Opportunities From the Coronavirus Disease 2019 Pandemic for Transforming Psychiatric Care With Telehealth

The influence of COVID-19 on attention-deficit/hyperactivity disorder diagnosis and treatment rates across age, gender, and socioeconomic status: A 20-year national cohort study

Infection and lockdowns resulting from COVID-19 have been suggested to increase the prevalence and treatment rates of Attention Deficit/Hyperactivity Disorder (ADHD). To accurately estimate the pandemic's effects, pre-pandemic data can be used to estimate diagnosis and treatment rates during the COVID-19 years as if the COVID-19 pandemic did not occur. However, accurate predictions require a broad dataset, both in terms of the number of cases and the pre-pandemic timeframe. In the current study, we modeled monthly ADHD diagnosis and treatment rates over the 18 years preceding the COVID-19 pandemic. The dataset included ∼3 million cases for individuals aged 6 to 18 from the Clalit Health Services' electronic database. Using a trained model, we projected monthly rates for post-lockdown and post-infection periods, enabling us to estimate the expected diagnosis and treatment rates without the COVID-19 pandemic. We then compared these predictions to observed data, stratified by age groups, gender, and socioeconomic status. Our findings suggest no influence of the COVID-19 pandemic on ADHD diagnosis or treatment rates. We show that a narrower timeframe for pre-COVID-19 data points can lead to incorrect conclusions that COVID-19 affected ADHD diagnosis rates. Findings are discussed, given the assumed impact of the COVID-19 pandemic on ADHD.

Frontiers and hotspots in anxiety disorders: A bibliometric analysis from 2004 to 2024

Objective

This study aimed to analyze research on anxiety disorders using VOSviewer and CiteSpace to identify research hotspots and future directions.

Methods

We conduct ed a comprehensive search on the Web of Science Core Collection (WoSCC) for relevant studies about anxiety disorders published within the past two decades (from 2004 to 2024). VOSviewer and CiteSpace were mainly used to analyze the authors, institutions, countries, publishing journals, reference co-citation patterns, keyword co-occurrence, keyword clustering, and other aspects to construct a knowledge atlas.

Results

A total of 22,267 publications related to anxiety disorders were retrieved. The number of publications about anxiety disorders has generally increased over time, with some fluctuations. The United States emerged as the most productive country, with Harvard University identified as the most prolific institution and Brenda W. J. H. Penninx as the most prolific author in the field.

Conclusion

This research identified the most influential publications, authors, journals, institutions, and countries in the field of anxiety research. Future research directions are involved advanced treatments based on pharmacotherapy, psychotherapy and digital interventions, mechanism exploration to anxiety disorders based on neurobiological and genetic basis, influence of social and environmental factors on the onset of anxiety disorders.

Feasibility study of a telehealth school-based behavioral parent training group program for attention-deficit/hyperactivity disorder

OBJECTIVE

To evaluate the feasibility and preliminary efficacy of Telehealth Behavioral Parent Training (T-BPT), a school telehealth group intervention for attention-deficit/hyperactivity disorder (ADHD) with a companion training program for school clinicians.

METHODS

T-BPT was developed in an iterative three-phase design in partnership with community stakeholders during the COVID-19 pandemic. School clinicians (N = 4) delivered T-BPT over 8 weeks to parents (N = 21, groups of 5-6 per school) of children (Grades 2-5) with ADHD while simultaneously receiving training and consultation from PhD-level study trainers. A single-arm open trial was used to assess feasibility, engagement, and preliminary efficacy.

RESULTS

Parents and school clinicians endorsed high feasibility, acceptability, and usability of T-BPT. Parent attendance was high (M = 94.6%) and a majority of parents (66.7%) attended all eight sessions. Preliminary outcomes indicate moderate to large reductions in parent-reported ADHD symptoms (ω2 = .36), functional and clinical global impairment (ω2s= .21 and .19, respectively), and distance learning challenges (ω2 = .22).

CONCLUSIONS

Results were in line with in-person delivery, indicating promising feasibility of school telehealth BPT groups. This study also provided further support for the feasibility of the remote training model for school clinicians. Implications of the commonly endorsed barriers and benefits beyond COVID-19 and relevance to under resourced communities are also discussed.

Expanding a Behavioral View on Digital Health Access: Drivers and Strategies to Promote Equity

The potential and threat of digital tools to achieve health equity has been highlighted for over a decade, but the success of achieving equitable access to health technologies remains challenging. Our paper addresses renewed concerns regarding equity in digital health access that were deepened during the COVID-19 pandemic. Our viewpoint is that (1) digital health tools have the potential to improve health equity if equitable access is achieved, and (2) improving access and equity in digital health can be strengthened by considering behavioral science-based strategies embedded in all phases of tool development. Using behavioral, equity, and access frameworks allowed for a unique and comprehensive exploration of current drivers of digital health inequities. This paper aims to present a compilation of strategies that can potentially have an actionable impact on digital health equity. Multilevel factors drive unequal access, so strategies require action from tool developers, individual delivery agents, organizations, and systems to effect change. Strategies were shaped with a behavioral medicine focus as the field has a unique role in improving digital health access; arguably, all digital tools require the user (individual, provider, and health system) to change behavior by engaging with the technology to generate impact. This paper presents a model that emphasizes using multilevel strategies across design, delivery, dissemination, and sustainment stages to advance digital health access and foster health equity.

New Brunswick's mental health action plan: A quantitative exploration of program efficacy in children and youth using the Canadian Community Health Survey

In 2011, the New Brunswick government released the New Brunswick Mental Health Action Plan 2011-2018 (Action Plan). Following the release of the Action Plan in 2011, two progress reports were released in 2013 and 2015, highlighting the implementation status of the Action Plan. While vague in their language, these reports indicated considerable progress in implementing the Action Plan, as various initiatives were undertaken to raise awareness and provide additional resources to facilitate early prevention and intervention in children and youth. However, whether these initiatives have yielded measurable improvements in population-level mental health outcomes in children and youth remains unclear. The current study explored the impact of the Action Plan by visualizing the trend in psychosocial outcomes and service utilization of vulnerable populations in New Brunswick before and after the implementation of the Action Plan using multiple datasets from the Canadian Community Health Survey. Survey-weighted ordinary least square regression analyses were performed to investigate measurable improvements in available mental health outcomes. The result revealed a declining trend in the mental wellness of vulnerable youth despite them consistently reporting higher frequencies of mental health service use. This study highlights the need for a concerted effort in providing effective mental health services to New Brunswick youth and, more broadly, Canadian youth, as well as ensuring rigorous routine outcome monitoring and evaluation plans are consistently implemented for future mental health strategies at the time of their initiation.

"Some distance between us": a UK mixed methods study exploring experiences of remote care for eating disorders during COVID-19

Introduction

COVID-19 necessitated a rapid move from face-to-face services to remote care for eating disorders/eating distress (EDs). This study explores the advantages and challenges of remote care, identifying future implications for service provision. Remote care has been considered in the broadest of terms, including therapeutic care (e.g., Cognitive Behavioural Therapy, peer support, forums, one-to-one and group care options).

Methods

Using a mixed methods approach, data were collected from 211 people with lived experience of EDs (PWLE), with and without formal diagnosis. 27 participants took part in semi-structured interviews/workshops and a further 184 participants took part via an online survey. Participants reported on their ED status, the impact of the pandemic on symptoms, the benefits, and challenges of remote care (and type of support accessed), and any reasons for not accessing support. Participants were invited to make future care recommendations.

