Patient Satisfaction and Willingness to Continue with Telemental Health Care During and After the Early Period of SARS-CoV-2 Pandemic: A User Survey

Objective: The SARS-CoV-2 pandemic and related lockdown periods generated an increase in the use of virtual care for mental health (MH). This study aimed to assess patient satisfaction with Telemental Health services (TMH) during first lockdown and factors related to their willingness to continue using this service. Methods: We conducted a cross-sectional survey of 364 MH outpatients from 9 centers in the Barcelona region (Spain), who received TMH between April 20 and May 22, 2020. We assessed sociodemographic and clinical characteristics, prior experience, and familiarity with technologies and satisfaction with TMH. Willingness to receive TMH after the lockdown was measured separately for telephone and videoconferencing. We performed descriptive statistics and bivariate and multivariate regression models to predict TMH willingness. Results: From 450 patients contacted, 364 were interviewed. Satisfaction with TMH was high (mean 9.24, standard deviation 0.07); 2.47% preferred only TMH visits after lockdown, 23.08% preferred mostly TMH visits, 50.82% accepted some TMH visits, and 23.63% would prefer in-person consultations. Female patients and those having received TMH during lockdown showed higher odds of willingness to receive TMH in the future, while patients unfamiliar with technologies showed lower odds. Concerning TMH through telephone, willingness was more likely in patients living with more persons. Videoconferencing willingness was more likely for people living with depression. Conclusions: TMH was well accepted during the first lockdown and patients were willing to maintain it after lockdown. Low familiarity with new technologies is an important barrier to TMH willingness, which needs to be addressed for appropriate implementation going forward.

Examining Burnout and Perspective on Videoconferencing in the Mental Health Workforce

Objective: To examine burnout and perspectives on videoconferencing over time for the mental health workforce. Methods: Members of an academic psychiatry department completed two anonymous surveys about virtual work and burnout 18 months apart (T1n = 274, response rate = 66.8%; T2n = 227, response rate = 36.7%). A subset completed the burnout subscale of the Stanford Professional Fulfillment Index (T1n = 145; T2n = 127). Results: Respondents were well satisfied with videoconferencing at both time points and satisfaction was higher at T2. Videoconferencing was not perceived to contribute to feelings of fatigue at either time point and burnout levels decreased from T1 to T2. Conclusions: Videoconferencing is well received by the mental health workforce and is not widely perceived to contribute to feelings of fatigue. Longer use of videoconferencing coincided with decreased levels of burnout. There are likely benefits to virtual work for the mental health workforce and virtual work may be protective from burnout.

Expanding our understanding of digital mental health interventions for Indigenous youth: An updated systematic review

Past research has examined available literature on electronic mental health interventions for Indigenous youth with mental health concerns. However, as there have recently been increases in both the number of studies examining electronic mental health interventions and the need for such interventions (i.e. during periods of pandemic isolation), the present systematic review aims to provide an updated summary of the available peer-reviewed and grey literature on electronic mental health interventions applicable to Indigenous youth. The purpose of this review is to better understand the processes used for electronic mental health intervention development. Among the 48 studies discussed, smoking cessation and suicide were the most commonly targeted mental health concerns in interventions. Text message and smartphone application (app) interventions were the most frequently used delivery methods. Qualitative, quantitative, and/or mixed outcomes were presented in several studies, while other studies outlined intervention development processes or study protocols, indicating high activity in future electronic mental health intervention research. Among the findings, common facilitators included the use of community-based participatory research approaches, representation of culture, and various methods of motivating participant engagement. Meanwhile, common barriers included the lack of necessary resources and limits on the amount of support that online interventions can provide. Considerations regarding the standards and criteria for the development of future electronic mental health interventions for Indigenous youth are offered and future research directions are discussed.

"It Was Broken Here Before": Present day impact of historical trauma in telemental health services in a rural and remote Aleutian Islands Community

Telemental health technology is a feasible tool for providing behavioral healthcare in rural areas. However, there is scant literature about implementing this technology within Indigenous populations. The Aleutian Pribilof Islands Association is an urban-based Tribal Health Organization in Alaska tasked with providing behavioral health services to remote Unangax̂ communities. To expand telemental health services, a formative program evaluation was conducted to examine the acceptability of and barriers to implementing telemental health. Using a qualitative approach, five individuals with lived experience in the same community were interviewed using a semi-structured format. Data were analyzed using critical thematic analysis and situated within the context of historical trauma. Five themes were constructed that showed broken trust as the primary barrier to services, despite the substantial obstacles related to communications infrastructure. When situated within the context of historical trauma, the results show how colonization spurred and has maintained broken trust. The clinical, research, and policy implications resulting from this study point to the need for decolonization and integration of culture in behavioral health services. These findings can be informative for organizations and providers seeking to implement telemental health in Indigenous communities.

Telemedicine from Home or the Office: Perceptions of Mental Health Providers

Introduction: The COVID-19 pandemic led to a rapid transition to telemedicine for mental health care and redefined many providers' work environments and practices. The purpose of the study was to investigate the impact of work location on telemental health (TMH) benefits, disruptions, and concerns to further understand the rapid implementation of telemedicine for mental health treatment. Methods: A sample of 175 practicing TMH providers completed an online survey between July and August 2020. Providers answered questions about personal demographics and practice characteristics. Next, they answered questions about benefits, disruptions, and concerns regarding the use of telemedicine in their practice. Chi-square and independent samples t-test were conducted to identify work location differences for personal demographics and clinical practice characteristics. Three multivariate analyses of covariance were conducted to examine overall differences in perceptions of telemedicine benefits, concerns, and disruptions based on work location while covarying for provider race, ethnicity, percentage of caseload seen through telemedicine, practice type, specialty, and primary method of reimbursement. Results: TMH providers who primarily work from an office reported more benefit of reduced costs/overhead (ηp2 = 0.039), less benefit of limiting the spread of the virus (ηp2 = 0.028), and more concern about reimbursement (ηp2 = 0.046) than those who primarily work from home. We observed no difference in disruptions, patient access to care, quality of care, and work-life balance. Discussion: Exploration into work location of TMH providers aids in understanding of clinical workflows and provider wellbeing. Our findings suggest that telemedicine may be easily integrated into different types of clinical workflows and work locations.

Development and Implementation of a Telemental Health Program for Caregivers in a Children's Hospital Setting

Introduction: Caregivers of children with chronic illness, such as hematology-oncology conditions, face numerous stressors, and a subset experience persistent distress and poor psychological outcomes. Many logistical and ethical barriers complicate the provision of mental health care to caregivers in children's hospital settings. Telemental health (TMH) is one method to increase access and reduce barriers. Methods: A partnership was established with an outside TMH agency to provide mental health care to caregivers of children with hematology-oncology conditions. Development and implementation strategies are described, and feasibility was measured on four dimensions. Results: One hundred twenty-seven (n = 127) caregivers were referred for TMH services in the first 28 months of program implementation. Of the total, 63/127 (49%) received TMH services for at least one session. Most caregivers had a child in active medical treatment (89%). A small portion (11%) of caregivers were bereaved or had a child in hospice care. Program feasibility was enhanced by hospital leadership support and availability of staffing, financial, and technology resources. Available resources also contributed to the practicality of program development and swift implementation and integration within the defined hospital system. Discussion: Partnership with an outside TMH agency increased access to care and reduced barriers to treating caregivers in a children's hospital setting. Offering mental health interventions to caregivers aligns with evidence-based standards of care. Future research will elucidate caregiver satisfaction with this modality of treatment and whether use of TMH reduces disparities in caregiver receipt of mental health care in children's hospital settings.

