The widespread rapid adaptation to remote mental healthcare delivery forced by the COVID-19 pandemic generated an explosion of research on telemental health (delivering care through SMS text messaging, chat functions, telephone and video calls (Sheridan et al., 2021; Agency for Healthcare Research and Quality, 2022). Research during this period provides an opportunity to learn from universal telemental health implementation.

Prior to the pandemic, research found telemental health was acceptable and advantageous for some service users, but studies were small-scale or with volunteer participants (Barnett et al., 2021; Bashshur et al., 2016; Hilty et al., 2013; Hubley et al., 2016; Salmoiraghi & Hussain, 2015; Varker et al., 2019). With professionals and service users engaging in telemental health on an unprecedented scale during the pandemic, it became necessary to understand the acceptability, barriers, facilitators and differential impact on different service user groups of telemental health.

As COVID-19 restrictions now lift globally, we need to synthesise our learning to help specify the role for telemental health going forward; to determine whether it is safe, inclusive, acceptable, effective, cost-effective and efficient for routine long-term care.

I describe three papers published in the last two years by the NIHR Mental Health Policy Research Unit (London, UK) examining these questions. Each paper brings a unique angle:

1. A systematic review investigating implementation, adoption, and perceptions of telemental health in the first wave of COVID-19 (Appleton et al, 2021);
2. A qualitative study of service user perspectives on receiving telemental health throughout the pandemic (Vera San Juan et al, 2021);
3. A rapid realist review that synthesises the most up-to-date evidence about what works for whom, and in which context (Schlief et al, 2022).

Methods

Study 1: A systematic review investigating implementation, adoption, and perceptions of telemental health in the first wave of COVID-19 (Appleton et al, 2021)

Four databases (PubMed, PsycINFO, CINAHL, Web of Science) and pre-print servers were searched from February to December 2020.

Inclusion criteria were broad:

• staff, patients, family/carers from any mental healthcare setting
• all forms of telemental health
• comparator or not
• qualitative or quantitative outcomes of implementation effectiveness, barriers, facilitators, clinical effectiveness, cost-effectiveness, acceptability, economic impacts and impacts of digital exclusion

Results of studies were synthesised using well-established implementation science frameworks (Damschroder et al., 2009; Proctor et al., 2011).

Study 2: A qualitative study of service user perspectives on receiving telemental health throughout the pandemic (Vera San Juan et al, 2021)

Semi-structured interviews were conducted with adult mental health service users who had been recruited as part of a broader study exploring loneliness and mental health during the COVID-19 pandemic (Gillard et al., 2021), to gain participants’ views on telemental health. Authors (including lived experience researchers, clinicians and university researchers) used a collaborative framework to identify themes.

Study 3: A rapid realist review that synthesises the most up-to-date evidence about what works for whom, and in which context (Schlief et al, 2022)

Rapid realist review methodology uses a Context-Mechanism-Outcome (CMO) framework to produce policy recommendations through synthesising evidence and stakeholder expertise (Saul et al., 2013). In this study, academics, clinicians, experts and lived experience researchers developed the CMO question “which telemental health approaches work, for whom and in what context?”. Sources were identified from qualitative, quantitative, service evaluations, audits, case-series and grey literature. They included studies of any mental health service, and any staff, service users and family or other supporters of service users. Overarching CMO configurations were developed.

Results

Study 1: A systematic review investigating implementation, adoption, and perceptions of telemental health in the first wave of COVID-19 (Appleton et al, 2021)

Seventy-seven studies from five countries (all high-income) were included; only nine involved service users.

Findings suggested that moving to telemental health in a crisis was acceptable, feasible and valuable for service users in continuing to access support when routine care was not available. Advantages of remote care included: convenience; accessibility for those geographically remote or with mobility problems; reduced travel costs; therapists gaining insight into the service user’s home environment; service users finding it easier to communicate openly behind a screen; and opportunities for others to participate in service users’ care, e.g family/carers able to attend family therapy or psychoeducation.

However, online care presented barriers to certain groups, for example those with psychosis, learning difficulties or autism. In some contexts, telemental health was less acceptable: for new patients; physical health appointments; service users without private space at home; and therapies requiring a physical presence (e.g. exposure therapy, role play). Reported barriers to high-quality care included: reduced ability to develop and maintain strong therapeutic relationships; lack of connectedness; difficulties recognising nonverbal cues, assessing symptoms, and keeping service users engaged. Cost-effectiveness and risk of digital exclusion were under-studied.

