Evaluating the Digital Frontier: A Mixed-Methods Exploration of the Implementation of Digital Mental Health Interventions

Background: Digital mental health interventions (DMHI) have been increasingly integrated into routine service provision. As we move past the height of the COVID-19 pandemic, an opportunity has arisen to systematically investigate the short- and long-term viability of these interventions. Objectives: This thesis has three main objectives: i. Evaluate the current state of implementing DMHI, including digitally delivered trauma-focused psychotherapies, through an implementation science lens. ii. Identify strengths and weaknesses of currently implemented DMHI. iii. Clarify whether these DMHI are appropriately addressing the needs of clients, clinicians, and community partners. Methods: This dissertation explored DMHI using a range of methodologies, including a scoping review, mixed methods studies, and qualitative approached as described briefly below. A scoping review, informed by the Alberta Quality Matrix of Health, systematically mapped existing peer-reviewed research on synchronous, therapist-delivered web-based psychotherapy for individuals with a mental illness. A pilot mixed-methods study investigated perceptions of digitally delivered psychotherapies utilized for trauma affected populations, as reported by Canadian military members, Veterans, and Public Safety Personnel who had undergone these interventions, and a mixed methods study identified strengths and weaknesses of digitally delivered psychotherapies utilized for trauma affected populations based on the perceptions of Canadian mental health clinicians who had provided these interventions. An additional mixed methods study investigated and identified factors that may affect the current and future implementation of DMHI in mental health care systems and ascertain current micro, meso, and macro level factors related to the use of DMHI. A randomized control trial (RCT) was conducted to investigated whether web-based, synchronous clinician-delivered eye movement desensitization and reprocessing (EMDR), primarily targeting experiences, beliefs, or affective states associated with suicidal thinking, would aid in reducing suicidal ideation (SI) compared to treatment as usual. In addition, a qualitative study explored the experiences of civilian adult mental health outpatients who received web-based, therapist-delivered EMDR targeting suicidal state related content during the Randomized Controlled Trial Investigating Virtual Eye Movement Desensitization and Reprocessing for Adults with Suicidal Ideation. Results: The review revealed that most studies measured treatment effectiveness and acceptability health quality dimensions. Important aspects of health care quality (accessibility, appropriateness, efficiency, and safety) had received little scientific examination, underscoring a need to address these gaps. There are also significant issues related to the generalizability of this literature, including the underrepresentation of many geographic regions, cultures, populations, clinical contexts, and psychotherapy modalities. For the study investigating perceptions of digitally delivered psychotherapies utilized for trauma affected populations, participants indicated unique advantages of DMHI, including increased accessibility of treatment, cost effectiveness, and more efficient use of resources. The subsequent mixed-methods study investigating factors that may affect the current and future implementation of DMHI reported participant support of the use of digitally delivered psychotherapies, sharing that these interventions appeared to offer similar quality of care as in-person delivery. Client and clinician participants expressed satisfaction with the implementation of DMHI. Community partner participants generally agreed, reporting that such services will play an integral role in mental health care moving forward. Community partners shared a concern that uncertainty surrounding policies and regulations related to DMHI must be addressed moving forward. The RCT results indicated that EMDR group participants exhibited decreases in median SI, depression, anxiety, and posttraumatic symptom scale scores from baseline to the four-month follow-up, while also reporting numerically fewer adverse events during study participation compared to treatment as usual group participants. These results provide promising preliminary evidence that web-based EMDR may be a viable delivery approach to addressing SI. Qualitative study participants reported benefits from receiving web-based EMDR focused on SI, while also reporting that the treatment was intensely emotional. Thematic analysis revealed five main themes: (1) systemic obstacles to recovery, (2) relational attunement creating safety, (3) moving past the stuckness of suicidal states, (4) post-traumatic growth and resilience, and (5) unique needs and preferences. Discussion: This work revealed that participants generally supported the continued use of DMHI, citing several key advantages of DMHI over in-person care, such as increased accessibility of treatment. Participants reported feeling that DMHI typically offered good treatment effectiveness, safety, and overall quality of care, although their perceived appropriateness varied amongst individuals. The results of this dissertation may be used to inform DMHI-specific policies, practices, and training opportunities in the future.

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