Development of a Resource Guide to Support the Engagement of Mental Health Providers and Patients With Digital Health Tools: Multimethod Study

Background As mental illness continues to affect 1 in 5 individuals, and the need for support has increased during the COVID-19 pandemic, the promise of digital mental health tools remains largely unrealized due to a lack of uptake by patients and providers. Currently, most efforts on supporting the uptake of digital mental health tools remain fragmented across organizations and geography. There is a critical need to synthesize these efforts in order to provide a coordinated strategy of supporting the adoption of digital mental health tools. Objective The specific aim of this project is to develop a web-based resource document to support the engagement of mental health providers and patients in the use of digital mental health tools. Methods The web-based resource was developed using a multimethod approach. A grey literature review was conducted in 2019 to identify relevant toolkits that are available in the public domain. This was supplemented with an environmental scan where individuals with expertise in the development, acquisition, implementation, and evaluation of digital mental health tools were invited to contribute additional tools or documents not identified in the grey literature search. An engagement workshop was held with stakeholders to explore how the resource document should be developed and delivered. These findings were collectively used to develop the final iteration of the resource document. Results Based on a gray literature review and environmental scan with 27 experts, 25 resources were identified and included in the resource guide. These resources were developed for patients and providers by organizations from 5 countries. An engagement workshop was held with 14 stakeholders, and barriers related to cultural sensitivity, sustainability, and accessibility of the toolkit were identified. The final iteration of the resource document was developed by the research team using findings from the gray literature review, environmental scan, and engagement workshop. The contents of the 45-page resource guide are directed at mental health care providers, administrators, and patients (inclusive of families and caregivers). Conclusions The use of a multimethod approach led to the development of a resource guide that builds on existing evidence on digital mental health tools and was co-designed with stakeholders and end-users. The resource guide is now publicly available online for free and is being promoted through digital health and mental health websites. Future work should explore how this document can be integrated into clinical care delivery and pathways.


Introduction Goals and objective
The goals of this document 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 document is to identify existing digital health resources, to allow users to choose and integrate appropriate resources into the client-provider interaction.
A summary of the project can be found on page 33.

Audience
Our primary audience is health care providers working in mental health in Canada who are looking for support in integrating digital health tools into their clinical practice. This includes: · 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 in this document. We invite clients and caregivers to use the document to identify resources that might be helpful to them.
The primary audience for this document 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.
What is in this document?
This document describes 18 resources that can support the integration of digital mental health tools into the interaction between client and provider. The resources have a wide range of objectives, formats and audiences. For a concise, high-level review of the key features of each resource, see the Resource Chart (page 13).

Mental Health, Technology and You
This client guide offers descriptions of digital mental health tools, as well as personal stories, a journey map and tips for staying safe online. The guide helps clients understand digital mental health tools and imagine how they might use them.
It is not itself a tool for digital mental health care, but rather helps people understand and use digital mental health tools.
These types of resources are 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. Many gaps remain. For example: · 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.

What this document is not
This document 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 (see Appendix 1: Glossary [page 38] for more information).
· an expert rating or review of the resources presented; we encourage you to assess yourself whether the resource meets your needs · updated in an ongoing way; this document was published in early 2020 and represents the state of the field at that time.

Finding a resource
The most direct way to access a specific resource is to: 1. Go to the Resource Chart (page 13).
2. Review the features of the resources and note the page number for the summary of the resource you're interested in.
3. Go to that page in the Resource Summaries section to learn more about the resource.
4. Follow the hyperlink or cut and paste the URL into a web browser to access the resource.
You can also browse the Resource Summaries section (page 15) in a more open-ended way.
Finally, you may search the document by using your PDF reader's search function, often accessed by Ctrl + f.

Using the resources
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 section (Is This the Right Tool for You?, page 9) of barriers and facilitating factors that influence the uptake of digital mental health tools.
Exploring the use of digital mental health tools Advances in technology continue to revolutionize the health care system and influence the practice of health care professionals. 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. 11 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. 2,11

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 Is this the right tool for you? Questions for clients Many clients are interested in digital mental health tools and may research them on their own, while others may come to a provider seeking information on tools. Research has identified many factors that can help a client use a digital tool successfully, as well as factors that may impede success.
This section highlights factors that may respectively help or hinder clients' use of digital mental health tools. It presents a series of questions, compiled through a comprehensive literature review, on the barriers and facilitators of digital mental tool uptake among clients. * You can help a client understand what might help them use a tool consistently by asking appropriate questions from the lists below, which correspond to different types of tool. (However, the questions will not recommend a specific tool, or how best to use a tool with your client.)

Questions to identify potential success factors or areas of concern
· Are you interested in using digital health tools in general?
· Do you know where to find the kind of tool you're looking for?
· Does the tool have features you want to use?
· Are you confident the tool is accurate, effective and trustworthy?
· Does the tool seem user-friendly? For example, is it easy to navigate?
Can you understand what to do next?
· How much does it cost to use the tool? Is there a one-time cost, or do you need to keep paying?
· Does the tool have clear privacy and security policies?
· Is it clear what personal data is being collected and why? How much personal data are you comfortable sharing?
· Can you find more information on the tool as you learn to use it?
· Are you comfortable with the language used in the tool?

