Using telehealth to assess depression and suicide ideation and provide mental health interventions to groups of chronically ill adolescents and young adults

Abstract

Telehealth distance health care is a significant resource for young, chronically ill patient populations given their numerous medical complexities and their concomitant depression and/or suicide ideation experiences. This manuscript shares the telehealth methods used to prepare for a larger study of interventions for increasing adolescents’ and young adults’ chronic care resiliency and skills for preventing depression. The young patients in this study were prescribed lifelong home parenteral nutrition infusions, treatment for those with short gut bowel diseases. The training methods for our mental health nurse and psychologist to conduct depression and suicide ideation assessments from a distance are presented. The study implementation methods of group facilitated interventions and discussion are reviewed. The group discussions were conducted via audiovisual telehealth devices over encrypted firewall-protected connections with patients in their own homes and professionals in an office. The results of assessments of the 40 participants, 25% (n = 10) with depressive symptoms or suicide ideation, are described. Following participants’ assessments, their subsequent depression measures were all in the normal range, without any suicide ideation, across the year of the study. Patient evaluation ratings were high in the areas of being able to connect with other young patients in similar situations, using the audiovisual equipment, and learning new useful information from the interventions. The methods developed for the study ensured that the safety and well-being of participants were supported through telehealth.

1 |. INTRODUCTION

Using specific telehealth-based methods to assess depression and suicide ideation in chronically ill adolescents and young adults adds safety to distance healthcare services that these young populations can access. Adolescents and young adults with severe chronic illnesses have complex prescribed home treatments to manage, physical limitations, developmental challenges, and psychological vulnerabilities (Pinquart & Shen, 2011a). The young participants in this telehealth research were prescribed lifelong home parenteral nutrition (HPN) for patients with life-threatening, short gut bowel diseases (Mundi et al., 2017). The majority of these patients begin HPN in childhood or adolescence, making the psychological challenges they encounter lifelong (Andolina et al., 2019). Living with HPN poses substantial challenges related to restriction of normal eating and drinking, adjusting to a stoma in many cases, and being tethered to a 12-h nightly intravenous nutrition infusion. These infusions are required five to seven nights of each week, leading to sleep disturbances and constant fatigue (Kelly et al., 2016).

HPN patients also have limited physical activities, consistently experience embarrassing gastrointestinal (GI) symptoms, and report being bullied due to their frailty and other disease-related limitations (van Goudoever & Vlaardingerbroek, 2013). These chronically ill youth undergo frequent uncomfortable medical procedures, face numerous annual hospitalizations, and have extensive school absenteeism (Vallabh et al., 2017). As a result of these experiences, these patients are vulnerable to negative school outcomes, emotional maladjustment, and social withdrawal, as they are often reluctant to disclose their illness to healthy peers (Pinquart & Shen, 2011b).

The cognitive demands of managing complex infusions and being vigilant for early warning signs of GI exacerbations requiring treatments or hospitalization are psychologically stressful. Having an uncommon, complex illness also makes it difficult to find local care expertise, including obtaining mental health care. Yet, our previous research verified that the use of mobile technology to assist these patients in receiving needed support and chronic care education in their homes is an important and affordable solution (Kim et al., 2014). Recurrences of mild, situational depression are well-documented in this HPN patient population (Huisman-de Waal et al., 2006). Situational or reactive depression is defined as short duration episodes of low mood due to situational factors (i.e., social isolation, hospitalization, or severe GI pain; Smith et al., 2003). Short reactive symptoms or situational depression are associated with these GI patients’ loss of sleep, low energy, schedule disruption due to twice-daily HPN infusion procedures, and worry concerning their medical condition and their family’s stress. Even though most depressive symptoms are situational, major clinical depression does occur in this population. This type of depression can also be treated via telehealth (Nelson et al., 2006). Fortunately, suicides have very rarely been identified, although poor HPN management has been associated with patient self-harm (Hysing et al., 2015).

