Technology-Based Mental Health Treatment and the Impact on the Therapeutic Alliance

Therapeutic alliance in videoconferencing psychotherapy compared to psychotherapy in person: A systematic review and meta-analysis

INTRODUCTION

Videoconferencing psychotherapy (VCP) delivers treatment to individuals with limited access to face-to-face mental healthcare. VCP's effectiveness has been demonstrated for various disorders and therapeutic interventions. However, there is contradictory evidence regarding the therapeutic alliance in VCP as compared to psychotherapy in person (PIP). This meta-analysis examines whether therapeutic alliance differs by psychotherapy's delivery format, namely VCP versus PIP.

METHODS

We searched five databases for trials comparing the therapeutic alliance in VCP and PIP, wherein the therapeutic alliance was rated by either patients or therapists or both. Eighteen publications were included, and the difference between VCP and PIP was assessed. Furthermore, we tested possible moderators of the difference in therapeutic alliance between VCP and PIP by meta-regression, and we assessed the risk of bias of this meta-analysis.

RESULTS

The meta-analysis revealed no statistically significant difference in the therapeutic alliance between VCP and PIP for alliance ratings by patients (SMD = -0.09; 95% CI = -0.26; 0.07) as well as by therapists (SMD = 0.04; 95% CI = -0.17; 0.25). No significant moderators were found.

DISCUSSION

In this meta-analysis, VCP and PIP did not differ with respect to the therapeutic alliance as rated by either patients or therapists. Further research is required into mechanisms driving the therapeutic alliance in VCP and PIP.

Sexual Interventions in the Metaverse: Attitudes Towards Novel Therapeutic Approaches, a Qualitative Study

BACKGROUND AND OBJECTIVE

Mental health treatment for psychosexual problems is effective, but treatment rates are low. Metaverse-based therapy offers one solution to increase overall treatment rates. Understanding attitudes towards this novel approach could lead to wider adoption of metaverse-based therapy, resulting in higher treatment rates for psychosexual problems.

METHODS

Twenty-one participants across three focus groups of different ages shared their perceptions and attitudes about metaverse-based therapy broadly and for treating sexual disorders. A content analysis of the transcribed text from the focus groups using qualitative data analysis software was conducted.

RESULTS

Participants identified several perceived benefits of metaverse-based intervention, including avoiding the perceived embarrassment of going to a clinic and accessing patients (a) with diverse physical or mental functionality, (b) living in remote areas and/or (c) balancing different family/work obligations or duties. The two main concerns with metaverse-based therapy were the fear of online therapy being less personal than traditional therapy and the technological fluency needed. Clarifying their acceptance of the therapy, participants reported that they would be more likely to engage in metaverse-based therapy if they trusted their therapist. Also, although it might be effective for mild and moderate disorders, participants were more reluctant about its use for severe mental illness.

CONCLUSIONS

Results suggest that attitudes towards metaverse-based intervention are mainly positive, since it removes some barriers that hinder access to psychological treatment in general and, specifically, for problems of a sexual nature.

PATIENT AND PUBLIC CONTRIBUTION

During the design stage, a person with sexual difficulties was consulted to understand the patient's perspective. Members of the public advised the implementation of the focus groups. Three potential service users were involved in the coding of the text during the content analysis.

Patient perceptions of digital and therapist-led CBT for insomnia: A qualitative study

OBJECTIVES

Technology has the potential to increase access to evidence-based insomnia treatment. Patient preferences/perceptions of automated digital cognitive behavior therapy for insomnia (CBTI) and telehealth-delivered CBTI remain largely unexplored among middle-aged and older adults. Using a qualitative approach, the current study describes patients' reasons for participating in the clinical trial, preferences for digital CBTI (dCBTI) versus therapist-led CBTI, patient attitudes toward dCBTI, and patient attitudes toward telehealth-delivered therapist-led CBTI.

METHOD

Middle-aged and older adults (N = 80) completed a semi-structured interview before CBTI exposure. Qualitative responses were coded, and themes were inductively extracted.

RESULTS

Most (62.5%) of the participants expressed a preference for therapist-led CBTI to dCBTI. Convenience was the most commonly reported advantage of dCBTI (n = 55) and telehealth-delivered CBTI (n = 65). Decreasing transit time and pandemic-related health concerns were identified as advantages to dCBTI and telehealth-delivered CBTI. Lack of human connection and limited personalization were perceived as disadvantages of dCBTI. Only three participants reported technological barriers to dCBTI and telehealth-delivered CBTI.

CONCLUSION

Findings suggest that, despite an overall preference for therapist-led treatment, most middle-aged and older adults are open to dCBTI. As both dCBTI and telehealth-delivered CBTI are perceived as convenient, these modalities offer the potential to increase access to insomnia care.

Psychiatric mental health nurse practitioners experiencing therapeutic alliance while using tele-mental health: A phenomenological study

BACKGROUND

Psychiatric mental health nurse practitioners have rapidly adopted and implemented tele-mental health in their practice; however it is unclear how this modality of care affects the experiential quality of therapeutic alliance, simply defined as the interpersonal working bond between provider and patient.

OBJECTIVE

This study is the first to explore how psychiatric mental health nurse practitioners experience therapeutic alliance while using tele-mental health.

DESIGN

Husserlian phenomenological qualitative study.

PARTICIPANTS

A purposive, convenience sample of 17 American psychiatric mental health nurse practitioners who engaged in tele-mental health care were recruited online and interviewed.

METHODS

Phenomenological interview transcripts recorded and later thematically coded in the qualitative software MaxQDA.

RESULTS

From 1426 individual codes, five major themes and 16 subthemes were discovered. Overall, themes illuminated that psychiatric mental health nurse practitioners could build therapeutic alliance over tele-mental health using inherent interpersonal skills that had to be adapted to the technology. Adaptions included working with patient environmental factors, individual patient considerations, provider ambivalence, and technological observation shifting awareness and communication patterns.

CONCLUSIONS

When adapting for the tele-mental health environment, psychiatric mental health nurse practitioners experienced building and sustaining therapeutic alliance with most patients. Unparalleled aspects of tele-mental health allowed for a fuller clinical picture and logistical convenience to see patients more often with ease for both the provider and patient. However, experiential aspects of therapeutic alliance created during in-person care could not be replaced with tele-mental health. In conclusion, participants concluded that a hybrid care model would enhance therapeutic alliance for most patients.

Experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic: Implications for future telehealth delivery

INTRODUCTION

The novel coronavirus (COVID-19) pandemic necessitated the rapid uptake of telehealth to deliver treatment for alcohol and other drug (AOD) concerns. However, little is known about how the move from in-person to telehealth delivery impacted clients' experience of care. This qualitative study aimed to explore experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic, and their preferences regarding future telehealth care.

METHODS

Participants were aged 34-66 years (M = 44 years, 60% male) and were recruited from Victorian AOD treatment services and consumer networks. A total of 20 semi-structured interviews were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) experiences of the practical impacts of telehealth; (ii) experiences of telehealth interactions; and (iii) preferences for future telehealth. Contextual factors, including location and socioeconomic status, were found to impact clients' ability to access reliable telehealth with sufficient privacy. While telehealth was generally associated with increased treatment engagement (for a typically stigmatised population), participants noted varying effects on the therapeutic alliance. Although in-person treatment was generally favoured, participants often valued telehealth as a modality to provide empathic care during the pandemic. Participants expressed a preference for a hybrid treatment model in the future, in which they could choose a combination of telehealth and in-person services.

