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

Impacts of Telehealth Adoption on the Quality of Care for Individuals With Serious Mental Illness: Retrospective Observational Analysis of Veterans Affairs Administrative Data

Background

Telehealth implementation can be challenging for persons with serious mental illness (SMI), which may impact their quality of care and health outcomes. The literature on telehealth's impacts on SMI care outcomes is mixed, necessitating further investigation.

Objective

We examined the impacts of facility-level telehealth adoption on quality of care metrics over time among patients with SMI.

Methods

We analyzed Veterans Affairs (VA) administrative data across 138 facilities from January 2021 to December 2022. We performed longitudinal mixed-effects regressions to identify the relationships between the proportion of facility-level telehealth visits and SMI specialty care quality metrics: engagement with primary care; access and continuity of care across a range of mental health services including psychotherapy or psychosocial rehabilitation, SMI-specific intensive outpatient programs, and intensive case management; and continuity of mental health care after a high-risk event (eg, suicide attempt).

Results

Facilities with a higher proportion of telehealth visits had reduced access and continuity of physical and mental health care for patients with SMI (P<.05). Higher telehealth adoption was associated with reduced primary care engagement (z=-4.04; P<.001), reduced access to and continuity in SMI-specific intensive case management (z=-4.49; P<.001; z=-3.15; P<.002), reductions in the continuity of care within psychotherapy and psychosocial rehabilitation (z=-3.74; P<.001), and continuity of care after a high-risk event (z=-2.46; P<.01). Telehealth uptake initially increased access to intensive outpatient but did not improve its continuity over time (z=-4.47; P<.001). Except for continuity within SMI-specific intensive case management (z=2.62; P<.009), continuity did not improve over time as telehealth became routinized.

Conclusions

Although telehealth helped preserve health care access during the pandemic, telehealth may have tradeoffs with regard to quality of care for some individuals with SMI. These data suggest that engagement strategies used by SMI-specific intensive case management may have preserved quality and could benefit other settings. Strategies that enhance telehealth implementation-selected through a health equity lens-may improve quality of care among patients with SMI.

Prescription digital therapeutics: An emerging treatment option for negative symptoms in schizophrenia

Digital therapeutics-web-based programs, smartphone applications, and wearable devices designed to prevent, treat, or manage clinical conditions through software-driven, evidence-based intervention-can provide accessible alternatives and/or may supplement standard care for patients with serious mental illnesses (SMI), including schizophrenia. In this paper we provide a targeted summary of the rapidly growing field of digital therapeutics for schizophrenia and related SMI. We first define digital therapeutics. We then provide a brief summary of the emerging evidence of efficacy of digital therapeutics for improving clinical outcomes, focusing on potential mechanisms of action for addressing some of the most challenging problems, including negative symptoms of psychosis. Our focus on these promising targets for digital therapeutics, including the latest in prescription models in the commercial space, highlights future directions for research and practice in this exciting field.

Digital Mental Health for Schizophrenia and Other Severe Mental Illnesses: An International Consensus on Current Challenges and Potential Solutions

BACKGROUND

Digital approaches may be helpful in augmenting care to address unmet mental health needs, particularly for schizophrenia and severe mental illness (SMI).

OBJECTIVE

An international multidisciplinary group was convened to reach a consensus on the challenges and potential solutions regarding collecting data, delivering treatment, and the ethical challenges in digital mental health approaches for schizophrenia and SMI.

METHODS

The consensus development panel method was used, with an in-person meeting of 2 groups: the expert group and the panel. Membership was multidisciplinary including those with lived experience, with equal participation at all stages and coproduction of the consensus outputs and summary. Relevant literature was shared in advance of the meeting, and a systematic search of the recent literature on digital mental health interventions for schizophrenia and psychosis was completed to ensure that the panel was informed before the meeting with the expert group.

RESULTS

Four broad areas of challenge and proposed solutions were identified: (1) user involvement for real coproduction; (2) new approaches to methodology in digital mental health, including agreed standards, data sharing, measuring harms, prevention strategies, and mechanistic research; (3) regulation and funding issues; and (4) implementation in real-world settings (including multidisciplinary collaboration, training, augmenting existing service provision, and social and population-focused approaches). Examples are provided with more detail on human-centered research design, lived experience perspectives, and biomedical ethics in digital mental health approaches for SMI.

CONCLUSIONS

The group agreed by consensus on a number of recommendations: (1) a new and improved approach to digital mental health research (with agreed reporting standards, data sharing, and shared protocols), (2) equal emphasis on social and population research as well as biological and psychological approaches, (3) meaningful collaborations across varied disciplines that have previously not worked closely together, (4) increased focus on the business model and product with planning and new funding structures across the whole development pathway, (5) increased focus and reporting on ethical issues and potential harms, and (6) organizational changes to allow for true communication and coproduction with those with lived experience of SMI. This study approach, combining an international expert meeting with patient and public involvement and engagement throughout the process, consensus methodology, discussion, and publication, is a helpful way to identify directions for future research and clinical implementation in rapidly evolving areas and can be combined with measurements of real-world clinical impact over time. Similar initiatives will be helpful in other areas of digital mental health and similarly fast-evolving fields to focus research and organizational change and effect improved real-world clinical implementation.