Our research team, using specific assessment methods, has identified reactive depression symptoms, clinical depression, and suicide ideation across 15 years of working with HPN adolescents and young adults (Smith et al., 2016). In three trials, we have verified and written about these symptoms being detected using audiovisual telehealth devices (Smith et al., 2002, 2015, 2020). In this most recent trial, we also sought to enhance these chronically ill patients’ resiliency and mental health skills. These skills have been shown to improve young persons’ emotional status, academic achievement, and problem-solving relative to their illness management (Underwood, 2018). Thus, health professionals’ ability to provide mental health interventions and to conduct psychological assessments from a distance using audiovisual devices is an essential skill for telehealth distance care.

1.1 |. Study purpose

This study verified our methods for assessing adolescents and young adults who had signs or symptoms of depression or suicide ideation and for training professionals to implement mental health interventions using telehealth devices. Teenage and young adult patients prescribed lifelong HPN infusions were invited to participate in three iPad audiovisual group discussion sessions. Each participant signed our institutional review board (IRB)-approved consent form and adolescents between the ages of 13 and 17 years old also had parental signed consent. Our telehealth interventions were tested using encrypted, audiovisual group sessions with multiple patients each from their own homes.

The iPad discussion sessions were conducted using Zoom for Healthcare application software (app) which was preloaded onto each iPad. Zoom for Healthcare is HIPAA (Health Insurance Portability and Accountability Act) compliant and encrypted. This app’s licenses allow multiple attendees and simultaneous interactions among patients and our multidisciplinary professionals in each audio/visual group session. Our medical center’s telemedicine department obtained the licenses for our research study’s use. The iPads tablet computers were mailed to participants to connect from their homes during the audio/visual group sessions. Also loaded onto these participants’ iPads were health-related game applications (apps), which guided practice of mental health skills and resiliency building activities. Each of the game apps were used during the discussion sessions and repeatedly used during participants’ own time.

The iPad audiovisual discussion sessions were led by a licensed psychologist with a Ph.D. and extensive telehealth experience. The other professionals involved were a masters’ prepared pediatric nurse observer, an HPN counselor, and a mental health nurse specialist. The psychologist and nurse mental health specialist were experienced in managing suicide ideation, mood disorders, and discussing sensitive topics with adolescents. During each iPad audiovisual discussion, teens were first asked their perspectives about the topic of the session, an essential strategy for gaining young patients’ engagement. Further, all the professionals in this study had training on group discussion facilitation techniques and depression/suicide crises communication.

2 |. METHODS AND PROCEDURES

All participants completed the Beck Depression Inventory-II (Beck et al., 1996) quarterly across the year of the study. This inventory is validated for individuals aged 13 through young adulthood at 30 years. It is composed of questions relating to the emotional and physical symptoms of clinical depression. Patient participants who responded on the inventory to depressive symptoms or to having suicidal thoughts were then assessed individually. Those participants were contacted privately by the team’s mental health specialists for detailed one-on-one assessment and provided coordination to their local mental health care. Specifically, our research team had training in our IRB-approved procedures for responding to signs or symptoms of depression and followed safety procedures for assessing any suicide ideation.

2.1 |. Procedures and training for using telehealth assessment for depression and suicide ideation

All research team members participated in our Depression and Suicide Ideation Response Protocol Training for assessment of depressive symptoms; identification of suicidality; notifications to patients’ family, significant others, or local support; and appropriate documentation of follow-up status and mental health referrals (Berman et al., 2012; Campo, 2009; Epstein & Spirito, 2009). Any participant who demonstrated or reported symptoms of depression was further assessed for suicidal ideation as well as for the content of their suicidal thoughts. At each assessment, the specialists determined the intensity, frequency, and type of depressive symptoms. The mental health specialist also ascertained the duration and any known causation of each patien’s symptoms/ideation and determined the availability of family and mental health care for that person.