Federal telehealth policy changes during the COVID-19 public health emergency: Associations with telemental health use among rural and urban Medicare beneficiaries

PURPOSE

The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted.

METHODS

In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use.

FINDINGS

From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p < 0.0001) and from 1.1% to 61.3% (p < 0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR = 18.10, p < 0.001) and nearly 120-fold for their urban counterparts (OR = 119.75, p < 0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age.

CONCLUSIONS

TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities.

Impact of Private Payer Policies on the Transition to Telemental Health Care Among Privately Insured Patients with Mental Health Disorders

Introduction: Mental health patients in states without private payer telehealth reimbursement policies before the public health emergency (PHE) may have experienced reduced access to telemental health (TMH). We estimate the association between private payer telehealth policy status in 2019 and the transition to TMH in 2020. Methods: Retrospective cohort study of privately insured individuals 2-64 years old with a mental health disorder and without TMH use in 2019. We examined new telemental use in 2020 by three categories of policy reimbursement status in 2019 (partial parity, full parity vs. no policy), overall (any telemental), and by modality (live video, audio-only, and online assessments) using logistic regression models clustered by state. Results: Among the 34,612 enrollees, 54.7% received TMH for the first time. Relative to no policy states, enrollees in partial or full parity states were equally likely to receive TMH in 2020. However, enrollees in states with a private payer telehealth policy were less likely to receive audio-only (partial parity: odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.39-0.90; full parity: OR: 0.38, 95% CI: 0.26-0.55), but more likely to receive online assessments (full parity: OR: 2.28, 95% CI: 1.4-4.59). Conclusions: Privately insured enrollees similarly transitioned to TMH across states suggesting a broad impact of the PHE policies on access to this care. The differences in audio-only and online assessments suggest that providers were possibly better prepared to implement TMH care via live video or patient portals in states with telehealth policies.

Telepsychiatry in Australia: A Scoping Review

Telepsychiatry formed part of the Australian mental health response to COVID-19, but relevant reviews pre- and post-pandemic are sparse. This scoping review aimed to map the literature on telepsychiatry in Australia and identify key research priorities. We searched databases (Medline, PubMed, PsycINFO, Scopus, Web of Science, EBSCO Psychology & Behavioral Sciences Collection, Proquest databases, and Cochrane Central Register of Controlled Trials) and reference lists from January 1990 to December 2022. Keywords included telepsychiatry, videoconferencing, telephone consultation, psychiatry, mental health, and Australia. Two reviewers independently screened titles, abstracts, and full texts. We identified 96 publications, one-third of which appeared since 2020. Extracted data included article types, service types, usage levels, outcome measures, perceptions, and research gaps. Most publications were quantitative studies (n = 43) and narrative reports of services (n = 17). Seventy-six papers reported mostly publicly established services. Videoconferencing alone was the most common mode of telepsychiatry. There was increased use over time, with the emergence of metropolitan telepsychiatry during the pandemic. Few papers used validated outcome measures (n = 5) or conducted economic evaluations (n = 4). Content analysis of the papers identified perceptions of patient (and caregiver) benefits, clinical care, service sustainability, and technology capability/capacity. Benefits such as convenience and cost-saving, clinical care issues, and implementation challenges were mentioned. Research gaps in patient perspectives, outcomes, clinical practice, health economics, usage patterns, and technological issues were identified. There is consistent interest in, and growth of, telepsychiatry in Australia. The identified perception themes might serve as a framework for future research on user perspectives and service integration. Other research areas include usage trends, outcome measures, and economic evaluation.

Telehealth and the Psychiatric Mental Health Nurse Practitioner: Beyond the COVID-19 Pandemic

OBJECTIVE

Examine the advantages, disadvantages, and challenges of telehealth for the psychiatric mental health nurse practitioner (PMHNP) in practice and student education. Describe areas for future research and policy development regarding telehealth in PMHNP practice and training during and beyond the COVID-19 pandemic.

METHODS

Review current evidence, standards of practice, and education for the PMHNP.

RESULTS

Recent rapid pandemic-related shifts in utilization of telehealth for clinical practice and student education have highlighted the advantages, disadvantages, and areas in need of additional study.

CONCLUSIONS

Postpandemic telehealth care delivery will likely persist or expand. PMHNPs must advocate for high practice and education standards.

Evaluating Clinical Outcomes in Patients Being Treated Exclusively via Telepsychiatry: Retrospective Data Analysis

BACKGROUND

Depression and anxiety are highly prevalent conditions in the United States. Despite the availability of suitable therapeutic options, limited access to high-quality psychiatrists represents a major barrier to treatment. Although telepsychiatry has the potential to improve access to psychiatrists, treatment efficacy in the telepsychiatry model remains unclear.

OBJECTIVE

Our primary objective was to determine whether there was a clinically meaningful change in 1 of 2 validated outcome measures of depression and anxiety-the Patient Health Questionnaire-8 (PHQ-8) or the Generalized Anxiety Disorder-7 (GAD-7)-after receiving at least 8 weeks of treatment in an outpatient telepsychiatry setting.

METHODS

We included treatment-seeking patients enrolled in a large outpatient telepsychiatry service that accepts commercial insurance. All analyzed patients completed the GAD-7 and PHQ-8 prior to their first appointment and at least once after 8 weeks of treatment. Treatments included comprehensive diagnostic evaluation, supportive psychotherapy, and medication management.

RESULTS

In total, 1826 treatment-seeking patients were evaluated for clinically meaningful changes in GAD-7 and PHQ-8 scores during treatment. Mean treatment duration was 103 (SD 34) days. At baseline, 58.8% (1074/1826) and 60.1% (1097/1826) of patients exhibited at least moderate anxiety and depression, respectively. In response to treatment, mean change for GAD-7 was -6.71 (95% CI -7.03 to -6.40) and for PHQ-8 was -6.85 (95% CI -7.18 to -6.52). Patients with at least moderate symptoms at baseline showed a 45.7% reduction in GAD-7 scores and a 43.1% reduction in PHQ-8 scores. Effect sizes for GAD-7 and PHQ-8, as measured by Cohen d for paired samples, were d=1.30 (P<.001) and d=1.23 (P<.001), respectively. Changes in GAD-7 and PHQ-8 scores correlated with the type of insurance held by the patients. Greatest reductions in scores were observed among patients with commercial insurance (45% and 43.9% reductions in GAD-7 and PHQ-8 scores, respectively). Although patients with Medicare did exhibit statistically significant reductions in GAD-7 and PHQ-8 scores from baseline (P<.001), these improvements were attenuated compared to those in patients with commercial insurance (29.2% and 27.6% reduction in GAD-7 and PHQ-8 scores, respectively). Pairwise comparison tests revealed significant differences in treatment responses in patients with Medicare versus commercial insurance (P<.001). Responses were independent of patient geographic classification (urban vs rural; P=.48 for GAD-7 and P=.07 for PHQ-8). The finding that treatment efficacy was comparable among rural and urban patients indicated that telepsychiatry is a promising approach to overcome treatment disparities that stem from geographical constraints.

