Evidence-based practice for telemental health

Generating normative data from web-based administration of the Cambridge Neuropsychological Test Automated Battery using a Bayesian framework

Introduction

Normative cognitive data can distinguish impairment from healthy cognitive function and pathological decline from normal ageing. Traditional methods for deriving normative data typically require extremely large samples of healthy participants, stratifying test variation by pre-specified age groups and key demographic features (age, sex, education). Linear regression approaches can provide normative data from more sparsely sampled datasets, but non-normal distributions of many cognitive test results may lead to violation of model assumptions, limiting generalisability.

Method

The current study proposes a novel Bayesian framework for normative data generation. Participants (n = 728; 368 male and 360 female, age 18-75 years), completed the Cambridge Neuropsychological Test Automated Battery via the research crowdsourcing website Prolific.ac. Participants completed tests of visuospatial recognition memory (Spatial Working Memory test), visual episodic memory (Paired Associate Learning test) and sustained attention (Rapid Visual Information Processing test). Test outcomes were modelled as a function of age using Bayesian Generalised Linear Models, which were able to derive posterior distributions of the authentic data, drawing from a wide family of distributions. Markov Chain Monte Carlo algorithms generated a large synthetic dataset from posterior distributions for each outcome measure, capturing normative distributions of cognition as a function of age, sex and education.

Results

Comparison with stratified and linear regression methods showed converging results, with the Bayesian approach producing similar age, sex and education trends in the data, and similar categorisation of individual performance levels.

Conclusion

This study documents a novel, reproducible and robust method for describing normative cognitive performance with ageing using a large dataset.

Attitudes of Mental Health Professionals towards Telepsychology during the Pandemic: A Pilot Study

OBJECTIVE

This pilot study investigated mental health professionals' attitudes towards remote psychological consultations and internet-based interventions.

METHODS

An online survey in Italian and English was administered to a sample of 191 psychologists and psychotherapists to collect detailed information about their professional experience providing online psychological interventions a year and a half after the beginning of the SARS-CoV-2 pandemic.

RESULTS

The results did not reveal a statistically significant association between the participants' theoretical approaches and the number of patients treated via the online modality. Overall, most of the participants found advantages to the online setting but also noted critical issues regarding privacy and the ease of integrating new technology into their clinical practice.

CONCLUSIONS

According to the participants, despite the challenges that must be addressed, telehealth is a viable psychological therapeutic option that is destined to grow in importance in the near future.

Virtuele gezinsgerichte speltherapie: een klinische handleiding voor directieve gezinsgerichte speltherapie in online geestelijke gezondheidszorg

Relatietherapie en gezinstherapie zijn door vernieuwers en pioniers ontwikkeld, waarbij de individuele psychotherapie is omgevormd tot systeemtherapie. Ten gevolge van COVID-19 moeten systeemtherapeuten zich nu verder ontwikkelen om online geestelijke gezondheidszorg te kunnen aanbieden. In dit artikel geven we aanbevelingen en richtlijnen om een directieve gezinsgerichte speltherapie op eenzelfde fysieke locatie aan te passen naar online geestelijke gezondheidszorg. In dit artikel worden aanbevelingen besproken voor de evaluatie en structuur van de therapie, de taken van de therapeut, de voorbereiding van de sessie en voor hoe virtuele middelen kunnen worden ingezet om de therapie te versterken. Systemische speltherapie in een virtuele opzet kan goed werken als therapeuten de juiste aanpassingen doen, als zij vertrouwen op hun creativiteit, als zij ethisch te werk gaan en als zij durven te vernieuwen.

Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines

Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

Virtual Family Play Therapy: A Clinician's Guide to using Directed Family Play Therapy in Telemental Health

The field of marriage and family therapy was founded by innovators and pioneers, taking the practice of individual psychotherapy and making it systemic. Due to the impact of COVID-19, we now need further advancement by systemic therapists for telemental health services. The purpose of this paper is to propose recommendations and guidelines for adapting directed family play therapy from the same physical location services to telemental health. The article discusses recommendations for assessment, therapy structure, therapist roles, session preparation, and how to use virtual tools to enhance treatment. Systemic play therapy in a virtual format can work well if therapists make appropriate adjustments and rely on their creativity, high regard for ethics, and innovation.

A prospective study of remote delirium screening using the modified K-4AT for COVID-19 inpatients

Background

Delirium is a neuropsychiatric condition strongly associated with poor clinical outcomes such as high mortality and long hospitalization. In the patients with Coronavirus disease 2019 (COVID-19), delirium is common and it is considered as one of the risk factors for mortality. For those admitted to negative-pressure isolation units, a reliable, validated and contact-free delirium screening tool is required.

Materials and methods

We prospectively recruited eligible patients from multiple medical centers in South Korea. Delirium was evaluated using the Confusion Assessment Method (CAM) and 4'A's Test (4AT). The attentional component of the 4AT was modified such that respondents are required to count days, rather than months, backward in Korean. Blinded medical staff evaluated all patients and determined whether their symptoms met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). An independent population of COVID-19 patients was used to validate the 4AT as a remote delirium screening tool. We calculated the area under the receiver operating characteristic curve (AUC).