The research team was also trained to be diligent in observing signs and symptoms of depression and suicide ideation across all components of the intervention (e.g., participants’ responses on depression inventory forms, telephone contacts, and during the audiovisual sessions). Further, the modified Raskin Scale (Raskin et al., 1969) was used to guide team member observations of potential depressive indicators and suicide ideation based on verbal statements (e.g., reporting depressed mood, feelings of hopelessness, crying spells, tone of voice), behavioral symptoms (e.g., withdrawn body language, restlessness, flat facial expression, noncommunitive), and secondary symptoms (e.g., complaints of indecisiveness, hypersomnia, sudden bouts of extreme anger; Adams et al., 2017). Training materials included the US Department of Health & Human Services’ Mental Health Services and the National Suicide Prevention Lifeline (National Suicide Prevention Lifeline, n.d.; Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). Our IRB-approved Severe Depression/Suicide Ideation procedures used in these assessment approaches are aligned with the National Suicide Prevention Lifeline Best Practices & Suicide Toolkit for Adolescents (US Department of Health & Human Services, 2020).

2.2 |. Protocol for assessing and managing suicidal ideation via telehealth

This procedural assessment began when a participant displayed suicidal ideation or selected a suicide response on the depression inventory. Importantly, the mental health specialist asked all participants who revealed suicidal ideation if they had specific plans and means to harm themselves or end their lives. Each assessment determined whether the participant demonstrated suicidal ideation without a plan or demonstrated suicidal ideation with a plan. If a participant endorsed suicidal ideation with a plan, they were guided to tell someone (e.g., local family or social support) immediately.

If the participant was not engaging with a local person or support system, then our specialists communicated to the patient that they were required to contact their family or significant other immediately to share their high risk and their suicide plan with them. These patients and their family or support persons were told that the patient must not be left alone until he/she had spoken to a local professional. The specialist then strived to calm the situation and to answer all questions. The participant was informed that one of the study’s clinical experts would follow-up with them to be assured that they sought treatment referral.

Further, our team trained for using our specific procedures in situations when depressive symptoms or suicide ideation were revealed during a group audiovisual session. When this occurred, the research team was trained to explain to all group participants, including the depressed or suicidal person, that our specialists would provide individual support to that participant via a separate iPad screen. Before the separate connection being established, all participants in the session were told that disclosure of symptoms/ideation was important sharing to be commended and that this patien’s confidentiality would be maintained.

While the individual patient was being assessed, the remaining group participants were debriefed by the other professionals present in the session. These debriefing professionals addressed participant reactions to the participant with symptoms/ideation and reinforced the importance of recognizing symptoms, seeking treatment, and maintaining self-monitoring of emotions. Meanwhile, our team mental health specialist kept the depressed or suicidal participant on an individual iPad audiovisual session screen until another person was physically present with that participant. When speaking with the family member or another person present (in one instance this was a neighbor the team contacted via telephone) the specialist insisted the patient seek treatment immediately (through the hospital emergency room or by calling a mental health hotline). The disclosing participant was kept on the video/telephone (with a nearby parent/adult) and was told about the danger of having a suicide plan. The disclosing participant was then given the suicide phone line or text number in their area, told that 911 can be contacted, and instructed in how to maintain a suicide watch until treatment is obtained (SAMHSA, 2020; US Department of Health & Human Services, 2018).

This training procedure ensured that patients could be assessed privately and then connected for treatment with licensed mental health professionals in their respective locations. This response for identifying suicide ideation and then separating that person from the group has been IRB-approved for each of our studies since 2000 but only needed to be used twice; both times it resulted in successfully obtaining immediate mental healthcare treatment.

The professionals in this study did not engage in mental health treatment but were focused on recognizing and then assessing any signs or symptoms of depression and suicidality. However, the nursing interventions provided by these professionals were implemented to build these young patients’ resiliency, strengths, and contacts to local mental health specialists.

2.3 |. Mental health support interventions

The study interventions included three weekly 1-1.5 h-long group audiovisual discussion sessions with HPN patients and our multidisciplinary professionals. Across this study, there were 35 sessions conducted using encrypted iPad-based audiovisual connections. All group sessions were facilitated by our expert psychologist who led and integrated evidence-based intervention topics into the patient discussions (Andolina et al., 2019). These intervention sessions also provided participants with skill practice designed to promote mental health. Discussions included guides for online safety, resilience and relaxation, positive self-talk, mood monitoring, positive activity planning, thought monitoring, mindfulness, goal setting and problem-solving, and optimism and hope. Our expert psychologist taught participants how to seek and maintain ongoing peer and multiprofessional support. Figure 1 outlines the discussion intervention session topics and apps used for practicing health-related skills (Nelson et al., 2017). The apps selected for the study were developed and tested by educational and psychological specialists.