CONCLUSION

Client and clinician information and training are vital to improve the future delivery of telehealth for AOD treatment.

Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial

BACKGROUND/AIM

Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder.

METHODS

This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings.

RESULTS

Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05).

CONCLUSION

The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.

Therapeutic alliance in two forms of guided self-help for binge eating

The role of therapeutic alliance within psychological treatments for eating disorders (EDs), including those delivered remotely, is well established. However, few studies have investigated alliance in guided self-help, a widely recommended first-line treatment for EDs characterised by regular binge eating. Using data from a randomised controlled trial, the current study examined both facilitator and patient assessments of alliance within e-mail-assisted and face-to-face guided self-help and looked at associations between alliance, ED symptoms and ED-related impairment. One hundred thirteen patients and 11 facilitators completed measures of alliance during and following a course of guided self-help. Whilst ratings were reliable across patients and facilitators, alliance scores were higher both in the patient sample and in the face-to-face condition. Ratings of alliance showed no correlations with ED symptoms at post-treatment, and early alliance was not significantly associated with outcome, which could inform how early symptom change is encouraged in guided self-help.

UPSIDES Mental Health Peer Support in Face of the COVID-19 Pandemic: Actions and Insights

The outburst of the COVID-19 pandemic challenged vulnerable populations such as individuals with significant mental illness. In this fresh focus, we describe the innovative development of the UPSIDES mental health peer support intervention, in face of the COVID-19 pandemic in Israel. While the research program is still ongoing, in this paper we focus on the processes and lessons learned from dealing with the rapidly changing circumstances of the pandemic. We portray additional activities conducted above and beyond the UPSIDES protocol in order to maintain continuation and prevent dropout. We learned that an essential combination of keeping a close adherence with the core peer principles and UPSIDES' systematic program and the use of flexible telecommunication means, helped to maintain social connection and service users' participation throughout these times. The sudden pandemic challenges appeared to level out power imbalances and accelerated the formation of reciprocal and supportive relational interactions within the intervention. These processes highlight experiential knowledge as a unique asset, and peer support services as useful in supporting individuals with significant mental illness throughout COVID-19.

The Efficacy and Therapeutic Alliance of Augmented Reality Exposure Therapy in Treating Adults With Phobic Disorders: Systematic Review

BACKGROUND

Phobic disorders are characterized by excessive fear of a stimulus that can affect the quality of a patient's life. The lifetime prevalence in adults is 7.7% to 12.5%. The current literature provides evidence-based inferences about the effectiveness of in-vivo exposure therapy (IVET) in treating phobia. However, this method can put the therapist and the client in danger, with high drop out and refusal rates. A newer approach for exposure therapy using augmented reality technology is under assessment.

OBJECTIVE

This systematic review investigated the novel technology's efficacy, cost-efficacy, and therapeutic alliance in treating adults with phobia.

METHODS

An extensive search was conducted using 4 major databases (MEDLINE, PsycINFO, Embase, and Scopus) using a comprehensive list of synonyms for augmented reality exposure therapy (ARET) and phobic disorders. The search targeted any randomized control trial testing ARET in adults with phobic disorders up to August 8, 2022.

RESULTS

A total of 6 studies were included, with 208 participants providing results. Studies investigating the efficacy of ARET compared to no intervention showed significant results (P<.05) in the ARET group improvement. Head-to-head comparative studies comparing ARET to IVET showed no significant difference (P>.05) in the effectiveness and therapeutic alliance between both therapies. Further, the results demonstrated that the ARET group had a better long-term effect than IVET, with the ability to put the patients in more situations to face the feared object.

CONCLUSIONS

The current data suggest clinically significant efficacy and a promising therapeutic alliance of ARET. However, no data are available investigating the cost-effectiveness of ARET. Further research is warranted to ascertain ARET's cost-effectiveness and examine its efficacy in other populations and anxiety conditions.

Satisfaction, Perceived Usefulness, and Therapeutic Alliance as Correlates of Participant Engagement in a Pediatric Digital Mental Health Intervention: Cross-Sectional Questionnaire Study

BACKGROUND

Although evidence suggests that digital mental health interventions (DMHIs) are effective alternatives to traditional mental health care, participant engagement continues to be an issue, especially for pediatric DMHIs. Extant studies of DMHIs among adults suggest that participants' satisfaction, perceived usefulness, and therapeutic alliance are closely tied to engagement. However, these associations have not been investigated among children and adolescents involved in DMHIs.

OBJECTIVE

To address these gaps in extant DMHI research, the purpose of this study was to (1) develop and implement a measure to assess satisfaction, perceived usefulness, and therapeutic alliance among children and adolescents participating in a DMHI and (2) investigate satisfaction, perceived usefulness, and therapeutic alliance as correlates of children's and adolescents' engagement in the DMHI.

METHODS

Members (children and adolescents) of a pediatric DMHI who had completed at least one session with a care provider (eg, coach or therapist) were eligible for inclusion in the study. Adolescent members and caregivers of children completed a survey assessing satisfaction with service, perceived usefulness of care, and therapeutic alliance with care team members.

RESULTS

This study provides evidence for the reliability and validity of an adolescent- and caregiver-reported user experience assessment in a pediatric DMHI. Moreover, our findings suggest that adolescents' and caregivers' satisfaction and perceived usefulness are salient correlates of youths' engagement with a DMHI.

CONCLUSIONS

This study provides valuable preliminary evidence that caregivers' satisfaction and perceived usefulness are salient correlates of youths' engagement with a DMHI. Although further research is required, these findings offer preliminary evidence that caregivers play a critical role in effectively increasing engagement among children and adolescents involved in DMHIs.

Interplay Between Innovation and Intersubjectivity: Therapists Perceptions of Phantom Motor Execution Therapy and Its Effect on Phantom Limb Pain

Purpose

Interpersonal processes, including therapeutic alliance, may modulate the impact of interventions on pain experience. However, the role of interpersonal context on the effects of technology-enhanced interventions remains underexplored. This study elicited therapists' perspectives on how a novel rehabilitative process, involving Phantom Motor Execution (PME), may impact phantom limb pain. The mediating role of therapeutic alliance, and the way PME influenced its formation, was investigated.

Methods

A qualitative descriptive design, using a framework method, was used to explore therapists' (n=11) experiences of delivering PME treatment. Semi-structured online-based interviews were conducted.

Results

A 3-way interaction between therapist, patient, and the PME device was an overarching construct tying four themes together. It formed the context for change in phantom limb experience. The perceived therapeutic effects (theme 1) extended beyond those initially hypothesised and highlighted the mediating role of the key actors and context (theme 2). The therapeutic relationship was perceived as a transformative journey (theme 3), creating an opportunity for communication, collaboration, and bonding. It was seen as a cause and a consequence of therapeutic effects. Future directions, including the role of expertise-informed adaptations and enabling aspects of customised solutions, were indicated (theme 4).