Results

Out of 286 general inpatients, 28 (9.8%) inpatients had delirium. In this population, the patients with delirium were significantly older (p = 0.018) than the patients without delirium, and higher proportion of males were included in the delirium group (p < 0.001). The AUC of the 4AT was 0.992 [95% confidence interval (CI) 0.983-1.000] and the optimal cutoff was at 3. Of the independent COVID-19 patients, 13 of 108 (12.0%) had delirium. Demographically, the COVID-19 patients who had delirium only differed in employment status (p = 0.047) from the COVID-19 patients who did not have delirium. The AUC for remote screening using the 4AT was 0.996 (0.989-1.000). The optimal cutoff of this population was also at 3.

Conclusion

The modified K-4AT had acceptable reliability and validity when used to screen inpatients for delirium. More importantly, the 4AT efficiently screened for delirium during remote evaluations of COVID-19 patients, and the optimal cutoff was 3. The protocol presented herein can be used for remote screening of delirium using the 4AT.

Estimators for handling COVID-19-related intercurrent events with a hypothetical strategy

The COVID-19 pandemic has affected clinical trials across disease areas, raising the questions how interpretable results can be obtained from impacted studies. Applying the estimands framework, analyses may seek to estimate the treatment effect in the hypothetical absence of such impact. However, no established estimators exist. This simulation study, based on an ongoing clinical trial in patients with Tourette syndrome, compares the performance of candidate estimators for estimands including either a continuous or binary variable and applying a hypothetical strategy for COVID-19-related intercurrent events (IE). The performance is investigated in a wide range of scenarios, under the null and the alternative hypotheses, including different modeling assumptions for the effect of the IE and proportions of affected patients ranging from 10% to 80%. Bias and type I error inflation were minimal or absent for most estimators under most scenarios, with only multiple imputation- and weighting-based methods displaying a type I error inflation in some scenarios. Of more concern, all methods that discarded post-IE data displayed a sharp decrease of power proportional to the proportion of affected patients, corresponding to both a reduced precision of estimation and larger confidence intervals. The simulation study shows that de-mediation via g-estimation is a promising approach. Besides showing the best performance in our simulation study, these approaches allow to estimate the effect of the IE on the outcome and cross-compare between different studies affected by similar IEs. Importantly, the results can be extrapolated to IEs not related to COVID-19 that follow a similar causal structure.

Expectations and Concerns about the Use of Telemedicine for Autism Spectrum Disorder: A Cross-Sectional Survey of Parents and Healthcare Professionals

Telemedicine has recently been used for diagnosis and interventions inpatients with autism spectrum disorder (ASD), traditionally performed in-person, but little attention has been paid to user expectations prior to its use. The aim of this study is to compare the expectations and concerns of 50 healthcare professionals and 45 parents of children with ASD regarding the use of telemedicine for diagnostic or treatment purposes. Parents have higher expectations for the use of telemedicine as an alternative (p = 0.0223) and supplement (p = 0.0061) to in-person diagnosis of ASD, as well as a supplement to traditional intervention (p ≤ 0.0001). In addition, while they also have greater hope for improvement in family routines (p = 0.0034) and parenting skills in child management (p = 0.0147), they express greater concern about the need for active parental involvement/supervision during telemedicine services (p = 0.015) and changes in the behaviour of the child with ASD during telemedicine services (p = 0.049). On the other hand, healthcare professionals are more concerned about barriers such as lack of devices (p = 0.000), unfamiliarity with the technology (p = 0.000), poor quality of internet connection (p = 0.006), and severity of ASD (p = 0.000). To achieve promising healthcare for ASD patients, the telemedicine service should try to meet the needs and preferences of both healthcare professionals and parents, as well as identify and, if possible, reduce perceived barriers.

Can the Rorschach be Administered Remotely? A Review of Options and a Pilot Study Using a Newly Developed R-PAS App

The ongoing COVID-19 pandemic has required psychologists to adopt measures like physical distancing and mask wearing, though other safety procedures such as travel restrictions or prohibitions on in-person practice and research have fostered the use of tele-health tools. In this article, we review options for using the Rorschach task via videoconference and provide preliminary data from using a new electronic app for remote R-PAS administration to determine whether the remote administration in an electronic form yields different information than in-person administration with the cards in hand. As a pilot study, our focus is on the "first factor" of all Rorschach scores, i.e., complexity. Data were collected from 60 adult Italian community volunteers, and statistical analyses evaluated the extent to which the average complexity score significantly departed from R-PAS normative expectations (SS = 100), accompanied by Bayesian likelihoods for supporting the null hypothesis. Results suggest that the general level of complexity shown by the test-takers when administered the Rorschach remotely with the new R-PAS app closely resembles that previously observed using "standard" in-person procedures. Tentative analyses of other R-PAS scores suggested normative departures that could be due to the effects of the app, testing at home, or responses to the pandemic. We offer recommendations for future research and discuss practical implications.

A scoping review of telehealth diagnosis of autism spectrum disorder

Background

Considering the COVID-19 pandemic, understanding the reliability, validity, social validity, and feasibility of using telehealth to diagnose ASD is a critical public health issue. This paper examines evidence supporting the use of telehealth methods to diagnose ASD and outlines the necessary modifications and adaptations to support telehealth diagnosis.

Methods and procedures

Studies were identified by searching PubMed and PsychInfo electronic databases and references lists of relevant articles. Only peer reviewed articles published in English with a focus on using telehealth for the purposes of diagnosing ASD were included. Searches were conducted through June 3^rd, 2021.