FIGURE 1.

iPad session content discussed with professionals and reinforced by game apps [Color figure can be viewed at wileyonlinelibrary.com]

The National Institute of Mental Health has decades of research verifying the positive outcomes of using health-related informatics games with adolescents (Pham et al., 2016). The game app topics practiced by participants during the sessions and on their own schedule included resilience skills, depression prevention and recognition, and detection of early signs of HPN-type infections. Also taught were strategies these young patients could use to prepare for the challenging transition into adult healthcare services and to increase independence in their own healthcare management (Betz et al., 2013; Joly, 2015).

2.3.1 |. Depression prevention and management interventions

Based on our past studies, we confirmed that HPN patients were likely to report frequent and reoccurring experiences of depressive symptoms given the stress and daily challenges of managing this complex chronic illness (Winkler & Smith, 2014). Therefore, discussion sessions emphasized that depression is a common but treatable condition and that resources are available to reduce and prevent this mental suffering. Reactive or situational depression and potential clinical depression warning signs (e.g., persistent feelings of sadness or worthlessness, social isolation, sleep disruptions, appetite changes lasting more than 2 weeks) were discussed (Berman at al., 2012). These warning signs were reviewed with participants to help them recognize psychological and physical signs associated with depression, to underscore the usefulness of preventive activities as in the game apps, and to emphasize the value of talking with a professional. Discussing depression serves to reduce stigma and reinforce that seeking help is commonly done and provides important opportunities for improving mental health.

2.3.2 |. Mental well-being skills interventions

Skills for improving mental well-being such as positive self-talk and positive activity planning were introduced and practiced in the audiovisual sessions. Participants were quick to share the activities that improved their overall sense of well-being and connectedness to others. Participants shared ideas about how to navigate social reactions to their frailty or their restricted activities. One participant gave examples of planning uplifting activities but always making plans in “pencil,” commenting that being able to reschedule activities helped reduce disappointment when unexpected disease complications changed plans for fun activities. Patients also shared their perspectives on negative self-talk and on how to diminish occurrences of that negativity.

Participants were guided through practicing relaxation and mindfulness techniques during the audiovisual sessions. While some participants were familiar with relaxation techniques, most said mindfulness was new to them. Mindfulness was described by our professionals as the ability to focus on the present moment by concentrating on here and now. Participants were guided in practicing a body scan technique to engage in mindfulness, guiding their focus “from their toes up to their nose” (Biegel et al., 2009). Participants practiced these skills during the sessions along with the interventionist and their peers in the group (Perry-Parrish et al., 2016).

Participants were also engaged in the apps accessed from or loaded onto their iPads and encouraged to utilize iPad apps on their own to establish these resiliency techniques. For example, participants were taught to use the breathing skills app (Breat2Relax) during the audiovisual session to promote relaxation. Virtual Hope Box and MoodKit were also used in sessions and available on each iPad. These types of apps (n = 36) were recently reviewed and shown to improve biopsychosocial outcomes and management of stressors (Yellowlees, 2018).

2.3.3 |. Problem-solving interventions

Depressive symptoms and other emotional issues can be initiated by the common stressors that these HPN users face, including social and family relationships and difficulties, travel challenges, academic and career issues, and interference with obtaining home care medical supplies in a timely manner. Thus, simple problem-solving steps were discussed and practiced. These steps included trying to anticipate ahead, developing a plan, and not overreacting to problems. One HPN user described traveling by airplane for the first time without a family caregiver. This patient explained the problem-solving steps involved in establishing a travel HPN equipment plan, staying in touch with supports at home, establishing upon arrival an HPN setup and routine, and engaging a local support system.