Results

ED symptoms were reported as worsening during the pandemic with contributing factors including isolation, lack of routine, negative emotions, and feeling like the external situation was outside of one's control. Remote care was positively attributed to increased flexibility and facilitation of social connection. Identified barriers to access included lack of awareness about support availability, digital access/literacy, and competing commitments. Further challenges included approaches being perceived as too clinical (e.g., ED information and support presented using clinical language and/or limited to support within medical care settings, without acknowledging the broader context of disordered eating), uncertainty around remote care quality, and concerns that remote platforms may facilitate masking of symptoms. Participants reported distress caused by online platforms where self-view is the default during video calls. They expressed a need for more holistic approaches to remote care, including: "real stories" of recovery, and hybrid (online and offline) options for greater flexibility and widening of access and choice. Participants also expressed a need for appropriate digital literacy training.

Discussion

Future recommendations emphasise user-centred holistic and hybrid approaches to ED remote support, with training to address digital literacy barriers and facilitate user control of platform functionalities (e.g., self-view). This study underscores the need for continued remote care with a focus on inclusivity and user empowerment.

Digital Psychosocial Follow-up for Childhood Critical Illness Survivors: A Qualitative Interview Study on Health Professionals' Perspectives

Background

Digital solutions have been reported to provide positive psychological and social outcomes to childhood critical illness survivors, a group with an increased risk for long-term adverse psychosocial effects.

Objective

To explore health professionals' perspectives on the potential of digital psychosocial follow-up for childhood critical illness survivors.

Methods

Using a qualitative approach, expert interviews with six health professionals working at a Norwegian hospital were conducted. Transcribed interviews were analyzed using Braun and Clarke's six-phase thematic analysis framework. Concurrent data collection and analysis using inductive coding was also employed, and a model of codes was constructed.

Results

The interview yielded thirteen unique codes regarding the health professionals' perspectives on the potential for digital psychosocial follow-up for childhood critical illness survivors, organized in a model comprising the two main themes: Affecting Factors and Digital Usage. Demographic factors (the child's medical condition, age, gender, and residence) and environmental factors (the child's family and health professionals) tended to affect the current psychosocial follow-up. Hospital limitations concerning a lack of digital solutions, worse relationship building with video communication, and children's already high screen time reflected the current state of digital usage. However, ongoing digitalization, existing successful digital solutions, children's good digital skills, and an ongoing process of creating an artifact are also seen as opportunities for digital usage in future psychosocial follow-up for childhood critical illness survivors.

Conclusions

Researchers can build further on these findings to investigate the potential of digital psychosocial follow-up for childhood critical illness survivors, and clinicians can use it as a starting point for improving psychosocial follow-up.

Tele-psychotherapy during the COVID-19 pandemic: a mini-review

The COVID-19 pandemic has dramatically changed psychotherapy practices. Psychotherapy around the world has shifted from predominantly face-to-face settings to overwhelmingly online settings since the beginning of the pandemic. Many studies have been published on this topic, but there has been no review of the literature focused on the experience of psychotherapists. Our goal was to identify the challenging issues of teletherapy, including the efficiency of online consultations and the extent to which they are accepted by therapists and patients. A PubMed literature search using the [("Teletherapy" OR "Telebehavioral health" OR "telepsychotherapy") AND ("COVID-19")] search string retrieved 46 studies focused on mental health professionals, as detailed in a PRISMA flow diagram. Two reviewers independently screened the abstracts and excluded those that were outside the scope of the review. The selection of articles kept for review was discussed by all three authors. Overall, the review contributes to the description and evaluation of tele mental health services, including teletherapy, online counseling, digital mental health tools, and remote monitoring.

Effect of Internet-Delivered Emotion Regulation Individual Therapy for Adolescents With Nonsuicidal Self-Injury Disorder: A Randomized Clinical Trial

Importance

Nonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking.

Objective

To test the hypotheses that an internet-delivered emotion regulation individual therapy for adolescents delivered adjunctive to treatment as usual is superior to treatment as usual only in reducing nonsuicidal self-injury and that improvements in emotion regulation mediate these treatment effects.

Design, Setting, and Participants

This 3-site, single-masked, randomized superiority trial enrolled participants from November 20, 2017, to April 9, 2020. Eligible participants were aged between 13 and 17 years and met diagnostic criteria for nonsuicidal self-injury disorder; they were enrolled as a mixed cohort of consecutive patients and volunteers. Parents participated in parallel to their children. The primary end point was at 1 month after treatment. Participants were followed up at 3 months posttreatment. Data collection ended in January 2021.

Interventions

Twelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only.

Main Outcomes and Measures

Primary outcome was the youth version of the Deliberate Self-harm Inventory, both self-reported by participants prior to treatment, once every week during treatment, and for 4 weeks posttreatment, and clinician-rated by masked assessors prior to treatment and at 1 and 3 months posttreatment.

Results

A total of 166 adolescents (mean [SD] age, 15.0 [1.2] years; 154 [92.8%] female) were randomized to internet-delivered emotion regulation therapy plus treatment as usual (84 participants) or treatment as usual only (82 participants). The experimental intervention was superior to the control condition in reducing clinician-rated nonsuicidal self-injury (82% vs 47% reduction; incidence rate ratio, 0.34; 95% CI, 0.20-0.57) from pretreatment to 1-month posttreatment. These results were maintained at 3-month posttreatment. Improvements in emotion dysregulation mediated improvements in self-injury during treatment.

Conclusions and Relevance

In this randomized clinical trial, a 12-week, therapist-guided, internet-delivered emotion regulation therapy delivered adjunctive to treatment as usual was efficacious in reducing self-injury, and mediation analysis supported the theorized role of emotion regulation as the mechanism of change in this treatment. This treatment may increase availability of evidence-based psychological treatments for adolescents with nonsuicidal self-injury.

Trial Registration

ClinicalTrials.gov Identifier: NCT03353961.

Thinking Beyond the Device: An Overview of Human- and Equity-Centered Approaches for Health Technology Design

A shift in the traditional technocentric view of medical device design to a human-centered one is needed to bridge existing translational gaps and improve health equity. To ensure the successful and equitable adoption of health technology innovations, engineers must think beyond the device and the direct end user and must seek a more holistic understanding of broader stakeholder needs and the intended context of use early in a design process. The objectives of this review article are (a) to provide rationale for the need to incorporate meaningful stakeholder analysis and contextual investigation in health technology development and biomedical engineering pedagogy, (b) to review existing frameworks and human- and equity-centered approaches to stakeholder engagement and contextual investigation for improved adoption of innovative technologies, and (c) to present case studyexamples of medical device design that apply these approaches to bridge the gaps between biomedical engineers and the contexts for which they are designing.

Impact of Digital Literacy Training on Outcomes for People With Serious Mental Illness in Community and Inpatient Settings

OBJECTIVE

The authors explored whether a digital literacy program, Digital Outreach for Obtaining Resources and Skills (DOORS), could improve self-reported functional skills and clinical outcomes among people with serious mental illness.

METHODS

The 8-week program was offered to participants receiving treatment in community mental health centers (N=113) and an inpatient psychiatric unit (N=74). Pre- and postintervention self-report surveys were collected. Descriptive statistics and two-tailed t tests were used for analysis.

RESULTS

For patients treated in a community center, improvements were observed in 27 of the 29 self-reported functional skills that measured digital literacy. Changes in seven of these skills were statistically significant. Although these participants reported larger improvements in clinical outcomes than did inpatient participants, no statistically significant changes in symptoms were seen in either setting.

CONCLUSIONS

Digital skills training is necessary to increase access to care through technology. DOORS can improve self-reported digital literacy, but further research is necessary to determine its immediate impact on symptoms.

