Background
Methods
Design/aim
Context and setting
Geographical context
Healthcare system
Region of Community Mental Health Clinic | ~Adult population | # of months clinic used ICBT at time of survey | # patients from clinic treated with ICBT (n = 864) | # of patients from clinic treated by external OTU (n = 479) | # patients from clinic treated by clinic therapist (n = 385) | # of therapists from clinic who used ICBT (n = 40) | # of therapists from each clinic completed survey (n = 22) | # of managers from each clinic completed survey (n = 11) |
---|---|---|---|---|---|---|---|---|
Regina Qu’Appelle | 218,783 | 27 | 386 | 215 | 171 | 13 | 8 | 3 |
Saskatoon | 263,065 | 29 | 213 | 117 | 96 | 10 | 6 | 1 |
Five Hills | 43,261 | 28 | 91 | 45 | 46 | 6 | 2 | 2 |
Sun Country | 44,870 | 28 | 40 | 16 | 24 | 3 | 1 | 1 |
Cypress | 34,525 | 26 | 48 | 34 | 14 | 2 | 1 | 1 |
Kelsey Trail | 31,663 | 20 | 36 | 27 | 9 | 1 | 1 | 1 |
Prince Albert Parkland | 58,595 | 19 | 50 | 25 | 25 | 5 | 3 | 2 |
Online Therapy Unit (OUT) at the University of Regina facilitated ICBT in the community clinics | The OTU was founded to provide centralized assistance with implementation of ICBT in the community clinics. The OTU created a platform and website that allowed therapists to deliver ICBT; established policies and procedures for therapists to deliver ICBT; trained therapists in the provision of ICBT; provided ongoing supervision and consultation with cases; provided technical assistance; screened patients; matched patients to therapists; monitored the service and treatment outcomes; and identified and resolved barriers to implementation. Key actions of the OTU as an external facilitator of change are outlined below. |
Accessed new funding | Research funding was obtained to support the operation of the OTU. |
Developed resource sharing agreement | The OTU developed a partnership with Macquarie University in order to trial a previously developed ICBT Course in Saskatchewan. |
Built a coalition between OTU and community mental health clinics | Partnerships were formed between OTU and seven community mental health clinics. |
Educational meetings | The OTU educated and trained therapists in the provision of ICBT. |
Developed tools for promoting ICBT | The OTU developed posters, letters for physicians, and an online video to inform the community about ICBT. |
Consensus discussions | Tri-quarterly meetings were held between the OTU and the Directors of the community clinics. During these meetings, positive experiences with ICBT delivery were shared. Barriers to implementation were discussed, such as: 1) how to best educate patients about ICBT; 2) which patients should be included/excluded from ICBT; 3) how to assign therapists to work with ICBT patients; 4) how to provide supervision to therapists; and 5) how to manage health records related to ICBT. |
Individuated pilot by community mental health clinics | Each clinic determined the number of therapists they would train in ICBT, and the number of patients who would receive ICBT. |
Monthly updates | The OTU provided monthly updates to clinics on the number of patients screened, treated, and completing ICBT. |
Audit and provide feedback | The OTU audited the provision of ICBT within each of the community clinics. Feedback was provided to the therapists on methods that could be employed to improve delivery of ICBT. |
Email reminders | Therapists received email reminders periodically regarding important aspects of providing ICBT (e.g., reminding therapists to complete weekly check-ins with patients, to build supportive relationships with patients, to remind patients to complete the course, to assist patients in applying ICBT content to life circumstances). |
Online therapy process
Screening conducted by OTU | Online screening assessed patients for basic eligibility:(1) 18 years or older; (2) residents of Saskatchewan, Canada; (3) self-reporting symptoms of depression and or anxiety; (4) able to access and comfortable using computers and the Internet; (5) reporting no past history of psychotic symptoms; (6) available to participate in ICBT for 8 weeks; and (7) willing to provide a physician as an emergency contact. Eligible patients then completed additional online questions about their background and psychological symptoms/distress. A follow-up telephone interview was conducted by the OTU to ensure patients’ consented to ICBT and were not at high risk of suicide, needing help with a different disorder (e.g., alcohol or drugs, psychosis, bipolar), or in receipt of regular therapy. |
