The lack of access to mental healthcare, particularly psychiatric services, is well documented. In some cases, especially for people living in rural and remote areas, there is virtually no in-person therapy available, or at best, long waits for those in need of mental health treatment.¹ This mental health crisis has been considerably magnified during the COVID-19 pandemic, as entire populations are affected by this uncertain outbreak. Apart from collective anxiety about the disease itself, COVID-19 is affecting peoples’ livelihood. The stark reality of its impact was evident when approximately one million Canadians applied for Canadian Emergency Response Benefits on the very first day it was offered to the public on April 6, 2020.² Rising rates of alcohol sales and domestic violence during this social isolation era further compound this growing mental health emergency.^3,4 Moreover, individuals who would normally have access to mental health services to cope with these challenges are unable to do so due to the imposition of social distancing directives.⁵ It is complex and complicated situation. 

Today, most health care systems offer mental health services on a face-to-face basis. It’s time that thought is given to how we can change the delivery model and open the door to more accessible and effective mental health care. Considering current social distancing regulations sanctioned to prevent and control the spread of the COVID-19, a new approach is necessary now, more than ever. Simply put, the time is upon us to implement remote and digital health interventions, such as Internet-delivered cognitive behavioural therapy (ICBT).⁶

ICBT is an innovative digital mental health intervention.⁷ It utilizes the principles of traditional cognitive behavioural therapy (CBT), to provide psychotherapeutic services for various mental illnesses, including mood and anxiety disorders to both individuals and groups via the Internet.⁸ ICBT can be accessed by multiple digital devices (laptop, smartphone etc.) with or without therapist support,⁸ and its content and delivery may differ based on the condition of the individual undergoing treatment.⁸ ICBT can overcome limitations associated with traditional face-to-face therapy, and evidence confirms the clinical effectiveness of ICBT, especially for the treatment of depression and generalized anxiety.^9,10 Thus, ICBT can be a critical therapeutic tool in bridging mental health service gaps during pandemics such as COVID-19.¹¹ Moreover, ICBT can be readily incorporated into existing health care systems.¹² 

An example of such an approach can be found in Saskatchewan, where ICBT is being implemented by the University of Regina’s Online Therapy Unit.¹³ This integration of ICBT into provincial healthcare services provides the much needed headstart to tackle mental health crises during this pandemic. Having said that, there are several hurdles to the successful implementation and uptake ICBT. Based on the ongoing digital health intervention research being conducted at Digital Epidemiology and Population Health Laboratory (DEPtH Lab), and the Online Therapy Unit, we are proposing evidence-based policies that would help overcome the current uncertain mental health care landscape due to the COVID pandemic.

In general, individuals facing high stress levels due financial concerns, and those with chaotic lives tend to have a lower awareness of treatment access.¹³ Clearly, there is a need to raise the public visibility of digital health interventions such as ICBT. The online nature of the therapy increases accessibility by providing free-of-cost service access in Saskatchewan, which could be particularly beneficial for individuals suffering the mental health effects as a result of the pandemic. To meet mental health needs of such vulnerable populations, particularly those in rural and remote areas, policymakers should consider targeted population health promotion initiatives to raise awareness.¹ Information on cost-free services available and benefits of ICBT should be effectively communicated with rural communities in order to demonstrate that location is not a factor when it comes to the delivery of online mental health therapy. Such health promotion efforts, properly planned and implemented, will also benefit other low-income groups such as immigrants, who might also have limited knowledge of healthcare access. 

Due to the historical stigma associated with mental illness, the effectiveness of campaigns to raise awareness of mental health services can be challenging. However, the COVID-19 public health emergency offers an opportunity to raise the profile and need for innovative mental health care delivery. In the current global scenario, citizens are looking for governments to lead and are paying close attention to direction from policy makers. It has created a public environment that opens a pathway for decision-makers to not only promote evidence-based digital health interventions such as ICBT, but also create awareness and emphasize the need for citizens to proactively seek remote health care services.