Conclusion

This study pointed to intrapersonal, interpersonal, and contextual factors that should be considered in clinical implementation of novel rehabilitative tools. The results demonstrated that therapists have unique insights and a crucial role in facilitating PME treatment. The study highlighted the need to consider the biopsychosocial model of pain in designing, evaluating, and implementing technology-supported interventions.

Autistic young people's experiences of remote psychological interventions during COVID-19

LAY ABSTRACT

Recently, therapy has been delivered at a distance (i.e. remotely) to help control the spread of coronavirus. Clinicians have voiced concerns that remote delivery is unsuitable for certain individuals, including those who are autistic, but they have also highlighted potential benefits for autistic individuals. Benefits include some individuals feeling more comfortable receiving therapy at home. This is the first study to interview autistic individuals about their experience of remote therapy. Participants were six young people aged 15-18 years and eight clinicians. Participants described their experience of remote delivery, including challenges, benefits, and suggestions. Most of these supported previous research findings, but some were new or provided further insight into those already identified. A newly identified challenge was knowing online social etiquette. All participants found aspects of the experience challenging, but all identified benefits and most voiced that remote sessions should be offered to young people. Participants further identified individual characteristics that may make someone less suited to remote delivery (e.g. shyness). They also identified ways of making the experience of remote delivery easier (e.g. sitting with a pet). Young people's and clinicians' views were similar overall, with only subtle differences. For example, young people uniquely voiced that remote delivery was similar to in-person, that benefits were hard to identify, and provided distinct reasons for the social interaction feeling less intense remotely. Findings may be used to improve remote delivery, for guiding future research, and as a case for continuing to offer it to those who may most benefit.

Use of Technologies in the Therapy of Social Cognition Deficits in Neurological and Mental Diseases: A Systematic Review

Objective: This article systematically reviews the effects of technology-based (TB) treatments on impaired social cognition (SC) in neurological and mental disorders. Methods: Strictly adhering to the PRISMA guidelines, a systematic search was carried out in PsycINFO, PubMed, and Web of Science (last search: April 22, 2021) to identify studies that, implementing a control group design, evaluated TB treatments targeting deficits in emotion recognition, Theory of Mind (ToM) and social behavior in adult patients with nondevelopmental and nonprogressive neurological or mental disorders. Risk of bias was assessed using the PEDro Scale, certainty assessment followed the GRADE approach. Results: Sixteen studies involving 857 patients, all focusing on psychotic disorders, were retrieved. The most pronounced effects were observed concerning emotion recognition with all studies revealing overall improvements. Regarding ToM and social behavior, results were mixed. However, the number of studies including outcome measures for these domains, is significantly lower compared to the domain of emotion recognition, limiting the validity of the results. Risk of bias and certainty assessment revealed further limitations of evidence. Conclusion: TB treatment achieves positive effects especially with regard to emotion recognition impairments, at least for patients with schizophrenia. Future research should expand the evaluation of TB training of other SC domains, ought to be carried out in more diverse patient populations, rely on different devices, and include follow-up measurements.

Are we ready for Telepsychiatry? Benefits and challenges of digital psychotherapy

Background: Telemedicine is one of the most modern and fastest-growing branches of medicine. The most common form is video consultation. We distinguish between synchronous and asynchronous telepsychiatry. This study aims to show the benefits of using telepsychiatry services, the challenges it poses to users, and to evaluate its use against traditional therapy. Materials and methods: A review of literature from 1956-2023 in EMBASE, OpenKnowledge and PubMed databases was conducted. Keywords used were: telepsychiatry, teletherapy, and digital psychiatry. Ninety-eight articles were included. Discussion: Telepsychiatry is an opportunity for regions affected by medical staff shortages. It bypasses cultural barriers, the problem of traveling and reduces the cost of medical point-of-service. Telepsychiatry is an opportunity for patients who do not use psychiatrists due to discrimination in a conservative society. Groups that may find it challenging include the elderly, the blind, and the deaf. Creating a healthy therapeutic alliance through a screen can be impossible, making it difficult to achieve successful therapy. A barrier to developing telepsychiatry is the need for more guidelines for dealing with medical errors. Conclusions: Telemedicine can help in accessing specialized care regardless of location. Telepsychiatry provides a safe and anonymous environment for patients reluctant to receive inpatient therapy. The effectiveness of online therapy is primarily debated. Telepsychiatry should be limited to follow-up consultations and well-known patients - it is a form of complementing the diagnosis and treatment process. The authors point to the need for developing specific guidelines for conducting teletherapy with particular attention to the problem of suicide. Keywords: telepsychiatry, teletherapy, digital psychiatry.

Long-term psychodynamic psychotherapy in a face-to-face versus videoconferencing setting: A single case study

OBJECTIVE

Due to the coronavirus pandemic and crisis, psychotherapists around the world were forced to switch to video- or tele-based treatments overnight. To date, only a few studies on the effectiveness of video-based psychodynamic psychotherapy via the Internet exist. Therefore, the goal of the present study was to examine symptom improvement, therapeutic relationship, nonverbal synchrony processes, and intersession processes within a systematic single case design and compare face-to-face to video-based approaches in long-term psychodynamic-oriented psychotherapy.

METHODS

We examined 85 sessions of a client with major depression whose psychodynamic psychotherapy changed from a face-to-face setting to a video-based setting. Video recordings were analyzed using motion energy analysis, and nonverbal synchrony was computed using a surrogate synchrony approach. Time series analyses were performed to analyze changes in symptom severity, therapeutic relationship, and intersession processes.

RESULTS

The results showed that symptom severity improved descriptively, but not significantly, across the entire course of psychotherapy. There were significant differences, however, in the therapeutic relationship, intersession experiences, and synchronous behavior between the face-to-face and video-based settings.

CONCLUSION

The results indicate that the presented methodology is well situated to investigate the question whether psychodynamic psychotherapy in video-based setting works in the sameway as in a face-to-face setting.

Synthesis of the Evidence on What Works for Whom in Telemental Health: Rapid Realist Review

BACKGROUND

Telemental health (delivering mental health care via video calls, telephone calls, or SMS text messages) is becoming increasingly widespread. Telemental health appears to be useful and effective in providing care to some service users in some settings, especially during an emergency restricting face-to-face contact, such as the COVID-19 pandemic. However, important limitations have been reported, and telemental health implementation risks the reinforcement of pre-existing inequalities in service provision. If it is to be widely incorporated into routine care, a clear understanding is needed of when and for whom it is an acceptable and effective approach and when face-to-face care is needed.

OBJECTIVE

This rapid realist review aims to develop a theory about which telemental health approaches work (or do not work), for whom, in which contexts, and through what mechanisms.

METHODS

Rapid realist reviewing involves synthesizing relevant evidence and stakeholder expertise to allow timely development of context-mechanism-outcome (CMO) configurations in areas where evidence is urgently needed to inform policy and practice. The CMO configurations encapsulate theories about what works for whom and by what mechanisms. Sources included eligible papers from 2 previous systematic reviews conducted by our team on telemental health; an updated search using the strategy from these reviews; a call for relevant evidence, including "gray literature," to the public and key experts; and website searches of relevant voluntary and statutory organizations. CMO configurations formulated from these sources were iteratively refined, including through discussions with an expert reference group, including researchers with relevant lived experience and frontline clinicians, and consultation with experts focused on three priority groups: children and young people, users of inpatient and crisis care services, and digitally excluded groups.