Coordination | Patients were assigned to the first available registered therapist in one of the participating community clinics. If unavailable, the patient was offered treatment by a supervised graduate student or a registered provider working in the OTU. |
Website | ICBT was available through a single secure server managed by the OTU. All patients and therapists used login credentials to access the course and communicated through this server. |
ICBT Program | All patients were offered an ICBT course, called the Wellbeing Course [see 7 for details]. This is a transdiagnostic cognitive behavioural intervention targeting symptoms of depression and anxiety. It comprises 5 online lessons (text-based with visual images) released over 8 weeks that provide psychoeducation and instructions about: 1) symptom identification and the cognitive behavioral model; 2) thought monitoring and challenging; 3) de-arousal strategies and pleasant activity scheduling; 4) graduated exposure; and 5) relapse prevention. Patients are assigned homework to facilitate acquisition of skills. |
Therapist-assistance | Patients were able to contact therapists by secure email for 8 weeks. Therapists responded to patient emails once a week, with a message that:1) highlighted the lesson content; 2) answered questions and assisted patients in applying skills; 3) reinforced progress, completion of the lessons, and practice of skills; and 4) provided support and normalized patient challenges. Therapists had the option to phone patients or send additional messages if they deemed this would facilitate treatment. Therapists were instructed to spend ~15 to 20 min on therapist-assistance per week. |
Outcome monitoring | Patients completed brief measures of depression and anxiety [see 7 for details on measures] prior to each lesson to assist therapists in systematically assessing patient progress. |
Participants
Procedure
Analyses
CFIR Constructs | Positive Comments | Negative Comments | All | Representative Comments | ||||
---|---|---|---|---|---|---|---|---|
Therapists | Managers | Total | Therapists | Managers | Total | Total | ||
Intervention Characteristics | ||||||||
Innovation | – | 0 | 0 | – | – | 0 | – | |
Evidence strength & quality | 7 | 3 | 10 | 2 | 0 | 2 | “I work from the perspective that this is an evidenced based service.” (Manager) | |
Relative advantage | 13 | 5 | 18 | 1 | 1 | 2 | “They are able to get all of the CBT approach and materials without having to come in for 5–6 weeks of face-to-face appointments. Most people can’t commit to that amount of time, so we often don’t get the opportunity to walk clients through an entire CBT program in the office.” (Therapist) | |
Adaptability | 1 | 1 | 2 | 8 | 3 | 11 | “Some staff that offer the service have noted that the format is somewhat rigid and this does not fit well with their service delivery style.” (Manager) | |
Trialability | – | 2 | 2 | – | – | 0 | – | |
Complexity | – | – | 0 | 4 | 2 | 6 | “Therapeutic alliance is a little more difficult to establish when the non-verbal communication is not a part of the eq. I think it also depends on the age of the client and their communication style.” (Therapist) | |
Design quality and packaging | 12 | 4 | 16 | 4 | 0 | 4 | “The course has excellent material that is well thought out and organized.” (Therapist) | |
Cost | 1 | – | 1 | 1 | – | 1 | – | |
Construct Total
|
49
|
26
| 75 | |||||
Outer Setting | ||||||||
Needs & resources | 5 | 2 | 7 | 3 | 1 | 4 | “It’s great to have another program clients can access when as a health region there are such long wait times for clients to be seen.” (Therapist) | |
Cosmopolitanism | – | 4 | 4 | – | – | 0 | “This is a great program. I really like the current model of delivery where U of R is the leader and the region provides counsellors to support.” (Manager) | |
Peer pressure | – | – | 0 | – | – | 0 | – | |
External policy & incentives | – | – | 0 | – | – | 0 | – | |
Construct Total
|
11
|
4
| 15 | |||||
Inner Setting | ||||||||
Structural characteristics | – | – | 0 | 2 | 2 | 4 | “Staff changing roles and positions has had an impact.” (Manager) | |
Networks & communications | – | – | 0 | – | – | 0 | – | |