CONCLUSIONS

In this large retrospective data analysis of treatment-seeking patients using a telepsychiatry platform, we found robust and clinically significant improvement in depression and anxiety symptoms during treatment. The results provide further evidence that telepsychiatry is highly effective and has the potential to improve access to psychiatric care.

College student mental health, treatment utilization, and reduced enrollment: Findings across a state university system during the COVID-19 pandemic

Objective: This study measured the rate of college student mental health concerns and mental health service utilization. The roles of mental health and seeking treatment regarding anticipated enrollment were explored. Methods: One thousand eight hundred thirty-one randomly selected students participated in this online survey. Results: Most students reported clinically significant symptoms (88.3%), and many sought treatment in the past year (28.8%). Most students had favorable attitudes toward telemental health. Barriers to seeking care included a preference for self-management of symptoms (68.8%) and limited time (43.3%). Mental health was the most commonly reported reason for anticipating reduced enrollment (ps < .001), and these individuals were more likely to seek treatment. Conclusions: Past and anticipated use of mental health treatment likely exceeds on-campus capacity. Student mental health and retention are linked, and treatment may support retention. Nontraditional services, including telemental health, could help address increasing symptom severity and demand for services.

Counselors' Perceptions of Their Preparedness for Telemental Health Services: A Phenomenological Examination

Background

To examine counselors' perceptions of their formal preparation for engaging in telemental health (TMH) counseling with the intent of gaining an understanding of their lived experiences.

Materials and Methods

Semistructured interviews were conducted with seven seasoned counselors who regularly engage in technology-mediated distance counseling.

Results

The results highlighted themes within two emerging categories: the counselor and training/education. Themes related to motivation and specific counselor attributes emerged from the first category and themes of availability, inadequacy, and modality emerged from the second category.

Discussion

The implications from this study suggest a lack of availability and standardization of effective training on TMH delivery.

Conclusion

This study identifies areas of potential future research related to counselors' preparation experiences as well specific areas of need for TMH training in counseling graduate programs and other natural opportunities.

Online versus in-person delivery of cognitive behaviour therapy for obsessive compulsive disorder: An examination of effectiveness

Cognitive behavioural therapy (CBT) including exposure and response prevention is the first-line psychological treatment for obsessive compulsive disorder (OCD). Given changes in the clinical landscape, there are increasing efforts to evaluate its effectiveness in online contexts. Mirroring the traditional in-person delivery, few studies have assessed the role of therapist-guided, manual-based CBT for OCD delivered in real-time via videoconferencing methods. The present study sought to fill this gap by comparing in-person and online delivery of group-based CBT for the treatment of OCD. A convenience sample of participants with moderate to severe OCD (n = 144) were recruited from a naturalistic database from two large OCD specialty assessment and treatment centres. Patients received group-based CBT that was provided in-person (pre-COVID-19 pandemic; March 2018 to March 2020) or online via videoconferencing (during the COVID-19 pandemic; March 2020 to April 2021). In both delivery methods, treatment consisted of 2-h weekly sessions led by trained clinicians. Analyses revealed that, regardless of treatment modality, both in-person and online groups demonstrated significant, reliable, and statistically equivalent improvements in OCD symptoms post-treatment. Videoconferenced, clinician-led CBT may be a promising alternative to in-person delivery for those with moderate to severe OCD symptoms.

Manipal model of telepsychiatry

Telepsychiatry can be understood as an interactive mental health service providing mode using information and communication technology. In recent decades, services provided under the umbrella term of telepsychiatry expanded to cater clinical services, diagnostic services, interventions, therapies, education, and research. Since telepsychiatry has been practiced in India for two decades, various models have emerged to meet the country's demands and the logistics that are available. Both synchronous and asynchronous modes of telepsychiatry had been in practice in India depending on the availability of logistics. Most of the telepsychiatry services in India had focused on providing clinical care to reach the unreached population. Furthermore, telepsychiatry had been used to train mental health professionals and healthcare workers from other disciplines. However, not many models had incorporated the idea of hands-on training of the postgraduates/trainees of psychiatric social work (PSW) in telepsychiatry under supervision. This was addressed in the Manipal model of telepsychiatry. Manipal model of telepsychiatry has begun in 2016 with a novel idea to train mental health profession trainees in addition to cover other clinical services, research, and education. In the last eight years, four centers of Karnataka state have been covered under this model with progressive growth in a number of patients and this acted as a hands-on training model for the postgraduate trainees in starting telepsychiatry services independently. Furthermore, it provided an opportunity to develop the organization skills of trainees, improved their oratory skills, and improved their expertise in using information technology for mental healthcare delivery.

Outcome trajectories in a county mental health clinic before and after telemental health: a retrospective COVID-19 cohort study

Background/objectives

Telemental health (TMH) care has received increased attention, most recently due to the COVID-19 pandemic. Many treatment settings and clinicians were forced to rapidly shift to TMH modalities, including clinicians with limited exposure to and possibly negative attitudes toward alternative treatment delivery formats. With the shift to new modalities, effectiveness research is necessary to understand if patients are receiving the same quality of care as before the pandemic and their receipt of mostly in person services. This study compared the naturalistic treatment outcome trajectories for a cohort of patients who received in-person services prior to the pandemic and a distinct cohort of patients who received TMH services after the onset of the pandemic, in a community mental health setting with limited exposure to TMH prior to the COVID-19 pandemic.

Materials and methods

We adopted a retrospective cohort design to examine treatment modality as a between-group moderator of symptom change trajectory on the self-report Patient Health Questionnaire (PHQ-9) in a sample of N = 958 patients in the Northeast United States. Treatment durations differed in the naturalistic treatment setting and we examined patient-reported outcomes up to a maximum of one year.

Results

Statistically significant average decreases in symptom severity were found over the course of up to one year of treatment, yet the average outcome trajectory was not significantly different between two modality cohorts (in person delivery before the pandemic versus TMH delivery after pandemic onset).

Conclusion

These findings suggest that even in a setting with limited exposure to or training in TMH, the average outcome trajectory for patients who received TMH was statistically similar to the outcome trajectory for patients in an earlier cohort who received in-person services prior to the pandemic onset. Overall, the results appear to support continued use of TMH services in community treatment settings.