Outcomes and results

A total of 10 studies were identified as meeting inclusion criteria. Of the eight papers that reported on reliability (e.g., accuracy), telehealth methods to diagnose ASD were between 80–91% accurate when compared with traditional in-person diagnosis. Six studies reported on validity (i.e., sensitivity and/or specificity). All six studies calculated sensitivity, with values ranging from 75% and 100%. Five of the six studies calculated specificity, with values ranging from 68.75% and 100%. The seven papers that reported social validity indicated that caregivers, as well as adult participants and clinicians, were mostly satisfied with telehealth. Feasibility was reported by seven studies and suggests that telehealth methods appear largely viable, though some challenges were reported.

Conclusions and implications

Although findings reviewed here are promising, more research is needed to verify the accuracy, validity, and feasibility of utilizing telehealth to diagnose ASD. Studies with larger sample sizes and samples across sites will be critical, as these will allow clinicians to identify subjects most likely to benefit from telehealth as well as those more likely to require an in-person assessment. This research is important not only due to the current pandemic, but also due to increased prevalence rates of ASD and an insufficient number of diagnostic providers—particularly in rural and/or otherwise under-served communities.

Lessons for psychiatrists from the COVID pandemic: the need for expanded roles and additional competencies

The disaster of the COVID-19 pandemic has fundamentally changed the norms of psychiatric practice: from its methods of care delivery to its methods of practice. Traditional methods of care delivery using in-person visits became impractical or unsafe. Meanwhile, the pandemic has resulted in an increased demand for services. The resulting pivot to telepsychiatry required a skillset that was not a part of traditional psychiatry training. To meet the demand for services, many providers needed to join collaborative models of care to help scale their expertise. Although many innovative collaborative models of care exist, providers remain in their traditional consultative roles within many of those models. In a disaster, when there is an expanding mental health care need in the population, psychiatrists need to adapt their practice to meet expanded roles that naturally build on their usual ones. We explore the expanded roles that psychiatrists will need to fill based on what is known about the field of disaster mental health and principles from Psychological First Aid (PFA). In preparation for a new normal, in what George Everly describes as a 'disaster of uncertainty,' we propose evolutions in the way psychiatrists are trained. Specific training on telepsychiatry best practices will prepare psychiatrists to use this method most effectively and appropriately. Additional training should focus on the core competencies of disaster psychiatry: effective crisis leadership and strategic planning, disaster surveillance, knowledge of benign vs. concerning symptoms, psychological triage, implementation of crisis interventions, resource facilitation, crisis communication, and self and peer care. Developing and integrating these competencies into psychiatry training programs will best prepare psychiatrists for the expanding mental health care needs of the community in this ongoing disaster and future ones.

Rapid Adoption and Implementation of Telehealth Group Psychotherapy During COVID 19: Practical Strategies and Recommendations

Behavioral health services have been tasked with rapidly adopting and implementing teletherapy during the SARS-CoV-2/COVID-19 pandemic to assure patient and staff safety. Existing teletherapy guidelines were developed prior to the pandemic and do not capture the nuances of rapidly transitioning in-person individual and group-based treatments to a teletherapy format. In this paper, we describe our approach to quickly adapting to a teletherapy technology platform for an intensive outpatient program (IOP) guided by cognitive and behavioral modular principles for adults with serious mental illness. A review of existing guidelines was conducted and the staged approach for teletherapy implementation (Muir et al., 2020) was selected as the most appropriate model for our organizational context. We describe the most pertinent implementation strategies and report our preliminary findings detailing the feasibility of IOPs delivered via telehealth. This model of rapid teletherapy implementation offers practical clinical guidelines for administrators and clinicians seeking to transition traditional in-person behavioral health services to a teletherapy format.

Couple teletherapy in the era of COVID-19: Experiences and recommendations

The unprecedented times of the novel Coronavirus quarantine and subsequent stay-at-home orders have changed the way many couple therapists provide clinical services. Understanding couple therapists' experiences with teletherapy is important for optimizing future telehealth delivery with couples. Thus, the purpose of this mixed methods survey study was to explore couple therapists' experiences of transitioning from in-person/traditional therapy to online/telehealth delivery. A total of 58 couple therapists completed an online survey for this study. Reported are both quantitative and qualitative findings. Overall, this study found that couple therapists experienced a positive shift from traditional/in-person therapy to online/telehealth therapy, with a majority of couple therapists (74%) reporting they would continue providing teletherapy after the novel Coronavirus pandemic and social distancing regulations had ended. Thematic analysis was used to identify themes from couple therapists' experiences related to advantages, challenges, and recommendations for practice. Implications for clinical training and future research are discussed.

Potential impact of COVID-19 on ongoing clinical trials: a simulation study with the neurological Yale Global Tic Severity Scale based on the CANNA-TICS study

The COVID‐19 pandemic has manifold impacts on clinical trials. In response, drug regulatory agencies and public health bodies have issued guidance on how to assess potential impacts on ongoing clinical trials and stress the importance of a risk‐assessment as a pre‐requisite for modifications to the clinical trial conduct. This article presents a simulation study to assess the impact on the power of an ongoing clinical trial without the need to unblind trial data and compromise trial integrity. In the context of the CANNA‐TICS trial, investigating the effect of nabiximols on reducing the total tic score of the Yale Global Tic Severity Scale (YGTSS‐TTS) in patients with chronic tic disorders and Tourette syndrome, the impact of the two COVID‐19 related intercurrent events handled by a treatment policy strategy is investigated using a multiplicative and additive data generating model. The empirical power is examined for the analysis of the YGTSS‐TTS as a continuous and dichotomized endpoint using analysis techniques adjusted and unadjusted for the occurrence of the intercurrent event. In the investigated scenarios, the simulation studies showed that substantial power losses are possible, potentially making sample size increases necessary to retain sufficient power. However, we were also able to identify scenarios with only limited loss of power. By adjusting for the occurrence of the intercurrent event, the power loss could be diminished to different degrees in most scenarios. In summary, the presented risk assessment approach may support decisions on trial modifications like sample size increases, while maintaining trial integrity.