RESULTS

A total of 108 scientific and gray literature sources were included. From our initial CMO configurations, we derived 30 overarching CMO configurations within four domains: connecting effectively; flexibility and personalization; safety, privacy, and confidentiality; and therapeutic quality and relationship. Reports and stakeholder input emphasized the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care. The review also identified particular service users likely to be disadvantaged by telemental health implementation and a need to ensure that face-to-face care of equivalent timeliness remains available. Mechanisms underlying the successful and unsuccessful application of telemental health are discussed.

CONCLUSIONS

Service user choice, privacy and safety, the ability to connect effectively, and fostering strong therapeutic relationships need to be prioritized in delivering telemental health care. Guidelines and strategies coproduced with service users and frontline staff are needed to optimize telemental health implementation in real-world settings.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO); CRD42021260910; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021260910.

Provider Perspectives on Telemental Health Usage After COVID-19: A Retrospective Analysis (Preprint)

Background

Mental health care pivoted to telemedicine during the COVID-19 pandemic, and there is uncertainty around the sustainability of this rapid shift.

Objective

This study examined how intentions to continue using telemedicine after the COVID-19 pandemic are influenced by provider perceptions of usefulness, ease of use, and professional social influence, facilitating organizational conditions.

Methods

We conducted a web-based, cross-sectional survey of 369 telemental health providers between February and March 2021. A hierarchical linear regression analysis was conducted to predict intentions to continue using telemedicine after the COVID-19 pandemic.

Results

Most providers began using telemedicine in March 2020 or later (257/369, 69.6%) and attended to ≥50% of their clients via telemedicine (299/369, 81.0%). Intention to continue using telemedicine after the COVID-19 pandemic was predicted by the telemedicine caseload (β=.10; P=.005), perceived usefulness in general (β=.10; P=.008), ease of use (β=.08; P=.04), social influence (β=.68; P<.001), and facilitating conditions (β=.08; P=.047).

Conclusions

Exploration of the predictors of telemedicine usage beyond the COVID-19 pandemic aids in surveillance of telemedicine usage, integration with future clinic workflows, and the shaping of public policy. It is important to consider telemedicine services as not only a response to a crisis but also an effective and useful solution for everyday life. Our results suggest widespread, sustainable telemedicine adoption.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Implementation of telepsychiatry in Kenya: acceptability study

BACKGROUND

COVID-19-related restrictions on in-person contact in healthcare, increasing psychiatric illness during the pandemic and pre-existing shortages of mental healthcare providers have led to the emergence of telepsychiatry as an attractive option for the delivery of care. Telepsychiatry has been promoted as economical and effective, but its acceptance in low- and middle-income countries is poorly understood.

AIMS

To explore the acceptance, experiences and perspectives of patients and healthcare providers in the uptake of telepsychiatry services in a middle-income country.

METHOD

Focus group discussions were conducted on the WhatsApp platform with patients and care providers who have engaged in telepsychiatry. Data were analysed using a thematic approach.

RESULTS

Three main themes emerged from the five focus groups: (a) technical access, (b) user experience and (c) perceived effectiveness compared with face-to-face (in-person) interactions. Care providers reported challenges establishing rapport with the patient, particularly for initial sessions, maintaining privacy during sessions and detecting non-verbal cues on video. Patients cited internet connectivity problems, difficulty finding private space to have their sessions and cost as major challenges. Patients also felt in-person sessions were better for initial visits. Both patients and providers reported difficulties making insurance payment claims for telepsychiatry services. Overall, participants were mostly positive about telepsychiatry, citing its convenience and overall perceived effectiveness compared with in-person sessions.

CONCLUSIONS

Telepsychiatry is an acceptable platform for delivery of out-patient psychiatric services in a middle-income country. Patients and providers appreciate the convenience it offers and would like it integrated as a routine mode of delivery of care.

Perceptions of Telemental Health Care Delivery During COVID-19: A Cross-Sectional Study With Providers, February-March 2021

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.

Telehealth Versus Face-to-face Psychotherapy for Less Common Mental Health Conditions: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mental disorders are a leading cause of distress and disability worldwide. To meet patient demand, there is a need for increased access to high-quality, evidence-based mental health care. Telehealth has become well established in the treatment of illnesses, including mental health conditions.

OBJECTIVE

This study aims to conduct a robust evidence synthesis to assess whether there is evidence of differences between telehealth and face-to-face care for the management of less common mental and physical health conditions requiring psychotherapy.

METHODS

In this systematic review, we included randomized controlled trials comparing telehealth (telephone, video, or both) versus the face-to-face delivery of psychotherapy for less common mental health conditions and physical health conditions requiring psychotherapy. The psychotherapy delivered had to be comparable between the telehealth and face-to-face groups, and it had to be delivered by general practitioners, primary care nurses, or allied health staff (such as psychologists and counselors). Patient (symptom severity, overall improvement in psychological symptoms, and function), process (working alliance and client satisfaction), and financial (cost) outcomes were included.

RESULTS

A total of 12 randomized controlled trials were included, with 931 patients in aggregate; therapies included cognitive behavioral and family therapies delivered in populations encompassing addiction disorders, eating disorders, childhood mental health problems, and chronic conditions. Telehealth was delivered by video in 7 trials, by telephone in 3 trials, and by both in 1 trial, and the delivery mode was unclear in 1 trial. The risk of bias for the 12 trials was low or unclear for most domains, except for the lack of the blinding of participants, owing to the nature of the comparison. There were no significant differences in symptom severity between telehealth and face-to-face therapy immediately after treatment (standardized mean difference [SMD] 0.05, 95% CI -0.17 to 0.27) or at any other follow-up time point. Similarly, there were no significant differences immediately after treatment between telehealth and face-to-face care delivery on any of the other outcomes meta-analyzed, including overall improvement (SMD 0.00, 95% CI -0.40 to 0.39), function (SMD 0.13, 95% CI -0.16 to 0.42), working alliance client (SMD 0.11, 95% CI -0.34 to 0.57), working alliance therapist (SMD -0.16, 95% CI -0.91 to 0.59), and client satisfaction (SMD 0.12, 95% CI -0.30 to 0.53), or at any other time point (3, 6, and 12 months).

CONCLUSIONS

With regard to effectively treating less common mental health conditions and physical conditions requiring psychological support, there is insufficient evidence of a difference between psychotherapy delivered via telehealth and the same therapy delivered face-to-face. However, there was no includable evidence in this review for some serious mental health conditions, such as schizophrenia and bipolar disorders, and further high-quality research is needed to determine whether telehealth is a viable, equivalent treatment option for these conditions.

The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.

