E-Mental Health: A Rapid

Review of the Literature

Shalini Lal, Ph.D.
Carol E. Adair, Ph.D.

Objective: The authors conducted a review of the literature on e-mental of Medical Internet Research was
health, including its applications, strengths, limitations, and evidence published (4). Christensen and col-
base. Methods: The rapid review approach, an emerging type of knowl- leagues (5) defined e-mental health as
edge synthesis, was used in response to a request for information from “mental health services and informa-
policy makers. MEDLINE was searched from 2005 to 2010 by using tion delivered or enhanced through
relevant terms. The search was supplemented with a general Internet the Internet and related technolo-
search and a search focused on key authors. Results: A total of 115 gies.” However, there is no agreement
documents were reviewed: 94% were peer-reviewed articles, and 51% on a field-specific definition. Some
described primary research. Most of the research (76%) originated in the scholars consider e-mental health to
United States, Australia, or the Netherlands. The review identified include only initiatives delivered di-
e-mental health applications addressing four areas of mental health rectly to mental health service users
service delivery: information provision; screening, assessment, and (6) and only on the Internet (6,7) (as
monitoring; intervention; and social support. Currently, applications are opposed to, for example, delivery via
most frequently aimed at adults with depression or anxiety disorders. stand-alone computers or video semi-
Some interventions have demonstrated effectiveness in early trials. Many nars). Others adopt a wider definition
believe that e-mental health has enormous potential to address the gap that includes frontline delivery activi-
between the identified need for services and the limited capacity and ties related to screening, mental health
resources to provide conventional treatment. Strengths of e-mental promotion and prevention, provision of
health initiatives noted in the literature include improved accessibility, treatment, staff training, administrative
reduced costs (although start-up and research and development costs are support (for example, patient records),
necessary), flexibility in terms of standardization and personalization, and research (4).
interactivity, and consumer engagement. Conclusions: E-mental health Because of the growth of the
applications are proliferating and hold promise to expand access to care. e-mental health field, it is difficult
Further discussion and research are needed on how to effectively in- for policy makers and practitioners to
corporate e-mental health into service systems and to apply it to diverse stay abreast of available applications
populations. (Psychiatric Services 65:24–32, 2014; doi: 10.1176/appi. and the evidence for their effective-
ps.201300009) ness. In response to a request from
a Canadian executive-level policy
maker, we conducted a rapid review

I
nnovations in information and involves the use of ICT to connect of the literature on e-mental health.
communication technology (ICT) patients and providers in real time In this article, we report briefly on the
are transforming the landscape across geographical distances (2) for review methods and summarize key
of health service delivery. This eme- the delivery of typical care and where findings.
rging field, often referred to as the use of real-time video is the main
“e-health,” includes key features, such modality (3). Methods
as electronic, efficient, enhancing Interest is also increasing in the Rapid reviews are an emerging type of
quality, evidence based, empowering, application of ICT in mental health knowledge synthesis used to inform
encouraging, education, enabling, care. For example, the first interna- health-related policy decisions and
extending, ethics, and equity (1). tional e-mental health summit was discussions, especially when informa-
E-health is a broader concept than held in 2009 in Amsterdam, and tion needs are immediate (8–11).
telehealth (and telemedicine), which a summit-specific issue of the Journal Rapid reviews streamline systematic
review methods—for example, by fo-
Dr. Lal is with the Department of Psychiatry, McGill University Institute, and the cusing the literature search (8)
Douglas Mental Health University Institute, Montreal, Quebec, Canada (e-mail: shalini. while still aiming to produce valid
[email protected]). Dr. Adair is with the Department of Psychiatry and Community conclusions. The requirements for the
Health Sciences, University of Calgary, Calgary, Alberta, Canada. review, which was undertaken with