If it's offered, will they come? Practical considerations when offering intensive PTSD treatment in an outpatient Veterans Affairs PTSD clinic

Evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are efficacious; however, treatment dropout remains high. The delivery of intensive EBPs for PTSD (i.e., sessions three times per week or more) and telemental health may address barriers impacting dropout. Current evidence for intensive EBPs comes primarily from programs specifically designed for this level of care. Therefore, the feasibility of delivering intensive EBPs for PTSD in traditional outpatient clinics remains unclear. The aim of this pilot study was to identify veteran level of interest in intensive treatment and explore the feasibility of delivering intensive treatment via telemental health in an outpatient PTSD clinic at a Veterans Affairs (VA) hospital. One provider offered intensive treatment to 14 veterans. Three of the veterans initiated intensive treatment and completed with benefit. Veteranand system-level barriers, as well as veteran preferences for initiating intensive therapy and suggestions for implementing intensive EBPs in a routine outpatient clinic, are discussed.

Content Recommendation Systems in Web-Based Mental Health Care: Real-world Application and Formative Evaluation

BACKGROUND

Recommender systems have great potential in mental health care to personalize self-guided content for patients, allowing them to supplement their mental health treatment in a scalable way.

OBJECTIVE

In this paper, we describe and evaluate 2 knowledge-based content recommendation systems as parts of Ginger, an on-demand mental health platform, to bolster engagement in self-guided mental health content.

METHODS

We developed two algorithms to provide content recommendations in the Ginger mental health smartphone app: (1) one that uses users' responses to app onboarding questions to recommend content cards and (2) one that uses the semantic similarity between the transcript of a coaching conversation and the description of content cards to make recommendations after every session. As a measure of success for these recommendation algorithms, we examined the relevance of content cards to users' conversations with their coach and completion rates of selected content within the app measured over 14,018 users.

RESULTS

In a real-world setting, content consumed in the recommendations section (or "Explore" in the app) had the highest completion rates (3353/7871, 42.6%) compared to other sections of the app, which had an average completion rate of 37.35% (21,982/58,614; P<.001). Within the app's recommendations section, conversation-based content recommendations had 11.4% (1108/2364) higher completion rates per card than onboarding response-based recommendations (1712/4067; P=.003) and 26.1% higher than random recommendations (534/1440; P=.005). Studied via subject matter experts' annotations, conversation-based recommendations had a 16.1% higher relevance rate for the top 5 recommended cards, averaged across sessions of varying lengths, compared to a random control (110 conversational sessions). Finally, it was observed that both age and gender variables were sensitive to different recommendation methods, with responsiveness to personalized recommendations being higher if the users were older than 35 years or identified as male.

CONCLUSIONS

Recommender systems can help scale and supplement digital mental health care with personalized content and self-care recommendations. Onboarding-based recommendations are ideal for "cold starting" the process of recommending content for new users and users that tend to use the app just for content but not for therapy or coaching. The conversation-based recommendation algorithm allows for dynamic recommendations based on information gathered during coaching sessions, which is a critical capability, given the changing nature of mental health needs during treatment. The proposed algorithms are just one step toward the direction of outcome-driven personalization in mental health. Our future work will involve a robust causal evaluation of these algorithms using randomized controlled trials, along with consumer feedback-driven improvement of these algorithms, to drive better clinical outcomes.

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.

"One Degree of Separation": A Mixed-Methods Evaluation of Canadian Mental Health Care User and Provider Experiences With Remote Care During COVID-19

OBJECTIVES

The COVID-19 pandemic has contributed to a shift from in-person to remote mental health care. While remote care methods have long existed, their widespread use is unprecedented. There is little research about mental health care user and provider experiences with this transition, and no published studies to date have compared satisfaction between these groups.

METHODS

Canadian mental health care users (n = 332) and providers (n = 107) completed an online self-report survey from October 2020 to February 2021 hosted by the Canadian Biomarker Integration Network in Depression. Using a mixed-methods approach, participants were asked about their use of remote care, including satisfaction, barriers to use, helpful and unhelpful factors, and suggestions for improvement.

RESULTS

Overall, 59% to 63% of health care users and 59% of health care providers were satisfied with remote care. Users reported the greatest satisfaction with the convenience of remote care, while providers were most satisfied with the speed of provision of care; all groups were least satisfied with therapeutic rapport. Health care providers were less satisfied with the user-friendliness of remote care (P < 0.001) than users, while health care users were less satisfied than providers with continuity of care (P < 0.001). The use of a video-based platform was associated with remote care satisfaction among health care users (P < 0.02), and qualitative responses support the importance of visual cues in maintaining therapeutic rapport remotely. The majority of users (55%) and providers (87%) reported a likelihood of using remote care after the pandemic.

CONCLUSIONS

Remote mental health care is generally accepted by both users and providers, and the majority would consider using remote care following the pandemic. Suggestions for improvement include greater use of video, increased attention to body language and eye contact, consistency with in-person care, as well as increased provider training and administrative support.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparison of online and in-person counseling outcomes using solution-focused brief therapy for college students with anxiety

ObjectiveThis study compared online, synchronous video counseling to in-person counseling using solution-focused brief therapy for college students with mild to moderate anxiety. Participants: Participants were 49 undergraduate students who were seeking counseling for mild to moderate anxiety. The study was conducted from November, 2017 to December 2018. Methods: In a randomized, non-inferiority design, undergraduate participants were randomly assigned to online, synchronous video counseling or in-person treatment for anxiety using solution-focused brief therapy (SFBT). Participants completed the Beck's Anxiety Inventory (BAI) and College Counseling Assessment of Psychological Symptoms (CCAPS) to assess outcomes. Results: The results showed significant changes in scores on the BAI and the CCAPS Generalized Anxiety and Social Anxiety subscales for participants in both study conditions, and no significant differences in effectiveness of the two delivery methods. Conclusions: The findings provide support for the treatment of college students with anxiety with SFBT through online, synchronous video counseling. Limitations related to sample size and diversity are discussed.

Adaptation or Revolution: Telemental Health and Advanced Practice Psychiatric Nursing During COVID-19

OBJECTIVE

This article will describe the current COVID-19 crisis and the evolving mental health concerns associated with it, discuss how mental health practice has changed, and ways in which psychiatric mental health nurse practitioners (PMHNPs) can adapt and prepare for the future.

METHOD

A search of current literature on the COVID-19 crisis, and topics relevant to the mental health components associated with the pandemic are reviewed. Telemental health (TMH) and PMHNP practice are discussed as they relate to the unfolding picture of the viral pandemic.

RESULTS

The COVID-19 crisis is having far-reaching implications for mental health treatment and in particular for PMHNPs in practice settings. There have been widespread consequences of the containment measures used for the protection and mitigation of the disease. One such result has been the inability of patients to have face-to-face contact with their providers. The role of TMH has become increasingly important as an adaptation in professional practice.