Therapeutic Alliance in Cognitive Behavioural Therapy in Child and Adolescent Mental Health-Current Trends and Future Challenges

This extended literature review proposes to present the trends in the therapeutic alliance, outcomes, and measures in the last decade within the premises of individual cognitive behaviour therapy (CBT) and its innovations, used as an interventional measure in the context of child and adolescent mental health setting. A brief background of the rationale for conducting this literature search is presented at the start. This is followed by the methodology and design which incorporates the inclusion and exclusion criteria and the basis for the same. The critical appraisal of the primary studies is presented in the literature review section with a brief description of the summary features of the studies in the study tables followed by the results and discussion of the study findings. To summarise, the literature review of primary studies conducted in the last decade demonstrates the need for further research to be conducted both in the field of CBT in children and therapeutic alliance, competence, and therapy outcomes, integrating perspectives in child development, carer alliance, and the social construct theory in children, to allow for further innovations in CBT in the context of increasing challenges in the current times of exponentially developing technology and its utility without compromising the quality of therapy. In conclusion, recommendations are made as a guideline for future studies and research in this field.

'Can you hear me?': communication, relationship and ethics in video-based telepsychiatric consultations

Telepsychiatry has long been discussed as a supplement to or substitute for face-to-face therapeutic consultations. The current pandemic crisis has fueled the development in an unprecedented way. More and more psychiatric consultations are now carried out online as video-based consultations. Treatment results appear to be comparable with those of face-to-face care in terms of clinical outcome, acceptance, adherence and patient satisfaction. However, evidence on videoconferencing in a variety of different fields indicates that there are extensive changes in the communication behaviour in online conversations. We hypothesise that this might impact ethically relevant aspects of the therapeutic relationship, which plays a prominent role in psychiatry. In this paper, we review effects of video-based consultations on communication between therapists and patients in psychiatry. Based on a common understanding of video-based consultations as changing the lived experience of communication, we categorise these effects according to sensory, spatial and technical aspects. Departing from a power-based model of therapeutic relationships, we then discuss the ethical significance of this changed communication situation, based on dimensions of respect for autonomy, lucidity, fidelity, justice and humanity. We conclude that there is evidence for ethically relevant changes of the therapeutic relationship in video-based telepsychiatric consultations. These changes need to be more carefully considered in psychiatric practice and future studies.

Benefits of Digital Mental Health Care Interventions for Correctional Workers and Other Public Safety Personnel: A Narrative Review

Chronic exposure to stressors and potentially psychologically traumatic events contributes to the high prevalence of mental health disorders in correctional workers (CWs) and other public safety personnel (PSP). Digital mental health interventions are an accessible and scalable method of improving and maintaining the mental health of this population. The current review explores the benefits of digital mental health interventions for PSP-with a focus on CWs-and how these innovations can address the limitations in in-person mental health care. A systematic literature search of five databases (Medline, PsycInfo, Embase, CINAHL, Google Scholar) was conducted until March 2022. The search yielded 16 publications that focused on digital mental health interventions or care available to CWs and other PSP. The benefits of digital innovations were summarized into five categories which discussed (1) their ability to enhance accessibility and reduce stigma; (2) the provision of evidence-based and structured psychotherapy programs; (3) variability in the degree of therapist engagement; (4) the integration of proactive interventions; and (5) enhancing engagement by acknowledging unique experiences and interpersonal relationships. Although digital mental health technologies for CWs are still in their infancy, there is strong evidence to support their effectiveness in ameliorating symptoms of mental distress. Future research should consider how ethnicity, gender, culture, sexual orientation, and socioeconomic status can be integrated into these therapies and how the interplay between different stakeholders and organizations can impact the effectiveness of online therapies and programs.

Efficacy of short-term telemedicine motivation-based intervention for individuals with Internet Use Disorder - A pilot-study

BACKGROUND

Internet Use Disorders (IUD) cover a range of online-related behavioral addictions, which are acknowledged and strengthened by the inclusion of (online) gaming disorder in the ICD-11 by the World Health Organization. Internet-based telemedicine interventions offer the possibility to reach out for individuals with IUD where the disorder emerges, in order to enhance their motivation to change their Internet use behavior.

METHODS

In the course of the short-term telemedicine motivation-based intervention, adult participants took part in two webcam-based counselling sessions based on Motivational Interviewing techniques. Two weeks after the first webcam-based counselling session the second took place. Participants completed questionnaires regarding the motivation to change their Internet use behavior (iSOCRATES) and symptoms of IUD (s-IAT) at three times of measurement: t0 (pre-intervention), t1 (mid-intervention) and t2 (post-intervention).

RESULTS

73 affected individuals (83.6% male, average age 35 years (SD = 12.49) took part in the whole intervention including the questionnaire-based post intervention survey (t2). Over the course of the telemedicine intervention, a significant increase in the motivation to change with regard to the own Internet use behavior as well as a significant reduction in the symptom severity of an IUD and duration of Internet use (reduction of 2 hrs/d) were shown.

CONCLUSION

The telemedicine pilot study shows that online-based consultation can be effective and helpful for individuals with IUD. Therefore, such a telemedicine intervention may be a suitable extension to the already existing analogous care system.

Adolescent Perspectives on How an Adjunctive Mobile App for Social Anxiety Treatment Impacts Treatment Engagement in Telehealth Group Therapy

Adjunctive mobile mental health apps to supplement mental health treatment have been growing in recent years given their ability to address treatment engagement barriers. However, few studies have explicitly examined how these mobile apps impact treatment engagement, and even fewer have investigated this topic through adolescents’ perspectives. To this end, we conducted semi-structured interviews with five adolescents who used an adjunctive mobile mental health app in combination with telehealth cognitive behavioral group therapy for social anxiety. Using a multidimensional framework of treatment engagement, we elicited their perspectives on how the app impacted their engagement in telehealth group therapy and gathered their suggestions for improving the app. Using a consensual qualitative research approach, we learned that adolescents felt the app increased their comfort with others in therapy and their expectations about the effectiveness of mental health apps. They also indicated that the app prepared them for in-session participation and facilitated out-of-session skills practice. Adolescents had valuable suggestions such as adding app features to facilitate social connectedness between group members and adding appointment reminders in the app. This preliminary study highlights implications for future adjunctive mobile mental health app developers and researchers to increase adolescents’ treatment engagement in mental health services.

The Impact of COVID-19 on Provider Perceptions of Telemental Health

The present study was designed to assess mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic, as well as the nature of their TMH utilization. The study aimed to gather information about positive and negative attitudes towards TMH, perceptions and correlates based on the modality of care, and beliefs about the overall effectiveness of TMH as compared to face-to-face care. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1448 mental health providers and included demographic and professional information, experiences with and perceptions of TMH prior to and during the COVID-19 Pandemic, as well as a brief measure of pandemic-related stress. The COVID-19 Pandemic resulted in an increased use of TMH in the study sample. During COVID-19, providers reported increased agreement with TMH being necessary, important, and effective for care delivery. Providers who primarily used video, compared with telephone, reported that TMH was more useful, satisfying, and effective. While negative attitude towards TMH was predicted only by prior attitudes and belief in TMH effectiveness, positive attitude towards TMH was also predicted by female sex and current level of pandemic related stress. TMH use during the pandemic was predicted by primary use of video platform and previous TMH use. The 2020 COVID-19 Pandemic resulted in increased use of TMH and significantly increased positive perceptions about TMH among mental health providers.

