Help is just a click away: Improving mental health through Internet-delivered cognitive behavioural therapy

By the age of 40, half of all Canadians will face a mental health condition. Despite how common these conditions can be, finding the right type of professional help can be challenging – particularly for Canadians living in rural or remote areas.

"So many of my patients went years without getting help for their mental health, often because of the barriers they faced in trying to access the right support," says Dr. Heather Hadjistavropoulos, a registered doctoral psychologist and professor at the University of Regina. "For example, many lived in rural or remote areas, which made it hard for them to find help and follow through with therapist appointments. And, unfortunately, the stigma surrounding mental health is still very real and can discourage some people from seeking help."

These barriers gave Dr. Hadjistavropoulos the motivation to explore Internet-delivered cognitive behavioural therapy (ICBT) as a possible solution for Canadians experiencing mental health challenges, especially for those living outside of large cities.

Traditional cognitive behavioural therapy (CBT) takes place in person, typically on a short-term basis (5 to 20 sessions), and has proven to be incredibly effective for treating depression, anxiety, alcohol misuse, eating disorders, and more. The big question for Dr. Hadjistavropoulos when she began this research was whether the same level of success could be achieved using virtual tools and methods, and how to most efficiently offer this service within Canada's mental health care system.

"Traditional CBT is geared toward helping patients disrupt their own negative thought patterns, modify behaviours, and develop problem-solving skills to deal with difficult situations," explains Dr. Hadjistavropoulos. "This is usually done in a collaborative way, between the patient and the therapist, so it naturally becomes highly personalized. That's part of what makes it work. So, I knew from the outset that replicating these results with ICBT, while very possible, was going to require some finessing to make sure it could meet the needs of Canadians and become a routine part of mental health care."

In 2010, she founded and launched the Online Therapy Unit, based out of the University of Regina, to offer ICBT to patients while also, conducting research that serves to improve the service continually over time.

Connecting patients with the care they need—virtually

Early research had shown that ICBT could indeed be quite effective, but Dr. Hadjistavropoulos emphasizes that it is not necessarily a "plug and play" approach that will allow any ICBT program to work for any patient.

"With ICBT, we are not talking about simply taking in-person therapy and putting it online with video calls to recreate a traditional session," she explains. "ICBT, as a standardized approach to therapy, involves structured online lesson plans and self-directed exercises that patients access online and implement in their day-to-day life. In that way, context is really important to make sure those online resources actually meet patients' needs, which is where a lot of the research comes in."

Her own research began over a decade ago when she and her team at the Online Therapy Unit adapted an ICBT program originally developed at Swinburne University in Australia. The goal was to test the effectiveness of ICBT and get a better understanding of how it could be used in a Canadian context, with minor modifications made to the materials, including language, to fit the Saskatchewan context. Participants were then invited to try out this model, which involved structured lessons that progressed over 12 weeks, along with weekly check-ins with a therapist via email.

"We started with three distinct programs," explains Dr. Hadjistavropoulos. "One program was for individuals experiencing depression, one was for anxiety, and one was for panic. In the end, our research showed that while the programs were effective for some patients, they didn't quite work for everyone."

The study revealed three main issues with the approach: the length, the specificity, and the level of communication. Although the Australian model had been designed as a 12-week program, only about half of the Saskatchewan participants completed all the modules because they felt the overall program was too long. Those who completed the materials often took more than 6-months to complete the program. Many participants were also dealing with more than one condition at a time, so separating the lesson plans for depression and anxiety didn't address all of their needs. And, finally, the therapists involved in the project also needed more support to make the best use of the email check-ins with patients, particularly to ensure they were using their own time efficiently and could communicate clearly and not simply repeating all of the messages in the online materials.

"This was exactly what we needed to learn," recalls Dr. Hadjistavropoulos, "because we were determined to make our ICBT resources even better – in a way that would make it feasible to offer ICBT as part of routine mental health care."

Research findings build a more personalized program

Ever since that first test drive, Dr. Hadjistavropoulos's research has been focused on improving the effectiveness of the Online Therapy Unit's ICBT offerings. 

In 2013, her team started collaborating with a research group at Macquarie University, also in Australia. Macquarie researchers had developed a briefer 8-week ICBT program that was transdiagnostic, meaning it addressed multiple conditions patients can face simultaneously, such as depression, anxiety, panic and stress.