Mobilizing this two-way engagement can be facilitated by deploying therapy that adopts patient-oriented approaches. Involving patients in the design of therapy empowers them to become active and equal partners in digital health interventions, from conceptualization to knowledge dissemination. The use of empowering patient-oriented approaches will also play an important role in mitigating fear of the treatment itself, the stigma often associated with it, and discrimination by society, which are major attitudinal barriers to seek mental health treatment. Beyond reducing public stigma, when patients are provided a platform to share their experiences,¹⁴ it can provide a pathway to counter detrimental self-labeling, where patients internalize negative perceptions of themselves. Moreover, patient-oriented public health policy can play an important role in drawing a wider range of populations to try digital health interventions, which are essential to overcome the abrupt suspension of in-person mental healthcare services as part of social distancing policies.

An issue that needs to be addressed in the application of digital health interventions is the so called “digital divide”, which is fundamentally caused by Internet inequity. Internet inequity is defined as differential access to the internet based on the wealth of a country (high-, low- or middle-income), geographic region (urban, rural, or remote), socioeconomic status, gender, age, or ethnicity.¹⁵ Internet inequity is a significant barrier to digital health interventions, and could have the determinental effect of widening existing inequities by excluding vulnerable populations who do not have access to Internet.¹⁶ From a global perspective, with varying Internet bandwidth across different low-, middle-, and high-income countries, Internet inequity is responsible for a significant digital divide.¹⁷ 

Clearly, effective implementation of digital health interventions such as ICBT requires addressing the systemic issue of Internet inequity. As the United Nations has noted, access to the internet is a human right,¹⁸ bringing with it the a moral and ethical responsibility to develop policies that address Internet inequity. Crises such as the COVID-19 pandemic should provide the impetus for specific efforts to create greater equity in accessing the Internet. A market-based solution to address this systemic challenge is to further increase competition by allowing more telecommunication companies to provide services at cheaper rates, an approach that not only lies outside the healthcare system but also involves national security and foreign relations complexities as demonstrated by the Huawei impasse relating to the creation of a 5G network.¹⁹ 

The cost of a home and mobile Internet access can be a significant barrier to patients, especially those who are already in socioeconomically deprived rural communities and innercity neighbourhoods. A more feasible policy solution would be to provide resources to deprived communities to facilitate free Internet and computer access points in community health centres or libraries, where individuals not only gain access to to Internet, which is a basic human right, but also obtain access to digital health interventions. This would ensure more Internet access to rural communities as well as address the existing inequity of poor mental health treatment options.

The mental health crisis, especially during the current pandemic, is global health challenge, impacting the health and livelihood of millions of individuals. Policies proposed here have significant public health implications in addressing anxiety and depression during this pandemic, an issue that if often overlooked in the broader public health discussion. The potential benefits are clear. A critical component of tacking mental health crises is the ability to expand care to large populations, and increased ICBT access provides a platform that can traverse geographic regions and minimize deficiencies of traditional healthcare systems. Moreover, the proposed policies will lead to increased access to mental health services, with the potential to minimize inequities between urban and rural residents. Patient-oriented public health policy has particular implications for individuals with financial concerns, and it helps to address stigma by changing societal attitudes towards mental illness. Finally, public policy to address Internet inequity as part of delivering mental health therapy to populations that lack access to treatment goes to the root of Internet connectivity and digital divide, and would play a significant role in bridging the gap between urban, rural, and remote residents.

In shaping health policy change, the two major barriers to implementation are political realities and institutional structures.²⁰ The factors that contribute to these barriers include non-alliance of interests, financial and human resource constraints, and lack of coordination between stakeholders. For instance, creating awareness of digital health interventions by implementing patient-oriented awareness will require systems integration across several human services ministries such as Health, Social Services, and Justice. If relevant policy actors are not part of conceptualization to ensure that the policy change aligns with their interests, they might not provide the support needed. The key to addressing this barrier is to ensure that the majority of stakeholders buy-in to the policy change and that their interests align with the proposed recommendations.