Provision of Psychodynamic Psychotherapy in Austria during the COVID-19 Pandemic: A Cross-Sectional Study

The COVID-19 pandemic has brought massive changes in the provision of psychotherapy. To avoid or reduce the risk of infection, many therapists switched from face-to-face sessions in personal contact to remote psychotherapy, i.e., psychotherapy delivered by telephone or videoconferencing. This study examined the attitudes toward and practice of remote psychotherapy among Austrian therapists with a psychodynamic orientation at the onset of the pandemic as well as changes in the therapeutic process that were experienced by the therapists due to switching to a remote setting. A total of 161 therapists with psychodynamic orientation took part in an online survey. The results show that attitudes toward remote psychotherapy changed positively in psychodynamically orientated therapists and most are willing to switch to remote settings, if necessary. However, many therapists reported negative effects of remote psychotherapy and prefer seeing their patients in-person. The strongest changes were experienced with regard to transference/countertransference, the therapeutic process and the intensity of session. The analysis further revealed an overall decrease in the number of patients treated, indicating an undersupply of psychotherapy, at least during the first wave of COVID-19 infection in Austria. In summary, the experience during the first COVID-19 lockdown has led to an increase in remote psychotherapy and more openness toward these treatment modalities among psychodynamically oriented therapists. However, in-person therapy will remain the first choice for most therapists.

Use of Telemedicine in Depression Care by Physicians: Scoping Review

BACKGROUND

Depression is a common disorder, and it creates burdens on people's mental and physical health as well as societal costs. Although traditional in-person consultations are the usual mode of caring for patients with depression, telemedicine may be well suited to psychiatric assessment and management. Telepsychiatry can be defined as the use of information and communication technologies such as videoconferencing and telephone calls for the care of psychopathologies.

OBJECTIVE

This review aims to evaluate the extent and nature of the existing literature on the use of telemedicine for the care of depression by physicians. This review also aims to examine the effects and perceptions regarding this virtual care and determine how it compares to traditional in-person care.

METHODS

The Arksey and O'Malley framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were followed. Relevant articles were identified through a search of three databases (MEDLINE, Cochrane Database of Systematic Reviews, and PsycArticles) on October 11, 2020. The search terms were "(virtual OR telemedicine OR teleconsultation* OR telehealth OR phone* OR webcam* OR telepsychiatry) AND (depress*)". Eligibility criteria were applied to select studies about the use of telemedicine for the care of patients with depression specifically by physicians. An Excel file (Microsoft Corporation) was used to chart data from all included articles.

RESULTS

The search resulted in the identification of 28 articles, and all 13 nonreview studies were analyzed in detail. Most nonreview studies were conducted in the United States during the last decade. Most telemedicine programs were led by psychiatrists, and the average study population size was 135. In all applicable studies, telepsychiatry tended to perform at least as well as in-person care regarding improvement in depression severity, patient satisfaction, quality of life, functioning, cost-effectiveness, and most other perceptions and variables. Cultural sensitivity and collaborative care were part of the design of some telemedicine programs.

CONCLUSIONS

Additional randomized, high-quality studies are recommended to evaluate various outcomes of the use of telemedicine for depression care, including depression variables, perceptions, health care outcomes and other outcomes. Studies should be conducted in various clinical contexts, including primary care. Telepsychiatry is a promising modality of care for patients suffering from depression.

Therapists' Experience of Video Consultation in Specialized Mental Health Services During the COVID-19 Pandemic: Qualitative Interview Study

Background

As part of political and professional development with increased focus on including service users within mental health services, these services are being transformed. Specifically, they are shifting from institutional to noninstitutional care provision with increased integration of the use of electronic health and digitalization. In the period from March to May 2020, COVID-19 restrictions forced rapid changes in the organization and provision of mental health services through the increased use of digital solutions in therapy.

Objective

The aim of this study was to develop and advance comprehensive knowledge about how therapists experience the use of video consultation (VC). To reach this objective, we evaluated therapists’ experiences of using VC in specialized mental health services in the early phase of COVID-19 restrictions. The following questions were explored through interviews: Which opportunities and challenges appeared when using VC during the period of COVID-19 restrictions? In a short-term care pathway, for whom does VC work and for whom does it not work?

Methods

This study employed a qualitative approach based on an abductive strategy and hermeneutic-phenomenological methodology. Therapists and managers in mental health departments in a hospital were interviewed via Skype for Business from March to May 2020, using a thematic interview guide that aimed to encourage reflections on the use of VC during COVID-19 restrictions.

Results

Therapists included in this study experienced advantages in using VC under circumstances that did not permit face-to-face consultations. The continuity that VC offered the service users was seen as a valuable asset. Various negative aspects concerning the therapeutic environment such as lack of safety for the most vulnerable service users and topics deemed unsuitable for VC lowered the therapists’ overall impression of the service. The themes that arose in the data analysis have been categorized in the following main topics: (1) VC—“it’s better than nothing”; (2) VC affects therapists’ work situation—opportunities and challenges in working conditions; and (3) challenges of VC when performing professional assessment and therapy on the screen.

Conclusions

Experiences with VC in a mental health hospital during COVID-19 restrictions indicate that there are overall advantages to using VC when circumstances do not permit face-to-face consultations. Nevertheless, various negative aspects in the use of VC lowered the therapists’ overall impression of VC. Further qualitative research is needed, and future studies should focus on service users’ experiences, cocreation between different stakeholders, and how to scale up the use of VC while ensuring that the service provided is appropriate, safe, and available.

Seeing the Value of Video: A Qualitative Study on Patient Preference for Using Video in a Veteran Affairs Telemental Health Program Evaluation

Background: As the use of telemental health-mental health care delivered through video or phone-has increased in the era of COVID, it is important to understand patients' preferences and perspectives regarding the use of video for telehealth visits. A new web-based treatment program for veterans uses video visits with mental health experts to supplement its online cognitive behavioral therapy to treat clinically significant symptoms of depression and/or post-traumatic stress disorder. Objective: As part of the program evaluation, Veterans were asked, "How important was it for you to be able to physically see your provider through video telehealth?" to understand whether they thought using video was important and why it may or may not be important. Materials and Methods: The study uses data from the program's exit survey and exit interview. The surveys and interviews were conducted over a 19-month period. Surveys and interviews were conducted over the phone with note taking. Matrix and content analyses were used to analyze the qualitative data-predetermined themes and emergent themes were analyzed and inform findings. Results: Seventy-three veterans completed a survey. Of these, 64 completed an interview. The majority of veterans surveyed (75%) said that it was "very important" to physically see their provider through video telehealth, 23% said that it was at least "somewhat important" or "not at all important." This study highlights three main themes found in the qualitative data: patients discuss (1) advantages of using video, (2) why they dislike video, and (3) technological barriers to using video. Conclusions: Being able to visually see a provider, and be seen by a provider, has distinct benefits for care and relationship building that are difficult to achieve over the phone. This has important implications for the future delivery of telemental health care and deserves consideration as patients and providers decide whether to use phone or video for remotely delivered care.