Emotional support was discussed as an adjunct to problem solving. Calm attitude maintenance and positive affirmations were used to reduce reactive emotions and support solving each issue. Emotional support was exemplified and pointed out throughout the sessions as active listening, replying respectfully, and clearly validating the problem. The participants made suggestions about how they solved problems commonly encountered by those on lifelong HPN. They listened attentively to each other, allowing each other to complete sharing personal problems. Even through difficulties with audiovisual screen setups, participants tried not to interrupt but rather took turns in speaking.

A universal challenge for these young patients, which often underscores a depressive episode, is the transitioning to independent home infusion care. Several participants shared that they were not emotionally prepared for the drastically different adult medical services environment where they needed to manage all the responsibilities of HPN. Thus, common challenges related to transitioning into adult healthcare systems were discussed at intervention sessions. This was an opportunity for participants to share their concerns and hear our recommended methods for moving from pediatric specialty care to adult medical care services, where fewer specialists and referrals are available within the practice (Joly, 2015).

These teens and young adults were guided to assume responsibility for making medical appointments, arranging transportation to appointments, and ordering their monthly medical supplies. In addition, participants were encouraged to set in advance a secondary backup plan for obtaining assistance when a medical complication arises. Many participants were unaware of existing supports for adolescents and young adults who are transitioning into greater responsibility for managing their own healthcare needs. Transition resources were shared with the group and were well received (Afzali & Wahbeh, 2017). One patient shared the importance of understanding that transitioning responsibility for healthcare planning and decision-making is not necessarily a linear process. Considering these patients have an average of three to five hospitalizations annually for disease exacerbations, a recommendation for developing transition plans for calling in reliable help and supportive resources was worked on. In past studies, these problem-solving steps and anticipating transitions were used to avoid emotional responses to problems, overcome feelings of failure or inadequacy, and prevent depressive symptoms.

3 |. DEPRESSION/SUICIDE ASSESSMENT OUTCOMES

Of the 40 patient participants, 25% (n = 10) selected one of the depressive symptoms or one of the suicide responses on the depression inventory, made comments or displayed depressive symptoms in the audiovisual group sessions, or wrote about issues that caused the professionals to be concerned about possible suicidal ideation. Notably, 9 of the 10 professional assessments were prompted by the patient selecting on their data forms a suicide item (e.g., having thoughts of killing themselves). However, eight of these nine participants also selected that they would not carry out these thoughts. The one patient who did not answer that he/she would not carry out his/her suicidal thoughts was assessed as having severe depression and was participating in local mental healthcare services. During each one-on-one assessment, all participants were asked about suicidal thoughts and plans; all denied having suicidal thoughts at that time or ever having had a plan. Each of these assessments were documented and reviewed within 24 h by our experienced study safety monitor. Upon review, all assessments were deemed to have been conducted for the patien’s benefit and for maintaining the patien’s safety.

Our psychologist followed up with each of these participants and guided them through using hopefulness and problem-solving skills to address the issues leading to their low moods or thoughts of suicide. Across these participants, the factors documented as being related to their low moods included problems with school or career, family or friends’ concerns, or challenges with a legal or healthcare system. Each of these patients agreed, following their assessment, to be seen in-person by their local mental health experts. Notably, all subsequent depression inventory scores were in the normal range, with no suicide ideation displayed across the year they participated in the study. At the time of each assessment, our specialists also enforced the National Suicide Prevention Lifeline (1-800-273-8255), a national network of local crisis centers, and explained their 24/7 operation of the call number as a resource; not in place of treatment or referral but for immediate and accessible support and crisis resources.

During one follow-up assessment, a young patient reported a lack of symptoms him/herself but expressed concern about friends and family members. This patient mentioned he/she had friends who were so depressed they sometimes told him/her about their suicidal thoughts. The psychologist reminded this patient about the National Suicide Prevention Lifeline. The patient was then taught to encourage his/her friends and family to talk to family members or adults they trust and to contact local mental health experts as well. Another example of our methods being used was when our nurse mental health specialist conducted a follow-up phone call to a young participant who reported he/she had been very sad but whose assessment did not reveal any depressive symptoms. The nurse mental health specialist, with this patien’s permission, also spoke with this patien’s family who clarified the patien’s sadness had resolved and that there were no concerns about mental health at that time.

