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Innovative E-Solutions for Promoting Collaborative Mental Healthcare

In collaboration with Dr. Farah Ahmad and other CHCs, we are developing and pilot testing innovative e-health based solutions to improve mental health assessment and care for vulnerable client groups. The Interactive Computer-Assisted Client Assessment Survey (iCCAS) is a multi-language, user-friendly, touch-screen-based tool completed by patients while waiting to see a clinician. This tool screens for common mental health disorders (CMDs) and generates point-of-care reports for clinicians and patients to facilitate better assessment and care.

Our Project Team Members
This project is an academic-community partnership led by an interdisciplinary team. Our team members include: Farah Ahmad (York University, Health Policy & Management), Yogendra Shakya (Access Alliance, Research Scientist), Cliff Ledwos (Access Alliance, Clinical Director), Kwame Mckenzie (CAMH, Wellesley Institute), Michael Rotondi (York University, Biostatistics in School of Kinesiology); Laura Muldoon (Somerset West Community Health Centre & Dept. of Family Medicine, University of Ottawa). Our partners include Alliance for Healthier Communities and Canadian Association of Community Health Centers.

Our Research Goals and Methods
Vulnerable client communities we serve (immigrants, refugees, non-status, racialized groups, low-income families) face elevated risk for mental health issues. However, these very groups encounter many institutional (e.g lack of culturally sensitive care, language barrier, time constrains of primary care providers) and social barriers (e.g. stigma) in talking about and accessing mental health services. The key goal of this project is to assess the role and effectiveness of an e-health screening tool (iCCAS) to improve mental healthcare for vulnerable client groups. This tool assesses for four common mental health issues including depression, post-traumatic stress disorder (PTSD), general anxiety and alcohol dependency. The tool also looks at key social determinants of mental health (e.g., education, language ability, housing, financial resources, immigration status and social support). Once the client completes the iCCAS survey (while waiting to see a clinician), the tool generates real-time individualized reports for patients and clinicians to use at the point of care. Our first tool (CaPRA) focused on Access Alliance clients from Afghanistan; the tool was translated into Farsi. We built on this to develop a more comprehensive tool ( iCCAS). We conducted a randomized control trial in English and Spanish with 147 participants; these participants were randomly assigned to iCCAS stream (75) or Usual Care stream (72). After the visit with their primary care provider, we then conducted exit surveys with all participants (iCCAS and Usual Care). We also conducted follow-up interviews with primary care providers who were part of this study.

What we found
Based on participants who did the iCCAS survey, study results suggest that our clients have a very high rate of common mental health issues: 29% had probable major depression, 28% had symptoms consistent with PTSD, 17% had probable generalized anxiety disorder, and 9% percent screened positive for alcohol dependency. These rates are two to three times higher than the Canadian average. The study also found that only about one third of these clients reported being diagnosed with and on active treatment for mental health issues. In other words, a large percentage of our clients with mental health issues are not getting the appropriate mental healthcare. Further, study findings indicate that clients at risk for these common mental health issues had lower social support.

We found promising potentials for iCCAS. Compared to study participants in Usual Care, those who did iCCAS were statistically more likely (59% compared to 40%) to have mental health discussions with their providers. Among those who had a discussion, mental health related referrals were provided to 20% in iCCAS group and 15% in the usual care. Clinician detection of mental health concerns occurred for 38.7% in iCCAS group and 27.8% in the usual care. When we analyzed to see the links with social determinants, we found that language barrier, education level and employment status appear to significantly affect detection of mental health issues.

Overall, providers perceived iCCAS as a useful mental health assessment tool to incorporate into everyday clinical practices and the clients found iCCAS easy to use.

You can read more about our study findings in these publications:

Next Steps
We are planning to conduct a multisite trial of the tool using a stepped wedge cluster randomized trial design. For the next phase we are going to add a collaborative care component in the form of weekly discussions between psychiatrist and primary care clinicians. We call this iCCAS Plus. We plan to offer iCCAS Plus in seven languages to reach diverse groups. We are waiting to hear on our CIHR grant application. In the meantime, we are doing knowledge translation activities to share results from our two phases.

Our Funders
This study was funded by a Canadian Institutes of Health Research (CIHR) eHealth Catalyst Grant (FRN # 126526). During this work Dr. Ahmad’s time was partly supported by the CIHR New Investigator Award.

For more info contact research@accessalliance.ca or Dr Farah Ahmad at farahmad@yorku.ca.