Changing face-to-face psychological care to remote mode: facilitators and obstacles in the COVID-19 pandemic

OBJECTIVE

to verify associations between sociodemographic variables and factors that facilitate and hinder the transition from face-to-face psychological care to remote mode in the first year of the COVID-19 pandemic.

METHOD

this is an analytical, quantitative, cross-sectional study. After approval by the Research Ethics Committee, data collection was performed by applying an online form consisting of 55 questions. Data were analyzed using descriptive and inferential statistics techniques.

RESULTS

the intentional sampling consisted of a total of 385 Brazilian psychologists, mostly women (67.01%), young professionals with up to five years of graduation (44.16%) most of activities in the private clinic. It was found that training time between five and 10 years was associated with a greater perception of difficulties and that previous experience with remote care facilitated adaptation in the transition from one modality to another.

CONCLUSION

considering that call center can be a powerful tool in the health scenario, it is suggested the inclusion of remote care issues in the research agenda and syllabus in the curricula of health training courses.

Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability

OBJECTIVE

The objective of this study was to determine the effect of music therapy as an alternative treatment on depression in children and adolescents with attention-deficit hyperactivity disorder (ADHD) by activating serotonin (5-HT) and improving stress coping ability.

METHODS

This study is designed based on randomization method. A total of 36 subjects participated in the experiment, consisting of an ADHD control group (n = 18) and ADHD music therapy group (n = 18). The ADHD control group received standard care, while the ADHD music therapy group received music therapy and standard care. The ADHD music therapy group received both active music therapy (improvisation) and receptive music therapy (music listening) for 50 minutes, twice a week, for 3 months: a total of 24 times. From a neurophysiological perspective, changes in depression and stress were tracked by measuring 5-HT secretion, cortisol expression, blood pressure (BP), heart rate (HR), and CDI and DHQ psychological scales.

RESULTS

The ADHD music therapy group's 5-HT secretion increased (p < 0.001), whereas cortisol expression (p < 0.001), BP (p < 0.001) and HR (p < 0.001) decreased. The CDI and DHQ psychological scales also showed positive changes (p < 0.01 and p < 0.001, respectively). However, the ADHD Con G's (who did not receive music therapy) 5-HT secretion did not increase, whereas cortisol expression, BP, and HR did not decrease. In addition, the CDI and DHQ psychological scales did not display positive changes.

CONCLUSIONS

In conclusion, the application of music therapy as an alternative treatment for ADHD children and adolescents showed positive neurophysiological and psychological effects. Therefore, this study would like to propose a new alternative to medicine for preventing and treating depression through various uses of music therapy.

Assessing Changes in Parent Sensitivity in Telehealth and Hybrid Implementation of Attachment and Biobehavioral Catch-Up During the COVID-19 Pandemic

During the COVID-19 pandemic, home visiting services for families with young children pivoted to continue providing services virtually. One such service was Attachment and Biobehavioral Catch-up (ABC), a brief prevention/intervention program targeting increased parental sensitivity. 70 families participated in a sensitivity assessment before and after receiving ABC. Forty-three families received the program fully through telehealth, and 27 families received the program through an in-person/telehealth hybrid format. Parent sensitivity was assessed pre- and post-intervention, and results suggested that when ABC was delivered through a telehealth or hybrid format, parents showed increased following the lead and decreased intrusiveness from pre- to post-intervention, with moderate effect sizes. Ongoing supervision in the model, weekly fidelity maintenance checks, and the flexibility of families and parent coaches likely contributed to the maintenance of significant change in parental sensitivity from pre- to post-intervention during the move from face-to-face home visiting to the provision of virtual services.

'The key to this is not so much the technology. It's the individual who is using the technology': Perspectives on telehealth delivery for autistic adults during the COVID-19 pandemic

LAY ABSTRACT

The COVID-19 pandemic meant that a lot of healthcare services had to move online, such as to video-calls, or to telephone. However, not many studies have looked at how autistic adults feel about this kind of service delivery. It is important to know this, as autistic people may have poorer health than non-autistic people, and they may also struggle to access services more than non-autistic people. This study asked 11 autistic adults (aged 27-67 years), seven family members/carers (aged 44-75) reporting about autistic adults and six service providers about their experiences of accessing or providing a telehealth service. These experiences were collected through interviews, which were then analysed through thematic analysis. Two main themes were: technology aids communication and access - except when it doesn't, and in/flexibility. The themes pointed out some positive aspects of telehealth delivery, including improved communication and decreased stress. The themes also pointed out negative aspects of telehealth, such as increased rigidity of the healthcare system, amplifying pre-existing barriers. Because autistic people have many barriers to accessing healthcare, this study encourages researchers and healthcare providers to think about how such barriers could be addressed through telehealth, and about the possible limitations of telehealth for some autistic people.

Telehealth Transdiagnostic Cognitive Behavioral Therapy for Depression in Parkinson's Disease: A Pilot Randomized Controlled Trial

Background

Cognitive behavioral therapy (CBT) is an effective treatment for depression in persons with Parkinson's disease (PwPD), but there are significant barriers preventing PwPD from receiving care in person. Telehealth CBT circumvents many of these barriers.

Objectives

We conducted a pilot randomized controlled trial evaluating the efficacy, feasibility, and acceptability of telehealth transdiagnostic CBT intervention for depression in PwPD.

Methods

Twelve PwPD with Major Depressive Disorder were enrolled, half randomly assigned to the treatment-immediate condition (TI) and half to the waitlist control condition (WLC). TI and WLC participants received 12 CBT sessions and assessments before treatment, immediately after treatment, and at the 6-week follow-up.

Results

The intervention was efficacious for treating depression in PwPD, with secondary benefits to anxiety, apathy, learning, memory, and quality of life. Improvements were largely maintained at follow-up. The intervention was highly feasible and acceptable.

Conclusions

Telehealth transdiagnostic CBT was an effective intervention for PwPD with depression.

[CLINICAL AND FUNCTIONAL OUTCOMES IN DAY HOSPITALS IN TIMES OF COVID-19]

Objective - Mental health services have been clearly affected by the pandemic and its restrictions. In our day hospital units users attended on fewer days, group therapy was drastically reduced, the number of users in groups was limited and individual and group teletherapy was initiated. This study evaluates the impact of these changes on clinical and functional outcomes.Methods - This is a descriptive study prospectively comparing two cohorts of users: those admitted and discharged from our day hospitals before or during the pandemic. All users received a multidisciplinary assessment at admission and discharge including clinician and user-rated scales on psychopathology, daily living skills, quality of life and caregiver burdens. Improvement in both groups was compared.Results - Both cohorts were homogenous at admission. Length of admission was not different for the two groups, but users admitted during the pandemic attended the day hospital on significantly fewer days. Improvement observed in most scales was equivalent in both groups, suggesting a similar evolution of both cohorts.Conclusions - Despite the reduction in assistance days and group therapeutic interventions no major changes were found in the outcomes of both groups. This study shows that careful adaptations and availability, even in critical situations, can result in equally effective treatments. Further research is essential to determine which of these adaptations should be maintained beyond the pandemic.

Perinatal mental health and COVID-19: Navigating a way forward

The COVID-19 pandemic and its aftermath have increased pre-existing inequalities and risk factors for mental disorders in general, but perinatal mental disorders are of particular concern. They are already underdiagnosed and undertreated, and this has been magnified by the pandemic. Access to services (both psychiatric and obstetric) has been reduced, and in-person contact has been restricted because of the increased risks. Rates of perinatal anxiety and depressive symptoms have increased. In the face of these challenges, clear guidance in perinatal mental health is needed for patients and clinicians. However, a systematic search of the available resources showed only a small amount of guidance from a few countries, with a focus on the acute phase of the pandemic rather than the challenges of new variants and variable rates of infection. Telepsychiatry offers advantages during times of restricted social contact and also as an additional route for accessing a wide range of digital technologies. While there is a strong evidence base for general telepsychiatry, the particular issues in perinatal mental health need further examination. Clinicians will need expertise and training to navigate a hybrid model, flexibly combining in person and remote assessments according to risk, clinical need and individual patient preferences. There are also wider issues of care planning in the context of varying infection rates, restrictions and vaccination access in different countries. Clinicians will need to focus on prevention, treatment, risk assessment and symptom monitoring, but there will also need to be an urgent and coordinated focus on guidance and planning across all organisations involved in perinatal mental health care.