Pediatric behavioral telehealth in the age of COVID-19: Brief evidence review and practice considerations

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

Using telehealth to assess depression and suicide ideation and provide mental health interventions to groups of chronically ill adolescents and young adults

Telehealth distance health care is a significant resource for young, chronically ill patient populations given their numerous medical complexities and their concomitant depression and/or suicide ideation experiences. This manuscript shares the telehealth methods used to prepare for a larger study of interventions for increasing adolescents' and young adults' chronic care resiliency and skills for preventing depression. The young patients in this study were prescribed lifelong home parenteral nutrition infusions, treatment for those with short gut bowel diseases. The training methods for our mental health nurse and psychologist to conduct depression and suicide ideation assessments from a distance are presented. The study implementation methods of group facilitated interventions and discussion are reviewed. The group discussions were conducted via audiovisual telehealth devices over encrypted firewall-protected connections with patients in their own homes and professionals in an office. The results of assessments of the 40 participants, 25% (n = 10) with depressive symptoms or suicide ideation, are described. Following participants' assessments, their subsequent depression measures were all in the normal range, without any suicide ideation, across the year of the study. Patient evaluation ratings were high in the areas of being able to connect with other young patients in similar situations, using the audiovisual equipment, and learning new useful information from the interventions. The methods developed for the study ensured that the safety and well-being of participants were supported through telehealth.

Experiences of Psychotherapists With Remote Psychotherapy During the COVID-19 Pandemic: Cross-sectional Web-Based Survey Study

BACKGROUND

The current situation around the COVID-19 pandemic and the measures necessary to fight it are creating challenges for psychotherapists, who usually treat patients face-to-face with personal contact. The pandemic is accelerating the use of remote psychotherapy (ie, psychotherapy provided via telephone or the internet). However, some psychotherapists have expressed reservations regarding remote psychotherapy. As psychotherapists are the individuals who determine the frequency of use of remote psychotherapy, the potential of enabling mental health care during the COVID-19 pandemic in line with the protective measures to fight COVID-19 can be realized only if psychotherapists are willing to use remote psychotherapy.

OBJECTIVE

This study aimed to investigate the experiences of psychotherapists with remote psychotherapy in the first weeks of the COVID-19 lockdown in Austria (between March 24 and April 1, 2020).

METHODS

Austrian psychotherapists were invited to take part in a web-based survey. The therapeutic orientations of the psychotherapists (behavioral, humanistic, psychodynamic, or systemic), their rating of the comparability of remote psychotherapy (web- or telephone-based) with face-to-face psychotherapy involving personal contact, and potential discrepancies between their actual experiences and previous expectations with remote psychotherapy were assessed. Data from 1162 psychotherapists practicing before and during the COVID-19 lockdown were analyzed.

RESULTS

Psychotherapy conducted via telephone or the internet was reported to not be totally comparable to psychotherapy with personal contact (P<.001). Psychodynamic (P=.001) and humanistic (P=.005) therapists reported a higher comparability of telephone-based psychotherapy to in-person psychotherapy than behavioral therapists. Experiences with remote therapy (both web- and telephone-based) were more positive than previously expected (P<.001). Psychodynamic therapists reported more positive experiences with telephone-based psychotherapy than expected compared to behavioral (P=.03) and systemic (P=.002) therapists. In general, web-based psychotherapy was rated more positively (regarding comparability to psychotherapy with personal contact and experiences vs expectations) than telephone-based psychotherapy (P<.001); however, psychodynamic therapists reported their previous expectations to be equal to their actual experiences for both telephone- and web-based psychotherapy.

CONCLUSIONS

Psychotherapists found their experiences with remote psychotherapy (ie, web- or telephone-based psychotherapy) to be better than expected but found that this mode was not totally comparable to face-to-face psychotherapy with personal contact. Especially, behavioral therapists were found to rate telephone-based psychotherapy less favorably than therapists with other theoretical backgrounds.

A Teleneuropsychology Consultation Service Model for Children with Neurodevelopmental and Acquired Disorders Residing in Rural State Regions

OBJECTIVE

Accessing neuropsychological services, which are often centralized in urban regions, poses unique challenges to children and families in rural regions. In 2017, urban neuropsychologists and a pediatrician practicing in a rural region of New Mexico started to develop a teleneuropsychology (TeleNP) consultation service model to efficiently triage and determine a clinical course of action. This pilot project, aimed at expanding clinical access to specialized pediatric services in rural areas, evolved over the course of 2 years prior to the coronavirus disease 2019 pandemic.