Study 2: A qualitative study of service user perspectives on receiving telemental health throughout the pandemic (Vera San Juan et al, 2021)

Fourty-four adults experiencing mental health problems prior to the pandemic were interviewed. Participants were mostly female (N = 28, 63%), young (under 55 years-old; N = 33, 75%), white/white British (N = 28, 63%), in urban settings (N = 35, 80%) and from community mental health teams (N = 22, 50%).

Authors organised findings into four topics.

1. The first topic – ‘what works for whom: experiences and preferences’ – explored how individual experiences and preferences meant telemental health worked for some in some contexts but not for others in other contexts.
2. Relatedly, the second topic – ‘varied settings for telemental health’ – describes certain settings where telemental health was greatly beneficial. Namely, participants felt telemental health was most beneficial for those with ‘functional’ or administrative appointments that could be easily solved without a face-to-face appointment, as well as those who faced geographical or mobility barriers getting to appointments. Additionally, it was thought it could be good for those experiencing anxiety or paranoia preventing them from attending clinic. However, participants reported it negatively impacted ‘relational’ appointments such as psychological therapy or other situations where face-to-face was important for developing a therapeutic relationship. It also was reported to hinder risk management and fostering relational security. Similarly to the systematic review’s findings, certain groups were thought to be disproportionately affected: people with autism, new patients, older service users and those less technologically able.
3. A third topic was around patient safety and privacy. Some reported that distressing or risky events that occurred online were poorly managed, as was maintaining confidentiality for those without a private or safe space at home.
4. The fourth and final topic was focussed on future telemental healthcare and this topic identified that most service users preferred a hybrid model, combining the advantages of face-to-face and remote care.

Study 3: A rapid realist review that synthesises the most up-to-date evidence about what works for whom, and in which context (Schlief et al, 2022)

One-hundred-and-eight sources were identified. Most were primary research (N=72); others were service evaluations/audits (N=19), guidance documents (N=4), briefing papers (N=3), commentaries/editorials/discussions (N=4), letters (N=2), and one each of a review, news article, webpage and service-user-led report.

Four context-mechanism-outcome (CMO) domains were identified.

1. First, the ‘connecting effectively’ domain highlighted the importance of appropriate software, hardware, internet connection, training, confidence and knowledge of digital platforms for both staff and service users. Without these basics, some service users are at risk of digital exclusion, amplifying existing inequalities.
2. The second domain recognised the benefits of ‘flexibility and personalisation’ telemental health allows, especially for those facing geographical or mobility barriers, caring/work commitments, anxiety disorders, or worry attending stigmatising places.
3. The third, ‘safety and privacy’ domain reiterates ensuring private spaces, data security, confidentiality and high-quality risk assessments.
4. The final domain identified similar barriers to ‘therapeutic quality and relationships’ already reported. On the other hand, regular telemental health check-ins or SMS reminders could provide opportunities for increased therapeutic contact and service user engagement.

Conclusions

All studies reported some common findings and research gaps.

• First, they all found telemental health to be acceptable, feasible and valuable, at least in an emergency context.
• Second, all reported some advantages of telemental health and agreed service users should have the choice of accessing these benefits. However, safety, privacy and therapeutic relationships were unanimously reported to be poorer quality online.
• Third, all shared ethical, organisational, cultural and digital poverty concerns of telemental health use.

The systematic review concluded telemental health is a “largely effective method to enable continuation of mental health support during the COVID-19 pandemic” but did not address the applicability of telemental health outside an acute and extreme pandemic situation.

The qualitative study was more critical of telemental health. Service users recognised some advantages and appreciated remote care options when other forms were not available, but highlighted its significant limitations in providing confidential, relational care and risk management. A hybrid model was preferred.

The recent rapid realist review concluded similar findings, but added nuance and context. It highlighted that service user choice, privacy and safety, the ability to connect effectively, and build strong therapeutic relationships, need to be prioritised when delivering telemental health. It found contexts where face-to-face care is preferred or needed by service users, but recognised telemental health is potentially advantageous for those who cannot travel, and may allow service users access to out-of-area services or specialist support (e.g. cultural or LGBTQ). However, concerns remain around confidentiality, privacy, safety and digital exclusion; those in need are disproportionately affected, exacerbating inequalities (the “digital inverse care law” (Davies et al., 2021)).

“The most important finding of this realist review is the significance of personal choice and that one size does not fit all for telemental health.”
– Quote from Study 3 (Schlief et al, 2022)

Strengths and limitations

All studies have strengths to add to the current evidence base. However, limitations emerge across all three that impede generalisability. Despite efforts to ensure diverse inclusion, most study samples included mental health professionals, not service users. Where service users were included, they were well enough to participate and digitally literate. Further, research was conducted during 2020-2021 when COVID-19 restrictions were strict. High-quality studies on routine telemental health, where face-to-face care is now possible, are lacking.