Digital and In-Person Interpersonal Emotion Regulation: The Role of Anxiety, Depression, and Stress

Interpersonal emotion regulation (IER) is the process by which individuals change their emotional experiences by socially interacting with others. While the literature on IER for in-person settings is growing, there is a dearth of research exploring IER in digital social interactions (i.e., via technology) - especially when considering the presence of psychopathology. The aim of this study was to compare perceived IER efficacy and use in digital versus in-person contexts and explore the impact that anxiety, depression, and stress have on IER. A sample of 93 university undergraduate students showed that participants perceived in-person IER as more efficacious than digital IER, and participants high in anxiety, depression, and stress tended to use both modalities of IER more than those low anxiety, depression, and stress. This study addresses a critical gap in our understanding of emotion regulation in digital environments and sheds light on how this is related to psychopathology and the psychotherapy experience.

Suicide and Telehealth Treatments: A PRISMA Scoping Review

BACKGROUND

This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.).

AIM

The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom).

METHOD

To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021.

RESULTS

Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project.

LIMITATIONS

Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review.

CONCLUSION

Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.

Impact of the COVID-19 Pandemic on the Global Delivery of Mental Health Services and Telemental Health: Systematic Review

BACKGROUND

The COVID-19 pandemic required mental health services around the world to adapt quickly to the new restrictions and regulations put in place to reduce the risk of transmission. As face-to-face contact became difficult, virtual methods were implemented to continue to safely provide mental health care. However, it is unclear to what extent service provision transitioned to telemental health worldwide.

OBJECTIVE

We aimed to systematically review the global research literature on how mental health service provision adapted during the first year of the pandemic.

METHODS

We searched systematically for quantitative papers focusing on the impact of the COVID-19 pandemic on mental health services published until April 13, 2021, in the PubMed, Embase, medRxiv, and bioXriv electronic bibliographic databases, using the COVID-19 Open Access Project online platform. The screening process and data extraction were independently completed by at least two authors, and any disagreement was resolved by discussion with a senior member of the team. The findings were summarized narratively in the context of each country's COVID-19 Stringency Index, which reflects the stringency of a government's response to COVID-19 restrictions at a specific time.

RESULTS

Of the identified 24,339 records, 101 papers were included after the screening process. Reports on general services (n=72) showed that several countries' face-to-face services reduced their activities at the start of the pandemic, with reductions in the total number of delivered visits and with some services forced to close. In contrast, telemental health use rapidly increased in many countries across the world at the beginning of the pandemic (n=55), with almost complete virtualization of general and specialistic care services by the end of the first year. Considering the reported COVID-19 Stringency Index values, the increased use of virtual means seems to correspond to periods when the Stringency Index values were at their highest in several countries. However, due to specific care requirements, telemental health could not be used in certain subgroups of patients, such as those on clozapine or depot treatments and those who continued to need face-to-face visits.

CONCLUSIONS

During the pandemic, mental health services had to adapt quickly in the short term, implementing or increasing the use of telemental health services across the globe. Limited access to digital means, poor digital skills, and patients' preferences and individual needs may have contributed to differences in implementing and accessing telemental health services during the pandemic. In the long term, a blended approach, combining in-person and virtual modalities, that takes into consideration the needs, preferences, and digital skills of patients may better support the future development of mental health services. It will be required to improve confidence with digital device use, training, and experience in all modalities for both clinicians and service users.

Effects of the COVID-19 Restrictions on Eating Behaviour and Eating Disorder Symptomology in Female Adolescents

Confinement due to the COVID-19 pandemic imposes a burden on adolescents worldwide and may seriously impact patients with an eating disorder (ED). The current FRanconian Anorexia Nervosa during COVID-19 (FRANCO) study explored (1) perceived change of depressive and ED symptomology during lockdown, (2) the role of social media, and (3) coping strategies of anorexia nervosa (AN) patients and clinical as well as healthy comparison groups. From June 2021 to September 2021, 222 female adolescents (19 with AN, 20 with depression, 45 with a self-reported psychiatric disorder (SRPD), and 138 controls) aged 11.2 to 18.9 years completed a one-time anonymous survey retrospectively reporting back on ED and depressive symptomology before and during the pandemic, the impact of social media, and coping strategies. A reduced quality of life (QoL) due to confinement was observed in almost half of female adolescents. All groups reported a significant perceived increase of disordered eating, overeating, anxiety, and depressive symptoms and emotion-regulation problems. In AN patients, significantly higher percentual deterioration of disordered eating and anxiety and depressive symptoms was found. For controls, a younger age and higher susceptibility of the sociocultural body image significantly correlated with increased disordered eating. Large-scale media literacy interventions are recommended.

Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R): protocol for a pilot randomised controlled study

BACKGROUND

Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18-35 in terms of years lived with disability. Current pharmacological and psychological interventions intervention have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning.

METHODS/DESIGN

The CReSt-R intervention trial is a single center, pilot randomised controlled study based at the National University of Ireland (NUI), Galway. The trial will recruit participants from four clinical sites with assessment and intervention completed by the primary NUI Galway team. The trial will explore the feasibility, acceptability, and effectiveness of a novel psychosocial intervention for early psychosis based on a combined cognitive remediation training and cognitive behavioural therapy approach focused on social recovery. Participants, aged 16-35 within the first 5 years of a diagnosed psychotic disorder, will be recruited from the Children and Adolescent Mental Health Service and the Adult Mental Health Services in the region.

DISCUSSION

Cognitive remediation training (for improving cognition) and social recovery focused cognitive behavioural therapy, have both separately demonstrated effectiveness. This trial will evaluate the feasibility, acceptability, and explore the efficacy of a treatment approach that combines both approaches as part of an integrated, multicomponent intervention.

TRIAL REGISTRATION

Cognitive Remediation & Social Recovery in Early Psychosis (CReSt-R): ClincialTrials.gov Identifier NCT04273685. Trial registered Feb 18th, 2020. Last updated April 14th, 2021.

From Digital Health to Digital Well-being: Systematic Scoping Review

Background

Digital health refers to the proper use of technology for improving the health and well-being of people and enhancing the care of patients through the intelligent processing of clinical and genetic data. Despite increasing interest in well-being in both health care and technology, there is no clear understanding of what constitutes well-being, which leads to uncertainty in how to create well-being through digital health. In an effort to clarify this uncertainty, Brey developed a framework to define problems in technology for well-being using the following four categories: epistemological problem, scope problem, specification problem, and aggregation problem.

Objective

This systematic scoping review aims to gain insights into how to define and address well-being in digital health.

Methods

We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Papers were identified from 6 databases and included if they addressed the design or evaluation of digital health and reported the enhancement of patient well-being as their purpose. These papers were divided into design and evaluation papers. We studied how the 4 problems in technology for well-being are considered per paper.

