In September 2017 the Mental Health Commission of Canada in collaboration with the Government of Newfoundland and Labrador and Memorial University of Newfoundland (MUN) launched an e-mental health demonstration project to introduce Stepped Care 2.0 into the mental health system1.  This initiative has sparked a movement of reform within mental health systems of care across Canada and was the first step in recognizing the need to provide various levels of intensity of evidence-based care to ensure the most effective care is delivered based on patient requirements.  Knowing that patients’ journeys are fluid and needs change over time, having a number of stepped levels of care ensures the right level of intensity is provided at the right time.  This theory centers care on the client’s needs and reduces the burden on the client and system. Moreover, it can provide a population health approach to prevention of and effective treatment of mental health issues and promotion of mental well-being across the lifespan.


Many e-Mental Health (EMH) systems of care exist in Canada, and over the past two years during the COVID-19 pandemic when many organizations had to re-think how mental health care is delivered, we witnessed a variety of distance-based programs (virtual or telehealth) quickly emerge.  However, many do not incorporate a stepped-care process or only offer limited choices of services for clients.


Taking stepped care to the next level involves looking at moving EMH systems of care from providing treatment to incorporating processes for providing information and assessment services.  This will transform EMH systems of care into more robust systems providing services on various levels of intensity and needs, and by collecting data on how the services impact outcomes we can help inform future mental health policy.  We know that EMH services can be very effective in increasing access, as the majority seeking online help hadn’t sought help about their mental health symptoms prior to accessing the online programs.  However, not all who are seeking access to services necessarily want treatment. Titov et. al (2019)report 58% of individuals are seeking an evaluation and recommendations about options, and further reports that EMH programs are used by a broad cross section of the adult population and has the ability to improve to inequity of access and engagement with older adults, who typically experience difficulty accessing mental health services2[2].  This is particularly true for those in lower socio-economic status and individuals of diverse backgrounds who may have mistrust in the health care system.




Leveraging research and technology to build an e-triage system within stepped care EMH programs can provide greater opportunities for clients to make informed decisions about the type of EMH services they prefer.  Strongest Families Institute (SFI) is a Canadian based charity who has been a pioneer in developing and delivering telephone-based coached mental health services. SFI’s evidence based EMH system, technology and programs are grounded in more than 20 years of social science research. SFI’s pediatric programs (formerly Family Help) were originally tested in clinical trials and are intensive, spanning five months of weekly para-professional telephone support coaching. However, the results indicate that SFI programs were effective in overcoming diagnosable pediatric mental health disorders[3],[4]. SFI’s goal has been to enhance our intensive programs to align with a stepped care to provide our valuable skills to the broader population as a population mental health promotion and prevention approach.


In 2019, with funding from the Public Health Agency of Canada (PHAC) and a partnership with the Newfoundland Government, SFI launched a quality improvement project to align our proven five-month, twelve skill intensive Parents Empowering Kids (PEK) program (Level 4) (formerly known as the Active Child Program) to align with a stepped care model. The PEK program now has three lower intensity levels: level 1-self-help; level 2-self-help with minimal coaching support; and level 3- brief six skill program with weekly coaching. This PHAC project has been co-designed with a variety of community members with lived experience from a variety of backgrounds. This project is winding down with more than 1000 parents of children ages 3 to 12 from four Atlantic Canadian provinces. SFI is planning national dissemination as next steps.


During the pandemic, SFI pivoted quickly to respond as one of the primary EMH systems that was able to scale. Part of this process included the ongoing development of our PHAC PEK stepped care pilot project along with our adult ICAN anxiety and depression stepped care program that is part of a Health Canada project with Stepped Care Solutions. In the year of 2020-21, SFI helped more than 13,000 Canadians with strong outcomes demonstrating significant improvement in presenting mental health problems, low attrition rates and high client satisfaction.


To build on Titov’s work in the adult EMH field, SFI implemented an etriaging system within our PHAC project, and our adult ICAN anxiety and depression program through Wellness Together Canada (WTC) provides clients a choice of evaluation only or evaluation plus services. Having this etriaging system available to Canadians during the pandemic allowed timely access to SFI services through a self-referral process instead of the traditional process of direct referrals from the formal mental health system. Clients seamlessly gained online access to SFI’s etriaging process that includes validated scales that informed selection of client service level intensity.




It simply will not be good enough to build and implement e-triaging systems. We must commit to a co-design approach to get this right. We also must be data-driven to inform change and improvement. We must also commit to data reporting, by measuring adherence and outcome data on new innovations. Focusing on data and analysis allows us to build in more concepts and designs to meet the needs of individuals seeking help. If individuals are primarily interested in evaluation only, then we must create pathways to provide clients the choice to select the applicable service that meets their needs.   With these considerations, we can provide timely and effective treatment to prevent and intervene early, at first signs of mental health issues, and promote mental well-being across the lifespan, reducing burden to individuals, families, and the health system.



Dr[1]. Patricia Lingley-Pottie, President & CEO, Strongest Families Institute (SFI) and IRIS platform

Theresa Cunningham, SFI Interim Vice President of Strategy & Engagement

Kimberley Woodford, SFI Research, Innovation & Evaluation Specialist


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[1] Newfoundland and Labrador Stepped Care 2.0 E-Mental Health Demonstration Project Final Report, Mental Health Commission of Canada, 2019, 978-1-77318-115-8

[2] Titov, N., Hadjistavropoulos, H. D., Nielssen, O., Mohr, D. C. & Andersson, G. (2019). “From Research to Practice: Ten Lessons in Delivering Digital Mental Health Services.”  8(8).

[3] McGrath, P.J., Lingley-Pottie, P., Thurston, C., MacLean, C., Cunningham, C., Waschbusch, D.A, Watters, C., Stewart, S., Bagnell, A., Santor, D. & Chaplin, W. (2011). Telephone-Based Mental Health Interventions for Child Disruptive Behavior or Anxiety Disorders: Randomized Trials and Overall Analysis. Journal of the American Academy of Child and Adolescent Psychiatry; 50(11):1162-1172

[4] Lingley-Pottie, P., McGrath, P.J. (2016). Imagine a Mental Health Service that Builds Stronger Families. Journal of the Canadian Paediatric Society; 21(5): 247-248.