METHOD

Providers earned the trust of the local community, gained understanding of pertinent sociocultural factors, and acquired knowledge of the clinical and educational concerns for the children residing in the rural community. The application of a culturally informed approach that highlights the importance of community participation and collaboration steered the decision to implement a TeleNP consultation model. By widening access to neuropsychology, this service helped to determine whether neuropsychological testing procedures were medically indicated.

RESULTS

We summarize the distinct processes that needed to occur at each location to support the implementation of telemedicine. We propose a clinical service decision tree with specific criteria to help guide providers on how to triage cases in order to increase access to specialized healthcare.

CONCLUSION

The success of implementing a TeleNP consultation service hinges upon ongoing care coordination between providers, clerical staff, patients, and families with clear goals and expectations, maintenance of legal and ethical standards, and development of specific administrative and clinical processes supporting the use of TeleNP.

Remote cognitive and behavioral assessment: Report of the Alzheimer Society of Canada Task Force on dementia care best practices for COVID-19

INTRODUCTION

Despite the urgent need for remote neurobehavioral assessment of individuals with cognitive impairment, guidance is lacking. Our goal is to provide a multi-dimensional framework for remotely assessing cognitive, functional, behavioral, and physical aspects of people with cognitive impairment, along with ethical and technical considerations.

METHODS

Literature review on remote cognitive assessment and multidisciplinary expert opinion from behavioral neurologists, neuropsychiatrists, neuropsychologists, and geriatricians was integrated under the auspices of the Alzheimer Society of Canada Task Force on Dementia Care Best Practices for COVID-19. Telephone and video approaches to assessments were considered.

RESULTS

Remote assessment is shown to be acceptable to patients and caregivers. Informed consent, informant history, and attention to privacy and autonomy are paramount. A range of screening and domain-specific instruments are available for telephone or video assessment of cognition, function, and behavior. Some neuropsychological tests administered by videoconferencing show good agreement with in-person assessment but still lack validation and norms. Aspects of the remote dementia-focused neurological examination can be performed reliably.

DISCUSSION

Despite challenges, current literature and practice support implementation of telemedicine assessments for patients with cognitive impairment. Convergence of data across the clinical interview, reliable and brief remote cognitive tests, and remote neurological exam increase confidence in clinical interpretation and diagnosis.

Social Media, E-Health, and Medical Ethics

Given the profound influence of social media and emerging evidence of its effects on human behavior and health, bioethicists have an important role to play in the development of professional standards of conduct for health professionals using social media and in the design of online systems themselves. In short, social media is a bioethics issue that has serious implications for medical practice, research, and public health. Here, we inventory several ethical issues across four areas at the intersection of social media and health: the impact of social networking sites on the doctor-patient relationship, the development of e-health platforms to deliver care, the use of online data and algorithms to inform health research, and the broader public health consequences of widespread social media use. In doing so, we review discussions of these topics and emphasize the need for bioethics to focus more deeply on the ways online technology platforms are designed and implemented. We argue that bioethicists should turn their attention to the ways in which consumer engagement, bias, and profit maximization shape online content and, consequently, human behavior and health. We also offer a set of recommendations and suggest future directions for addressing ethical challenges in these domains.

Outcomes of Depression Screening for Adolescents Accessing Pediatric Primary Care-Based Services

PURPOSE

Assess outcomes of depression screening among adolescents accessing pediatric primary care-based services. These findings will contribute to development of clinical protocols for depression screening and intervention in primary care settings.

DESIGN AND METHODS

Retrospective chart review conducted via electronic medical records at a pediatric primary care-based clinic to extract PHQ-9 data for adolescents screened from 1/17/2018 to 4/18/2018. De-identified data included age, gender, ethnicity, provider, PHQ-9, and referral/follow-up/medication status.

RESULTS

Data included 1213 adolescents of whom N = 600 were depressed without additional comorbidities; 96 adolescents had PHQ-9 scores >5. Descriptive analyses by age, gender, ethnicity, referral type, follow-up, and provider services identified targeted primary care-based interventions for depression and referral. Depression screening occurred primarily at well child visits. 82.5% of those with PHQ-9 scores >5 were not currently receiving treatment. Overall, referrals by physicians (45.8%) and nurse practitioners (42.9%) were equivalent with more referrals for adolescents with moderate-severe depression. Nurse practitioners provided more counseling than physicians among adolescents with mild to moderate depression.

CONCLUSIONS

Adolescent mental health necessitates an enhanced continuum of care. Primary care-based interventions provided by pediatric nurse practitioners are imperative to address adolescent mental health needs. Findings provide practical means to incorporate protocols for depression enhancing primary care-based mental health access.

PRACTICE IMPLICATIONS

Need for incorporation of practical modalities for depression assessment and follow up as recommended by American Academy of Pediatrics. Future study for comparison of methods (phone/text reminder, follow up appointment, online resource reminder, telehealth), indicated to enhance follow-up care for adolescents experiencing depression.

Videoconferencing in psychiatry, a meta-analysis of assessment and treatment

Context

Videoconferencing in psychiatry allows psychiatric counseling to be dealt remotely. A number of human randomised clinical trials (RCTs) on this topic were conducted but not systematically analysed since 2005.

Objects

A meta-analysis was undertaken to test the hypothesis of non-inferiority of remote psychiatric counseling, including both assessment and treatment, compared to face-to-face setting. Focus of research was the general psychiatric approach, which includes pharmacotherapy, counseling and some not specific psychotherapeutic techniques such as listening, reformulation and clarification among others. Specific forms of psychotherapies were not included in this analysis.