CONCLUSION

Technology has rapidly transformed traditional practice due to the COVID-19 crisis and there is strong evidence that it is well accepted by patients and providers. It is incumbent on PMHNPs to embrace TMH and become educated on best practices and TMH services.

The Impact of the COVID-19 Pandemic on Mental Health Care of Children and Adolescents in Switzerland: Results of a Survey among Mental Health Care Professionals after One Year of COVID-19

Background: To assess the impact of the COVID-19 pandemic on treatment demand and supply in children and adolescents with mental disorders during the first year of the pandemic from the perspective of child and adolescent psychiatrists and psychologists in Switzerland. Methods: The survey was conducted anonymously, in German or French and online in April/May 2021. Mental health professionals working in child and adolescent psychiatry, psychotherapy services or independent practices were contacted by email. Results: N = 454 professionals completed the survey (176 child and adolescent psychiatrists and 276 psychologists). After an initial period of decreased demand during the lockdown in spring 2020, requests for treatment increased, considerably exceeding the demand pre-pandemic and reaching a peak in January/February/March 2021. The vast majority of professionals (78.2%) estimated that there was currently too little supply during the pandemic, which differed from the evaluation of the pre-pandemic situation (37%). A total of 65% of participants indicated that waiting time until the initiation of treatment increased during the pandemic, 41% reported their current workload to be somewhat higher and 44.5% much higher. Conclusions: For the first pandemic year, youth mental health professionals reported a large increase in the treatment demand and waiting time and a worrisome overload of treatment services.

Provider perspectives on telemental health implementation: Lessons learned during the COVID-19 pandemic and paths forward

After years of slow and fragmented implementation of telemental health (TMH), the coronavirus disease (COVID-19) pandemic necessitated widespread adoption. With the initial state of public health emergency behind us, we are at a decision point on whether to continue with TMH or return to a largely in-person care model. In this qualitative study, we investigated clinicians' perspectives on advantages and disadvantages of TMH in outpatient mental healthcare as well as considerations for future implementation. We conducted 29 semistructured interviews with outpatient mental health providers. Data were analyzed using rapid qualitative analysis methodology. Advantages included increased utilization of services, improved therapeutic processes, and improved provider wellbeing. Providers, however, also noted that TMH has some disadvantages in terms of therapeutic processes and provider wellbeing, and they reported technology issues as an additional disadvantage. Overall providers reported they can provide high quality care via TMH, but indicated some patient populations and appointment types are a better fit for in-person services. Most providers preferred a hybrid model of care moving forward with reimbursement discrepancies and out-of-state licensure restrictions as barriers. They indicated that, as TMH becomes a mainstay in psychiatric care, training and professional guidelines will be important. Continued implementation of TMH alongside in-person care is likely to offer improved access and enhanced service quality when applied to the right patient populations and appointment types. Effective implementation may require policy and systems level support on equitable reimbursement rates, out-of-state licensure restrictions and professional guidelines for delivering TMH. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient and provider predictors of telemental health use prior to and during the COVID-19 pandemic within the Department of Veterans Affairs

The current study examined patient and provider differences in use of phone, video, and in-person mental health (MH) services. Participants included patients who completed ≥ 1 MH appointment within the Department of Veterans Affairs (VA) from 10/1/17-7/10/20 and providers who completed ≥ 100 VA MH appointments from 10/1/17-7/10/20. Adjusted odds ratios (aORs) are reported of patients and providers: (a) completing ≥1 video MH appointment in the pre-COVID (10/1/17-3/10/20) and COVID (3/11/20-7/10/20) periods; and (b) completing the majority of MH visits via phone, video, or in-person during COVID. The sample included 2,480,119 patients/31,971 providers in the pre-COVID period, and 1,054,670 patients/23,712 providers in the COVID period. During the pre-COVID and COVID periods, older patients had lower odds of completing ≥ 1 video visit (aORs < .65). During the COVID period, older age and low socioeconomic status predicted lower odds of having ≥ 50% of visits via video versus in-person or phone (aORs < .68); schizophrenia and MH hospitalization history predicted lower odds of having ≥ 50% of visits via video or phone versus in-person (aORs < . 64). During the pre-COVID and COVID periods, nonpsychologists (e.g., psychiatrists) had lower odds of completing video visits (aORs < . 44). Older providers had lower odds of completing ≥ 50% of visits via video during COVID (aORs <. 69). Findings demonstrate a digital divide, such that older and lower income patients, and older providers, engaged in less video care. Nonpsychologists also had lower video use. Barriers to use must be identified and strategies must be implemented to ensure equitable access to video MH services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study

BACKGROUND

Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic.

OBJECTIVE

The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic.

METHODS

A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively.

RESULTS

A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement.

CONCLUSIONS

Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Teletherapy Versus In-Person Psychotherapy for Depression: A Meta-Analysis of Randomized Controlled Trials

Introduction: The recent surge in telehealth service delivery represents a promising development in the field's ability to address access gaps in health care across underserved populations. Telehealth also carries the potential to help reduce the societal burden of mental illnesses such as major depression, which often go untreated. There is now a sufficiently large corpus of randomized controlled trials to examine the comparative effectiveness of teletherapy and in-person services meta-analytically. Methods: We searched the PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for articles from January 1, 2000 to February 1, 2021 to identify randomized head-to-head trials of video-based versus in-person delivery of psychotherapy to reduce depressive symptoms. We conducted a random-effects meta-analysis to evaluate potential differences in efficacy rates. We calculated and meta-analyzed odds ratios to examine differential attrition rates between video and in-person conditions. Finally, we conducted subgroup analyses based on the primary treatment focus (depression or another condition) of each trial. Results: Primary study analyses yielded evidence that video-based psychotherapy is roughly comparable in efficacy with in-person psychotherapy for reducing depressive symptoms (g = 0.04, 95% confidence interval [CI = -0.12 to 0.20], p = 0.60, I² = 5%). Likewise, attrition rates between the two conditions were not significantly different (odds ratio = 1.07, 95% CI = [0.78 to 1.49], p = 0.63, I² = 25%). Finally, we did not observe significant subgroup differences in either efficacy (p = 0.38) or attrition (p = 0.94). Conclusions: The present findings suggest that video-based teletherapy may be a feasible and effective alternative to in-person services for reducing depressive symptoms. Continued research on the effectiveness of telehealth in clinically depressed samples, and further elucidation of the access barriers entailed by each delivery modality, can help the field better determine which patients will derive the greatest benefit from each mode of intervention.

A Buprenorphine Program Evaluation Before and During the COVID-19 Pandemic

This project evaluated the service delivery (ie, attendance rate) of a buprenorphine management treatment program and compared patient recovery-related information between service methods. This was a medical record review and cross-sectional comparison of pre–COVID-19 vs post onset of COVID-19 data. In the sample of 28 adults, mean attendance rates did not differ significantly before (99.46%) vs during the pandemic (96.13%; t = 1.92, P = .07). Patient participation in therapy before and during the pandemic did differ significantly (χ² = 1.98, P = .03). The use of telemental health services within a BMT program may be a viable option when normal in-person services are disrupted.