24 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2014 Vol. 65 No. 1

a two-week deadline, were for a short and has substantial capture of the the application, the health conditions
(maximum eight pages) but in-depth content of health services research and populations targeted, and the
synthesis of the current state of the and overlap with similar sources. components and technologies used.]
science on the topic. The personnel The initial search (December 2010) With respect to information pro-
available was one senior (doctoral- yielded 158 titles or abstracts. Similar vision, there is an identified need to
level) mental health services researcher keywords were also used in a brief on- ensure the quality of information
(CEA). Later, a second (doctoral-level) line grey literature search, which about mental health. Therefore, tools
mental health services researcher (SL) retrieved additional relevant docu- such as the Brief DISCERN (13) have
validated the conclusions by screen- ments, such as a list of in-progress been developed to help users assess
ing all titles and abstracts, extracting trials, a policy report, and recent the quality of mental health–related
and synthesizing additional data, and conference proceedings. Two experts content on Web sites.
reviewing the findings. on e-mental health were also con- Screening and assessment tools
The overarching review question tacted by e-mail for comment on the have been available for many years
was: What is currently known on the appropriateness of the identified lit- on stand-alone computers, but more
topic of e-mental health? (Even erature and additional articles. Final recent developments are Internet-
though telepsychiatry is typically in- searches focused on the work of pro- based screening tools to provide
cluded in e-mental health definitions, minent authors (for example, Chris- broader access to individuals for self-
we did not include this subtopic be- tensen, Hickie, and Titov). These assessment (particularly to under-
cause its literature is already well searches yielded an additional 50 titles served or hard-to-reach groups) or
developed with several systematic and abstracts, resulting in 208 titles and for use by professionals in specific
reviews and reviews of reviews.) abstracts screened for duplicates and settings (for example, primary care)
Several secondary questions were relevancy. (30). For example, Diamond and
developed and refined as the review Further details on the rapid review colleagues (16) described an Internet-
progressed: What types of e-mental method and our search and selection based behavioral health screening tool
health initiatives have been devel- strategy are provided in an online data for adolescents and young adults in
oped? What are the strengths and supplement to this article. primary care. It requires minimal time
benefits of e-mental health? What to complete; addresses a broad spec-
are the concerns with and barriers to Results trum of psychiatric symptoms, risk
use of e-mental health? What is the General description behaviors, and patient strengths; is
state of the evidence for the effec- of the literature automatically scored online; and al-
tiveness of e-mental health? How has The screening process resulted in 115 lows results to be integrated into the
e-mental health been integrated in documents, which were reviewed. Of patient’s electronic medical record
service systems and policy? these, 108 (94%) had been peer re- and into system-level performance
The rapid review method used is viewed. Publication dates were from measurement.
similar to Khangura and colleagues’ 2000 to 2010, with most (N=91, 79%) Social support in e-mental health
(10) seven-step process. Briefly, the published between 2007 and 2010, occurs through several types of Web-
search focused on English, peer- which confirmed an expected increase based formats, including discussion
reviewed full abstracts in MEDLINE in the volume of literature on the topic groups, bulletin boards, chat rooms,
from 2005 to 2010 and used the over time. Of the 115 documents, 59 blogs, and social media. For example,
MESH terms mental disorders and (51%) reported primary empirical Scharer (25) reported on a pilot study
internet and the following non- studies, of which 25 (42%) were that examined the effectiveness of an
MESH key words: e-mental health, conducted in the United States, 13 online electronic bulletin board to
e-therapy, computer, computer- (22%) in Australia, and seven (12%) in provide social support to parents of
based therapy, computer-based treat- the Netherlands. children with mental illness. Parents
ment, web-based therapy, web-based made use of the bulletin board over
treatment. We excluded search terms Types of e-mental health initiatives a four-month period, actively posting
related to telehealth because that is The review identified e-mental health messages to each other about their
a distinct, and well-established subset applications addressing four areas children’s illness or about the group.
of the e-health field that mainly of mental health service delivery: E-mental health interventions were
considers the use of telecommunica- information provision (6,12); screen- classified in our review by stage (pro-
tions to connect service providers and ing, assessment, and monitoring motion, prevention, early interven-
patients across geographical distances (13–20); intervention (21–24); and tion, active treatment, maintenance,
(3) (as opposed to delivering auto- social support (25). Many applica- and relapse prevention), type of re-
mated, self-management interven- tions addressed several areas of lationship (for example, between
tions, for example). The search was mental health service delivery con- a professional and a consumer, be-
run in MEDLINE because of time currently (26–29). [A table listing tween consumers, and between pro-
constraints and because it is the most examples of these e-mental health fessionals), and treatment or therapy
widely searched database for health- programs and initiatives is provided modality (for example, cognitive-
related topics, has comprehensive in the online data supplement. It sum- behavioral therapy [CBT] and psy-
coverage (more than 5,500 journals), marizes information on the purpose of choeducation). Treatments identified

