr DC. Opportunities for and tensions surrounding the use of technology-enabled mental health services in community mental health care. Adm Policy Ment Health. 2020;47:139–49.
12. Berry N, Bucci S, Lobban F. Use of the internet and mobile phones for self-management of severe mental health problems: Qualitative study of staff views. JMIR Ment Health. 2017;4:e52.
13. Bucci S, Schwannauer M, Berry N. The digital revolution and its impact on mental health care. Psychol Psychother Theory Res Pract. 2019;92:277–97.
14. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211.
15. Rosenstock IM. Historical origins of the health belief model. Health Educ Monograph. 1974;2:328–35.
16. Agency for Healthcare Research and Quality. AHRQ publishing and communications guidelines. section 1 : product development. Toolkit Internet. Rockville, MD: AHRQ. Created 2013 Feb. Reviewed 2020 Jan cited 2019 May. Available from https://www.ahrq.gov/research/publications/pubcomguide/pcguide1a.html##_Toc7696924

Project team

Gillian Strudwick, RN, PhD, CAMH, Toronto

David McLay, PhD, CAMH, Toronto

Leanne M. Currie, RN, PhD, University of British Columbia, Vancouver

Nicole Thomson, OT Reg. (Ont.), PhD, CAMH, Toronto

Eric Maillet, RN, PhD, University of Sherbrooke, Longueil

Janis Campbell, MEd, Memorial University of Newfoundland, St. John’s

Alanna Miller, BSc, McGill University, Montreal

Hwayeon Danielle Shin, BScN, RN, Dalhousie University, Halifax

Vanessa Strong, MSc, Memorial University of Newfoundland, St. John’s

Project genesis

In Canada, numerous digital health tools have been developed specifically for people with mental illness, which has the potential to lead to significant benefits. However, engagement of providers and clients with these tools is often inconsistent, and in many cases poor. Uptake needs to be improved for benefits to be realized. Some resources to support the uptake of these digital tools have been developed, but these resources are not well known and have not been consolidated into a single document. Thus, a project that aims to consolidate these resources was identified as a need. The project was completed in April 2020. An update to the resource list was completed in early 2021.

Version 1 of the resource collection: https://tinyurl.com/digitalMH

Guiding principles

Discussions by the project team, along with valuable feedback from stakeholders from across Canada—including those with lived experience of mental illness—led to the definition of guiding principles for the project. These principles include the following:

• The client is the focus of the interaction, even though the audience for this project is health care providers.
• Empowerment is crucial for behaviour change, as acknowledged in several behaviour change models, such as the theory of planned behaviour and the health belief model.(14,15)
• Through support and choice, the client is empowered to use e-mental health tools in the way they deem most appropriate.
• Empowering health care providers to feel more comfortable with technology may increase their self-perceived competence with their clients.
• Practicality and user-friendliness are key objectives of the design of the tool.
• We will define clearly the audience of the project, including who is not the audience.
• We will acknowledge the lack of tools that target Indigenous people.

Goals and objective

The goals of this project are to:

• support the increased use of digital health tools in mental health clinical practice in Canada
• help health care providers to empower clients (and their caregivers) to use and benefit from digital mental health tools. The objective of the project is to identify existing digital health resources, to allow users to choose and integrate appropriate resources into the client–provider interaction.

Project design

The project was developed using methods recommended by the United States Agency for Healthcare Research and Quality (AHRQ) on toolkit creation.(16)

The project design including environmental scan (participants list below), grey literature search methodology (lists of organizations included below), and workshop are published in:
Strudwick G, McLay D, Lo B, Shin HD, Currie L, Thomson N, Maillet E, Strong V, Miller A, Shen N, Campbell J. Development of a Resource Guide to Support the Engagement of Mental Health Providers and Patients with Digital Health Tools: A Multi-method Study
JMIR Preprints. 14/11/2020:25773
DOI: 10.2196/preprints.25773
URL: https://preprints.jmir.org/preprint/25773