Study 1: A systematic review investigating implementation, adoption, and perceptions of telemental health in the first wave of COVID-19 (Appleton et al, 2021)

Strengths

• The search strategy was comprehensive and inclusive of unpublished and published work, with no location or language restriction. Given the rapid nature of research during COVID-19, including unpublished pre-print work was necessary. However, consequently, some research is not peer-reviewed.
• Over half of the studies were “high quality”.
• The breadth of countries and healthcare systems included may help generalise findings globally.

Limitations

• The majority of studies were descriptive not evaluative; clinical effectiveness outcomes were only reported in 9 of 77 included studies.
• We need to be cautious about the generalisability of findings. All included studies were undertaken during the first wave of the COVID-19 pandemic when restrictions were highest, and most studies were cross-sectional with no follow-up data. This limits generalisations outside this acute setting. Further, whilst international studies were included, all research was from high-income countries.
• Lastly, of the 45 primary research studies, only 9 involved service users, excluding a crucial patient perspective.

Study 2: A qualitative study of service user perspectives on receiving telemental health throughout the pandemic (Vera San Juan et al, 2021)

Strengths

• Analysis was collaborative, involving lived experience researchers and practicing clinicians.
• Purposive sampling was used to improve diversity. Organisations working with ethnic minority and marginalised communities were approached to increase participation.

Limitations

• Participants were initially recruited for a study exploring loneliness and mental health during the COVID-19 pandemic and were re-interviewed about telemental health. This might skew the sample to those with an interest in or experience of loneliness, who may value online interactions more.
• Participants were well enough to take part, mostly female, young (26-55 years old), from an urban setting, and receiving community care. Therefore we cannot assume the findings apply to those with severe mental illness or non-community settings. We should note that older study participants had divergent views to younger ones.
• Lastly, recruitment was largely through social media and interviews were done using videoconferencing, so participants were technologically confident. Findings likely under-report the disadvantages of remote working and needs of digitally-excluded people.

Study 3: A rapid realist review that synthesises the most up-to-date evidence about what works for whom, and in which context (Schlief et al, 2022)

Strengths

• Evidence included policy, third sector, lived experience and health technology sources, not only academic publications.
• Lived experience and minority group representatives were contacted to identify sources missed through usual academic streams.
• Clinical and lived experience researchers contributed to theory development and reviewed the overarching CMOs domains.

Limitations

As with any secondary research, findings are only as good as the evidence informing the review:

• Many sources of evidence included non-diverse, non-representative or generalisable samples. The authors state: “most available literature focused exclusively on staff perspectives of telemental health and crucially neglected to include the views or experiences of service users and their families or other supporters”. Through the rapid realist review method of creating general themes, nuanced understanding of these marginalised groups may therefore be lost.
• Literature lacked evidence on children and young people (who were one of their identified priority groups).
• Third, rapid realist review methods do not quality assess studies using traditional methods, so we are unable to formally quantify or compare the quality standards of sources included.

Implications for practice

These three papers suggest telemental health could be used in future response-planning to an emergency which renders face-to-face care unsafe. For it to be widely incorporated into routine care going forward, a personalised approach must be considered, which applies the ‘good’ aspects of telemental health, mitigates the ‘bad’ aspects and avoids the ‘ugly’ inequality gap it has the potential to widen. This has implications for how services could adapt and improve to accommodate telemental health.

First, practical and socical infrastructure need to be improved. Access to technology as well as the confidence and ability to use it, for both staff and service users, is a minimum requirement. This includes better technological infrastructure; staff and service user IT training; IT support personnel for troubleshooting; and protocols to safeguard privacy, data security and confidentiality. Service planners could consider collaboration with local voluntary and community sectors to mitigate against digital poverty and exclusion. Where I work in the NHS, this seems like a daydream, but should be prioritised by service planners. Keeping up technologically with other sectors is equally important for staff; benefits of digital working could be appropriately utilised to improve staff wellbeing and retention.

Second, clinical teams need to adapt. Shared decision making is standard practice, but services may need to consider adjusting e.g. informed consent, for the benefits and risks of remote working to support patient choice.

Although patient empowerment is a priority, face-to-face care may be strongly recommended for certain groups. Service managers and clinicians should consider the risks of telemental health (safety, privacy, vulnerability, exclusion and inequality) for their patient population to make informed decisions with service users. Developing a framework or checklist guide which assesses individual service’s or service user’s suitability to telemental healthcare could be a useful next step for integrating telemental health long-term; mental health teams globally could benefit from such a tool.

Third, some adaptations will require government and local authority: better data protection regulation, financial support to address digital poverty, and policies to narrow inequalities e.g. national wifi coverage.