Digital health interventions would require inter-sectoral collaboration, which would include stakeholders from academia, practitioners, and policymakers. To ensure this collaboration, throughout the policy development, implementation, and monitoring processes, barriers should be continually assessed and addressed. This will require stimulating stakeholders’ commitment to take action, identifying resources required for the proposed solution, implementing the solution to remove barriers, and endorsing accountability instruments to ensure that barriers are addressed. It is also essential that policy actors or stakeholders provide technical support in developing monitoring and evaluation plans that track both process and outcome indicators of the policy, including qualitative and contextual information. 

Inadequate funding and lack of highly skilled personnel could impact policy implementation. To strategically address these issues, there is a need to conduct cost-benefit analyses to allocate resources for optimal implementation. Funds could be sourced from political institutions (both upstream and downstream) connected to the improvement of mental health in the province.

The key to addressing these barriers is to ensure that the majority of stakeholders have buy-in to the policy change and that their interests align with the proposed recommendations. Inadequate funding and lack of highly skilled personnel could impact policy implementation. To strategically address these issues, there is a need to conduct cost-benefit analyses to allocate resources for optimal implementation.

This global crisis is an opportunity to scale-up digital health interventions such as ICBT to overcome the constraints of traditional face-to-face mental health treatment. The mental health crisis is going to stay long after we overcome the COVID-19 pandemic, and the reimagination and reinvention of existing digital health tools during this pandemic can usher in a new era to tackle pervasive mental health illnesses. In doing so, we have the opportunity to address systemic issues such as Internet inequity, which has immense implications for population health and wellbeing.

Download pdf.

ISSN 2369-0224 (Print) ISSN 2369-0232 (Online)