Culture | 2 | 3 | 5 | – | 1 | 1 | “Our staff are invested in providing good services to the public” (Manager) | |
Implementation climate | 3 | 4 | 7 | 18 | 4 | 22 | “The majority of in-person intakes would have a higher need based on the complexity of their cases or severity of their symptoms, therefore I have a hard time justifying the time spent on ICBT/client over in-person counselling.” (Therapist) | |
Readiness for implementation | 8 | 6 | 14 | 35 | 13 | 48 | “I think that there is a negative view of ICBT at this time, as it is seen as another “demand” on therapists’ time without other responsibilities being modified.” (Therapist) | |
Construct Total
|
26
|
75
| 101 | |||||
Individual Characteristics | ||||||||
Knowledge & beliefs about the innovation | 8 | 4 | 12 | 9 | 5 | 14 | “There are several therapists who have a strong interest in ICBT and this positively influences the implementation of ICBT. ”(Therapist) “But for some reason ICBT is a bit boring as a therapist to deliver for me. And it’s exhausting. I don’t really like writing out my therapy.” (Therapist) | |
Self-efficacy | – | – | 0 | – | 1 | 1 | – | |
Individual stage of change | – | 1 | 1 | 1 | 3 | 4 | “Most of us struggle with change” (Manager) | |
Individual identification with organization | – | – | 0 | – | – | 0 | – | |
Other personal attributes | 1 | 2 | 3 | 0 | 2 | 2 | “Some are more comfortable both with computers and with the written communication methods of the program.” (Manager) | |
Construct Total
|
16
|
21
| 37 | |||||
Implementation Processes | ||||||||
Planning | 2 | 3 | 5 | – | – | 0 | “Very well planned and organized, all positive.” (Manager) | |
Engaging | 14 | 8 | 22 | 11 | 9 | 20 | “A lot of patients in our region were quite aware of ICBT. It seemed that they had been hearing about it from both their personal networks and from professional caregivers that they were involved with.” (Therapist) “I just think more people could be involved in providing the service.” (Therapist) | |
Executing | 6 | 3 | 9 | 2 | – | 2 | “It seemed like ICBT was implemented fairly efficiently in our health region.” (Therapist) | |
Reflecting & evaluating | 2 | 3 | 5 | 1 | 0 | 1 | “We communicated the patient outcomes to staff & senior leadership in very visual undisputable ways.” (Manager) | |
Construct Total
|
41
|
23
| 64 | |||||
TOTAL COMMENTS
|
143
|
149
|
292
|
Questions | Therapists M (SD) (n = 22) | Managers M (SD) (n = 11) | Overall M (SD) (n = 33) | |
---|---|---|---|---|
Intervention Characteristics
|
4.36
(0.72)
|
4.78
(0.37)
|
4.5
(0.65)
| |
1. It is positive that the ICBT Wellbeing Course was developed externally and the health region did not have to develop our own ICBT program | 4.32 (0.95) | 4.91 (0.30) | 4.52 (0.83) | |
2. The research evidence on the ICBT Wellbeing course is strong | 4.18
(1.01) | 4.82(0.41) | 4.39 (0.90) | |
3. ICBT has a number of advantages for clients | 4.36
(0.95) | 4.82
(0.41) | 4.52 (0.83) | |
4. It has been beneficial to be able to trial the ICBT Wellbeing Course on a small scale in our health region | 3.86 (1.08) | 4.82(0.60) | 4.18 (1.04) | |
5. It is beneficial that the ICBT Wellbeing course treats both depression and anxiety | 4.73 (0.55) | 4.91 (0.30) | 4.79 (0.49) | |
6. It is beneficial that the ICBT course involves 5 lessons spread over 8–9 weeks | 4.45 (0.86) | 4.55 (0.69) | 4.48 (0.80) | |
7. The ICBT materials are of high quality | 4.73 (0.55) | 4.82 (0.60) | 4.76 (0.56) | |
8. It is beneficial that there is no additional cost to the health region to deliver the ICBT Wellbeing course | 4.23 (1.48) | 4.64 (0.92) | 4.36 (1.32) | |
Outer Setting Characteristics
|
3.6
(0.52)
|
4.16
(0.40)
|
3.79
(0.55)
| |
9. My health region is aware of the high need for mental health care | 4.05 (1.25) | 4.36 (0.92) | 4.15 (1.15) | |
10. My health region benefits from partnering with the Online Therapy Unit | 4.05 (1.40) | 4.73 (0.14) | 4.27 (1.21) | |
11. There is pressure from other health regions in Saskatchewan to implement ICBT | 2.91 (0.68) | 2.91 (0.83) | 2.91 (0.72) | |
12. There is pressure from Saskatchewan Health to implement ICBT | 3.41 (0.80) | 4.55 (0.52) | 3.79 (0.89) | |
13. My health region is aware of recommendations of other groups to implement ICBT | 3.59 (0.85) | 4.27 (0.79) | 3.82 (0.88) | |
Inner Setting Characteristics
|
3.10
(0.47)
|
3.74
(0.55)
|
3.32
(0.58)
| |
