October 10, 2022

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By Chiachen Cheng



Associate Professor Chiachen Cheng, IEPA’s Vice President North America and psychiatrist at Northern Ontario School of Medicine University provides practical tips for clinicians implementing early intervention in rural and remote and remote areas.

Imagine a geographic area the size of France. With a population of under 200,000 people. That means there is 0.4 person per km2. Then imagine that you are the only Child & Adolescent Psychiatrist for the entire area for the next 14 months. Our area also has had an epidemic of Indigenous youth suicide over the past 25 years. And – clinical work is only half of your work time. The other half includes research, administrative and teaching in the rural psychiatry residency program. That was my Monday this week. How do I not run for the hills, or, what helps me continue working in these conditions?  Here are 5 lessons I have learned over the past 17 years providing transdiagnostic care in northern, rural Canada.

1. Consider the “unusual suspects”
Transdiagnostic care has moved far beyond traditional 1:1 in-person care in a mental health providers’ office. The unusual suspects are the creative solutions that defy the “same” way of doing things. Solutions that consider creative use of technology, community co-creation initiatives, addressing social economic determinants of health (including climate change impact), and innovative models for service delivery are some of the strategies.

2. Surround yourself with people who disagree with you
As we lead service change, we need to be able to safely say “I don’t agree with you”. This is hard, and often very difficult to do, especially to our funders or supervisors. However, it’s worth it. As a service leader, this is the best way to reveal our bias’ and blindspots. Finding a path forward when we disagree; this is how we truly innovate and find the unusual suspects.

3. Find your “people”
The pandemic has taught us to use technology to stay socially connected. Just because the geography is isolated, does not mean we need to be isolated. Finding our network takes us out of isolation. For example, I found my people by connecting with the IEPA. The friends and collaborators whom I have met through the IEPA has eliminated the professional isolation from working in underserviced rural areas.

4. Listen to the people you are trying to serve
This work is not possible without truly listening to the voice of lived experience. In Canada, the history of intergenerational trauma, loss, and residential schools have had a significant impact on the suicide and substance use rate among the youth living in rural/remote/northern areas. Trauma-informed care needs to be at the forefront of care, especially with Indigenous communities and youth.

5. Find inspiration
As hoakie as it sounds, every time I am in clinic, I am inspired by the strength and courage that I see. Despite the complex trauma, or systemic barriers, kids/youth and their families trust me with their stories. I find inspiration in their courage to take steps forward. I am inspired that they often want to give back, and participate in research to help others. I am inspired by their wish to recover.

Available quality research evidence, which impacts informed decision-making, this is foundational to systems change. Research, evaluation and innovative knowledge translation especially involving youth (and their families) living in rural and remote areas continues to be needed and important, especially to contribute to evidence-informed service planning and delivery.


Chi Cheng is Child & Adolescent, Youth Psychiatrist & Associate Professor in Psychiatry Section, Clinical Sciences at the Northern Ontario School of Medicine University (NOSMU) and IEPA’s Vice President North America. Chi’s practice has both clinical and research functions. Over time her clinical practice has evolved and increasingly encompasses early intervention across the transdiagnostic field of youth mental health.

Chi participates in peer review including at NOSMU, Sick Kids Foundation, and Canadian Institutes of Health Research. Her research focus is on the intersection of youth mental health, vulnerable population and rural health services. Her research includes program implementation and development, fidelity to Early Psychosis Intervention standards, evaluation of training and service delivery in rural and remote regions, and pathways to care among vulnerable populations such as youth, or Indigenous communities.


You can follow Associate Professor Chiachen Cheng on Twitter @drchicheng




Benavides-Vaello, S., Strode, A., Sheeran, B. C. (2013). Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review. Journal of Behavioral Health Services & Research, 40, 111-20. https://dx.doi.org/10.1007/s11414-012-9299-6

De Cotta, T., Knox, J., Farmer, J., White, C., Davis, H. (2021). Community co-produced mental health initiatives in rural australia: a scoping review. Australian Journal of Rural Health, 29, 865-878. https://dx.doi.org/10.1111/ajr.12793

Ferris-Day, P., Hoare, K., Wilson, R. L., Minton, C., Donaldson, A. (2021). An integrated review of the barriers and facilitators for accessing and engaging with mental health in a rural setting. International Journal of Mental Health Nursing, 30, 1525-1538. https://dx.doi.org/10.1111/inm.12929

Garcia, J. L. (2020). Historical trauma and american indian/alaska native youth mental health development and delinquency. New Directions for Child & Adolescent Development, 2020, 41-58. https://dx.doi.org/10.1002/cad.20332

Hand, L. J. (2022). The role of telemedicine in rural mental health care around the globe. Telemedicine Journal & E-Health, 28, 285-294. https://dx.doi.org/10.1089/tmj.2020.0536

Isobel, S., Wilson, A., Gill, K., Howe, D. (2021). ‘what would a trauma-informed mental health service look like?’ perspectives of people who access services. International Journal of Mental Health Nursing, 30, 495-505. https://dx.doi.org/10.1111/inm.12813


Declaration of Interests:


•       Northern Ontario School of Medicine University

•       Centre for Rural and Northern Health Research, Thunder Bay

•       Ontario Science Table – Mental Health Working Group

Grants/Research Support:

•       Canadian Institutes of Health Research

•       Ontario Trillium Foundation, Youth Opportunities Fund

•       PSI Foundation – 50th anniversary mid career award

•       Sick Kids Foundation – New Investigator Research Grant

•       St. Joseph’s Care Group, Thunder Bay


•       St. Joseph’s Care Group, Thunder Bay

Grants Review / Editorial Board

•       NOAMA – Clinical Innovations Opportunity Fund

•       Canadian Institutes of Health Research

•       Sick Kids Foundation

•       City of Thunder Bay

•       National Institutes of Health

•       Early Intervention in Psychiatry Journal

•       Frontiers in Health Services Journal

Industry Funding/Support

•       none



This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.