# Closing the Research-To-Practice Gap in Digital Psychiatry: The Need to Integrate Implementation Science https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/ Stored in Evernote [[27-01-2022]] #hope-s [[HOPE-S Project Index]] **Recent meta-analysis support digital mental health intervention in depression** As seen in the recent meta-analysis by Wells et al**[1](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 1. Wells MJ, Owen JJ, McCray LW, et al. Computer-assisted cognitive behavior therapy for depression in primary care: a systematic review and meta-analysis. Prim Care Companion CNS Disord. 2018;20(2):17r02196. PubMed CrossRef")** published in _The Primary Care Companion for CNS Disorders_ and the review article by Apaydin et al**[2](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 2. Apaydin EA, Maher AR, Raaen L, et al. The use of technology in the clinical care of depression: an evidence map. J Clin Psychiatry. 2018;79(5):18r12118. PubMed CrossRef")** and recent meta-analysis by Wright et al**[3](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 3. Wright JH, Owen JJ, Richards D, et al. Computer-assisted cognitive-behavior therapy for depression: a systematic review and meta-analysis. J Clin Psychiatry. 2019;80(2):18r12188.")** published in _The Journal of Clinical Psychiatry_, the efficacy of digital mental health interventions for common psychiatric concerns such as depression is well supported in many randomized controlled trials. **Even though study may show that there is efficiacy, adoption rate may be low.** - innovation and efficacy alone do not result in adoption in real-world clinical settings. A study conducted by Gilbody and colleagues**[4](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 4. Gilbody S, Littlewood E, Hewitt C, et al; REEACT Team. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h5627. PubMed CrossRef")** illustrates this point. Primary care patients were randomized to receive evidence-based computerized cognitive-behavioral therapy (cCBT) for depression or treatment as usual, and impact on depressive symptoms was evaluated. The authors concluded that "while cCBT has been shown to be efficacious in developer led trials, it was not effective in usual NHS [National Health Service] care settings. The main reason for this was low adherence and engagement with treatment, rather than lack of efficacy."**[4(p11)](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 4. Gilbody S, Littlewood E, Hewitt C, et al; REEACT Team. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h5627. PubMed CrossRef")** **What is Implementation Science?** The field of implementation science, defined as the study of methods to promote the systematic uptake of research findings and evidence-based practices into routine care, provides a guide for this line of inquiry.**[7](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined " 7. Eccles MP, Mittman BS. Welcome to implementation science. Implement Sci. 2006;1(1):1. CrossRef")** implementation studies use increasingly well defined methods and frameworks to ask questions about how to integrate these interventions into health care systems. studying and encouraging uptake calls for expanding current implementation frameworks to more heavily consider patient characteristics, needs, and behaviors. **How to implement digital health intervention service?** First, we need to include a process-oriented perspective - _how the intervention is introduced_, such as what is said to patients by clinic staff, what is written in patient handouts, and where patients’  questions are directed - _the specifics of adoption and use patterns_, such as how patients enroll, how the intervention impacts clinicians’  workflow, and when and how patients use it - _describing any follow-up_, such as if clinicians or research staff follow up with patients and if patients receive automated or personalized messages if they disengage - _a detailed account of any financial or personnel resources provided by research or program evaluation teams._ Second. Qualitatively understand user behavior. - Second, we need to systematically collect _qualitative data_ to deepen our understanding of how contextual factors, process dynamics, and other nuances impact intervention adoption and use. Conducting semistructured interviews with patients (or subsets of patients), for example, will shed light on the reasons underlying low engagement. Similarly, interviewing clinicians and clinic administrators will generate insights on ways organizations can support improved adoption and sustained engagement. While such interviewing requires significant effort, the data resulting from such interviews will be invaluable. Third. Have an implementation strategies. - Third, we need to intentionally _apply implementation strategies_.**[16](https://www.psychiatrist.com/jcp/psychiatry/implementing-digital-mental-health-interventions/undefined "16. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21. PubMed CrossRef")** To date, in digital mental health, we have limited knowledge of what techniques might improve adoption and use. Many techniques have been suggested, from facilitation to contingency management (ie, paying participants and/or providers for engaging). Specifying implementation strategies used in clinical or research settings will be important, as will comparing alternative strategies. We may, for example, evaluate the impact of employing a staff member with 50% dedicated time to following-up with patients and providers who are using the digital intervention and how such follow-up impacts use patterns (an example of facilitation).