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were self-led or led by a therapist or address the gap between the identi- terms of access to conventional
were a combination (for example, self- fied need for mental health services in services. Finally, some are concerned
led and therapist guided). Interven- the population and the limited capac- that the availability of e-mental health
tions were provided as the primary ity and resources to provide conven- services may lead some individuals to
therapy or adjunct to conventional in- tional treatment services (13,30). postpone seeking needed conven-
person therapy and were delivered to Strengths of e-mental health initia- tional care or that some will receive
individuals or groups or both. For tives noted in the literature include inappropriate or harmful care when
example, MoodGYM is an exemplary improved accessibility, reduced costs there is insufficient quality control
Web-based, interactive intervention (although start-up and research and over content (7).
that has been developed and evalu- development costs are necessary), Ethical and liability concerns have
ated in several randomized controlled flexibility in terms of standardization been cited. For example, when partic-
trials (27,31–33). Its purpose is to and personalization, interactivity, and ipants are from outside the regulatory
enhance coping skills in relation to consumer engagement (5,30,34–38). jurisdiction, ethical responsibilities
depression, and it includes assess- E-health technologies are considered cannot be met; other concerns are
ments, workbooks, games, online to be particularly promising for rural that participants cannot be reliably
exercises, and feedback. MoodGYM and remote populations. They are also identified and that privacy cannot
is freely available to the public and has promising for subpopulations that be guaranteed for typed or recorded
been translated into several languages. have other barriers to access (attitu- communications (5,34,37,38,41). To
Most of the interventions studied dinal, financial, or temporal) or that address these issues, several profes-
were situated on a specific point of the avoid treatment because of stigma. sional organizations (for example, the
continuum of care (for example, pre- For example, by using Internet-based American Psychological Association)
vention, mental health promotion, or social support, individuals can share have developed guidelines (38), and an
intervention) and used a single format; their perspectives freely while pre- international organization to set stand-
however, a few incorporated several serving their anonymity. Further ards has been established—the Inter-
types of approaches. For example, details and examples of benefits are national Society for Mental Health
Tillfors and colleagues (34) investi- summarized in a box on the next page. Online. Even so, adherence has been
gated whether an Internet-delivered found to be lacking, and concerns
self-help intervention in conjunction Concerns and barriers remain (7,39,42,43). At the same time,
with minimal e-mail contact was as Some concerns and barriers are asso- remedies for the above-mentioned
effective as adding in-person group ciated with using e-mental health. concerns are emerging. Technology
sessions to the Internet intervention. There are concerns that e-mental for the protection of security and con-
They found that adding in-person health will replace important and fidentiality has improved, and some
group sessions did not result in signif- needed conventional services; divert efforts are being made to review Web
icant differences in outcomes. attention away from improvements to site content for quality (35,44,45). In
Typically, e-mental health interven- or funding for conventional services; Australia, a Web portal called Beacon
tions mimicked traditional treatment and be costly to develop, deploy, and has been set up that provides quality
approaches in that they often ad- evaluate (5). Another issue raised in ratings for mental health Web sites
dressed single disorders; none were the literature is related to the financial and recommends evidence-based
designed for individuals with comor- interests of developers and research- interventions (46).
bid mental and substances use disor- ers, which may produce a risk of
ders. The most frequent disorders publication bias (39). Others have Consumer engagement,
addressed by the 59 empirical studies highlighted the limited evidence base reach, and response
were depression or anxiety (18 stud- for interventions, lack of quality A handful of recent studies have shed
ies, 31%). Several interventions fo- control and care standards, and slow some light on the role of e-mental
cused on mental health promotion or uptake by or reluctance among health health providing prevention or in-
prevention, including early identifica- care professionals (39,40). Some tervention programming for particu-
tion (eight studies, 14%). Most inter- question the ability of professionals lar groups of individuals, such as
ventions were developed specifically to establish therapeutic relationships youths, socioeconomically diverse
for adults (40 studies, 68%), followed on line and the feasibility of online populations, rural and remote popu-
by interventions targeting adolescents treatment for certain population lations, the general public, and
or young adults (11 studies, 19%). groups (for example, patients with patients. One study investigated the
Recent e-mental health initiatives re- severe depression) (39). Emmelkamp preferences for e-mental health ser-
flect the shift in the mid-2000s to Web (39) described “technological pho- vices in an online Australian sample
2.0 technologies (that is, more in- bia,” whereby professionals may be (N=218) (47). Among individuals in
teractive, multimedia, and user-driven unfamiliar with technology and anx- the general population who were
technologies) (35). ious about its use in professional care. already using the Internet, a large
Concerns have also been expressed majority (77%) expressed a preference
Strengths and benefits about the potential to further margin- for face-to-face services, but less than
Many authors believe that e-mental alize individuals who have physical, 10% indicated that they would not
health has enormous potential to financial, or cognitive barriers in use e-mental health services. The