Design

RCTs including ≥ 10 subjects per arm were identified in Medline, the Cochrane Library, Embase and the reference list of single papers. A random-effect and a mixed-effect model served for test the hypothesis under analysis.

Results

Twenty-six RCTs were included in the analysis, involving 765 (assessment) and 1585 patients (efficacy). The non-inferiority of remote psychiatric counseling was reported both for assessment and treatment. Heterogeneity could not be excluded for assessment, but was excluded for treatment while taking into account clinical and study related variables (P-values = 0.003 and 0.06, respectively).

Conclusion

High levels of consistency between remote and in vivo psychiatric assessment is reported. Efficacy of remote psychiatric counseling was shown to be not inferior compared to in vivo settings. Heterogeneity could not be excluded for assessment, and further analyses are mandatory. The presence of multiple diagnoses included in the analysis was a limit of the present investigation.

A systematic review of providers' attitudes toward telemental health via videoconferencing

Telemental health conducted via videoconferencing (TMH-V) has the potential to improve access to care, and providers' attitudes toward this innovation play a crucial role in its uptake. This systematic review examined providers' attitudes toward TMH-V through the lens of the unified theory of acceptance and use of technology (UTAUT). Findings suggest that providers have positive overall attitudes toward TMH-V despite describing multiple drawbacks. Therefore, the relative advantages of TMH-V, such as its ability to increase access to care, may outweigh its disadvantages, including technological problems, increased hassle, and perceptions of impersonality. Providers' attitudes may also be related to their degree of prior TMH-V experience, and acceptance may increase with use. Limitations and implications of findings for implementation efforts are discussed.

Facility and state-level factors associated with telemental health (TMH) adoption among mental health facilities in the United States

INTRODUCTION

Telemental health (TMH) is a promising approach to increase access to mental healthcare. This study examined the TMH adoption rates and associations with facility- and state-level factors among US mental health (MH) facilities.

METHODS

This retrospective, cross-sectional study used linked data for 2016 from the National Mental Health Services Survey (N = 11,833), Area Health Resources File, and national reports for broadband access and telehealth policies. The associations of facility and state-level characteristics with TMH adoption were examined with multi-level logistic regressions.

RESULTS

Overall, 25.9% had used TMH. Having veteran affiliation [Adjusted Odds Ratio (AOR) = 18.53, 95% Confidence Interval (95%CI): 10.66-32.21] and greater Information Technology (IT) capacity [AOR(95%CI): 2.89(2.10-3.98)] were the strongest correlates of TMH adoption. Other facility characteristics associated with higher likelihood of TMH adoption were: public ownership, high patient volumes, having comprehensive MH treatments or Quality Improvement practices, having private or non-Medicaid public payers, and treating elderly patients (AORs: 1.16-2.41). TMH adoption was less likely among facilities treating more African Americans or patients with substance abuse disorders. TMH adoption varied substantially across states, with adoption more likely in states issuing special telehealth licences and those with more rural counties.

DISCUSSION

One in four MH facilities adopted TMH in 2016. TMH adoption varied by multiple facility- and state-level factors. Our findings suggest that: legal/regulatory burden and lower facility IT capacity may discourage TMH adoption; significant racial disparities exist in TMH adoption; and there is a need to increase TMH use for substance abuse disorders.

Optional Web-Based Videoconferencing Added to Office-Based Care for Women Receiving Psychotherapy During the Postpartum Period: Pilot Randomized Controlled Trial

Background

Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care.

Objective

The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period.

Methods

We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score.

Results

We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms.

Conclusions

The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive.

A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial

: media-1vid110.1542/5984243450001PEDS-VA_2018-2738Video Abstract OBJECTIVES: To improve the mental health (MH) referral process for children referred from primary care to community mental health clinics (CMHCs) by using a community-partnered approach.

METHODS

Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.

RESULTS

A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.

CONCLUSIONS

A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.

Implementing a Home-Based Telehealth Group Adherence Intervention with Adolescent Transplant Recipients

Introduction: To improve access to care and engage adolescent transplant recipients for adherence-promoting interventions, innovative solutions utilizing technology are needed. Materials and Methods: This study describes the implementation of a five-session group intervention targeting medication adherence in adolescent transplant recipients through home-based telemedicine. Results: Seven videoconferencing groups were conducted with a total of 33 participants living a median of 57 miles away from their transplant medical center. The median coefficient of variation (CV) of tacrolimus (immunosuppression medication) decreased from 32.2% to 23.5% from the pregroup to postgroup phase. Analyses indicated that the group was acceptable and engaging for participants, as highlighted by one participant reporting, "I liked how me and the group members came together… it felt like a little family." Overall satisfaction with the group and with the technology was endorsed by 86%. The group intervention was generally feasible; however, there were technological difficulties reported by participants and the facilitator, particularly given the diversity of the home-based connections and equipment. Other adaptations helped improve recruitment, attendance, and participation. Discussion: Implementing a telehealth group can pose unique challenges, especially with a group of adolescent participants. Although nonsignificant, we observed a decrease in the median CV of tacrolimus, indicating that medication adherence generally improved after group intervention. Our experience facilitating these groups provides insights into strategies to optimize feasibility and the participant experience. Distance of participants from the hospital is an important consideration and provides a strong rationale for the need for telemedicine-enabled approaches. We explore and discuss the challenges to implementing a home-based group, suggest practical strategies and developmentally sensitive adjustments when working with adolescents, and propose strategies to prepare clinicians for obstacles that may present when implementing a telehealth group with youth.

