key: cord-0841268-g3ki2hzq
authors: Siegel, Ashley; Zuo, Yushen; Moghaddamcharkari, Nika; McIntyre, Roger S.; Rosenblat, Joshua D.
title: Barriers, benefits and interventions for improving the delivery of telemental health services during the coronavirus disease 2019 pandemic: a systematic review
date: 2021-04-29
journal: Curr Opin Psychiatry
DOI: 10.1097/yco.0000000000000714
sha: 5a30f48a89ec49f0fabe931e082f6803d5f3cbf7
doc_id: 841268
cord_uid: g3ki2hzq

PURPOSE OF REVIEW: To reduce the spread of infection from the coronavirus disease 2019 (COVID-19), mental healthcare facilities were forced to make the rapid transition from face-to-face services to virtual care. This systematic review aims to synthesize the extant literature reporting on barriers of telemental health (TMH) during the COVID-19 pandemic and how facilities have worked to overcome these barriers, to inform best practices for TMH delivery. RECENT FINDINGS: Most recent findings came from case studies from mental health professionals which reported on barriers related to institutional, provider and patient factors, and how these barriers were overcome. Common barriers identified in the literature include: technological difficulties; issues regarding safety, privacy and confidentiality; therapeutic delivery and the patient-provider relationship; and a loss of sense of community. Studies also reported on the benefits to TMH interventions/tools, as well as suggestions for improvements in the delivery of TMH services. SUMMARY: As the COVID-19 pandemic evolves, mental healthcare providers continue to find creative and feasible solutions to overcome barriers to the delivery of TMH. Dissemination of these solutions is imperative to ensure the best quality of mental healthcare for patients across the globe.

In March 2020, the coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health Organization (WHO) [1] . Due to the absence of a vaccine, social distancing has been adopted as part of the mitigation strategies. Despite its benefits in slowing the spread of COVID-19, social distancing is accompanied with several consequences, including a rapid increase in the levels of psychological distress worldwide and projected increase in rates of suicide [2] [3] [4] . In response to these well founded concerns, telemental health (TMH) has been implemented as the main mode of service delivery during these unprecedented times [2] .

TMH encompasses the delivery of mental health services, both psychiatric and psychological, via different technological platforms. Unique to the field of psychiatry and mental health, in-person contact is not always essential in providing care.

As such, TMH is a plausible and logical option. However, as countries across the world have adopted TMH, numerous barriers have been identified. These barriers include, but are not limited to: lack of access to required technology or technical difficulties [ ]; reduced quality of therapeutic delivery and patient-provider relationships; and a loss of sense of community [9 && ,10 & ]. Moreover, although federal and state regulators have recognized the importance of telehealth during these times, further legal and regulatory actions are necessary to remove public policy barriers [11] .

Based on the current state of the pandemic, mental healthcare will continue to be delivered virtually for the foreseeable future. Thus, it is imperative that additional attention and resources be allocated to evaluating this method of care. The current situation provides a unique opportunity to improve the delivery of mental healthcare and expand the scope of individuals who can be reached by mental health professionals. There is a growing body of literature in which psychiatrists and other mental health professionals are sharing their experiences with TMH and providing feasible solutions to common barriers. The current review aims to summarize this literature to inform mental healthcare providers regarding optimal delivery of TMH.

A systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on PubMed, GoogleScholar, Web of Science and PsychInfo from database inception to August 2020 [12] . A manual citation search was conducted in the reference list of the included articles and other relevant reviews. The search terms that were used were: (COVID-19 OR 2019-nCoV OR SARS-CoV-2 OR coronavirus) AND (psychiatry) AND (eHealth OR mHealth OR Mobile Health OR telehealth OR health, mobile OR telemedicine). The PRISMA flow diagram details the search and selection process applied during our systematic literature search and critical review (Fig. 1) .