1. Staniszewska S, Mockford C, Chadburn G, et al. Experiences of in-patient mental health services: systematic review. Br J Psychiatry 2019; 214: 329–338.
2. Smith, A. Nearly 1 Million Canadians Applied for CERB on Day 1.  Toronto Storeys. [Internet] April 7, 2020 [cited 2020 April 09]. Available from: https://torontostoreys.com/cerb-1-million-canadians-apply/
3. Lillianna, B. Alcohol sales spike as consumers stockpile amid COVID-19 pandemic. Fooddive. [Internet] April 2, 2020 [cited 2020 April 09]. Available from: https://www.fooddive.com/news/alcohol-sales-spike-as-consumers-stockpile-during-coronavirus-pandemic/575331/
4. Waugh, N. Canada faces a domestic violence crisis. CBC examines the problem. CBC News [Internet] Mar 05, 2020 [cited 2020 April 09]. Available from: https://www.cbc.ca/news/canada/canada-faces-a-domestic-violence-crisis-cbc-examines-the-problem-1.5477392
5. Smith, L.A,  Laplante, D.N. Pressures of COVID-19 could be catastrophic for mental health system. CBC News Opinion [Internet] April 01, 2020 [cited 2020 April 09]. Available from: https://www.cbc.ca/news/opinion/opinion-covid-19-mental-health-1.5513201
6. McCall,  H. C., Hadjistavropoulos, H. D., & Loutzenhiser, L. (2019).  Reconsidering the ethics of exclusion criteria in research on digital  mental health interventions. Ethics & Behavior. doi:10.1080/10508422.2019.1684295
7. Gratzer D, Khalid-Khan F. Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness. CMAJ. 2016 Mar 1;188(4):263-72. doi:10.1503/cmaj.150007
8. Chandler J, Shapiro D. Conducting clinical research using crowdsourced convenience samples. Annual Review of Clinical Psychology. 2016; 12:53-81. doi:10.1146/annurev-clinpsy-021815-093623
9. Kroenke K, Spitzer RL, Williams JB. The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine. 2001 Sep;16(9):606-13. doi:10.1046/j.1525-1497.2001.016009606.
10. Löwe B, Decker O, Müller S, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical care. 2008 Mar 1;46(3):266-74.
11. Titov N, Dear BF, Johnston L, Lorian C, Zou J, Wootton B, Spence J, McEvoy PM, Rapee RM. Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomized controlled trial. PloS one. 2013;8(7).
12. Hadjistavropoulos HD, Nugent MM, Dirkse D, Pugh N. Implementation of internet-delivered cognitive behavior therapy within community mental health clinics: a process evaluation using the consolidated framework for implementation research. BMC psychiatry. 2017 Dec;17 (1):331.
13. Moskalenko M, Hadjistavropoulos H, Katapally TR. Barriers to patient interest in Internet-based cognitive behavioral therapy: informing e-health policies through quantitative analysis. Health Policy and Technology (In-Press). doi.org/10.1016/j.hlpt.2020.04.004
14. The SMART Platform. Knowledge Mobilization. Available from: https://www.smartstudysask.com/knowledge-mobilization.
15. Katapally TR. The SMART Framework: Integration of Citizen Science, Community-Based Participatory Research, and Systems Science for Population Health Science in the Digital Age. JMIR mHealth and uHealth. 2019;7(8):e14056.
16. Zhang X, Perez-Stable EJ, Bourne PE, et al. Big Data Science: Opportunities and Challenges to Address Minority Health and Health Disparities in the 21st Century. Ethn Dis 2017; 27: 95–106.
17. Hilbert M. The bad news is that the digital access divide is here to stay: Domestically installed bandwidths among 172 countries for 1986-2014. Telecomm Policy 2016; 40: 567–581.
18. Office of the High Commissioner UNHR. OHCHR | SR on the promotion and protection of the right to freedom of opinion and expression. https://www.ohchr.org/en/issues/freedomopinion/pages/opinionindex.aspx (2011).
19. Luedi J. Northern Canada could be left out in the cold if Ottawa passes Huawei 5G ban | CBC News, https://www.cbc.ca/news/canada/north/opinion-huawei-northern-telecom-1.5479193 (accessed 24 April 2020).
20. Béland D, Katapally TR. Shaping policy change in population health: policy entrepreneurs, ideas, and institutions. Int J Health Policy Manag. 2018;7(5):369–373. doi:10.15171/ijhpm.2017.143 doi 10.15171/ijhpm.2017.143

Dr. Tarun Katapally is an Associate Professor and Patient-Oriented Research Leader at the Johnson Shoyama Graduate School of Public Policy. He holds an adjunct faculty position in the College of Medicine at the University of Saskatchewan and is a research affiliate with the Saskatchewan Centre for Patient-Oriented Research. He established the Digital Epidemiology and Population Health Laboratory (DEPtH Lab) in 2017, which implements the SMART Platform by combining the concepts of citizen science, community-based participatory research, and systems science. Internationally, he is the India lead for the generation of the Global Report Cards on physical activity of children and youth, a knowledge translation endeavour to inform policy on active living across 49 countries. Dr. Katapally’s expertise is linking advanced mixed-methods and complex analytical techniques with citizen science and community-based participatory research to understand the impact of policy and policy-driven contexts and systems on the health and wellbeing of populations.

Eric Kwabia is a registered nurse by profession. He acquired his BSc Nursing degree from the University of Ghana in 2009 and completed his MSc in Telemedicine and eHealth at The Arctic University of Norway in 2015. Prior to moving to Regina, Eric worked with the Ministry of Health in Ghana as a Program coordinator for Telenursing and eHealth. Currently, he is completing a Master’s degree in Public Policy at the Johnson Shoyama Graduate School of Public Policy and working as a Graduate Research Assistant at the DEPtH Lab. He is interested in health research interventions using the SMART Platform. Eric’s career objective is to become an eHealth policy expert and a renowned researcher in academia.