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authors highlighted the importance of
raising public awareness, knowledge, Strengths and benefits associated
and understanding about e-mental
health services. More than 50% of
with e-mental health initiatives
the sample expressed the need to Improved accessibility
learn more about e-mental health For geographically hard-to-reach populations
For populations with other types of barriers, such as lack of child care,
services and about issues related to transportation, insurance coverage, and time off work
confidentiality. For populations desiring anonymity or persons who feel stigma or who are
More than 90% of youths now use dissatisfied with conventional services
the Internet, and it is seen as a prom- From multiple locations, such as schools, workplaces, clinics, and hospitals
ising medium for reaching that age In terms of convenience and timing; for example, can be available at any time
of day and in private, and the user can control the pace
group (28,48). In a large population-
based sample of 2,000 young people Reduced costs
aged 12 to 25 in Australia, 77% In terms of operating cost (although start-up and research and development
costs are necessary)
reported seeking information about In relation to reaching large numbers simultaneously (for example, can be
mental health problems whether or broad scale or stand alone)
not they had the problem themselves In terms of therapist time optimization and communication efficiencies
(49). In another study among military Flexibility in terms of standardization and personalization
personnel, who are predominantly Can be implemented with high fidelity and also tailored to individual needs
younger males, one-third of 352 Can be developed according to the best research and design evidence
respondents who reported that they Can be designed for virtually any mental health issue or topic
were not willing to talk to a counselor Interactivity and consumer engagement
in person indicated that they would be Through incorporation of multimedia
willing to use technology to address Through consumer empowerment
their concerns (50). Can improve continuity of care (for example, can be integrated within a set of
services across the service continuum)
Preliminary research has also in-
dicated that mental health service
users value the use of e-mental health.
A qualitative study of 36 participants factors, need to be taken into account available; for example, guidelines for
found that their primary motive for in planning Internet-based interven- program design and for study meth-
Internet use was to access social tions for specific population groups (55). ods have been published (36,59).
support and their secondary motive In the past five years, several
was for information (51). Respon- Evidence base for e-mental health reviews, including systematic reviews
dents noted that hearing about other Although evaluation of some inter- and meta-analyses of randomized
individuals’ experiences helped them ventions is limited, an encouraging controlled trials, have documented
to feel less isolated and more hopeful. amount of rigorous research is avail- the progress made; effectiveness has
Respondents also liked the conve- able, depending on the developmen- been demonstrated in particular for
nience, privacy, and anonymity of tal stage of the intervention. Research interventions (both therapist assisted
the Internet. On the other hand, on Web-based interventions has both and self-directed) addressing depres-
several authors have documented opportunities and challenges. Studies sion and anxiety disorders (57,59,60).
low access to and use of the Internet are relatively inexpensive to conduct, For example, a systematic review of
among persons with more serious and large samples can be used. meta-analyses of the efficacy of
mental illnesses, such as those with Interventions are easily standardized, Internet-based self-help for depres-
co-occurring substance use and seri- randomized or controlled designs are sion and anxiety disorders reported
ous mental illness (52,53). Cost, lack feasible (often with wait list controls), that these interventions are effective
of training, and impairment (in cog- and data are easily collected. Chal- and that effect sizes are comparable to
nition, concentration, executive func- lenges include low rates of completion those observed in similar interven-
tion, and motor control) can present because of the relative ease with tions delivered in person (60). Sys-
barriers for individuals with serious which participants can drop out of tematic reviews of Internet-based
mental illness, further disenfranchis- studies. In addition, it is difficult to CBT interventions (prevention and
ing them from services (54). How- study both the intervention and the treatment) for anxiety and depression
ever, evidence is emerging that with mode of delivery; contamination of among adults have found that they are
a user-friendly interface, high levels of the control group is possible because as effective as or more effective than
engagement and positive outcomes participants can access similar services treatment as usual (57). Preliminary
can be obtained in online interven- elsewhere on the Web; the ability to evidence has also been reported for
tions for individuals with serious conduct double-blind studies is lim- the effectiveness of Internet-based
mental illnesses such as schizophre- ited; and biases related to using interventions to address issues such
nia and their families (26). Nonethe- self-report measures are a problem as stress, insomnia, and substance
less, access to and attitudes toward (56–58). Increasingly, resources for abuse (61). There are still some
technology, as well as socioeconomic optimizing practice and evaluation are interventions for which evidence is