Throughout the study, participants were informed that the study psychologist and/or nurse mental health specialist was available to talk with them if they had concerns or questions. Three participants requested an individual session after attending the first audiovisual meeting. These participants described their own experiences with unresolved problems. Their assessments did not identify clinical depression or suicide ideation. All three shared their appreciation of the specialis’s feedback and the resources that were shared with them. Participants who shared their depressive symptoms and/or suicidal thoughts stated this allowed them to understand their thoughts and to destigmatize seeking mental healthcare from professionals.

3.1 |. Overall results from implementing the telehealth intervention delivery

All the patients commented on the iPad delivery being easy compared with some other open source methods they had used. Various types of supportive interactions were observed among the group participants, including affirmations, humor, and emotional and informational support. Connecting with one another and the group social support dynamics appeared to reinforce learning and willingness to share personal experiences and identify areas needing attention.

Each participant evaluated the iPad sessions anonymously. All rated that they had benefited from meeting with “others like me,” knowing “I am not the only one who gets the blues,” and connecting with multiple health professionals using distance mobile devices. The audiovisual sessions were rated by participants as assisting them in understanding that depression is a cluster of several signs and symptoms, and that no one sign/symptom indicates that depression is present, yet any sign and symptom should be shared with healthcare providers.

Many of these HPN users described how social media provided them with opportunities to connect with others when their health limited their ability to attend social events. They also noted that their medical issues are less obvious when they interact with others through social media. Further, participants rated that the iPad session information and discussions positively improved their social media safety, resilience skills, shared problem-solving abilities, and transition to adult healthcare services (Smith et al., 2020). Notably, these participants recommended that these topics be retained for future interventions to prepare and support young HPN users.

All participants rated that they would continue with support/education groups (Chopy et al., 2015; Metzger et al., 2012). Finally, practice during the discussions using health-related game apps was described as enhancing skills for managing their complex chronic illness. Overall, HPN patients reported they were satisfied with what they learned from the iPad intervention sessions and their engagement in the sessions using telehealth devices “was easy.” They described feeling supported and expressed appreciation for being able to connect with others with similar experiences. In addition, our goal to enhance these chronically ill young persons’ resiliencies was verified in their evaluations of the sessions.

4 |. DISCUSSION

Despite the complexities of living with and managing severe chronic illness, a small number of these HPN participants reported symptoms consistent with depression and had initially indicated they had suicidal thoughts. Fortunately, across the remainder of the study year following each assessment, none of these 10 reported depressive symptoms or selected the inventory items for suicide thoughts. Given that many HPN patients experience lifelong episodes of reactive depression and have mood fluctuations due to the medical, physical, and social demands of managing chronic illness, it is imperative to assess and address the mental health and well-being of this population when providing distance services.

Telehealth methods and interventions are particularly well-suited for HPN patients who may not have the opportunity to seek mental health outside of their homes due to their stringent medical and daily 12-h intravenous infusion schedules. Additionally, our iPad-based group interventions were without the demands of travel or exposure to many of the common health infection risks that HPN patients encounter in clinic visits. Systematic reviews, meta-analyses, and evaluations of Internet-delivered interventions, including groups, have shown positive results in improving mental health of adolescents and young adults (Calthorpe et al., 2020; Nelson et al., 2006; Rogers et al., 2017). In one clinical trial using telehealth videophones, the young subjects’ depression improved at a faster rate and parents reported fewer disruptive behaviors than families in outpatient group visits with controls matched on age and length of symptoms (Nelson & Duncan, 2015).

