What works for whom with telemental health? A rapid realist review

Abstract

Background: Telemental health (delivering mental health care via video calls, telephone calls or text messages) is 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 reinforcing pre-existing inequalities in service provision. If it is to be widely incorporated in 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: The aim of this rapid realist review was to develop 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 synthesising 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 CMOs encapsulate theories about what works for whom, and by what mechanisms. Sources included eligible papers from (a) two previous systematic reviews conducted by our team on telemental health, (b) an updated search using the strategy from these reviews, (c) a call for relevant evidence, including "grey literature", to the public and key experts, and (d) website searches of relevant voluntary and statutory organisations. CMOs formulated from these sources were iteratively refined, including through (a) discussion with an expert reference group including researchers with relevant lived experience and front-line clinicians and (b) consultation with experts focused on three priority groups: 1) children and young people, 2) users of inpatient and crisis care services, and 3) digitally excluded groups. Results: A total of 108 scientific and grey literature sources were included. From our initial CMOs, we derived 30 overarching CMOs within four domains: 1) connecting effectively; 2) flexibility and personalisation; 3) safety, privacy and confidentiality; and 4) therapeutic quality and relationship. Reports and stakeholder input emphasised 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 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 prioritised in delivering telemental health care. Guidelines and strategies co-produced with service users and frontline staff are needed to optimise telemental health implementation in real-world settings. MS and KRKS are joint first authors.

Implementation strategies for telemental health: a systematic review

“…Other recent studies further support and supplement these conclusions. In our recent rapid realist review of TMH (35), we found that providing staff with training on the use of technology to deliver mental health services, a strategy reported by several studies in the current review, was reported to increase confidence in and uptake of TMH. The rapid realist review also found that adapting the use of TMH to take into account service user preferences was beneficial in removing barriers to accessing TMH (35) (see Box 1 for further discussion).…”

Communicating to connect with patients

“…fewer 'no shows' and greater understanding of the person's social context), psychiatrists also find it more difficult to detect subtle changes in tone of voice, inflection, affect and gaze and also harder to develop rapport (Chen 2020). Evidence suggests that therapeutic relationships are difficult to establish in remote first appointments but can be sustained if there is a pre-existing relationship (Schlief 2022).…”

Are remote mental healthcare interventions cost-effective? A systematic review of economic evaluations of remote mental healthcare

“…For example, service users have identified increased flexibility as a key advantage of remote care (1), and a recent rapid realist review (2) found that telemental health care can improve access to mental health support for people who may struggle to travel to face-to-face appointments due to disability, anxiety about travel, or caring or work responsibilities.…”

“…Reported benefits for staff included an opportunity for more flexible working, less time spent travelling, and communicating with other clinicians at different sites (2,3). However, it is important to note that telemental health is not suitable for everyone; not all service users may wish for care to be remote and inequalities and digital exclusion should be taken into consideration during the decision to offer mental health care remotely (1,2). Clinicians have also reported finding telemental health less suitable than face-to-face care when treating trauma, or for service users in crisis or those with psychotic symptoms or severe anxiety (3).…”

“…The following databases used inNaslund et al (2020) were not included in this review due to organisational access and the number of duplicates already identified: Web of Science, Health Economic Evaluations Database, Cost-Effectiveness Analysis Registry, Research Papers in Economics (RcPEc), and European Network of Health Economic Evaluation Database (EURONHEED) 2. In CINAHL we were unable to apply MeSH terms, and in EconLit the simplified grey literature strategy was used (see TableS2).…”