Best Practices in Videoconferencing-Based Telemental Health April 2018

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health

Objective

To develop an intervention to improve the mental health referral and care process for children referred by primary care providers (PCPs) to community mental health clinics (MHCs) using a community partnered approach.

Design

A Project Working Group (PWG) with representatives from each partner organization met monthly for 6 months.

Setting

Multi-site federally qualified health center (FQHC) and two community MHCs in Los Angeles county.

Participants

26 stakeholders (14 FQHC clinic providers/staff, 8 MHC providers/staff, 4 parents) comprised the PWG.

Data Sources

Qualitative interviews, PWG meeting notes, intervention processes and workflow reports.

Intervention

The PWG reviewed qualitative data from stakeholders (interviews of 7 parents and 13 providers/staff). The PWG met monthly to identify key transition points where access to and coordination of care were likely compromised and to develop solutions.

Results

Three critical transition points and system solutions were identified: 1) Parents refuse initial referral to the MHC due to stigma regarding mental health services. Solution: During initial referral, parents watch a video introducing them to the MHC. 2) Parents don't complete the MHC's screening after referral. Solution: A live videoconference session connecting parents at the FQHC with MHC staff ensures completion of the screening and eligibility process. 3) PCPs reject transfer of patients back to primary care for ongoing psychotropic medication management. Solution: Regularly scheduled live videoconferences connect PCPs and MHC providers.

Conclusions

A community partnered approach to care design utilizing telehealth for care coordination between clinics can potentially be used to address key challenges in MHC access for children.

Evidence for telehealth group-based treatment: A systematic review

Background

Interest in the use of telehealth interventions to increase access to healthcare services is growing. Group-based interventions have the potential to increase patient access to highly needed services. The aim of this study was to systematically review the available literature on group-based video teleconference services.

Methods

The English-language literature was searched using Ovid MEDLINE, PubMed, PsycINFO and CINAHL for terms related to telehealth, group therapy and support groups. Abstracts were reviewed for relevance based on inclusion criteria. Multiple study types were reviewed, including open-label, qualitative and randomised controlled trial study designs. Data were compiled regarding participants, study intervention and outcomes. Specific areas of interest were the feasibility of and satisfaction with telehealth technology, as well as the effect of video teleconference delivery on group dynamics, including therapeutic alliance.

Results

Forty published studies met the inclusion criteria and were included in the review. Six were randomised controlled trials. Among the studies, there was a broad range of study designs, participants, group interventions and outcome measures. Video teleconference groups were found to be feasible and resulted in similar treatment outcomes to in-person groups. However, few studies were designed to demonstrate noninferiority of video teleconference groups compared with in-person groups. Studies that examined group process factors showed small decreases in therapeutic alliance in the video teleconference participants.

Conclusions

Video teleconference groups are feasible and produce outcomes similar to in-person treatment, with high participant satisfaction despite technical challenges. Additional research is needed to identify optimal methods of video teleconference group delivery to maximise clinical benefit and treatment outcomes.

Experiences and Attitudes Among Psychiatric Mental Health Advanced Practice Nurses in the Use of Telemental Health: Results of an Online Survey

BACKGROUND

Telemental health (TMH) growth is driven by recent trends in health delivery systems and disparities in access to mental health services. There are currently no standard educational guidelines to prepare psychiatric mental health advanced practice nurses (PMH-APRNs) in TMH delivery.

OBJECTIVE

To survey practicing PMH-APRNs across the United States about their experiences and attitudes about use of TMH.

DESIGN

Eighty-three participants from the American Psychiatric Nurses Association online discussion board completed a nine-item survey.

QUESTIONS INCLUDED

Length of time practicing as a PMH-APRN, TMH use in practice, populations served, and TMH background.

RESULTS

A majority had been practicing as a PMH-APRN for less than a decade and had used TMH, although most reported no prior education or training in this delivery method. Participants did indicate a desire for TMH education.

CONCLUSION

This survey affirms the prevalence of TMH use among PMH-APRN providers, lack of formal training, and necessity for standardized educational guidelines in TMH delivery.

Clinical Update: Telepsychiatry With Children and Adolescents

This Clinical Update reviews the use of telepsychiatry to deliver psychiatric, mental health, and care coordination services to children and adolescents across settings as direct service and in collaboration with primary care providers or other clinicians. The update defines terms and presents the current status of telepsychiatry as a mode of health service delivery. The update presents procedures for conducting telepsychiatry services and optimizing the clinical experience.