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.

Clinician Perceptions of the Negative Impact of Telehealth Services in the Management of Drug-Induced Movement Disorders and Opportunities for Quality Improvement: A 2021 Internet-Based Survey

PURPOSE

Tardive dyskinesia (TD) is a drug-induced movement disorder (DIMD) seen in patients taking dopamine-receptor blocking agents (DRBAs). Clinicians should regularly monitor patients with or at risk of developing DIMDs; however, telehealth visits during the COVID-19 pandemic presented several significant challenges related to screening and care of these patients. In this observational survey study, respondents compared in-person with video/telephone visits to determine the impact on the evaluation, diagnosis, and monitoring of patients with DIMDs.

METHODS

The online survey was conducted (May 14-June 21, 2021) with qualified clinicians who prescribed a vesicular monoamine transporter 2 inhibitor or benztropine for DIMDs in the past 6 months, spent ≤70% of their professional time in the clinic, and conducted telehealth visits with ≥15% of their patients between December 2020 and January 2021. The questionnaire probed clinicians about their ability to evaluate, diagnose and monitor (hereinafter referred to as manage) patients with DIMDs via telehealth.

RESULTS

Survey respondents included 277 clinicians from psychiatry (n = 168) and neurology (n = 109) practices. Certain signs and symptoms (visual cues) used for diagnosis of DIMDs were not observable through telehealth and evaluation was comparatively more difficult with phone visits than video visits. Patients without caregivers and lower-functioning patients were at higher risk of missed diagnosis of DIMDs and were also difficult to monitor via telehealth. Limited access to computers or telephones and patients living alone were among the top socioeconomic barriers limiting clinicians' ability to diagnose DIMDs. Patients without a regular caregiver were also more difficult for clinicians to evaluate and monitor adequately. Further, most clinicians received no training related to evaluation of DIMDs via telehealth or engaging caregivers as health care partners.

CONCLUSION

Our study highlights specific limitations and challenges and provides considerations to help clinicians better manage DIMDs in the context of telehealth services.

Telepsychology May Improve Treatment Adherence in Patients with Psychogenic Nonepileptic Seizures

Introduction: Access to mental health care is a significant challenge in patients with psychogenic nonepileptic seizures (PNES). Telepsychology can curb the access barriers and improve adherence but the role of telepsychology in improving adherence has not been well investigated. The current study examines the utility of telepsychology during the COVID-19 pandemic and treatment adherence in PNES patients. Materials and Methods: Patients with PNES admitted to a 12-week counseling program were offered two visit types: telepsychology and in-office. Visit type, visit status, and demographic information were obtained from department database. Follow-up visits in 6 months were used to examine the effect of visit type on visit status. Adherence to treatment was measured by higher attendance of scheduled visits and less cancellation and no-show rates. Results: Two hundred fifty-seven (n) patients who scheduled virtual or telepsychology visits were included in the study. After adjusting for demographic variables, and accounting for repeated measures, telepsychology visits were significantly more likely to be attended (odds ratio [OR] = 2.40, 95% confidence interval [CI] = 1.69-3.41, p < 0.001) and were significantly less likely to be canceled (OR = 0.43, 95% CI = 0.29-0.64, p < 0.001). The regression model showed patients in the telepsychology visit group attended more than three times as many visits as in-office patients (incidence rate ratios = 3.16, 95% CI = 2.13-4.73, p < 0.001). Conclusions: Patients with PNES have logistical and psychological barriers that can impede their ability to attend counseling treatment. Receiving care remotely may have been associated with higher engagement with mental health treatment compared to having to travel to counseling clinics. Considering the symptom-related restrictions patients with PNES have and the barriers presented by the COVID-19 pandemic, telepsychology played a key role for continuation of mental health treatment.

Psychometric properties of the Telepsych User Experience Scale (TUES)

PURPOSE

To develop and psychometrically evaluate a brief measure of the telemental health experience among people receiving psychiatric and psychological care-the Telepsych User Experience Scale (TUES).

METHODS

The TUES was administered at 6 months to 364 study participants who screened positive for posttraumatic stress disorder and/or bipolar disorder and used telepsych services. The factor structure of the TUES was examined using exploratory and confirmatory factor analyses. Psychometric testing of the final scale examined (1) internal reliability, (2) criterion validity, (3) convergent validity, and (4) test-retest reliability using omega coefficients, negative binomial regression, and correlations, respectively. A week after the 12-month follow-up survey was completed, a retest was administered to 29 patients to assess reliability.

FINDINGS

Factor analytic methods indicated a single latent factor (user experience) and correlated error variance (method effect of item wording) for 2 items. To enhance clinical utility, we removed the 2 negatively worded items, resulting in a 5-item scale. Confirmatory analyses indicated excellent fit of the final model, which retained the best performing items from each hypothesized construct. The TUES demonstrated evidence of internal consistency (omega = 0.88-0.90), convergent validity, (r = 0.58), and criterion validity through telepsych engagement (incidence rate ratio = 1.19, P < .001), though test-retest reliability was unacceptable (r = 0.41).

CONCLUSION

The TUES is a pragmatic instrument with evidence of validity and internal reliability. Replication is necessary, but this initial psychometric evaluation suggests the TUES is a promising, brief yet comprehensive measure of telemental health user experience with clinical populations in rural settings.

Telemental Health Collaborative Care Medication Management: Implementation and Outcomes

Introduction:

Access to quality mental health medication management (MM) in the United States is limited, even among those with employment-based health insurance. This implementation, feasibility, and outcome study sought to design and evaluate an evidence-based telemental health MM service using a collaborative care model (CoCM).

Materials and Methods:

CoCM MM was available to adult employees/dependents through their employer benefits, in addition to therapy. Outcomes included Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) collected at baseline and throughout participation. This analysis was not deemed to be human subjects research by the Western Institutional Review Board.

Results:

Over 17 months, 212 people enrolled and completed >2 assessments; the enrollees were 58.96% female with average age of 32.00 years (standard deviation [SD] = 7.38). In people with moderate to severe depression or anxiety, PHQ-9 and GAD-7 scores reduced by an average of 7.27 (SD = 4.80) and 6.71 (SD = 5.18) points after at least 12 ± 4 weeks in the program. At 24 ± 4 weeks, the PHQ-9 and GAD-7 reductions were on average 7.17 (SD = 5.00) and 6.03 (SD = 5.37), respectively. Approximately 65.88% of participants with either baseline depression or anxiety had a response on either the PHQ-9 or GAD-7 at 12 ± 4 weeks and 44.71% of participants experienced remission; at 24 ± 4 weeks, 56.41% had response and 41.03% experienced remission.