Variability in the Integration of Peers in a Multi-site Digital Mental Health Innovation Project

Peer support specialists ("peers") who have the lived experience of, and are in recovery from, mental health challenges are increasingly being integrated into mental health care as a reimbursable service across the US. This study describes the ways peers were integrated into Help@Hand, a multi-site innovation project that engaged peers throughout efforts to develop and offer digital mental health interventions across counties/cities ("sites") in California. Using a mixed methods design, we collected quantitative data via quarterly online surveys, and qualitative data via semi-annual semi-structured phone interviews with key informants from Help@Hand sites. Quantitative data were summarized as descriptive findings and qualitative data from interviews were analyzed using rapid qualitative analysis methods. In the final analytic phase, interview quotes were used to illustrate the complex realities underlying quantitative responses. 117 quarterly surveys and 46 semi-annual interviews were completed by key informants from 14 sites between September 2020 and January 2023. Peers were integrated across diverse activities for support and implementation of digital mental health interventions, including development of training and educational materials (78.6% of sites), community outreach (64.3%), technology testing (85.7%), technology piloting (90.9%), digital literacy training (71.4%), device distribution (63.6%), technical assistance (72.7%), and cross-site collaboration (66.7%). Peer-engaged activities shifted over time, reflecting project phases. Peer-provided digital literacy training and technology-related support were key ingredients for project implementations. This study indicates the wide range of ways peers can be integrated into digital mental health intervention implementations. Considering contextual readiness for peer integration may enhance their engagement into programmatic activities.

Digital health literacy and digital engagement for people with severe mental ill health across the course of the COVID-19 pandemic in England

BACKGROUND

An unprecedented acceleration in digital mental health services happened during the COVID-19 pandemic. However, people with severe mental ill health (SMI) might be at risk of digital exclusion, partly because of a lack of digital skills, such as digital health literacy. The study seeks to examine how the use of the Internet has changed during the pandemic for people with SMI, and explore digital exclusion, symptomatic/health related barriers to internet engagement, and digital health literacy.

METHODS

Over the period from July 2020 to February 2022, n = 177 people with an SMI diagnosis (psychosis-spectrum disorder or bipolar affective disorder) in England completed three surveys providing sociodemographic information and answering questions regarding their health, use of the Internet, and digital health literacy.

RESULTS

42.5% of participants reported experiences of digital exclusion. Cochrane-Q analysis showed that there was significantly more use of the Internet at the last two assessments (80.8%, and 82.2%) compared to that at the beginning of the pandemic (65.8%; ps < 0.001). Although 34.2% of participants reported that their digital skills had improved during the pandemic, 54.4% still rated their Internet knowledge as being fair or worse than fair. Concentration difficulties (62.6%) and depression (56.1%) were among the most frequently reported symptomatic barriers to use the Internet. The sample was found to have generally moderate levels of digital health literacy (M = 26.0, SD = 9.6). Multiple regression analysis showed that higher literacy was associated with having outstanding/good self-reported knowledge of the Internet (ES = 6.00; 95% CI: 3.18-8.82; p < .001), a diagnosis of bipolar disorder (compared to psychosis spectrum disorder - ES = 5.14; 95% CI: 2.47-7.81; p < .001), and being female (ES = 3.18; 95% CI: 0.59-5.76; p = .016).

CONCLUSIONS

These findings underline the need for training and support among people with SMI to increase digital skills, facilitate digital engagement, and reduce digital engagement, as well as offering non-digital engagement options to service users with SMI.

Working towards a ready to implement digital literacy program

Background

As healthcare continues to expand online and digital care offerings multiply, the importance of digital inclusion and equity is now better recognized. Yet despite impressive regional grassroots efforts, today there remain few readily deployable programs designed to support patient digital literacy.

Methods

Digital Outreach for Obtaining Resources and Skills (DOORs) is one such digital literacy program that has evolved over the last 5 years to meet the rising demand. Through community partnerships, the DOORs curriculum and delivery has been updated to make the program more accessible and applicable as Coronavirus Disease 2019 (COVID-19) changes healthcare. Participants' experience in the most updated iteration of DOORS was assessed through surveys and semi-structured interviews.

Results

Improvements to DOORs include an updated DOORs curriculum, updated facilitator manual, an online platform with a learning management system, standardized training, patient-facing educational handouts, consolidation of all DOORs materials into a single package that is ready to be shared with other groups, implementation of a single-session intervention model, and Spanish translation. Participants reported improved confidence on 72% of the digital skills assessed. Thematic analysis resulted in three themes: awareness of divide, patient-centered design, and expanded skills and confidence.

Conclusions

Combined, these changes and participant outcomes better position DOORS to meet the rising need for digital literacy and offers a scalable model for teams across the world.