Provision of Psychotherapy One Year after the Beginning of the COVID-19 Pandemic in Austria

A previous study revealed that the majority of Austrian psychotherapists switched to remote settings during the first months of the COVID-19 pandemic. The current study investigated whether this change in treatment format was maintained after one year of the COVID-19 pandemic. From 16 February until 2 April 2021, a total of 238 Austrian psychotherapists completed an online survey. They were asked about the number of patients currently treated in-person, via telephone and via the internet. Psychotherapists rated three different aspects of psychotherapy (ability to actively listen to patients, ability to understand what is going on in the patients and ability to support patients emotionally) for three different formats (in-person with facemasks, telephone and internet) separately. The results show that, after one year of the pandemic, the majority (78.4%) of patients were treated in-person (compared to 21.7% during the first months of the COVID-19 pandemic; p < 0.001). This change in the treatment format was accompanied by a strong increase in the total number of patients treated by 77.2% on average (p < 0.001). Psychotherapists reported no differences between in-person psychotherapy with facemasks and psychotherapy via the internet with regard to the three investigated aspects of psychotherapy, while the surveyed aspects were rated less favorably for psychotherapy conducted via telephonic communication (p < 0.05). Further studies are needed to investigate the reasons why most psychotherapists switched back to the in-person format with the continuation of the COVID-19 pandemic.

Treatment provision for adults with ADHD during the COVID-19 pandemic: an exploratory study on patient and therapist experience with on-site sessions using face masks vs. telepsychiatric sessions

BACKGROUND

Maintaining the therapeutic care of psychiatric patients during the first wave of the COVID-19 pandemic in Switzerland required changes to the way in which sessions were conducted, such as telepsychiatric interventions or using face masks during on-site sessions. While little is known about how face masks affect the therapeutic experience of patients and therapists, the effectiveness of telepsychiatry is well documented for several psychiatric disorders. However, research on the benefits of telepsychiatry in adult patients with attention-deficit/hyperactivity disorder (ADHD) remains scarce. This seems problematic since the symptoms typically associated with ADHD, such as attention problems and distractibility, may lessen the utility of telepsychiatry for this particular group. The present study's aim was to explore how adult patients with ADHD and their therapists experienced therapy sessions during the COVID-19 pandemic in three different settings: face-to-face with the therapist wearing a face mask, via telephone, or via videoconferencing.

METHODS

In this exploratory, quantitatively driven mixed-method study (quantitative questionnaire data and qualitative data from open-ended responses), we assessed patients' evaluation of the session, their treatment satisfaction, and patients' and therapists' ratings of therapeutic alliance. We also collected qualitative comments on both sides' experience of the session. Overall, 97 therapist and 66 patient questionnaires were completed. Results are reported for the N = 60 cases for which data from both parties were available. Sequential multiple regressions adjusted for therapist and number of sessions were used for the main quantitative analyses.

RESULTS

No statistically significant differences regarding session flow, post-session positivity, satisfaction and therapeutic alliance were observed. The only exception was that telepsychiatric sessions were rated as significantly less deep than face-to-face sessions, an effect that may decline over time, especially in the videoconferencing group. Patients and therapists identified similar facilitating and complicating aspects, but differed in their emphasis of specific elements.

CONCLUSIONS

Both settings, on-site with the therapist wearing a face mask and telepsychiatric, seem to be valid options to continue treatment of adults with ADHD during a situation such as the COVID-19 pandemic. Aspects such as patient preference, session content, and therapeutic methods may be useful to identify the most suitable modality.

Videoconferencing Psychotherapy During the Pandemic: Exceptional Times With Enduring Effects?

With the advent of COVID-19, a sudden, unexpected, and forced shift has been produced in the field of psychotherapy. Worldwide, many therapists closed their offices and started to deliver psychotherapy online through a screen. Although different media started to be incorporated, videoconferencing is undoubtedly the most common way in which therapists are doing therapy these days. This is catalyzing a rapid change in the practice of psychotherapy with probable lasting effects and deserves to be carefully reflected upon. Therefore, in this paper our aim is to outline the main challenges for a medium that may have arrived to stay. In that sense, we review the literature to describe the state-of-the-art regarding the main aspects of videoconferencing psychotherapy as well as to suggest possible avenues for future research and practice.

Higher Acceptance of Videotelephonic Counseling Formats in Psychosomatic Medicine in Times of the COVID-19 Pandemic

Background: Due to the COVID-19 pandemic, the healthcare system in general and psychosomatics in particular were forced to change counseling-specific services and break up established structures. At the beginning of 2020, phone as well as videotelephonic counseling options had to be quickly established. Methods: Patients (n = 278) of the department of psychosomatic medicine and psychotherapy at the University Hospital Tübingen were asked to complete an ad hoc questionnaire to assess the acceptance of the counseling format following each counseling session (office, phone, video) in the period between July 2020 and February 2021. Results: Satisfaction and acceptance of the three counseling formats (office, phone, video) were rated (1-6) on average as "good" to "very good" in the three subgroups (1.5 ± 0.9). Likewise, the "therapeutic relationship" scored high in all three subgroups in terms of establishing a strong therapeutic relationship (4.4 ± 1.5). "Hurdles" were rated as low and tolerable (1.8 ± 1.3). The global assessment of therapeutic contact was significantly better in the video group compared to phone and office consultation (p < 0.05). Predictor analyses showed that there was an influence of age, but not gender, on the acceptance of digital counseling formats in the present sample [F _{(1, 277)} = 4.50, p = 0.04]. Discussion & Conclusion: Digital consultation formats were perceived by patients as promising addition to the classic face-to-face setting. Digital formats (phone, video) were not generally preferred to face-to-face counseling, but especially video counseling was accepted and perceived with great satisfaction and acceptance. Accordingly, the additional use of digital counseling formats, especially video-telephony, could be an opportunity to enrich the existing structures also after the pandemic.

Heartrate variability biofeedback for migraine using a smartphone application and sensor: A randomized controlled trial

INTRODUCTION

Although hand temperature and electromyograph biofeedback have evidence for migraine prevention, to date, no study has evaluated heartrate variability (HRV) biofeedback for migraine.

METHODS

2-arm randomized trial comparing an 8-week app-based HRV biofeedback (HeartMath) to waitlist control. Feasibility/acceptability outcomes included number and duration of sessions, satisfaction, barriers and adverse events. Primary clinical outcome was Migraine-Specific Quality of Life Questionnaire (MSQv2).

RESULTS

There were 52 participants (26/arm). On average, participants randomized to the Hearthmath group completed 29 sessions (SD = 29, range: 2-86) with an average length of 6:43 min over 36 days (SD = 27, range: 0, 88) before discontinuing. 9/29 reported technology barriers. 43% said that they were likely to recommend Heartmath to others. Average MSQv2 decreases were not significant between the Heartmath and waitlist control (estimate = 0.3, 95% CI = -3.1 - 3.6). High users of Heartmath reported a reduction in MSQv2 at day 30 (-12.3 points, p = 0.010) while low users did not (p = 0.765).

DISCUSSION

App-based HRV biofeedback was feasible and acceptable on a time-limited basis for people with migraine. Changes in the primary clinical outcome did not differ between biofeedback and control; however, high users of the app reported more benefit than low users.