Results

A total of 117 studies were eligible for analysis (n=46, 39.3% design papers and n=71, 60.7% evaluation papers). For the epistemological problem, the thematic analysis resulted in various definitions of well-being, which were grouped into the following seven values: healthy body, functional me, healthy mind, happy me, social me, self-managing me, and external conditions. Design papers mostly considered well-being as healthy body and self-managing me, whereas evaluation papers considered the values of healthy mind and happy me. Users were rarely involved in defining well-being. For the scope problem, patients with chronic care needs were commonly considered as the main users. Design papers also regularly involved other users, such as caregivers and relatives. These users were often not involved in evaluation papers. For the specification problem, most design and evaluation papers focused on the provision of care support through a digital platform. Design papers used numerous design methods, whereas evaluation papers mostly considered pre-post measurements and randomized controlled trials. For the aggregation problem, value conflicts were rarely described.

Conclusions

Current practice has found pragmatic ways of circumventing or dealing with the problems of digital health for well-being. Major differences exist between the design and evaluation of digital health, particularly regarding their conceptualization of well-being and the types of users studied. In addition, we found that current methodologies for designing and evaluating digital health can be improved. For optimal digital health for well-being, multidisciplinary collaborations that move beyond the common dichotomy of design and evaluation are needed.

Lessons learned from designing an asynchronous remote community approach for behavioral activation intervention for teens

Adolescent depression is common; however, over 60% of depressed adolescents do not receive mental health care. Digitally-delivered evidence-based psychosocial interventions (EBPIs) may provide an opportunity to improve access and engagement in mental health care. We present a case study that reviews lessons learned from using the Discover - Design - Build - Test (DDBT) model to create, develop, and evaluate a high-fidelity prototype of an app to deliver an EBPI for depression, behavioral activation (BA), on an Asynchronous Remote Communities (ARC) platform (referred to as ActivaTeen). We review work at each stage of the DDBT framework, including initial formative work, iterative design and development work, and an initial feasibility study. We engaged teens with depression, mental health clinicians, and expert evaluators through the process. We found that the DDBT model supported the research team in understanding the requirements for our prototype system, ActivaTeen, and conceiving of and developing specific ideas for implementation. Our work contributes a case study of how the DDBT framework can be applied to adapting an EBPI to a new, scalable and digital format. We provide lessons learned from engaging teens and clinicians with an asynchronous approach to EBPIs and human centered design considerations for teen mental health.

Distance Learning in Children with and without ADHD: A Case-control Study during the COVID-19 Pandemic

OBJECTIVE

This research involved the parents of ADHD students to explore how their children coped with online distance learning during COVID-19 pandemic and what implications this schooling method had on their emotional and behavioral well-being.

METHOD

Data were collected during lockdown using an online questionnaire addressed to 100 mothers and were compared with 184 matched controls from a national survey launched in the same period.

RESULTS

Attention span, spontaneous commitment, and autonomy in distance learning was found to be more limited in ADHD group. Compared to controls, 21.7% of ADHD students were not assessed and 40.9% did not receive grades. Behavioral changes were reported in both groups (64.2%), represented mainly by restlessness, aggressiveness, and anxiety.

CONCLUSION

Distance education increases academic difficulties, especially in ADHD pupils. The effects of lockdown should be adequately evaluated upon school reopening and appropriate recovery interventions should be planned.

The Impact of COVID-19 Lockdown on Daily Activities, Cognitions, and Stress in a Lonely and Distressed Population: Temporal Dynamic Network Analysis

Background

The COVID-19 pandemic and its associated lockdown measures impacted mental health worldwide. However, the temporal dynamics of causal factors that modulate mental health during lockdown are not well understood.

Objective

We aimed to understand how a COVID-19 lockdown changes the temporal dynamics of loneliness and other factors affecting mental health. This is the first study that compares network characteristics between lockdown stages to prioritize mental health intervention targets.

Methods

We combined ecological momentary assessments with wrist-worn motion tracking to investigate the mechanism and changes in network centrality of symptoms and behaviors before and during lockdown. A total of 258 participants who reported at least mild loneliness and distress were assessed 8 times a day for 7 consecutive days over a 213-day period from August 8, 2020, through March 9, 2021, in Germany, covering a “no-lockdown” and a “lockdown” stage. COVID-19–related worry, information-seeking, perceived restriction, and loneliness were assessed by digital visual analog scales ranging from 0 to 100. Social activity was assessed on a 7-point Likert scale, while physical activity was recorded from wrist-worn actigraphy devices.

Results

We built a multilevel vector autoregressive model to estimate dynamic networks. To compare network characteristics between a no-lockdown stage and a lockdown stage, we performed permutation tests. During lockdown, loneliness had the highest impact within the network, as indicated by its centrality index (ie, an index to identify variables that have a strong influence on the other variables). Moreover, during lockdown, the centrality of loneliness significantly increased. Physical activity contributed to a decrease in loneliness amid the lockdown stage.

Conclusions

The COVID-19 lockdown increased the central role of loneliness in triggering stress-related behaviors and cognition. Our study indicates that loneliness should be prioritized in mental health interventions during lockdown. Moreover, physical activity can serve as a buffer for loneliness amid social restrictions.

Interactive mental health assessments for Chinese Canadians: A pilot randomized controlled trial in nurse practitioner-led primary care clinic

INTRODUCTION

Mental health conditions like depression and anxiety are on the rise, but access to care remains a challenge. Immigrants and racialized communities including Chinese Canadians experience high level of access barriers including communication with clinicians. With the aim to facilitate mental health communications, we tested an Interactive Computer-assisted Client Assessment Survey (iCCAS) in Cantonese/Mandarin and English at a nurse practitioner-led primary care clinic in Toronto. The iCCAS offers a touch-screen, pre-consultation survey with questions on depression, anxiety, post-traumatic stress, alcohol abuse, and social context. The program generates point-of-care reports for the clinician and patient.

METHODS

A pilot randomized controlled trial examined the intervention impact on mental health discussion and symptom detection, compared with the usual care, followed by clinicians' qualitative interviews.

RESULTS

Fifty self-identified Chinese adult patients participated (iCCAS = 26, Usual Care = 24), response rate 79.4%. Participant mean age was 44.8 years and 92% were immigrants. There was an increase of 19% and 15% in the mental health discussion and detection of symptoms in the iCCAS group compared with the usual care. More participants in the iCCAS group were referred to a social worker or psychiatrist. Patients found the use of iCCAS easy and clinicians identified its benefits for themselves (eg, early identification and comfort) and patients (eg, self-awareness and anonymity) and proposed practice-integration.

DISCUSSION

The studied tool holds promise for enhancing clinician-patient mental health communications in primary care settings for overseas Chinese. Implications are discussed for in-person and virtual healthcare which could also inform responses to mental health crisis related to COVID-19.

Telepsychiatry: learning from the pandemic

This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.

Effects of COVID-19 on Patients in Adult Ambulatory Psychiatry: Using Patient-Rated Outcome Measures and Telemedicine

Introduction:

To examine the effects of coronavirus disease 2019 (COVID-19) on patients in an academic psychiatric ambulatory clinic, data from a measurement-based care (MBC) system were analyzed to evaluate impacts on psychiatric functioning in patients using telemedicine. Psychiatric functioning was evaluated for psychological distress (brief adjustment scale [BASE]-6), depression (patient health questionnaire [PHQ]-9), and anxiety (generalized anxiety disorder [GAD]-7), including initial alcohol (U.S. alcohol use disorders identification test) and substance use (drug abuse screening test-10) screening.

Methods:

This observational study included MBC data collected from November 2019 to March 2021. Patient-Reported Outcome Measures (PROMs) were examined to determine changes in symptomatology over the course of treatment, as well as symptom changes resulting from the pandemic. Patients were included in analyses if they completed at least one PROM in the MBC system.