Conclusions:

An evidence-based CoCM telemedicine service within an employee behavioral health benefit is feasible and effective in reducing anxiety and depression symptoms when using measurement-based care. Widespread implementation of a benefit like this could expand access to evidence-based mental health MM.

Implementation, Adoption, and Perceptions of Telemental Health During the COVID-19 Pandemic: Systematic Review

BACKGROUND

Early in 2020, mental health services had to rapidly shift from face-to-face models of care to delivering the majority of treatments remotely (by video or phone call or occasionally messaging) due to the COVID-19 pandemic. This resulted in several challenges for staff and patients, but also in benefits such as convenience or increased access for people with impaired mobility or in rural areas. There is a need to understand the extent and impacts of telemental health implementation, and barriers and facilitators to its effective and acceptable use. This is relevant both to future emergency adoption of telemental health and to debates on its future use in routine mental health care.

OBJECTIVE

To investigate the adoption and impacts of telemental health approaches during the COVID-19 pandemic, and facilitators and barriers to optimal implementation.

METHODS

Four databases (PubMed, PsycINFO, CINAHL, and Web of Science) were searched for primary research relating to remote working, mental health care, and the COVID-19 pandemic. Preprint servers were also searched. Results of studies were synthesized using framework synthesis.

RESULTS

A total of 77 papers met our inclusion criteria. In most studies, the majority of contacts could be transferred to a remote form during the pandemic, and good acceptability to service users and clinicians tended to be reported, at least where the alternative to remote contacts was interrupting care. However, a range of impediments to dealing optimal care by this means were also identified.

CONCLUSIONS

Implementation of telemental health allowed some continuing support to the majority of service users during the COVID-19 pandemic and has value in an emergency situation. However, not all service users can be reached by this means, and better evidence is now needed on long-term impacts on therapeutic relationships and quality of care, and on impacts on groups at risk of digital exclusion and how to mitigate these.

TRIAL REGISTRATION

PROSPERO International prospective register of systematic reviews CRD42021211025; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021211025.

Plan A, Plan B, and Plan C-OVID-19: adaptations for fly-in and fly-out mental health providers during COVID-19

Mental health providers have rapidly pivoted their in-person practices to teletherapy and telehealth interventions to address the increased demand for mental health services during the COVID-19 crisis. The change to service delivery has emphasised challenges for mental health service providers, particularly in regions that rely on fly-in and fly-out (FIFO) mental health service providers who are no longer able to travel to their places of work. In this qualitative study, we examined the impact of COVID-19 on the delivery of mental health services in Inuit Nunangat. Using a participatory action research methodology, we conducted semi-structured interviews with eight FIFO mental health service providers to understand their experiences and implement strategies to effectively deliver mental health services in a pandemic. We identified three themes through thematic analysis: 1) Service providers identify the challenges in adapting their practices to meet individual and community needs; 2) Service providers recognise the opportunities for enhancements to service delivery; 3) Service providers identify telemental health services as a potentially effective adjunct to in-person sessions. The findings support reconceptualising post-pandemic mental health service delivery to include both face-to-face and telemental health services.

iCOPE With COVID-19: A Brief Telemental Health Intervention for Children and Adolescents During the COVID-19 Pandemic

The COVID-19 pandemic has prompted extensive disruptions to the daily lives of children and adolescents worldwide, which has been associated with an increase in anxiety and depressive symptoms in youth. However, due to public health measures, in-person psychosocial care was initially reduced, causing barriers to mental health care access. This study investigated the feasibility, acceptability and preliminary effectiveness of iCOPE with COVID-19, a brief telemental health intervention for children and adolescents to address anxiety symptoms. Sessions were provided exclusively using videoconferencing technology. Feasibility and acceptability were measured with client satisfaction data. The main outcome measure for effectiveness was anxiety symptom severity measured using the Screen for Child Anxiety and Related Disorders (SCARED). Results indicated that the treatment was well accepted by participants. Significant reductions in anxiety were noted for social anxiety, and were observed to be trending towards a mean decrease for total anxiety. The findings suggest that this brief telemental health intervention focused on reducing anxiety related to COVID-19 is acceptable and feasible to children and adolescents. Future research using a large sample and with a longer follow-up period could inform whether symptom decreases are sustained over time.

Increasing access to care for trauma-exposed rural veterans: A mixed methods outcome evaluation of a web-based skills training program with telehealth-delivered coaching

PURPOSE

While rural veterans with trauma exposure report high rates of posttraumatic stress disorder (PTSD), depression, and functional impairment, utilization of health services is low. This pilot study used mixed qualitative and quantitative methods to evaluate the potential benefits of a transdiagnostic web-based skills training program paired with telehealth-delivered coaching to address a range of symptoms and functional difficulties. The study directed substantial outreach efforts to women veterans who had experienced military sexual trauma given their growing representation in the Veterans Healthcare Administration (VHA) and identified need for services.

METHODS

Participants were 32 trauma-exposed veterans enrolled in rural-serving VHA facilities who screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed at baseline, midpoint, posttreatment, and 3-month follow-up. Veterans completed exit interviews to identify benefits and limitations of the program.

RESULTS

Intent-to-treat analyses revealed significant symptom reduction for all outcomes, with large to moderate effect sizes at 3-month follow-up. Outcomes did not differ by gender or military sexual trauma status. Veterans' rating of the therapeutic alliance was high and interview responses indicated that the presence of the coach was critical to success in the program.

CONCLUSION

This remotely delivered transdiagnostic intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by veterans. The results indicate that further research (ie, a randomized controlled trial) is warranted. Attention to the role of the coach as a means by which to increase engagement and retention in technology-delivered interventions is warranted.

Rebooting Mental Health Care Delivery for the COVID-19 Pandemic (and Beyond): Guiding Cautions as Telehealth Enters the Clinical Mainstream

Across the COVID-19 pandemic, we have witnessed perhaps the field’s largest and most abrupt transformation in scope of practice. In the context of surging mental health needs and historically limited feasibility of traditional office-based services during the pandemic, telehealth has launched into the clinical mainstream and has become a dominant mode of outpatient mental health care delivery. The articles in this terrific Special Issue outline some of the field’s most exciting innovations from the past 18 months. The present commentary discusses how these unprecedented times have prompted unprecedented resourcefulness and innovation in the field. Issues related to evolving and uncertain telehealth regulation and reimbursement policies are discussed, and cautions for the road ahead are offered as we prepare for post-pandemic practices. The commentary concludes with a call to redouble efforts to move beyond the use of telehealth to largely treat only those populations who already enjoyed access to traditional office-based services. Understanding and overcoming barriers to telehealth care and ensuring equitable access to telehealth options are critical steps for actualizing the great potential of telehealth strategies for increasing the reach of supported care to underserved populations.

Domestic Violence and Mental Health During the COVID-19 Pandemic in Bangladesh

BACKGROUND

The COVID-19 lockdown, the advent of working from home, and other unprecedent events have resulted in multilayer and multidimensional impacts on our personal, social, and occupational lives. Mental health conditions are deteriorating, financial crises are increasing in prevalence, and the need to stay at home has resulted in the increased prevalence of domestic violence. In Bangladesh, where domestic violence is already prevalent, the lockdown period and stay-at-home orders could result in more opportunities and increased scope for perpetrators of domestic violence.