Environmental scan participants

• Kelly Anderson, Ontario, Western University
• Alexa Bagnell, Nova Scotia, IWK Health Centre
• Krista Balenko, Ontario, Canada Health Infoway
• Kim Barro, Nova Scotia, Nova Scotia Department of Health and Wellness
• Richard Booth, Ontario, Western University
• Elizabeth Cawley, Newfoundland and Labrador, Association of Atlantic Universities
• AnnMarie Churchill, Newfoundland and Labrador, Memorial University of Newfoundland
• Peter Cornish, Newfoundland and Labrador, Memorial University of Newfoundland
• Cheryl Forchuk, Ontario, Western University
• David Gratzer, Ontario, Centre for Addiction and Mental Health
• Heather Hadjistavropoulous, Saskatchewan, University of Regina
• Jennifer Heatley, Nova Scotia, Nova Scotia Department of Health and Wellness
• Amanda Hudson, Prince Edward Island, Health PEI
• Danielle Impey, Ontario, Mental Health Commission of Canada
• Sean Kidd, Ontario, Centre for Addiction and Mental Health
• Anne Kirvan, Ontario, Centre for Addiction and Mental Health
• Karim Kishavjee, Ontario, InfoClin
• Stan Kutcher, Nova Scotia, Dalhousie University
• Ashwin Kutty, Nova Scotia, We Us Them
• Shalini Lal, Quebec, Université de Montréal
• Patricia Lingley-Pottie, Nova Scotia, Dalhousie University
• Stacy Lloyd, United States, American Medical Association
• Rita MacAulay, Nova Scotia, Nova Scotia Department of Health and Wellness
• Gisele Maillet, New Brunswick, New Brunswick Department of Health
• Matt Menning, United States, American Medical Association
• Erin Michalak, British Columbia, University of British Columbia
• Josh Rash, Newfoundland and Labrador, Memorial University of Newfoundland
• Verna Ryan, Prince Edward Island, Health PEI
• Cristina Tassone, Ontario, Cancer Care Ontario
• Stacy Taylor, New Brunswick, New Brunswick Department of Health
• Lori Wozney, Nova Scotia, Nova Scotia Health Authority

Organizations included in original grey literature scan

Mental health organizations

• Canadian Mental Health Association
• Canadian Network for Mood and Anxiety Treatments
• depressionhurts.ca (Mood Disorders Society of Canada)
• ementalhealth.ca (Children’s Hospital of Eastern Ontario)
• Mental Health Canada
• Mood Disorders Society of Canada
• National Survivor User Network (United Kingdom)
• Ontario Centre of Excellence for Child and Youth Mental Health
• Ontario Shores Centre for Mental Health Sciences
• Portico Network
• Schizophrenia Society of Canada
• Youth Mental Health Canada

Medical organizations or hospitals

• Anxiety and Depression Association of America
• British Medical Association
• Canadian Federation of Mental Health Nurses
• Canadian Medical Association
• Centre for Effective Practice
• College of Physicians and Surgeons of Alberta
• Mayo Clinic
• Registered Nurses Association of Ontario
• St. Elizabeth Health Care (Ontario)

Client organizations or websites

• Canadian MPN Group
• Canadian Patient Safety Institute
• Canadian Public Health Association
• Canadian Virtual Hospice
• Choosing Wisely Canada
• Consumers Health Forum of Australia
• familydoctor.org (American Academy of Family Physicians)
• Gold Foundation (United States)
• Health Consumers Alliance of South Australia
• Here to Help BC
• Medivizor (United States)
• Mental Elf (United Kingdom)
• myhealth.alberta.ca (Alberta Health Services)
• Ontario Lung Association
• Open Arms Advocacy
• Patient Commando
• Patient Power (United States)
• patient.info (United Kingdom)
• Patients Advisor Network
• Patients Canada
• The Change Foundation
• Us TOO (United States)

Governmental organizations

• Agency for Healthcare Research and Quality (United States)
• Canada Health Infoway
• Canadian Health Coalition
• Centers for Disease Control and Prevention (United States)
• Department of Health and Human Services (United States)
• Digital Health Canada
• Federal Drug Administration (United States)
• National Health Service (United Kingdom)

Other

• MediaSmarts
• PREVNet

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