Abstract
Objective: Despite the high prevalence of mental disorders in rural areas, mental health services are lacking because of shortages of resources and difficulty in accessing such services. Telemental health services can be beneficial for these patients. This study summarizes the efficacy of telemental health in managing mental disorders in rural areas.
Materials and Methods: The MEDLINE and Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials on telemental health for mental disorders in rural areas until June 2022. The reviewers independently screened, extracted, and assessed study quality using the Risk of Bias 2 tool.
Results: Six eligible studies were identified on mental health symptoms, insomnia, depression, and schizophrenia. The quality of all the studies was moderate, and they all reported that telemental health effectively improved the symptoms of mental disorders. One study reported a reduction in relapse and rehospitalization rates in young individuals. Another study reported that it was effective in improving the symptoms of depression and anxiety in older individuals.
Conclusions: Although further studies are warranted, telemental health services could effectively improve the symptoms of mental disorders in rural areas.
Keywords: information and communication technology, mental health, remote consultation, rural medicine, telemedicine
Introduction
Mental disorders include various conditions (e.g., depression, insomnia, and schizophrenia)1). The prevalence of mental health problems in rural areas reportedly ranges from 15 to 33%2,3,4,5). In addition to living in rural areas, factors relevant to the rural environment, such as a lack of social support, solitary life, and comorbidities due to aging, are known to be related to worsening mental health3). Older people find it difficult to notice mild mental health concerns due to their high self-sufficiency in rural circumstances compared to urban areas6). Furthermore, mental health resource shortages remain in rural areas, and residents distant from urban areas have difficulty accessing such services7,8,9); therefore, the need for mental health services remains a priority.
Telemental health, which uses information and communication technology (ICT), has received a great deal of attention. Earlier studies demonstrated that telemental health could effectively improve patients’ mental symptoms6, 10,11,12). Telemental health services are not restricted by distance and are easy to access, even by residents of rural areas6, 13,14,15). Such remote services appear to be increasing in rural areas (partially influenced by the COVID-19 pandemic)13, 15). Thus, telemental health services should be investigated in a study population limited to residents of rural areas. This review aimed to determine the efficacy of telemental health services in the management of mental disorders in individuals living in rural areas.
Materials and Methods
The current review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISM) 2020 statement16). The MEDLINE and Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) that examined the efficacy (in terms of clinical data) of telemental health interventions in comparison to control (e.g., standard face-to-face) intervention for mental disorders until June 20, 2022. A combination of terms related to “telemedicine”, “mental health”, and “rural areas” were used to search for RCTs. The equipment used in telemental medicine is ICT (i.e., phones, tablets, faxes, the Internet, and personal computers).
Nonrandomized controlled trials and observational studies were excluded, and there were no restrictions on the language, country, or observation period. The type of mental disorders was not restricted. After auditing the reference lists for eligible studies, the available RCTs were included. First, two review authors (H.T. and A.N.) independently screened the titles and abstracts of the candidate reports for inclusion. Second, two review authors (J.W. and H.T.) independently performed full-text screening, extracted study characteristics and outcomes, and assessed the study quality using the Risk of Bias 2 tool17). Any disagreement was resolved through a discussion by review authors.
Results
Figure 1 illustrates the study selection process. A total of 606 reports were screened by title and abstract, and 32 articles were identified. After the full-text screening, six eligible RCTs were identified18,19,20,21,22,23). When the reference lists of these studies for this review were audited, no extra RCTs that met the inclusion criteria were identified. The overall Risk of Bias, as determined using the Risk of Bias 2 tool, was moderate in six RCTs.
Figure 1.
Flow of the literature search process.
Table 1 displays the characteristics of the eligible studies. The participants were young individuals (four studies)18,19,20,21) and older individuals (two studies)22, 23). Mental disorders included depression18, 20, 22), mental health symptoms19), insomnia23), and schizophrenia21). The telemental health completion rates were 73–100%18,19,20,21). Telemental health consultations were conducted using telephones or cell phones in five studies18, 19, 21,22,23) and the Internet in one study20). Programmed consultation methods17, 19, 20) and cognitive behavior therapeutic approaches20) were used in the interventions. Doctors or psychologists administered the interventions in three studies19, 22, 23) and non-professional assistants or health supporters in two studies18, 21). One study involved an automated (Internet-based) intervention20).
Table 1. Summary of the eligible studies.
| Authors & ref no. | Year | Country | Subject no. (I/C) | Completion rate, % (I/C) | Age (years) (I/C) | Mental disorders | Intervention | Interventionists | Details of intervention | Control to intervention | Outcomes | Follow-up (months) | Overall risk of bias |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Dwight-Johnson18) | 2011 | USA | 101 (50/51) | 84/70 | 40/41 | Major depression | Telephone CBT | Project assistants | Eight 45-minute telephone sessions over 6 months | Enhanced usual care | Depression (PHQ-9 and SCL) | 6 | Moderate |
| Reid19) | 2011 | UK | 62 (34/28) | ND | 57/55 | Mental health symptoms | Mobile type program | Doctors | A cell phone, self-start 4 times per day | Usual care | Mental health symptoms | 6 | Moderate |
| Schure20) | 2019 | USA | 343 (181/162) | 100/100 | 42/43 | Depression symptoms | Internet-based CBT | Internet | Freely-accessed internet-based CBT | Standard care | Depression (PHQ-9), anxiety (anxiety symptom severity), daily functioning, and resilience | 2 | Moderate |
| Xu21) | 2019 | China | 278 (139/139) | 96/99 | 47/46 | Schizophrenia | Text messages and telephone | Health supporter | Daily medication confirmation messages and telephone follow-up when needed | Free-medical program | Medication adherence, schizophrenia symptoms (CGI), clinical appointments, relapse, and re-hospitalization | 6 | Moderate |
| Almeida22) | 2021 | Australia | 307 (154/153) | 73/79 | ≥65 | Depression symptoms | Usual care plus telephone | Trained psychologist | 45-minute telephone sessions over 8 weeks | Standard care | Depression (PHQ-9), anxiety (GAD-7), SF-12 | 13 | Moderate |
| McCurry23) | 2021 | USA | 327 (163/164) | 73/78 | 70/70 | Insomnia | Telephone CBT | Trained psychologist, nurse, and social worker | Six 20- to 30-minute telephone sessions over 8 weeks | Education only | Insomnia (insomnia severity index), depression (PHQ-8), Flinders fatigue scale, and brief pain inventory-short form | 12 | Moderate |
C: control; CBT: cognitive behavior therapy; CGI: Clinical global impression; DAD: generalized anxiety disorder scale; GAD: generalized anxiety disorder scale; I: intervention; no.: number; ND: not detailed; PHQ-9: Patient Health Questionnaire-9; SCL: the Hopkins Symptom Checklist; SF: short-form health survey.