Articles were selected according to the following inclusion criteria: first, studies based on empirical evidence; second, assessed the barriers and/or benefits to TMH during the COVID-19 pandemic and the associated means for those overcoming barriers. Studies were excluded if they were not written or translated into English; discussed TMH outside of the COVID-19 context; discussed potential barriers rather than empirical findings. Figure 1 reports the flow diagram of inclusion of the studies. The quality of articles was assessed using the Cochrane Risk of Bias (Table 1) .

Barriers to TMH related to provider, patient and institutional factors were divided into four main categories: technical issues; safety, privacy and confidentiality; therapeutic delivery and the patientprovider relationship; and sense of community (Table 2) . Corresponding suggestions to barriers as well as benefits to TMH are also discussed ( ]. Different technical problems may occur during an online session and impede the progression of a treatment. Hospitals and clinics may face the challenge of lacking sufficient IT support staff readily available to help troubleshoot and assist in a smooth

TMH service delivery is critical during the COVID-19 pandemic.

Common barriers to delivery include technological issues; privacy, safety and confidentiality; therapeutic delivery and patient-provider relationships; and a loss of sense of community.

&& ]. To ensure a good experience during virtual treatment, it is recommended that providers and institutions offer a virtual orientation held by medical staff that provides information on the proper utilization of the technological platform [5 & ]. By dedicating a particular staff to help the corresponding patient with IT problems throughout the treatment sessions, it helps minimize the disruption of care for each patient [5 & ]. ]. It is beneficial for healthcare professionals to obtain proper training on telehealth treatment delivery (e.g. shadowing telehealth sessions, watching prerecorded sessions) prior to their formal telehealth sessions. However, the complex, timeconsuming training procedures followed by frequent updates and modifications of the protocols and guidelines make the learning and adaptation to this treatment modality much more difficult [13 & ]. For hospitals, clinics and other institutions that provide virtual care programs, it is essential for them to ensure IT support groups are constantly present and ready to offer professional help [9 && ]. Further, it would be beneficial for institutions to incorporate training for TMH delivery into their typical training regimens to be prepared for unforeseen circumstances such as the current pandemic.

Concerns regarding safety, privacy and confidentiality are raised among patients, providers and regulatory officials. Some patients are facing the challenge of maintaining quiet and private spaces in the home-setting during treatment sessions. Lack of privacy often affects patients' ability to talk openly during their session, which undoubtedly impacts the efficacy of treatment ].

The loss of personal boundaries between providers and patients is also of concern, as patients are unintentionally getting more personal information about the medical providers by being able to view their homes. This leads to difficulties in maintaining provider's professionalism during the session, and has the potential to also impact the patient- ]. Therapeutic barriers for specific patient populations also arise through the use of TMH. For patients with obsessive-compulsive disorder (OCD), they receive a series of exposures (ranging from easy to difficult) as part of their regular treatments. During the treatment transition period, due to quarantinerelated distress, there shows a delay in the practices of those more difficult exposures among patients with OCD, thus impeding their regular treatment Families that are unwilling to use video conferencing services often request telephone care [13 & ]. As mentioned previously, delivering services via telephone is a viable second option, especially when privacy, technological or financial barriers prevent the use of video conferencing platforms [6 & ,14 && ]. Providers have found that telephone use is the preferred method for patients of lower SES [6 & ]. However, one of the limitations for telephone consultations is that it is difficult to maintain the therapeutic alliance merely by talking over the phone, as it often feels less personal [14

]. In addition, the use of telephone prevents any visual or facial cues, making services such as behavioral therapy particularly difficult [10 & ]. Training on how to best deliver specific therapeutic interventions via telehealth and necessary modifications for telephone delivery should be provided for all clinicians. To ensure TMH can continue to be conducted via telephone when necessary, insurance companies should reduce the stringency of policies and extend coverage to telephone visits, at least for the duration of the pandemic.

