Optimizing the delivery of digital mental health interventions during the COVID-19 pandemic

Article by Dorsa Derakhshan

Graphic design by Colleen Paris

Not all patients happen to take convenient residence in the heart of a metropolitan area. Some are living in remote areas of provinces. With a considerable distance to the closest urban centre, these patients have unique concerns regarding the lack of access to healthcare services. Even with the utilization of televideo conferencing, Dr. Sanjeev Sockalingam has realized that there are insufficient resources and services available.

“I remember several patients not having access to therapists or psychiatrists in their local settings, and they often suffered as a result since they couldn’t access proper care,” he explains. “These events inspired me to think: how can we remotely provide care, and more specifically, how can we continue to expand mental health services for those individuals so that it could help with their recovery and overall care? How can we do better for our patients and their family members?”

Dr. Sanjeev Sockalingam is Vice Chair and Professor of Psychiatry at the University of Toronto and Vice President of Education and Clinician Scientist at the Centre for Addiction and Mental Health. He is passionate about integrated care in Consultation-Liaison Psychiatry, a collaborative clinical approach that emphasizes the optimization of biopsychosocial care, as well as conducting research on the integration of physical and mental health.

**Dr. Sanjeev Sockalingam**

Vice Chair, Education and Professor at Department of Psychiatry, University of Toronto

VP, Education and Clinician Scientist at Centre for Addiction and Mental Health

_{Photo credit: Mikaeel Valli}

Dr. Sockalingam’s research has been primarily inspired by his personal experiences treating patients in his clinical practice, many of whom have medical comorbidities, such as metabolic syndrome and mental illness. Quality improvement has been a major driving force in his career. Dr. Sockalingam has explored its possibilities in two avenues: 1) Development of accessible programs and interventions for patients living with mental illness and physical health comorbidities who are struggling with difficulties navigating access to treatments for both conditions; and 2) Promotion of education and knowledge translation to help prepare current and future healthcare providers for managing disparities in mental healthcare using integrated care models.

Dr. Sockalingam explains that the COVID-19 pandemic has deepened the current gaps and disparities in care. He proposes a solution: technology. Using technology to deliver psychotherapy and train healthcare providers may help enhance healthcare education and make care more accessible to patients. The inspiration for this project originated from the current experiences of patients and frontline healthcare workers during the COVID-19 pandemic.

“We had to rapidly scale up our ability to provide virtual care,” says Dr. Sockalingam. Some patients in his clinical practice have been fortunate to receive virtual care through televideo conferencing since the onset of the pandemic. However, many patients were continually struggling with accessing resources and coping with the COVID-19 virus itself. These patients were presenting with a new onset of mental health distress or the exacerbation of their previous mental health conditions. In addition to virtual visits, patients were receiving limited guidance on how to self-manage their emerging mental health issues, such as anxiety, depression, and loneliness.

Likewise, frontline care providers have been striving to cope with personal distress. They have been provided with a space to share their current challenges through The Extension for Community Healthcare Outcomes (ECHO) program, which was initially implemented across Ontario and has now expanded on a national scale.¹ One of the primary hindrances for these workers is the feeling of burnout due to the increased patient workload that needs traditional in-person care. ECHO exemplifies the utility of virtual programs and resources in the domain of healthcare and highlights the value that virtual care can provide by being a novel avenue for balancing care provision among many trained professionals.

There is a critical need to investigate the currently available digital interventions, ensure these tools are aligned with best practices, and curate a comprehensive resource which is accessible for use in clinical practice. Dr. Sockalingam emphasizes the significance of this project, “We wanted to make this resource accessible in the form of a consolidated toolkit that can actually be used for clinical purposes going forward”.

Due to the urgency posed by COVID-19, the development of this knowledge synthesis project has been quite rapid. The purpose of this research project is to investigate the efficacy of current digital interventions in mental health which aim to reduce mental health impacts of COVID-19, as well as identifying barriers to their access for underrepresented populations. The overarching goal is to curate an accessible, comprehensive resource that has been scientifically evaluated for its quality and is ready to be utilized effectively for clinical purposes going forward.