All the studies demonstrated that telemental health services effectively improved mental health symptoms for 2–13 months. Table 2 summarizes the key messages used in the respective studies. Telemental health effectively reduced relapse and rehospitalization rates in young individuals in particular21). Telephone care did not effectively reduce major depressive episodes (i.e., sadness or hopelessness, fatigue, weight gain or loss, change in sleep habits, loss of interest in activities, or suicidal thoughts); however, it did improve the symptoms of depression and anxiety, especially in older individuals22).
Table 2. Summary of key messages in the eligible studies.
| Authors & ref no. | Key messages |
|---|---|
| Dwight-Johnson18) | The telephone-based CBT intervention enhanced the access to psychotherapy. |
| Reid19) | The cell phone program increased the efficiencies in data collection and the engagement of participants as well as enhanced care on symptoms. |
| Schure20) | The internet-based CBT intervention reduced the depression and anxiety symptom severity as well as improved functioning and resilience relating to disease. |
| Xu21) | The use of text messages and telephone improved medication adherence as well as reduced relapse and re-hospitalization. |
| Almeida22) | The use of telephone improved the depression and anxiety symptoms, but was not effective in major depressive episodes. |
| McCurry23) | The telephone-based CBT intervention improved sleep, fatigue, and, to a lesser degree, pain. |
CBT: cognitive behavior therapy.
Discussion
The current review showed that telemental health serives could effectively improve mental health symptoms among individuals living in rural areas. These findings are in line with accepted knowledge regarding the effects of telemental health on patients’ mental symptoms regardless of area of residence8, 10,11,12). The current study results are noteworthy, as rural areas have a particular need for mental health services6,7,8). These findings will be also useful for developing telemental health strategies for rural areas.
The main technologies used for telemental health consultations in the studies reviewed were the telephone and the Internet (Table 1). These were thought to be popular as prior reviews reported that using these methods in telemental health reduced symptoms of depression and anxiety8, 24). Recently, videoconferencing has also been found to be useful for reducing the symptoms of depression10). We expect various technologies to be used according to the preferences of various individuals or communities.
In the current review, telemental health interventions were performed by professionals, non-professionals, or Internet automation (Table 1). Several methods and approaches, including cognitive behavior therapy, have been effective in improving the symptoms of mental disorders, regardless of the type of interventions. Given the shortage of mental health resources in rural areas7, 9), a telemental health system leveraging non-professionals and automated services would be helpful. This may also contribute to the sustainability of the mental care provided in these areas6).
Whether the effect of telemental health on outcomes differs by age is a matter of concern25). One study included in the current review showed that telemental health reduced disease relapse and rehospitalization in young individuals21). Another study showed that telephone care reduced the symptoms of depression and anxiety among older individuals but did not reduce major depressive episodes22). While rural areas are often characterized by an aging population, the prevalence of depression among older people in rural areas is approximately two times higher than that among older people in urban areas4). Therefore, the response of older individuals to telemental health is a critical consideration. Although such challenges have been seen in a few studies21, 22), further data are necessary to implement telemental health interventions based on rural residents’ age.
The spread of digital devices and infrastructures for ICT systems, human resources, and understanding lifestyles among community-dwelling people would be required in order to install telemental health services in rural areas12). The devices and infrastructures can include telephones, the Internet, and videoconferencing facilities for the rural installation8, 10, 24). Professionals, non-professionals, and automated services should also be considered as the possible ways18, 20, 21, 23). The cultural backgrounds related to lifestyles of rural areas may need to be considered to ensure acceptance of the services4).
The current study has several limitations. First, the number of studies was small because we were restricted to RCTs to obtain definitive evidence. However, the internal validity was, therefore, high as the completion rate for telemental health interventions was very high (73–100%). Second, the studies were conducted in only a few countries, while the need for mental health services exists worldwide. Third, of the eligible studies, factors in rural areas, such as the characteristics of rural populations and the degree of difficulty in accessing mental health services, were wholly undetermined. Fourth, the long-term effects of telemental health on outcomes remained unclear because the included studies were only performed over a 2–13 month period. Severe outcomes, including suicidal episodes, were not evaluated. Further long-term studies with multifaceted outcomes are required.
Conclusions
This systematic review showed that telemental health services could effectively improve the symptoms of mental disorders among rural residents. Further studies are needed to establish telemental health interventions in rural areas.
Funding: This work was partly supported by Jichi Medical University and Grants-in-Aid for Health, Labor, and Welfare Sciences Research from the Ministry of Health, Labor, and Welfare of Japan (21IA2004).
Conflicts of interest: The authors declare no conflict of interest associated with this study.
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