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2014 Vol. 65 No. 1 27

weak or contrary, such as one CBT- effects were of similar magnitude to connected to a hospital in Sydney,
based program for individuals with those of brief in-person interventions, Australia. The programs are consid-
obsessive-compulsive disorder (62), but the Internet-based interventions ered to be cost-effective alternatives
and not all studies evaluating the had the advantage of much broader to medication or face-to-face CBT
effectiveness of Internet-based inter- delivery (68). However, programs treatment. Programs are offered for
ventions for depression and anxiety aimed at preventing subsequent de- major depression, social phobia, panic
have found positive results (62,63). velopment of alcohol-related problems disorder, and generalized anxiety dis-
Lower effect sizes have generally among those who were nondrink- order. Programs are available free or
been found for interventions targeting ers at baseline were generally not at very low cost directly to the public;
alcohol and smoking cessation com- effective. general practitioners and other men-
pared with those for anxiety and More research is needed on in- tal health professionals can use these
depression (61). There are some dividual or subgroup predictors of programs in addition to or instead of
indications that programs work best differential outcomes of e-mental conventional care. Trial results show
for individuals with mild to moderate health interventions (21,69). More- high levels of patient adherence and
disorders; however, this group has over, even though there is some strong reductions in symptoms with
been the focus of most research. preliminary evidence supporting the very little investment of clinician time.
Despite the popularity of online lower cost of using e-mental health The authors discuss how e-mental
support groups, concerns about the approaches, true cost-effectiveness health programs might fit in a broader
encouragement of maladaptive behav- studies are just beginning to appear health service delivery context (for
iors, or support for continuing such in the literature (70). example, in U.S. health maintenance
behaviors, have surfaced—for exam- organizations, health care trusts in the
ple, in a recent survey of members of E-mental health, United Kingdom, and regional health
an eating disorders forum (64). systems, and policy authorities in Canada). They suggest
Systematic reviews are also begin- Most of the literature reviewed de- that the programs could be the first
ning to appear that address e-health scribed the development, imple- level of treatment for the proportion of
interventions for children and youths. mentation, and evaluation of single the population that desires Internet-
For example, Stinson and colleagues interventions in isolation. One very based treatment; however, with the
(65) found that symptoms improved important question that has been given support of a small team, individuals
in seven of nine identified self- limited attention is how e-mental who need more support could be
management interventions. A recent health interventions might best be identified and referred for more in-
narrative review of Internet-based situated in relation to an array of related tensive intervention.
prevention and treatment programs services for a broad population. In a rare An approach that reaches out to the
for anxiety and depression among exception, van Straten and colleagues total population but that is not fully
children and adolescents concluded (71) discussed a stepped-care approach connected to conventional services
that there was early support for for depression in primary care wherein has been described by Bennett
effectiveness but a need for more interventions advance from watchful and colleagues (27). At its center is
rigorous research as well as interven- waiting through self-guided but sup- “e-hub,” which is an online self-help
tions specifically targeting children ported intervention (including Web- mental health service available free to
(66). Recent innovations, such as based formats), brief face-to-face psy- the public. The service provides
those that embed prevention and chotherapy, and finally longer-term automated Web interventions for
early-intervention content in online face-to-face psychotherapy with consid- several needs, such as symptoms of
games, need more evaluation. A study eration of antidepressant medication. depression, anxiety, and social anxiety,
of one such program found a non- To ensure continuity of care, a care and an online bulletin board. Pro-
significant worsening effect on support manager monitors patient status at all grams focus on the prevention and
seeking, avoidance, and resilience out- levels and makes decisions about nec- early-intervention end of the spec-
comes, especially among males (29). essary transitions. Treatments at all trum. There is no therapist involve-
An interactive fantasy gaming ap- levels are evidence based. These ment in the interventions, and the
proach has also been developed by authors described trials of two different bulletin board is moderated by trained
Sally Merry, M.D., of Auckland, New e-mental health interventions, includ- consumers under the supervision of
Zealand (personal communication, ing one for younger adults, and most a clinical psychologist. Interested
Merry S, Dec. 2010). A recently pub- important, how they fit within the full individuals can contact the e-hub by
lished randomized controlled trial stepped-care model. Data on cost- e-mail. The organizers report a high
demonstrated its effectiveness among effectiveness of the full model are volume of use by individuals with and
adolescents seeking help for depres- unavailable, but the authors suggested without mental disorders, some over
sion in primary care settings (67). that the incidence of new cases of a lengthy period. The service is con-
In the area of substance use and depression and anxiety could be halved sidered most suitable for those who
abuse, a systematic review of Internet- by introducing this model. prefer to receive help anonymously,
based interventions for young people Andrews and Titov (72) described prefer self-help, or reside in rural or
found small positive effects for pro- the promotion of Internet-based remote areas. Quality control pro-
grams aimed at alcohol abuse; the treatment programs (a virtual clinic) cesses are included.