Lastly, future research should address: digital exclusion; telemental health for children and young people; and evaluation of routine telemental healthcare after the pandemic. The potential environmental benefits of transitioning to telemental health have also not been researched. Given the direct and indirect impacts of climate change on mental health (Lawrance et al., 2021), future research should consider this.

Statement of interest

No conflicts of interest.

Links

Primary papers

Appleton R, Williams J, Vera San Juan N, Needle JJ, Schlief M, Jordan H, et al. (2021) Implementation, Adoption, and Perceptions of Telemental Health During the COVID-19 Pandemic: Systematic Review. J Med Internet Res. 2021 Dec 9;23(12):e31746

Vera San Juan N, Shah P, Schlief M, Appleton R, Nyikavaranda P, Birken M, et al. (2021) Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis. PLOS ONE. 2021 Sep 16;16(9):e0257270

Schlief M, Saunders KRK, Appleton R, Barnett P, Vera San Juan N, Foye U, et al. (2022) Synthesis of the Evidence on What Works for Whom in Telemental Health: Rapid Realist Review. Interact J Med Res. 2022 Sep 29;11(2):e38239

Other references

Agency for Healthcare Research and Quality. (2022, October 29). Telehealth.

Appleton, R., Williams, J., Vera San Juan, N., Needle, J. J., Schlief, M., Jordan, H., Sheridan Rains, L., Goulding, L., Badhan, M., Roxburgh, E., Barnett, P., Spyridonidis, S., Tomaskova, M., Mo, J., Harju-Seppänen, J., Haime, Z., Casetta, C., Papamichail, A., Lloyd-Evans, B., … Johnson, S. (2021). Implementation, Adoption, and Perceptions of Telemental Health During the COVID-19 Pandemic: Systematic Review. J Med Internet Res, 23(12), e31746.

Barnett, P., Goulding, L., Casetta, C., Jordan, H., Sheridan-Rains, L., Steare, T., Williams, J., Wood, L., Gaughran, F., & Johnson, S. (2021). Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews. J Med Internet Res, 23(7), e26492.

Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemedicine Journal and E-Health : The Official Journal of the American Telemedicine Association, 22(2), 87–113.

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science : IS, 4, 50.

Davies, A. R., Honeyman, M., & Gann, B. (2021). Addressing the Digital Inverse Care Law in the Time of COVID-19: Potential for Digital Technology to Exacerbate or Mitigate Health Inequalities. Journal of Medical Internet Research, 23(4), e21726.

Gillard, S., Dare, C., Hardy, J., Nyikavaranda, P., Rowan Olive, R., Shah, P., Birken, M., Foye, U., Ocloo, J., Pearce, E., Stefanidou, T., Pitman, A., Simpson, A., Johnson, S., Lloyd-Evans, B., Anderson, K., Barber, N., Chhapia, A., Chipp, B., … NIHR Mental Health Policy Research Unit Covid coproduction research group. (2021). Experiences of living with mental health problems during the COVID-19 pandemic in the UK: a coproduced, participatory qualitative interview study. Social Psychiatry and Psychiatric Epidemiology, 56(8), 1447–1457.

Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 review. Telemed J E Health, 19(6), 444–454. PubMed.

Hubley, S., Lynch, S. B., Schneck, C., Thomas, M., & Shore, J. (2016). Review of key telepsychiatry outcomes. World Journal of Psychiatry, 6(2), 269–282.

Lawrance, E., Thompson, R., Fontana, G., & Jennings, N. (2021). The impact of climate change on mental health and emotional wellbeing: Current evidence and implications for policy and practice. Grantham Institute.

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health, 38(2), 65–76. PubMed.

Salmoiraghi, A., & Hussain, S. (2015). A Systematic Review of the Use of Telepsychiatry in Acute Settings. Journal of Psychiatric Practice, 21(5), 389–393.

Saul, J. E., Willis, C. D., Bitz, J., & Best, A. (2013). A time-responsive tool for informing policy making: Rapid realist review. Implementation Science, 8(1), 103.

Sheridan Rains, L., Johnson, S., Barnett, P., Steare, T., Needle, J. J., Carr, S., Lever Taylor, B., Bentivegna, F., Edbrooke-Childs, J., Scott, H. R., Rees, J., Shah, P., Lomani, J., Chipp, B., Barber, N., Dedat, Z., Oram, S., Morant, N., Simpson, A., & =COVID-19 Mental Health Policy Research Unit Group. (2021). Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: Framework synthesis of international experiences and responses. Soc Psychiatry Psychiatr Epidemiol, 56(1), 13–24. PubMed.

Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635.

Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635.

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