Early research on supportive peer group programs for children and adolescents had consistent strong outcomes of greater social interaction, increases quality of life, and fewer depressive symptoms found at the final 12-month measures compared with control groups across several clinical trials (Grootenhuis et al., 2009; Last et al., 2007; Scholten et al., 2013). The most frequently used and extensively verified Internet care provided from a distance include mental health services (Grady et al., 2011; Lamb et al., 2019; Shore et al., 2014). A meta-analysis of online programs found enhanced effects on group participants with higher depression scores (Eysenbach et al., 2004; Ritter et al., 2014). Another meta-analysis of 1733 Internet-based intervention studies included 268 randomized control trials where 57 of these trials demonstrated a health benefit (Rogers et al., 2017). Specifically, the successful Internet-delivered health interventions shared similar characteristics. The successful interventions were designed for a selected population, were provided over weeks to months, and had numerous activities of engagement for the subjects. These interactive intervention activities were prompted during follow-up periods and included self-monitoring. Our study interventions have each of these characteristics.

Unique to this study was the knowledge gained from these young patients compared with what was already known about their frequent challenges with depression and social isolation. For example, little had been reported on teen and young adults’ challenges of managing HPN during their developmental stages of seeking independence and transiting to adult health care from specialty pediatric care (Viner, 2008). This study also filled in gaps by identifying the stressors repeatedly experienced by these young people. These findings were published in the HPN multidisciplinary scientific journal (Smith et al., 2020).

Furthermore, these patients continued to use the interventions and mental health skill-building apps during the year follow-up period of this study; with the majority rating that these exercises and apps were helpful and routinely used. Examples were feeling “relaxed” and “in control” after engaging in the mindfulness exercises on their own. Other participants shared that it was good to review these techniques because they had forgotten how helpful relaxation, mood monitoring, and mindfulness can be.

Overall, our iPad delivery went smoothly, as we had previous experiences with the technology. Notably in this study, the iPad technology allowed for observing these young patients’ discussions and peer exchanges, as they are often reluctant to verbalize concerns to health professionals. Thus, our psychologist and nurse specialists were able to identify patients projecting depression and/or suicidality symptoms. Our professionals were also ready with verified methods for safely conducting one-on-one assessments from a distance. Lastly, recognizing the limitations of care from a distance and how to overcome common technical challenges was important to our study’s success.

4.1 |. Limitations and challenges of mobile distance mental health assessment and care

One limitation of this study is the small number within our sample; yet 25% of sample participants indicated they experienced depressive symptoms or thoughts of killing themselves, a significant percentage of adolescents. Also, considering the additional three participants who sought individual psychologist contact, it may be that group sessions limit individuals from sharing their mental health issues and emotions. As in any office or home care visit, patients can hide symptoms and deny concerns. Notably, participants’ psychological affect may not be easily observed. Thus, our training emphasized observing for lack of facial expressions and eye contact, nonparticipation, and sad demeanor. Each of these depression indicators were identified in our iPad studies.

There are also professional challenges to conducting successful mobile telehealth sessions. As noted, the training of professionals for facilitating group sessions is essential and more specific training is required when individual audiovisual mental health assessments are undertaken. In addition, when testing nursing interventions delivered over distance platforms, it is important to train for and measure the consistency of professionals’ intervention delivery (fidelity) and patients’ receipt and enactment of the new knowledge provided by the intervention (Bonar et al., 2020).

Technical challenges with distance care have been written about previously (Calthorpe et al., 2020; Smith et al., 2015). These challenges include the occasional dropped or slow connections, pixel blurring, and the need for online security. It should be noted that our study data collection occurred behind our medical center firewall; therefore, HIPAA and privacy were protected. In contrast, our participants did report interacting on open source networks where unknown participants joined in or hacked their groups. During this time of pandemic, online safety is particularly important as many open source care sites not monitored by health professionals for chronic illness management are being opened (Spaulding & Smith, 2020).

4.2 |. Conclusion

The training of our professionals prepared them for assessing and caring for these young, severely chronically ill patients from a distance using mobile telehealth iPad interactions. The procedures developed for assessing and supporting severely depressed and/or suicidal participants ensured the safety of participants (Inkster, 2018). The assurance and calm demeanor of the mental health specialists and their forthright discussion of mental health well-being, depression symptoms, and suicidal thoughts facilitated the ease of discussing depression and of completing these sensitive individual assessments. As described herein, careful methods and training of staff are needed for using telehealth successfully to assess depression and suicidality and to provide mental health support to teens and young adults.