Results:

A total of 2,145 patients actively participated in the MBC system completing at least one PROM, with engagement ranging from 35.07% to 83.50% depending on demographic factors, where completion rates were significantly different for age, payor status, and diagnostic group. Average baseline scores for new patients varied for the GAD-7, PHQ-9, and BASE-6. Within-person improvements in mental health before and after the pandemic were statistically significant for anxiety, depression, and psychological adjustment.

Discussion:

MBC is a helpful tool in determining treatment progress for patients engaging in telemedicine. This study showed that patients who engaged in psychiatric services incorporating PROMs had improvements in mental health during the COVID-19 pandemic. Additional research is needed exploring whether PROMs might serve as a protective or facilitative factor for those with mental illness during a crisis when in-person visits are not possible.

Transition age youth mental health: addressing the gap with telemedicine

Transition age youth (TAY), a demographic spanning ages 15-26, navigate a myriad of developmental transitions, ranging from identity formation and intimate relationships to substance use. Unfortunately, many young adults continue to have a dearth of mental health services and programing tailored to their unique developmental needs. Moreover, the systems of care in place are generally designed for treating traditional pediatric and adult patients but not ideally suited to meet the needs of TAY. Given the additional stressors from the COVID-19 pandemic, TAY are now, more than ever, in need of routine mental health care. We posit that the rapid expansion of telemedicine programming developed in response to the pandemic could be beneficial in mitigating this historic gap in care. In this commentary, we call on mental health providers and researchers to expand and invest in the growing number of telemedicine interventions and programming for this population so that TAY can begin to receive the care they so desperately need.

COVID-19 Pandemic and Impact on Patients with Autism Spectrum Disorder

The COVID-19 infectious disease pandemic has caused significant fear and uncertainty around the world and had significant adverse psychological impact. Children, adolescents and adults with autism spectrum disorder (ASD) are a particularly vulnerable population, impacted by stay-at-home orders, closures at nonessential services, and social distancing standards. This commentary describes various challenges faced by individuals with ASD in the United States including disruptions caused by educational and vocational changes, challenges to home and leisure routines, limited access to behavioral health services and changes in health services delivery due to the pandemic. We highlight the need for ongoing skills development for individuals and development within systems to better respond to needs of the ASD population in future emergencies.

Parent Coaching Fidelity Trajectories of In-Person and Telehealth Sessions during the COVID-19 Pandemic

The COVID-19 pandemic has posed significant challenges to delivery of preventive and mental health services, and providers have rapidly transitioned to telehealth service provision. Factors such as sudden isolation, financial strain, and physical and mental health stress presented unique challenges for providers and families and highlight the need for accessible and effective services. Thus, providers' fidelity of implementation during the pandemic is an important area for research. The current observational study compared providers' fidelity across in-person and telehealth-delivered sessions before and during the COVID-19 pandemic in Attachment and Biobehavioral Catch-up (ABC), a preventive parent coaching intervention for infants and toddlers. Participants included 24 providers (95% female, 42% White, M age = 37) who participated in ABC training and consultation during the COVID-19 pandemic. Providers' fidelity data (N = 593 sessions) were modeled longitudinally using hierarchical linear modeling, and separate intercepts and slopes were estimated for in-person and telehealth-delivered sessions. When data were modeled across all available sessions, results indicated that providers demonstrated improving fidelity over the course of training. When in-person and telehealth-delivered sessions were compared, providers' fidelity in telehealth-delivered ABC sessions was not significantly different from their fidelity in in-person sessions. Providers demonstrated improving fidelity over time in telehealth-delivered sessions. Thus, providers were able to maintain and improve ABC fidelity during the COVID-19 pandemic when provided with implementation support. Rapid transition to telehealth delivery can be successful when ongoing support such as consultation is provided.

Mental health trajectories of individuals and families following the COVID-19 pandemic: Study protocol of a longitudinal investigation and prevention program

Introduction

Many adults, adolescents and children are suffering from persistent stress symptoms in the face of the COVID-19 pandemic. This study aims to characterize long-term trajectories of mental health and to reduce the transition to manifest mental disorders by means of a stepped care program for indicated prevention.

Methods and analysis

Using a prospective-longitudinal design, we will assess the mental strain of the pandemic using the Patient Health Questionnaire, Strength and Difficulties Questionnaire and Spence Child Anxiety Scale. Hair samples will be collected to assess cortisol as a biological stress marker of the previous months. Additionally, we will implement a stepped-care program with online- and face-to-face-interventions for adults, adolescents, and children. After that we will assess long-term trajectories of mental health at 6, 12, and 24 months follow-up. The primary outcome will be psychological distress (depression, anxiety and somatoform symptoms). Data will be analyzed with general linear model and machine learning. This study will contribute to the understanding of the impact of the COVID-19 pandemic on mental health. The evaluation of the stepped-care program and longitudinal investigation will inform clinicians and mental health stakeholders on populations at risk, disease trajectories and the sufficiency of indicated prevention to ameliorate the mental strain of the pandemic.

Ethics and dissemination

The study is performed according to the Declaration of Helsinki and was approved by the Ethics Committee of the Department of Psychology at the Humboldt Universität zu Berlin (no. 2020-35).

Trial registration number

DRKS00023220.

Monthly Trends in Access to Care and Mental Health Services by Household Income Level During the COVID-19 Pandemic, United States, April: December 2020

Purpose: Since the start of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, ∼40% of U.S. adults have experienced delayed medical care. Rates of uninsurance, delayed care, and utilization of mental health services during the course of the pandemic have not been analyzed in detail. We examined monthly trends and disparities in access to care by household income levels in the United States. Methods: Using Census Bureau's nationally representative pooled 2020 Household Pulse Survey from April to December, 2020 (N=778,819), logistic regression models were used to analyze trends and inequalities in various access to care measures. Results: During the COVID-19 pandemic, the odds of being uninsured, having a delayed medical care due to pandemic, delayed care of something other than COVID-19, or delayed mental health care were, respectively, 5.54, 1.50, 1.85, and 2.18 times higher for adults with income <$25,000, compared to those with incomes ≥$200,000, controlling for age, sex, race/ethnicity, education, marital status, housing tenure, region of residence, and survey month. Income inequities in mental health care widened over the course of the pandemic, while the probability of delayed mental health care increased for all income groups. Although the odds of taking prescription medication for mental health were higher for low-income adults, the odds of receiving mental health services were generally lower for lower income adults, controlling for all covariates. Conclusion: In light of our findings on persistent health care inequities during the pandemic, increased policy efforts are needed to improve access to care in low-income populations as an equitable COVID-19 recovery response.

Effectiveness of a Guided Web-Based Intervention to Reduce Depressive Symptoms before Outpatient Psychotherapy: A Pragmatic Randomized Controlled Trial

INTRODUCTION

Psychotherapy is a first-line treatment for depression. However, capacities are limited, leading to long waiting times for outpatient psychotherapy in health care systems. Web-based interventions (WBI) could help to bridge this treatment gap.

OBJECTIVE

This study investigates the effectiveness of a guided cognitive-behavioral WBI in depressive patients seeking face-to-face psychotherapy.

METHODS

A 2-arm randomized controlled trial was conducted. Depressive patients (n = 136) recruited from the waiting lists of outpatient clinics were randomly assigned to an intervention group (IG; treatment as usual [TAU] + immediate access to WBI) or a control group (CG; TAU + access to WBI after follow-up). Depressive symptoms and secondary outcomes were assessed at baseline, 7 weeks, and 5 months after randomization.

RESULTS

Mixed-model analyses revealed a significant group × time interaction effect on depressive symptoms (F2, 121.5 = 3.91; p < 0.05). Between-group effect sizes were d = 0.55 at 7 weeks and d = 0.52 at 5 months. The IG was superior regarding psychological symptoms and mental health quality of life but not on physical health quality of life, attitudes, motivation for psychotherapy, or subjective need and uptake of psychotherapy.