Questions to identify potential success factors
· Does the tool seem convenient and flexible, so you can adapt it to your life?
Questions to identify potential areas of concern · Would any personal reasons, like your health, or how much time you have, make it difficult to use the tool?
· Is there any part of the design or function of the tool that makes it unusable for you? For example, does it have the right level of security, come with enough instructions, send an appropriate number of alerts?
· Many apps are not for emergency use; would this be a problem for you?

Questions to identify potential success factors
· Do you think you can use the information from the device to help yourself? How might you use it?
· Do you know other people who use this tool?
Questions to identify potential areas of concern · Are there any practical issues in your life that might make the tool inconvenient?
· Think about design features that will be important to you. For example, does the tool need to have a long battery life? Are the buttons easy to find and press? Is the screen text big enough?
· Do you need help remembering to use the tool? Does the tool have a reminder function?
Peer support through social media and other technologies

Questions to identify potential success factors
· Do you find support in social connections?
· Do you like to share stories, information and coping strategies, and learn from others?
· Do you value the support of your peers and the ability to give and take advice?
· Have other people suggested that you join an online community?
· Would it be an advantage to you to receive online support instead of face-to-face support?
· Do you want to have access to moderators or other professional support through the tool?
Questions to identify potential areas of concern · Do you think you might have emotions come up or feel vulnerable while online? What could help with this?
· Are you concerned about getting overloaded with information from online communities? Do you think you might get misleading information?
· Is it possible using an online community may make you more worried about your health condition?

Questions to identify potential success factors
· Does the tool seem to be entertaining?
· Does the tool look like it would hold your attention?
· Would you consider it an advantage if the tool provided access to therapy guidance?

Questions to identify potential areas of concern
· Do you think the game might distract you from therapy?
· Do you think it might lead you to connect less with other people in real life?
· Do you think you may not be able to stop playing the game?
· Do you think the game might lead you into its world and away from reality?
· Do you wonder if the game is appropriate for you as part of your care?
· Do you think the game might make your symptoms worse?

Questions to identify potential success factors
· Is the convenience and flexibility offered by the tool an advantage to you?
· If using the tool meant no wait time to receive care, would you like it more?
· Is the fact that the tool offers you access to a "live" person an advantage to you?
· If the tool offered a way to "get and give" support to other clients like you, would that be of interest to you?
Questions to identify potential areas of concern · Can you think of any practical issues in your life that might make the tool inconvenient?
· Would any personal reasons, like your health or how much time you have, make it difficult to use the tool?
· Do you prefer in-person visits over video visits?

Applicable to Canada?
Is US-focused, but much of the information is relevant to Canada

Requires internet connection to use?
Once downloaded, PDF document can be used without internet connection

Includes practical examples of use?
Yes; has an associated group on LinkedIn 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 document that aims to consolidate these resources was identified as a need.

Guiding principles
Discussions by the project team, along with valuable feedback from stakeholders from across Canada-including those with lived experience of mental illnessled 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 document 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 document.
· 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.

Project design
The document was developed using methods recommended by the United States Agency for Healthcare Research and Quality (AHRQ) on toolkit creation. 16 A focused literature review and environmental scan was completed in autumn 2019. The search methodology is outlined below. Search results were assessed using criteria determined by team discussion. Preference was given to resources that were directly applicable to a provider-client interaction in the Canadian setting, that contained no or little jurisdiction-dependent information, that were relatively recent and that were available in both English and French.
In early January 2020, a half-day workshop was convened to elicit stakeholders' feedback on a draft document content outline and draft resource summary, and to garner information on dissemination techniques. Among the 16 workshop participants were client advocates, health care providers, policy makers and academics. Two activities-a structured brainstorming activity and small group discussions-were used to elicit feedback on the drafts. Notes were recorded by the project team and then compiled and summarized to inform the final draft of the document. The project team maintained a list of workshop outcomes that were addressed in the revisions. This information was shared with workshop participants. The structure of the final document was informed by input from the stakeholder workshop.

Environmental scan
We began by compiling a list of experts in digital mental health from across Canada, and contacted them requesting information on any known resources related to the project. The list was compiled from professional contacts of the study team, known experts in digital mental health in Canada, and experts who had participated in similar projects. Experts also recommended others who should be contacted.

Grey literature search
An online search in September and October 2019, using the Google search engine, specific search terms and a targeted organizational website search, resulted in the review of 91 sites in total.
The following searches were undertaken, and the first 10 pages (minimum) were reviewed for potential results: Additionally, the websites of specific organizations, listed in Appendix 3, were also reviewed for applicable resources.

Literature reviews and gaps analysis
Two literature scans were completed by student members of the project team. The first review, completed by Vanessa Strong, identified literature on facilitators and barriers to the engagement of mental health providers in digital health tools. The second review, completed by Hwayeon Danielle Shin, identified literature on facilitators and barriers to mental health clients' engagement in digital health tools. Details of the search strategies for each review are available on request.
These reviews were synthesized and incorporated into this document based on feedback from the stakeholder workshop. Analysis of the collection was completed by student team member Alanna Miller. Summary statistics on the resources were tabulated. The Mental Health Commission of Canada's digital tools typology was used as a framework for a gaps analysis of the current collection of resources. 1 Pertinent results are included in the introduction of this document.

appendix 1: glossary
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.
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.
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.