OBJECTIVE

In this study, we aimed to determine the prevalence and pattern of domestic violence during the initial COVID-19 lockdown period in Bangladesh and the perceptions of domestic violence survivors with regard to mental health care.

METHODS

We conducted this cross-sectional web-based study among the Bangladeshi population and used a semistructured self-reported questionnaire to understand the patterns of domestic violence and perceptions on mental health care from August to September 2020. The questionnaire was disseminated on different organizational websites and social media pages (ie, those of organizations that provide mental health and domestic violence services). Data were analyzed by using IBM SPSS (version 22.0; IBM Corporation).

RESULTS

We found that 36.8% (50/136) of respondents had faced domestic violence at some point in their lives; psychological abuse was the most common type of violence. However, the prevalence of the economical abuse domestic violence type increased after the COVID-19 lockdown was enforced. Although 96.3% (102/136) of the participants believed that domestic violence survivors need mental health support, only 25% (34/136) of the respondents had an idea about the mental health services that are available for domestic violence survivors in Bangladesh and how and where they could avail mental health services.

CONCLUSIONS

Domestic violence is one of the most well-known stressors that have direct impacts on physical and mental health. However, the burden of domestic violence is often underreported, and its impact on mental health is neglected in Bangladesh. The burden of this problem has increased during the COVID-19 crisis, and the cry for mental health support is obvious in the country. However, it is necessary to provide information about available support services; telepsychiatry can be good option for providing immediate mental health support in a convenient and cost-effective manner.

Telehealth Utilization During COVID-19 Among People with Diagnosed Mental Health Conditions

Background: Despite the potential benefits and the demonstrated uptake throughout the coronavirus disease 2019 (COVID-19) pandemic, studies have found that telemental health is still underused. The objective of the study was to explore the associations between mental health diagnoses and telehealth utilization during the pandemic. Methods: The study utilized a cross-sectional survey among adult Arkansans (n = 754). Logistic regression was used to determine the association between a diagnosis of anxiety and/or depression and telehealth utilization. Results: Forty-two percent of respondents reported utilizing telehealth during the pandemic. Respondents with a diagnosis of anxiety and/or depression had three times greater odds of utilizing telehealth (odds ratio = 2.97) than those with no diagnoses. Discussion: Utilization of telehealth care during the COVID-19 pandemic was lower in our sample compared with other nationally representative surveys; however, utilization was higher among people with a diagnosis of anxiety and/or depression. Conclusions: The results indicate the need for outreach to increase telehealth utilization.

Enhancing Mental Health Treatment for Borderline Personality Disorder in Corrections

Improving mental health among inmates has been a long-term challenge for correctional systems. Although borderline personality disorder (BPD) has garnered limited attention in the literature, evidence suggests it is highly prevalent in corrections. It is important to provide comprehensive treatment for this condition, given its high prevalence and significant personal, societal, and economic burden. This article discusses two approaches aimed at enhancing mental health treatment for BPD in corrections. The first focuses on implementing evidence-based psychotherapy that is customized to the correctional setting. The other approach is expanding telemental health to overcome clinician shortages and maintain high-quality care.

Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems

PURPOSE

The COVID-19 pandemic has resulted in a widespread adoption of videoconferencing as a communication medium in mental health service delivery. This review considers the empirical literature to date on using videoconferencing to deliver psychological therapy to adults presenting with mental health problems.

METHOD

Papers were identified via search of relevant databases. Quantitative and qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and participant and therapist experiences.

RESULTS

Videoconferencing has an established evidence base in the delivery of cognitive behavioural therapies for post-traumatic stress disorder and depression, with prolonged exposure, cognitive processing therapy, and behavioural activation non-inferior to in-person delivery. There are large trials reporting efficacy for health anxiety and bulimia nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive behavioural therapies for other anxiety and eating disorders and obsessive-compulsive spectrum disorders, but there has yet to be study of use in severe and complex mental health problems. Therapists may find it more difficult to judge non-verbal behaviour, and there may be initial discomfort while adapting to videoconferencing, but client ratings of the therapeutic alliance are similar to in-person therapy, and videoconferencing may have advantages such as being less confronting. There may be useful opportunities for videoconferencing in embedding therapy delivery within the client's own environment.

CONCLUSIONS

Videoconferencing is an accessible and effective modality for therapy delivery. Future research needs to extend beyond testing whether videoconferencing can replicate in-person therapy delivery to consider unique therapeutic affordances of the videoconferencing modality.

PRACTITIONER POINTS

Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems. Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation. While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person. Videoconferencing provides opportunities to integrate therapeutic exercises within the person's day-to-day environment.

Home-Based Telemental Health: A Proposed Privacy and Safety Protocol and Tool

Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH) services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a component of the routine mental health care landscape. Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety Checklist/Time-Out and the Checklist Manifesto.Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment during subsequent visits. A sample workflow guides implementation. Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-TMH. Its modular format can be adapted to each site's resources. Going forward, the PSA Tool should help to facilitate the integration of HB-TMH into the routine mental health care landscape.

Therapist-Led, Internet-Delivered Treatment for Early Child Social Anxiety: A Waitlist-Controlled Evaluation of the iCALM Telehealth Program

Despite recent advances in the treatment of early child social anxiety, the broad accessibility of brick-and-mortar services has been limited by traditional barriers to care, and more recently by new obstacles related to efforts to slow the spread of COVID-19. The present waitlist-controlled trial examined the preliminary efficacy of a family-based behavioral parenting intervention (i.e., the iCALM Telehealth Program) that draws on Parent-Child Interaction Therapy and videoconferencing to remotely deliver clinician-led care for anxiety in early childhood. Young children (3-8 years) with a diagnosis of social anxiety disorder (N = 40; 65% from ethnic/racial minority backgrounds) were randomly assigned to iCALM or waitlist. Intent-to-treat analyses found that at post, independent evaluators classified roughly half of the iCALM-treated children, but only 6% of waitlist children, as "Responders" (Wald test = 4.51; p = .03). By Post, iCALM led to significantly greater reductions than waitlist in child anxiety symptoms, fear, discomfort, and anxiety-related social impairment, and also led to greater improvements in child soothability. By 6-month follow-up, the percentage of iCALM-treated children classified as "Responders" rose to roughly 60%. Exploratory moderation tests found iCALM was particularly effective in reducing life impairments and parental distress among families presenting with higher, relative to lower, levels of baseline parental accommodation. The present findings add to a growing body of research supporting the promise of technology-based strategies for broadening the portfolio of options for delivering clinician-led mental health services.

Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews

BACKGROUND

Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic.

OBJECTIVE

We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature.

METHODS

Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings.

RESULTS

In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking.

CONCLUSIONS

This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.