CONCLUSIONS

Patients waiting for face-to-face psychotherapy can benefit from a WBI when compared to TAU. Despite the reduction of depressive symptoms in the IG, the uptake of subsequent psychotherapy was still high in both groups. The effects remained stable at the 5-month follow-up. However, this study could not determine the proportion of specific intervention effects vs. nonspecific effects, such as positive outcome expectations or attention. Future research should focus on the long-term effects and cost-effectiveness of WBI before psychotherapy.

Impact of COVID-19 on telepsychiatry at the service and individual patient level across two UK NHS mental health Trusts

Background

The effects of COVID-19 on the shift to remote consultations remain to be properly investigated.

Objective

To quantify the extent, nature and clinical impact of the use of telepsychiatry during the COVID-19 pandemic and compare it with the data in the same period of the 2 years before the outbreak.

Methods

We used deidentified electronic health records routinely collected from two UK mental health Foundation Trusts (Oxford Health (OHFT) and Southern Health (SHFT)) between January and September in 2018, 2019 and 2020. We considered three outcomes: (1) service activity, (2) in-person versus remote modalities of consultation and (3) clinical outcomes using Health of the Nation Outcome Scales (HoNOS) data. HoNOS data were collected from two cohorts of patients (cohort 1: patients with ≥1 HoNOS assessment each year in 2018, 2019 and 2020; cohort 2: patients with ≥1 HoNOS assessment each year in 2019 and 2020), and analysed in clusters using superclasses (namely, psychotic, non-psychotic and organic), which are used to assess overall healthcare complexity in the National Health Service. All statistical analyses were done in Python.

Findings

Mental health service activity in 2020 increased in all scheduled community appointments (by 15.4% and 5.6% in OHFT and SHFT, respectively). Remote consultations registered a 3.5-fold to 6-fold increase from February to June 2020 (from 4685 to a peak of 26 245 appointments in OHFT and from 7117 to 24 987 appointments in SHFT), with post-lockdown monthly averages of 23 030 and 22 977 remote appointments/month in OHFT and SHFT, respectively. Video consultations comprised up to one-third of total telepsychiatric services per month from April to September 2020. For patients with dementia, non-attendance rates at in-person appointments were higher than remote appointments (17.2% vs 3.9%). The overall HoNOS cluster value increased only in the organic superclass (clusters 18–21, n=174; p<0.001) from 2019 to 2020, suggesting a specific impact of the COVID-19 pandemic on this population of patients.

Conclusions and clinical implications

The rapid shift to remote service delivery has not reached some groups of patients who may require more tailored management with telepsychiatry.

Cross cultural and global uses of a digital mental health app: results of focus groups with clinicians, patients and family members in India and the United States

BACKGROUND

Despite significant advancements in healthcare technology, digital health solutions - especially those for serious mental illnesses - continue to fall short of their potential across both clinical practice and efficacy. The utility and impact of medicine, including digital medicine, hinges on relationships, trust, and engagement, particularly in the field of mental health. This paper details results from Phase 1 of a two-part study that seeks to engage people with schizophrenia, their family members, and clinicians in co-designing a digital mental health platform for use across different cultures and contexts in the United States and India.

METHODS

Each site interviewed a mix of clinicians, patients, and their family members in focus groups (n = 20) of two to six participants. Open-ended questions and discussions inquired about their own smartphone use and, after a demonstration of the mindLAMP platform, specific feedback on the app's utility, design, and functionality.

RESULTS

Our results based on thematic analysis indicate three common themes: increased use and interest in technology during coronavirus disease 2019 (COVID-19), concerns over how data are used and shared, and a desire for concurrent human interaction to support app engagement.

CONCLUSION

People with schizophrenia, their family members, and clinicians are open to integrating technology into treatment to better understand their condition and help inform treatment. However, app engagement is dependent on technology that is complementary - not substitutive - of therapeutic care from a clinician.

Mental Health Service User and Worker Experiences of Psychosocial Support Via Telehealth Through the COVID-19 Pandemic: Qualitative Study

BACKGROUND

During the COVID-19 pandemic, we saw telehealth rapidly become the primary way to receive mental health care. International research has validated many of the benefits and challenges of telehealth known beforehand for specific population groups. However, if telehealth is to assume prominence in future mental health service delivery, greater understanding of its capacity to be used to provide psychosocial support to people with complex and enduring mental health conditions is needed.

OBJECTIVE

We focused on an Australian community-managed provider of psychosocial intervention and support. We aimed to understand service user and worker experiences of psychosocial support via telehealth throughout the COVID-19 pandemic.

METHODS

This study was jointly developed and conducted by people with lived experience of mental ill health or distress, mental health service providers, and university-based researchers. Semistructured interviews were conducted between August and November 2020 and explored participant experiences of receiving or providing psychosocial support via telehealth, including telephone, text, and videoconferencing. Qualitative data were analyzed thematically; quantitative data were collated and analyzed using descriptive statistics.

RESULTS

Service users (n=20) and workers (n=8) completed individual interviews via telephone or videoconferencing platform. Service users received psychosocial support services by telephone (12/20, 60%), by videoconferencing (6/20, 30%), and by both telephone and videoconferencing (2/20, 10%). Of note, 55% (11/20) of service user participants stated a future preference for in-person psychosocial support services, 30% (6/20) preferred to receive a mixture of in-person and telehealth, and 15% (3/20) elected telehealth only. Two meta-themes emerged as integral to worker and service user experience of telehealth during the pandemic: (1) creating safety and comfort and (2) a whole new way of working. The first meta-theme comprises subthemes relating to a sense of safety and comfort while using telehealth; including trusting in the relationship and having and exercising choice and control. The second meta-theme contains subthemes reflecting key challenges and opportunities associated with the shift from in-person psychosocial support to telehealth.

CONCLUSIONS

Overall, our findings highlighted that most service users experienced telehealth positively, but this was dependent on them continuing to get the support they needed in a way that was safe and comfortable. While access difficulties of a subgroup of service users should not be ignored, most service users and workers were able to adapt to telehealth by focusing on maintaining the relationship and using choice and flexibility to maintain service delivery. Although most research participants expressed a preference for a return to in-person psychosocial support or hybrid in-person and telehealth models, there was a general recognition that intentional use of telehealth could contribute to flexible and responsive service delivery. Challenges to telehealth provision of psychosocial support identified in this study are yet to be fully understood.

Digital mental health and neurodevelopmental services: a case-based realist evaluation

Background

The rapid movement of mental health services on the internet following the onset of the COVID-19 pandemic has demonstrated the potential advantages of digital delivery and has highlighted the need to learn from prepandemic digital services.

Objective

The aim of this study is to explore the different elements of interconnected digital mental health and neurodevelopmental services of a well-established provider to the UK National Health Service and how web-based delivery enables young people and their families to access high-quality assessments and interventions in a more timely, flexible, and person-centered manner than in-person delivery.

Methods

A realist evaluation multiple case–study design was used, with 9 pediatric cases (aged 8-15 years) identified as representative of the services provided by Healios. Presenting concerns included autism and ADHD, anxiety and panic attacks, low self-esteem, anger and self-harm. The research literature was used to define the program theory and six context-mechanism-outcome (CMO) statements. The CMOs formed the basis for the initial data extraction, with novel elements added via an iterative process.