Due to the confinement measurements implemented during this pandemic period (e.g. quarantine, physical distancing and social isolation), many patients have felt a loss of community, due to loss of interaction with fellow patients (i.e. in waiting rooms) and clinic staff [9 && ,10 & ]. There is also a decrease in support group programming and group sessions throughout treatment [9 && ,10 & ]. Loss of sense of a community appears to be a more prominent issue among individuals with lower SES [9 && ]. As sessions via telephone appear to often be more convenient for this population, the delivery of group therapy becomes even more unlikely, further compounding the loss of community. In situations where support groups may be beneficial for the client, providers are encouraged to give recommendations for affordable virtual support group options outside of their session [9 && ]. Similar challenges are faced by clinicians, as some clinics and hospitals are finding that there is insufficient communication between staff due to a loss of in-person interactions [5 support groups they can participate in [9 && ,10 & ]. One clinic found that having a staff member or volunteers dedicated to more continuous check-ins with patients was effective in helping patients feel as though they are still part of a supportive community [9 && ]. To address the problem of communication among medical providers, the use of web-based secure collaborative workspace (e.g. Microsoft Teams), video conference 'lunchrooms', and actively sharing self-care tips with other colleagues should be strongly encouraged during this critical period [5 & ].

Although the transition to TMH has come with complications, there have also been many identified benefits. 

One limitation to the current review is the potential of bias in included studies. All studies were case studies and based on providers subjective experience in delivering TMH services. Moreover, all studies were based on experiences within the first few months of the pandemic. As the COVID-19 situation develops, further barriers and benefits have likely surfaced. With the exception of one study, all studies were based on experiences of providers in the United States. Dissemination of knowledge and experiences from a wider range of countries is critical to gain a more comprehensive understanding of the barriers and benefits to TMH. As social distancing policies persist, it is critical that mental health providers continue to share their experiences with TMH and suggestions to overcome barriers. Future research should include more objective measures, such as retrospective studies and randomized control trials, to further determine barriers and benefits to TMH and how delivery can be optimized for different patient populations.

The rapid transition from face-to-face interventions to telehealth platforms has revolutionized the way mental healthcare is delivered around the world. It is important to keep in mind that the suggestions made in this review are not 'one size fits all.' Many solutions that work for some patient populations may not benefit others. For example, solutions that may improve therapeutic delivery for some may not be feasible for those of lower SES [9 && ]. As well, some barriers, such as technical barriers, may be more complicated for larger hospitals and institutions, as opposed to smaller clinics [13 & ]. Nevertheless, the transition to TMH has revealed many benefits to this form of mental healthcare delivery, and even once face-to-face interactions can resume, mental health providers should consider maintaining the option of virtual care for patients.

Yellowlees P, Nakagawa K, Pakyurek M, et al. Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19. Psychiatr Serv 2020; 71:749-752. A study describing the detailed processes, barriers and lessons learned during a rapid conversion from in person to virtual telepsychiatry clinic.

8. A study presenting different issues and challenges encountered during the implementation of a home-based telemental health program among young patients with psychiatric care demands. 14.

Olwill C, Mc Nally D, Douglas L. Psychiatrist experience of remote consultations by telephone in an outpatient psychiatric department during the COVID-19 pandemic. Ir J Psychol Med 2020; 1-8. A comprehensive study discussing identified challenges, benefits and requirements for conducting successful telephone psychiatric consultations based on the experience of a group of Irish psychiatrists.

Roger McIntyre has received research grant support from CIHR/GACD/Chinese National Natural Research Foundation; speaker/consultation fees from Lundbeck

Telemental health in the context of a pandemic: the COVID-19 experience

Telepsychiatry and other cutting edge technologies in Covid-19 pandemic: bridging the distance in mental health assistance

Impact of COVID-19 pandemic on mental health in the general population: a systematic review

Preventing suicide in the context of the COVID-19 pandemic

Development of a virtual partial hospital program for an acute psychiatric population: lessons learned and future directions for telepsychotherapy

Pediatric telebehavioral health: a transformational shift in care delivery in the era of COVID-19

A study describing experiences of utilizing telebehavioral health among pediatric patients with psychological problems during this transition period