14. My health region has an adequate number of therapists available to deliver ICBT | 3.05 (1.33) | 3.00 (1.27) | 3.03 (1.29) | |
15. The waiting list in my health region is long | 3.77 (1.34) | 3.82 (1.66) | 3.79 (1.43) | |
16. We had an adequate number of formal meetings to discuss ICBT within my clinic setting | 2.55 (1.30) | 3.91 (1.14) | 3.00 (1.39) | |
17. We had an adequate number of informal meetings/discussion to discuss ICBT within my clinic setting | 2.77 (1.23) | 3.73 (1.27) | 3.09 (1.31) | |
18. We have a positive clinic culture | 3.77 (1.27) | 4.00 (0.63) | 3.85 (1.09) | |
19. There is strong interest in doing things differently in my clinic | 3.55 (0.96) | 4.00 (0.89) | 3.70 (0.95) | |
20. It is easy to incorporate ICBT in our regular clinic work flow | 2.64 (1.36) | 3.73 (1.62) | 3.00 (1.52) | |
21. There is a high priority given to ICBT in my setting | 3.14 (0.99) | 3.82 (1.08) | 3.36 (1.06) | |
22. Therapists within my clinic who offer ICBT are recognized for their important work | 2.36 (1.14) | 3.73 (1.62) | 2.79 (1.29) | |
23. We have set specific goals for ICBT in my clinic setting | 2.68 (1.13) | 2.64 (1.21) | 2.67 (1.14) | |
24. We have adequate time to reflect on how ICBT is working and address challenges in my clinic setting | 2.14 (1.08) | 2.82 (1.25) | 2.36 (1.17) | |
25. Health region managers are committed to ICBT | 3.50 (1.06) | 4.45(0.69) | 3.82 (1.04) | |
26. Therapists have been given adequate time to learn and offer ICBT | 3.18 (1.37) | 4.00 (1.00) | 3.45 (1.30) | |
27. We had adequate access to information on ICBT from the Online Therapy Unit | 4.36 (0.79) | 4.82(0.41) | 4.52 (0.71) | |
Individual Characteristics
|
3.75
(0.64)
|
4.42
(0.50)
|
3.97
(0.67)
| |
28. Therapists trained in my health region have adequate knowledge about ICBT | 3.86 (0.94 | 4.27 (1.20) | 4.00 (1.03) | |
29. Therapists in my health region are committed to offering ICBT | 2.91 (1.11) | 3.82 (1.08) | 3.21 (1.17) | |
30. Therapists in my health region are competent to deliver ICBT | 3.95 (0.95) | 4.64 (0.67) | 4.18 (0.92) | |
31. Therapists in my health region are committed to improving the clinic | 3.86(0.89) | 4.73(0.47) | 4.15 (0.87) | |
32. Therapists in my health region have strong computer skills | 4.00 (0.69) | 4.36 (0.51) | 4.12 (0.65) | |
33. Therapists in my health region have a strong interest in learning | 3.91 (0.97) | 4.73(0.47) | 4.18 (0.92) | |
Implementation Process
|
3.92
(0.58)
|
4.37
(0.37)
|
4.07
(0.55)
| |
34. We spent adequate time planning how to deliver ICBT in advance in my health region | 2.59 (1.10) | 3.64 (1.21) | 2.94 (1.22) | |
35. Therapists in my health region received adequate training in ICBT | 3.86 (1.17) | 4.27 (0.91) | 4.00 (1.09) | |
36. My health region made sure that all staff were informed about ICBT, including those who did not actually provide ICBT | 3.27 (1.16) | 4.00 (0.41) | 3.52 (1.06) | |
37. It was helpful that the Online Therapy Unit obtained research funding to support ICBT in the province | 4.05 (1.05) | 4.82 (0.41) | 4.30 (0.95) | |
38. The Online Therapy Unit developed adequate policies and procedures for delivering ICBT | 4.18 (1.00) | 4.82 (0.41) | 4.39 (0.90) | |
39. The Online Therapy Unit website is adequate for delivery of ICBT | 4.45 (0.80) | 4.36 (1.03) | 4.42 (0.87) | |
40. The advertising materials developed by the Online Therapy Unit were adequate | 4.09 (0.87) | 4.09 (1.04) | 4.09 (0.91) | |
41. The Online Therapy Unit did an adequate job screening clients for ICBT | 3.95 (1.00) | 4.00 (0.89) | 3.97 (0.95) | |
42. The Online Therapy Unit did an adequate job matching therapists and clients | 3.77 (0.92) | 4.18 (0.75) | 3.91 (0.88) | |
43. The Online Therapy Unit did an adequate job providing technical assistance | 4.45 (0.74) | 4.36 (0.81) | 4.42 (0.75) | |
44. The Online Therapy Unit did an adequate job providing clinical assistance to therapists when needed | 4.36 (0.85) | 4.27 (0.91) | 4.33 (0.85) | |
45. The Online Therapy Unit did an adequate job of treating additional clients from our health region | 3.68 (0.95) | 4.82 (0.41) | 4.06 (0.97) | |
46. The Online Therapy Unit did an adequate job of keeping our health region informed of client utilization of ICBT | 4.05 (1.13) | 4.82 (0.41) | 4.30 (1.02) | |
47. The Online Therapy Unit did an adequate job of keeping our health region informed of ICBT client outcomes | 4.09 (1.02) | 4.73 (0.47) | 4.30 (0.92) |