Implementing eMental health services in routine mental health care: from barriers to strategies

Background. Common mental health disorders such as depression and anxiety have severe negative impact on mental wellbeing, quality of life and social and work-related functioning. E-Mental health (eMH) services such as Internet-based Cognitive Behaviour Therapy (iCBT), are proven to be effective in treating common mental health disorders. However, eMH services do not enter routine care as expected and their uptake in practice remains low, slow and costly. The difference between what is known and what is delivered in routine care, is one of the most critical issues in achieving effective, sustainable, and equitable mental health care. This dissertation aimed to contribute to understanding and reducing the research-to-practice gap in clinical mental health care. This thesis focussed on five research questions related to: decision-making in implementing eMH services, a taxonomy of barrier, characterisation of organisational implementation climate, the validity of NoMAD as an instrument to measure and monitor implementation outcomes, and the effectiveness of a toolkit for developing and applying tailored implementation strategies for implementing eMH services. Various methods were applied, including systematic reviews of existing literature, qualitative research using a concept mapping approach, a psychometric Confirmatory Factor Analysis, and an implementation effectiveness trial employing a Stepped Wedge cluster randomised study design with Linear Mixed Modelling with repeated measures. A substantial part of the research was carried out in an international context. Main findings. Implementation is preceded by a decision-making process. Various Health Technology Assessment (HTA) frameworks are adapted and used to assess various aspects of eMH services and by that, support systematic and evidence-informed decision making. In general, outcomes and instruments are not specified by the framework potentially limiting the applicability and comparability of assessments. Once the decision has been made, a logical next step is to identify the barriers that hinder implementation of the eMH service in routine care. Three barriers were reported most frequently in the scientific literature: (1) acceptance of patients and professionals, (2) appropriateness of the eMH service and specifically in relation to the therapeutic interaction, and (3) technological aspects of eMH services, including interoperability with other digital technologies. Focussing on the organisational context, a explorative study showed that organisational implementation is a relevant factor in implementing eMH services in routine care. Important elements include roles and skills of implementers, implementation targets, and the availability of a dedicated implementation team. Moreover, the implementation climate within a mental health care organisation not only is a (set of) static determinants, it can also be shaped in such way that the implementation of eMH services can be improved. To determine whether an implementation strategy is effective, reliable and valid measurement instruments are required. The Confirmatory Factor Analysis (CFA) reported in Chapter 5, confirmed the validity of the Normalization MeAsure Development Questionnaire (NoMAD) in samples of Dutch mental health service providers. NoMAD is theory-based and supports implementers in monitoring progress, and to compare outcomes of implementation strategies. One-size-fits-all implementation strategies most likely do not exist. Implementation takes place in a context and faces barriers that vary considerably from setting to setting and from time to time. Chapter 6 reports the effectiveness of a self-guided online toolkit (the ItFits-toolkit) that supports implementers in developing, applying and monitoring tailored implementation strategies for eMH services. Conclusions. The work presented in this dissertation touches upon four major topics relevant to implementing eMH services in practice: technology assessment and decision making, identifying barriers to implementation, measuring implementation outcomes, and developing effective implementation strategies that are matched to the local situation. It is possible to move from identifying barriers to developing and applying effective implementation strategies for eMH services that are tailored to the local context.