Implementation of internet-delivered cognitive behavior therapy within community mental health clinics: a process evaluation using the consolidated framework for implementation research

Abstract

BackgroundDepression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT.MethodsTherapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation.ResultsAnalyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care.ConclusionsThe results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings.Electronic supplementary materialThe online version of this article (10.1186/s12888-017-1496-7) contains supplementary material, which is available to authorized users.

Patient Perspectives on Strengths and Challenges of Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy: Using the Patient Voice to Improve Care

“…An implication, consistent with the literature is that there may be benefit in tailoring therapist support to patient needs (Lillevoll et al 2013 ; Richards et al 2016 ; Rozental et al 2015 ). This patient feedback parallels recent therapist feedback whereby therapists also expressed a desire to tailor the amount and nature of support to patients (Hadjistavropoulos et al 2017 ).…”

“…While the research evidence is promising, T-ICBT is largely unavailable on a routine basis for most patients (Hadjistavropoulos et al 2017 ). At this point, we do not fully understand what aspects of treatment are most valued and perceived as beneficial, which could provide helpful information to others who are interested in offering T-ICBT.…”

Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy

“…Higher ICBT-TRS scores among therapists with a psychology background could reflect greater training in research among psychology personnel and thus greater adherence to therapeutic guidelines. Higher ICBT-TRS scores among therapists working in a specialized clinic could reflect that therapists from community clinics have competing demands on their time which may interfere with therapist fidelity (Hadjistavropoulos, Nugent, Dirkse, & Pugh, 2017).…”

Why Uptake of Blended Internet-Based Interventions for Depression Is Challenging: A Qualitative Study on Therapists’ Perspectives

“…However, iCBT uptake in MHOs is limited. This might be partly because therapists perceive iCBT to be limited in crisis situations, ineligible for severe depressive symptoms, and having a one-size fits all approach [8,9]. In addition, given the relatively high density of mental health services, the need for iCBT in the Netherlands may differ from elsewhere.…”