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 No peer-reviewed articles had a stakeholder groups (such as families topic of e-mental health, which was
central focus on policy-level discus- and caregivers, service providers, and found to be highly useful for its
sions about e-mental health. How- policy makers), in the development specific intended policy discussion.
ever, the gray literature search yielded and deployment of initiatives is para- The apparent promise and pitfalls of
one major report on the topic from mount. Seventh, further research is e-mental health and the increasing
Australia, E-Mental Health in Aus- needed in relation to conditions other interest of policy makers in its potential
tralia: Implications of the Internet and than common disorders, such as for service system transformation in-
Related Technologies for Policy (5). psychotic disorders. Eighth, more dicate that careful monitoring of the
Although the report was published in rigorously conducted research is evidence base is warranted.
2004, much of the content is relevant needed, such as randomized con-
for other countries, because many trolled trials, and it is important to Acknowledgments and disclosures
are only at the beginning stages of understand which groups of individu-
e-mental health implementation. The als will benefit the most from such While conducting this review, Dr. Lal was
partially supported by a postdoctoral fellowship
report describes the advantages of interventions and to take into from Knowledge Translation Canada. Dr. Adair
e-mental health initiatives and barriers account cross-cultural and interna- conducted the initial review while under
to implementation (as described above). tional factors (for example, cultural contract with the Mental Health Commission
Five major recommendations for mov- adaptations). of Canada. The authors acknowledge Jayne
Barker, Ph.D., and Janice Popp, M.S.W., for
ing forward are included related to It is important to acknowledge the their assistance in refining the research ques-
access, ethical issues, quality and effec- limits of rapid review. They include tions to serve a policy purpose. The views
tiveness, technology, and funding. focusing the search on one electronic expressed herein are solely those of the authors.
Articles and studies identified by the database source (although we used The authors report no competing interests.
rapid review but not discussed here are the database that contains by far the
listed in References (73–103). largest number of health and medical References
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