Clinician behaviors in telehealth care delivery: a systematic review

Literature on telehealth care delivery often addresses clinical, cost, technological, system, and organizational impacts. Less is known about interpersonal behaviors such as communication patterns and therapeutic relationship-building, which may have workforce development considerations. The purpose of this study was to conduct a systematic literature review to identify interpersonal health care provider (HCP) behaviors and attributes related to provider-patient interaction during care in telehealth delivery. Electronic searches were conducted using five indexes/databases: CINAHL, ERIC, PsychInfo, ProQuest Dissertations, PubMed; with hand-searching of the immediate past 10 years of five journals. Search concepts included: communication, telehealth, education, and health care delivery. Of 5261 unique article abstracts initially identified, 338 full-text articles remained after exclusion criteria were applied and these were reviewed for eligibility. Finally, data were extracted from 45 articles. Through qualitative synthesis of the 45 articles, we noted that papers encompassed many disciplines and targeted care to people in many settings including: home care, primary and specialist care, mental health/counseling, and multi-site teams. Interpersonal behaviors were observed though not manipulated through study designs. Six themes were identified: HCP-based support for telehealth delivery; provider-patient interactions during the telehealth event; environmental attributes; and guidelines for education interventions or evaluation of HCP behaviors. Although unable to identify current best practices, important considerations for practice and education did emerge. These include: perceptions of the utility of telehealth; differences in communication patterns such as pace and type of discourse, reliance on visual cues by both provider and patient especially in communicating empathy and building rapport; and confidentiality and privacy in telehealth care delivery.

Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases

The use of telehealth and telemedicine offers powerful tools for delivering clinical care, conducting medical research, and enhancing access to infectious diseases physicians. The Infectious Diseases Society of America (IDSA) has prepared a position statement to educate members on the use of telehealth and telemedicine technologies. The development of telehealth and telemedicine programs requires the consideration of several issues such as HIPAA, state and local licensure requirements, credentialing and privileging, scope of care, quality, and responsibility and liability. IDSA supports appropriate use of telehealth and telemedicine to provide timely, cost-effective specialty care to resource-limited populations.

Considerations for Conducting Telemental Health with Children and Adolescents

Innovative technologies are increasingly used in order to address gaps in access to child behavioral health care. Telemental health is one technological modality in which child behavioral services can be practiced successfully across psychiatry, psychology, and developmental medicine. The authors discuss relevant issues related to delivering telemental health, including why this modality is necessary for delivery, what models and evidence for telemental health exist, when it should be considered across legal/regulatory and ethical considerations, where telemental health services are delivered, who is involved in delivery, and how best telemental health practices may be implemented with diverse youth.

A Review of Pediatric Telemental Health

Because of the widening gap between need for child mental health services and availability of child specialists, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. This article reviews real-time videoconferencing evidence across telemental health with children and adolescents. It summarizes emerging guidelines that inform best practices for child telemental health using videoconferencing. It presents a case example of best practices across behavioral health specialties. Videoconferencing is an effective approach to improving access to behavioral health interventions for children and adolescents. Telemental health shows promise for disseminating evidence-based treatments to underserved communities.

Institutionally based videoconferencing

The delivery of psychiatric care via video-teleconferencing (VTC) technology is thought to have reached a tipping point. As a medical speciality with relatively few material or technical requirements for service delivery, psychiatry has been one of the earliest to embrace the possibility of providing evaluations and treatment at a distance. Such technical infrastructure as is necessary can often be found in the institutions already in existence. It was natural therefore that institutionally based telepsychiatry would lay the foundation for the development of the field. In this article we review the history and development of institutional VTC in a wide variety of clinically supervised settings such as hospitals, outpatient clinics, and forensic settings. We cite evidence supporting institutionally sponsored use and expand on key takeaways for the development and expansion of videoconferencing in these settings. We also speculate on the future direction and development of psychiatric care provided by these arrangements.

Telemental health for children and adolescents

Most children and adolescents across the USA fail to receive adequate mental health services, especially in rural or underserved communities. The supply of child and adolescent psychiatrists is insufficient for the number of children in need of services and is not anticipated to grow. This calls for novel approaches to mental health care. Telemental health (TMH) offers one approach to increase access. TMH programmes serving young people are developing rapidly and available studies demonstrate that these services are feasible, acceptable, sustainable and likely as effective as in-person services. TMH services are utilized in clinical settings to provide direct care and consultation to primary care providers (PCPs), as well as in non-traditional settings, such as schools, correctional facilities and the home. Delivery of services to young people through TMH requires several adjustments to practice with adults regarding the model of care, cultural values, participating adults, rapport-building, pharmacotherapy and psychotherapy. Additional infrastructure accommodations at the patient site include space and staffing to conduct developmentally appropriate evaluations and treatment planning with parents, other providers, and community services. For TMH to optimally impact young people's access to mental health care, collaborative models of care are needed to support PCPs as frontline mental health-care providers, thereby effectively expanding the child and adolescent mental health workforce.

Service providers' experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service

BACKGROUND

Despite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits.

OBJECTIVE

Within the framework of Innovation Diffusion Theory, to study service providers' experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia.

METHODS

Qualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility.

RESULTS

Five themes with 11 sub-themes were identified: (1) "Existing Uses", with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) "Relative Advantage", with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) "Technical Complexity"; (4) "Technical Compatibility" with two sub-themes: technical-clinical and technical-administrative; and (5) "Broader Organisational Culture", with two sub-themes: organizational policy support and 'digital telehealth' culture.

CONCLUSIONS

The digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less "drop-out", less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture.

Usability evaluation of the digital anger thermometer app

The digital anger thermometer is a prototype for a mobile application (app) for use with adults in anger management treatment. The digital anger thermometer incorporates standards of software development in addition to anger management resources from the Substance Abuse and Mental Health Services Administration. The digital anger thermometer underwent a usability study conducted by five expert reviewers. The results indicate that it is easy to learn, efficient, and ergonomically sound. However, it does not offer support features or user-error tolerance. The digital anger thermometer prototype requires additional usability studies and comparative research in order for it to become an actual mental health app.