"In a nutshell, we found that this transdiagnostic ICBT works," she says, adding that the team was thrilled with this new program in terms of participant completion of the program as well as the efficiencies that were gained by offering transdiagnostic treatment. "This time, 76% of patients finished all modules in those eight weeks while showing large improvements in depression and anxiety. On average, we saw a 50% reduction in symptoms among participants from when they started the program to when we followed up with them three months after they finished it. These results are very similar to face-to-face therapy, showing that ICBT could be an effective alternative for mental health treatment. This is particularly important for those in rural and remote communities who face barriers such as physical access to therapy."

Dr. Hadjistavropoulos says most importantly, this approach also cut down on therapist costs to deliver the program and the research showed the program could be delivered both by therapists who specialize in ICBT and those who more commonly specialize face-to-face care.

Over time with research, the Online Therapy Unit team, including trainees, has made additional adaptations to the transdiagnostic ICBT program to address a wider range of needs and issues, including alcohol misuse, insomnia, health anxiety, waning motivation over treatment, work stress, postpartum issues, and agricultural stress.

The program, as offered, is designed to be adaptable. For example, patients are asked to fill out detailed questionnaires about their mental health and complete intake interviews with clinicians by phone so that their resulting course plan can be tailored for their unique situation.

"Having the questionnaires and intake interviews are key to making these courses as personalized as possible," says Dr. Hadjistavropoulos. "Whether a patient is having trouble sleeping, trouble with their relationships, or trouble with self-confidence and motivation, we have resources to address each of those specific needs."

The Online Therapy Unit continues to grow

As the Online Therapy Unit celebrated the success of their new ICBT program, they caught the attention of the Government of Saskatchewan. Since 2015, the team has received provincial funding to run their ICBT program as a mental health service for Saskatchewan residents. To date, they have helped more than 11,000 people – now serving 2,300 people each year – ranging from 18 to 81 years old.

"It's extremely rewarding as a researcher to see the immediate benefits of this program," says Dr. Hadjistavropoulos. "Even a year later when we follow-up with these patients, they say they are maintaining or still making gains and that is just incredible."

The research has also highlighted the added benefits of internet-delivered mental health services. "For some people, setting up one-on-one sessions with a therapist simply won't be convenient or might be overwhelming," explains Dr. Hadjistavropoulos. "But that's the beauty of an online treatment: the information can be downloaded and retained, so patients can keep going back to their toolbox at their own pace."

Dr. Hadjistavropoulos continues to build on that momentum. Over the past several years, her research has focused on better understanding the nuances of therapist support, such as quality and quantity of therapist behaviours, frequency of therapist support, and duration of therapist support.  "Our research to date has shown that weekly check-ins are optimal, but we want to ensure that therapists have the right tools and ask the right questions to help patients apply the ICBT lessons in their everyday lives," she explains. "Having the data on this will be incredibly useful as we work to expand access to ICBT to other provinces."

Part of this expansion also involves another pilot project, funded by Public Safety Canada, to tailor the team's 8-week ICBT program to suit the needs of Canadian public safety personnel, such as border services officers, public safety communications officials, correctional workers, firefighters, paramedics, and police (municipal, provincial, federal). This adaptation includes a major focus on post-traumatic stress injuries, and the pilot is already offering treatment to public safety personnel across five provinces. The study is expected to continue into 2023, but the early findings already show improvements in participant wellbeing, and 98% say they would recommend the program to others.

Even with this remarkable success, Dr. Hadjistavropoulos says she doesn't want to be the only one delivering ICBT in Canada. She does, however, want her continued research to be the benchmark and help set the gold standard for others delivering online therapy. She also hopes that her research will help ensure that ICBT is considered an important treatment option, as important as other mental health services. By doing that, she says ICBT will play a major role in Canada's health care future.

"There will always be a need for traditional face-to-face therapy, but ICBT is another doorway to care," she says. "We want to make sure, through our research, that the doorway is as open to as many Canadians as possible and is as effective and efficient as possible. As technology advances, funding research that explores how we can best use this technology to improve the mental health of Canadians will be critical to making progress and helping Canadians live healthier lives."

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