Intent to Adopt Video-Based Integrated Mental Health Care and the Characteristics of its Supporters: Mixed Methods Study Among General Practitioners Applying Diffusion of Innovations Theory

BACKGROUND

Most people with common mental disorders, including those with severe mental illness, are treated in general practice. Video-based integrated care models featuring mental health specialist video consultations (MHSVC) facilitate the involvement of specialist mental health care. However, the potential uptake by general practitioners (GPs) is unclear.

OBJECTIVE

This mixed method preimplementation study aims to assess GPs' intent to adopt MHSVC in their practice, identify predictors for early intent to adopt (quantitative strand), and characterize GPs with early intent to adopt based on the Diffusion of Innovations Theory (DOI) theory (qualitative strand).

METHODS

Applying a convergent parallel design, we conducted a survey of 177 GPs and followed it up with focus groups and individual interviews for a sample of 5 early adopters and 1 nonadopter. We identified predictors for intent to adopt through a cumulative logit model for ordinal multicategory responses for data with a proportional odds structure. A total of 2 coders independently analyzed the qualitative data, deriving common characteristics across the 5 early adopters. We interpreted the qualitative findings accounting for the generalized adopter categories of DOI.

RESULTS

This study found that about one in two GPs (87/176, 49.4%) assumed that patients would benefit from an MHSVC service model, about one in three GPs (62/176, 35.2%) intended to adopt such a model, the availability of a designated room was the only significant predictor of intent to adopt in GPs (β=2.03, SE 0.345, P<.001), supporting GPs expected to save time and took a solution-focused perspective on the practical implementation of MHSVC, and characteristics of supporting and nonsupporting GPs in the context of MHSVC corresponded well with the generalized adopter categories conceptualized in the DOI.

CONCLUSIONS

A significant proportion of GPs may function as early adopters and key stakeholders to facilitate the spread of MHSVC. Indeed, our findings correspond well with increasing utilization rates of telehealth in primary care and specialist health care services (eg, mental health facilities and community-based, federally qualified health centers in the United States). Future work should focus on specific measures to foster the intention to adopt among hesitant GPs.

'Precision' or 'personalized' psychiatry: different terms - same content?

Due to the increased lifetime prevalence and personal, social, and economic burden of mental disorders, psychiatry is in need of a significant change in several aspects of its clinical and research approaches. Over the last few decades, the development of personalized / precision medicine in psychiatry focusing on tailored therapies that fit each patient's unique individual, physiological, and genetic profile has not achieved the same results as those obtained in other branches, such as oncology. The long-awaited revolution has not yet surfaced. There are various explanations for this including imprecise diagnostic criteria, incomplete understanding of the molecular pathology involved, absence of available clinical tools and, finally, the characteristics of the patient. Since then, the co-existence of the two terms has sparked a great deal of discussion around the definition and differentiation between the two types of psychiatry, as they often seem similar or even superimposable. Generally, the two terminologies are used indiscriminately, alternatively, and / or separately, within the same scientific works. In this paper, an overview is provided on the overlap between the application and meaning of the terms 'precision psychiatry' and 'personalized psychiatry'.

Sharing clinical notes, and placebo and nocebo effects: Can documentation affect patient health?

This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.

Coping with the COVID-19 crisis: an overview of service adaptation and challenges encountered by a rural Psychiatry of Later Life (POLL) team

The COVID-19 pandemic has posed many challenges in maintaining standards of care and treatment for patients while managing the increased anxieties of patients, carers and the public in general. This paper highlights several clinical, administrative, medicolegal and IT implications of COVID-19 on the delivery of mental healthcare to an elderly vulnerable patient cohort due to recommended social distancing measures. Our Psychiatry of Later Life team has adapted to this by restricting face-to-face consultation, while continuing to provide telephone support. We have modified our documentation standard and have improved some aspects of our team working by facilitating flexible working arrangement and relevant training for staff as well as by embracing new technology. Notwithstanding the challenges therefore, this exceptional time has also opened avenues for new and innovative opportunities that can be further explored even when the current crisis eventually passes.

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.

Strategies to enhance communication with telemental health measurement-based care (tMBC)

Telehealth has always held great promise to increase access to mental health care, never more so than in the age of COVID-19, when clients can't or won't come to the clinician's physical location. A feasible and effective alternative to traditional in-person care, telemental health requires that clinicians adopt new strategies to build and maintain communication and the therapeutic relationship. This can be particularly troublesome for clinicians new to the modality, who may feel the loss of the "in-session" experience more acutely. As an evidence-based practice that is transtheoretical and transdiagnostic, telemental health measurement-based care (tMBC) is the ideal complement to enhance systematic ongoing monitoring, treatment engagement, and therapeutic alliance in the context of the virtual encounter. While tMBC mechanisms of actions are still being explored, there is promising evidence that tMBC improves clinician responsivity to acute client concerns. By using client-reported measures, tMBC provides an important pathway for clients to systematically communicate with their clinicians, which can guide therapeutic actions and contribute to shared understanding. This brief report summarizes the evidence for tMBC as a patient-centered communication tool and provides recommendations for evidence-based and practice-informed strategies to integrate tMBC into telehealth solutions, with suggestions for monitoring new concerns related to the COVID-19 crisis.

Changes in Provision of Psychotherapy in the Early Weeks of the COVID-19 Lockdown in Austria

Reducing personal contacts is a central measure against the spreading of the novel coronavirus disease (COVID-19). This troubles mental health, but also mental health care as treatments usually take place in personal contact and switching to remote treatments might be necessary in times of COVID-19. The present study investigated the question how the provision of psychotherapy changed in the early weeks of the COVID-19 lockdown in Austria and whether there were differences between the four therapeutic orientations eligible in Austria (psychodynamic, humanistic, systemic, behavioral). Psychotherapists (N = 1547) completed an online survey. They entered their number of patients treated on average per week (in personal contact, via telephone, via Internet) in the early weeks of the COVID-19 lockdown in Austria as well as (retrospectively) in the months before. The number of patients treated on average per week in personal contact decreased (on average 81%; p < 0.001), whereas the number of patients treated on average per week via telephone and via Internet increased (on average 979% and 1561%; both p < 0.001). Yet, the decrease of psychotherapies through personal contact was not compensated for by increases of remote psychotherapies (p < 0.001). No differences between the four therapeutic orientations emerged. Results imply an undersupply of psychotherapy in the COVID-19 lockdown and that further changes are necessary to cover the increased need for timely psychotherapy in times of COVID-19.

Computer-Assisted CBT and Mobile Apps for Depression: Assessment and Integration Into Clinical Care

A surge in the development of computer-assisted cognitive-behavioral therapy (CCBT) and mobile apps for depression has provided many tools with potential for enhancing treatment delivery. This article assesses progress in evaluation and implementation of CCBT and mobile apps for depression, with a focus on providing practical information on clinical applications. Advantage and disadvantages of these technologies are identified, outcome research is reviewed, and recommendations are made for clinical use. With increasing use of computer technology in everyday life, it is likely that clinicians and patients will pursue opportunities to employ computer tools in treatment for depression.