When asked by the editor to write a piece about my journey in operationalizing e-mental health interventions, the need for perseverance immediately came to mind. Each and every successful e-mental health implementation by any of my international colleagues probably took years of planning and negotiating with funders and suppliers. All this effort is humbly condensed into a 10 minute presentation at a conference to share our experiences.

My sojourn into the e-mental health space started around 2011. It took about 2 years of negotiations with funders before a self-help website and 2 mobile apps for cognitive behavioural therapy for anxiety and depression was launched in 2013. Being an early adopter of e-mental health in my country, many of my colleagues and funders could not appreciate the value of e-mental health resources. Prior to step care and population health strategies being commonplace, the typical thinking was to have face to face interventions with highly trained professionals. However, national data from the Singapore Mental Health Survey conducted roughly every 5 years showed that about 60% of those with depression and more than 80% of those with anxiety and addiction disorders would not seek help, the need to provide alternative interventions became apparent. About 2014, service needs required that I take up another position within the public healthcare service. After my departure, without the advocacy for e-mental health, the initial projects were discontinued by the funders after the grant ended.

In my new position in the National Addictions Management Service, I was able to produce self help apps for gambling disorder. However, I soon realized that without marketing for the app, the app could not reach consumers that needed it. A typical search for “gambling” in Google and Apple appstores produced apps for card games and casino apps. Self help interventions would not be found without a specific search for the app by its name. During this period, I received a generous grant from the Ministry of Health to operationalize therapist assisted eCBT. However, it was at least 7 years and 2 budget revisions later that the Singapore eCBT service started in 2023. In this project, the challenges were not the manpower nor the software but the IT security policy. There were many changes in public healthcare IT security policy between 2014 and 2020 and with each revision, the security was enhanced which added to costs necessitating budgetary revisions. The core software to deploy eCBT fundamentally did not change. However, IT policy required software to be put onto a healthcare cloud server, the code of the software had to checked for vulnerabilities and intrusion tests done to validate the security of the software. Not deterred by the requirements of public healthcare policy, I decided to start eCBT at a mental health charity where the IT regulations were not as demanding and we could use a subscription based eCBT software.

COVID-19 was a catalyst for e-mental health as lockdowns, patients concern for visiting clinics during COVID-19 spurred tele-health interventions. It also demonstrated to funders, the need for e-mental health. In a short space of months, video conference consultations with home delivery of medicines were provided to patients at home and nursing homes. Similar consultations were also provided to courts and prisons when lockdown did not permit visits to such institutions to review patients. Currently, I am exploring the use of self help apps to help people waiting to see a therapist as there is a wait-time of several weeks. This is subject to the availability of grants.

While I write this short story of successes, there were many long chapters of uncertainty at what barriers would come next. To the would be e-mental health innovator, I recommend perseverance, pragmatism and flexibility. Some of the successful projects presented at conferences, if done at small clinics or universities, may not have the same IT challenges as projects done at a nationwide public healthcare level. IT costs are a real challenge, and it is best to choose interventions for common diseases so that the user base can justify the spending. I personally would not recommend self created/funded apps as the app cannot compete in the Appstore for attention and app maintenance and compliance to IT policy would make it unsustainable. I have ventured through the uncertain landscape of e-mental health for more than a decade now. I am still convinced that e-mental health can benefit the non-help seeking population and complement the therapist in busy clinics. What it takes to succeed is patience, perseverance and firm conviction.

Regards

Chris

Dr Christopher Cheok, Chief and Senior Consultant, Dept of Forensic Psychiatry.