This project investigation went beyond curating papers describing digital interventions focused on diagnosable psychiatric interventions; it also included studies with a focus on mental health promotion and well-being. Studies of digital interventions’ target population included Canadian adults with clinical or subclinical symptoms of mental disorders. Dr. Sockalingam explains, “We didn’t limit our inquiry to diagnosable psychiatric conditions in order to capture tools to assist with mental health challenges more broadly. Based on COVID-19 literature, most individuals don’t develop full-blown clinical psychiatric conditions. Individuals are more likely to experience mental health distress”. Experimental variables explored in this research project included diversity of target patient population, accessibility factors such as cost of service, quality of assessment and reportable outcomes. Race, ethnicity and culture were key areas of focus related to equity and therefore the inclusion of indigenous patient populations and other underrepresented ethnicities was ensured.

Advanced online searches were conducted to find sites and organizations with key stakeholders in digital health on the national scale in order to ensure the proper capturing of currently available organizations and services, as well as authentically assessing their service in terms of quality and criteria. In order to ascertain the digital interventions were contemporary, studies included were published as early as the year 2000. The studies outlined interventions regarding mental health assessment, treatment, and well-being promotion. The range of articles examined was comprehensive and inclusive of commentaries and reviews in which interventions were regarded as modern innovations. The American Psychiatric Association (APA) Assessment Tool was applied to these resources to ensure quality assessment with respect to each of these interventions. Furthermore, the digital interventions were required to be defined by World Health Organization (WHO) Classification of Digital Health Technologies.

Despite the initial illusion of abundant resources, the study team discovered that most of the currently available resources did not meet the criteria for adequately addressing mental health concerns. Regarding mental health interventions, there was limited published information for reportable outcomes of digital interventions during COVID-19. Furthermore, reports were highly diverse regarding the types of intervention and areas of focus. In relation to equity, inclusivity and diversity, there were only few resources targeting specific populations of high need. For instance, none of the reports addressed Indigenous concerns. These times call for a heightened emphasis and consideration regarding equity and diversity issues, such as the critical inclusion and proper representation of the Indigenous patient population.²

Addressing the heterogeneity of the ‘quality’ of these resources posed a major issue. The following factors were taken into consideration: 1) Reliability: How can people access the resource in a reliable way? 2) Specificity: Is the intervention quite general or specific? How would people know whether they are meeting their specific needs? and 3) Diversity: Is there a limited number of available resources for specific patient populations? Diverse or underrepresented groups often have less access to more tailored versions of digital interventions. In addition, curating a resource that addresses diversity in terms of mental health needs is also essential.

Such prevalent challenges in virtual care reflect the obstacles that currently exist in traditional in-person care. Namely, in-person barriers are reflected in digital interventions.

This impact of this work, which was done in collaboration with co-principal investigators Drs. Strudwick and Crawford, is critical since patients, frontline workers and healthcare providers, as well as the general public are facing a plethora of online resources regarding mental health and COVID-19. Dr. Sockalingam emphasizes: “We went from initially having only few resources met with reluctance to witnessing an overwhelming sea of interventions being offered. Our team strived to curate, assess and synthesize all the available resources that are genuinely valid and appropriate for practical use.”

Preliminary findings are currently being disseminated with respect to knowledge synthesis.³The team has reviewed the literature and has grouped the studies in terms of their outcomes, the geographical location in which they were developed, and their target populations.

The purpose of the knowledge translation is to share the results through the ECHO Ontario program to healthcare providers working on the frontlines, as well as with internal and external digital health groups on a national scale through webinars, such as the Evidence Exchange Network (EENet).⁴ The results also led to the development of an online knowledge hub located on the CAMH website in which the online interventions and applications can be searched for by the use of keywords to make these online resources accessible to target population patients and families.⁵

Future directions include more focus towards select populations that are underrepresented such as youths, refugees and other marginalized groups. Additionally, conducting more rigorous evaluations of these digital interventions is required. Clinically, it is vital to strive towards curating more inclusive interventions that address disparities in access to care, employ similar standards for assessment and ensure consistent quality when offered to various patient populations. As such, Dr. Sockalingam believes this project will have immense impact in advancing care in both clinical and academic realms.

With sincere appreciation for the impact of academic work in the ongoing state of the world, Dr. Sockalingam acknowledges the current challenges researchers may be facing during this pandemic. As a word of advice, he suggests IMS research students virtually network and collaborate with other groups on novel projects and initiatives by taking full advantage of virtual technology in assisting with recruitment, delivery of interventions, and knowledge dissemination and translation. Dr. Sockalingam has been deeply inspired by the dedication and commitment of the clinical and research teams towards finding creative modern solutions, and taking on roles outside of their usual responsibilities to assist frontline workers while caring for patients and supporting the public during these unprecedented times.