Results

We identified 10 key elements of web-based services: flexible delivery and timely response, personalized care to the individual, comprehensive care enabled by multiple interconnected services, effective client engagement and productive therapeutic alliances, use of multiple communication tools, client satisfaction with the service, good clinical outcomes, ease of family involvement throughout sessions or from different locations, facilitation of multi-agency working and integration with National Health Services, and management of risk and safeguarding. These elements supported the six CMOs; there was clear evidence that young people and their families valued the responsiveness and flexibility of the web-based mental health service and, in particular, how quickly they were seen. There was also clear evidence of individual needs being met, good therapeutic alliances, and client satisfaction. Multiple communication tools appeared to maximize engagement and working digitally facilitated multi-agency communication and delivery of safe care. The abovementioned factors may be related to the finding of good clinical outcomes, but the methodology of this study does not allow any conclusions to be drawn regarding causality.

Conclusions

This study demonstrates the effectiveness of interconnected digital mental health and neurodevelopmental services as well as how web-based delivery enables young people and their families to access assessments and interventions in a more timely, flexible, and person-centered manner than in-person delivery. The 10 key elements of web-based service delivery identified through the 9 case studies suggest the potential advantages of web-based work. These elements can inform future research and aid in the delivery of high-quality digital services.

Use of Ecological Momentary Assessment Through a Passive Smartphone-Based App (eB2) by Patients With Schizophrenia: Acceptability Study

Background

Ecological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients’ behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability.

Objective

The aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance.

Methods

The participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on “being user versus nonuser” (acceptability), which was the main outcome measure.

Results

Out of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=.048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=.01) survived the multivariable regression model, thus predicting eB2 acceptability.

Conclusions

Acceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment.

Trial Registration

ClinicalTrials.gov NCT04104347; https://clinicaltrials.gov/ct2/show/NCT04104347

Addressing physical health in mental illness: the urgent need to translate evidence-based interventions into routine clinical practice

People affected by severe mental health disorders have a greatly reduced life expectancy compared to their non-affected peers. Cardiovascular disease is the main contributor to this early mortality, caused by higher rates of smoking, physical inactivity, unhealthy diet, sleep disturbance, excessive alcohol use or substance abuse and medication side effects. Therefore, we need to take a preventative approach and translate effective interventions for physical health into routine clinical practice. These interventions should be delivered across all stages of mental health disorders and could also have the added benefit of leading to improvements in mental health. Furthermore, we need to advocate to ensure that people affected by severe mental health disorders receive the appropriate medical assessments and treatments when indicated. This themed issue highlights that physical health is now an urgent priority for funding and development in mental health services. The widespread implementation of evidence-based interventions into routine clinical practice is an essential need for consideration by clinicians and policymakers.

Psychological Intervention and Treatment for Posttraumatic Stress Disorder During Pregnancy: A Systematic Review and Call to Action

Posttraumatic stress disorder (PTSD) during pregnancy is a significant global mental health concern that affects up to 1 in 5 trauma-exposed pregnant women and is associated with an increased risk of adverse maternal and infant complications and health outcomes. This systematic literature review, conducted in accordance with PRISMA guidelines, examined findings from studies of psychological interventions and treatments for prenatal PTSD to inform recommendations for future research. Relevant evidence was identified from reference reviews and electronic databases (i.e., PubMed, Google Scholar, PsychInfo, and Scopus). Included studies reported on the effect of nonpharmacological intervention or treatment of PTSD symptomatology delivered during pregnancy, with at least one postintervention follow-up collected during pregnancy to assess prenatal treatment outcomes. The systematic review was augmented with a discussion of lower-level evidence. Of the 954 articles screened, six peer-reviewed, quantitative reports met the inclusion criteria and featured three empirically based interventions, including two randomized controlled trials: Two psychoeducation interventions for PTSD and one treatment study of interpersonal psychotherapy in trauma-exposed pregnant women. Effect sizes for PTSD symptom change ranged from small to large, Cohen's d/η_p ² = 0.16-0.78. No studies examined evidence-based PTSD treatments (e.g., exposure therapy, cognitive processing therapy). A risk of bias assessment indicated variability in study quality. This review demonstrates that research on prenatal PTSD symptoms, diagnosis, and treatment is extremely limited despite a clear link between prenatal PTSD and perinatal complications. Early evidence supports further scientific inquiry into psychoeducation, psychotherapy treatments (e.g., exposure therapy), integrated prenatal care approaches, and community-based approaches.

Psychological symptoms during and after Austrian first lockdown in individuals with bipolar disorder? A follow-up control-group investigation

BACKGROUND

The coronavirus disease (COVID-19) pandemic, a global health crisis, has resulted in widespread socioeconomic restrictions including lockdown, social distancing, and self-isolation. To date, little is known about the psychological impact of the COVID-19 pandemic and lockdown on patients with bipolar disorder as a particularly vulnerable group.

METHODS

An online survey was conducted in Austria at two points of measurement (T1 April 2020 during the first lockdown vs. T2 May 2020 at post-lockdown). The sample comprises 20 patients with bipolar disorder (mean age = 49.4 ± 15.6 years) and 20 healthy controls (mean age = 32.7 ± 9.6 years). A 2 × 2 factorial design to compare two time points (T1 vs. T2) and two groups (patients vs. healthy controls) was used. Main outcome measures included the Brief Symptom Inventory-18 (BSI-18) and a (non-validated and non-standardized) assessment to determine COVID-19 fears and emotional distress due to social distancing. Multiple linear regression analyses were used to assess the longitudinal association of COVID-19 fears/emotional distress due to social distancing during lockdown (T1) and psychological symptoms after lockdown (T2).

RESULTS

At T1, results demonstrated higher scores in BSI-18 subscales depression, anxiety and global severity index as well as emotional distress due to social distancing in bipolar patients compared to controls. There was a significant time x group interaction in the BSI-18 subscale somatization showing a decreasing trend in patients with BD compared to controls. No time effects in BSI-18 subscales or COVID-19 fears/emotional distress due to social distancing were observed. Regression analyses showed that COVID-19 fears during lockdown predicted somatization, only in patients.

CONCLUSIONS

There was a connection between the lockdown measures and somatization symptoms observed in patients. When the first steps of easing the social restrictions in May 2020 took place, somatization decreased only in the bipolar compared to the control group. Higher COVID-19 fears during lockdown predicted later symptoms at post-lockdown. Long-term impacts of the COVID-19 pandemic need further investigations to improve current therapeutic approaches and prevent fears and distress during lockdown in individuals with bipolar disorder in times of crisis.

Is There an App for That?: Ethical Issues in the Digital Mental Health Response to COVID-19

Well before COVID-19, there was growing excitement about the potential of various digital technologies such as tele-health, smartphone apps, or AI chatbots to revolutionize mental healthcare. As the SARS-CoV-2 virus spread across the globe, clinicians warned of the mental illness epidemic within the coronavirus pandemic. Now, funding for digital mental health technologies is surging and many researchers are calling for widespread adoption to address the mental health sequelae of COVID-19. Reckoning with the ethical implications of these technologies is urgent because decisions made today will shape the future of mental health research and care for the foreseeable future. We contend that the most pressing ethical issues concern (1) the extent to which these technologies demonstrably improve mental health outcomes and (2) the likelihood that wide-scale adoption will exacerbate the existing health inequalities laid bare by the pandemic. We argue that the evidence for efficacy is weak and that the likelihood of increasing inequalities is high. First, we review recent trends in digital mental health. Next, we turn to the clinical literature to show that many technologies proposed as a response to COVID-19 are unlikely to improve outcomes. Then, we argue that even evidence-based technologies run the risk of increasing health disparities. We conclude by suggesting that policymakers should not allocate limited resources to the development of many digital mental health tools and should focus instead on evidence-based solutions to address mental health inequalities.