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Intervention characteristics: Whether the intervention was internally/externally developed, evidence supporting the intervention, advantages compared with other methods of delivery, adaptability, trialability, and complexity |
Remote care had advantages over face-to-face, for example, making therapy more accessible for certain groups such as service users in remote locations; saving users money on travel; helping therapists get a better idea about the service users’ home environment; some users benefitted from the distance, found it easier to communicate openly, and became more independent. The main barriers for clinicians to deliver quality therapy were picking up on nonverbal cues, assessing mental health symptoms, keeping service users engaged. Video and phone calls were the most common modalities; however, studies also reported the use of emails, instant messaging services, apps, videos, and forums. Duration of telemental health appointments were shorter than face-to-face; clinicians reported it required more concentration and was more tiring. In some cases, studies have reported using shorter but more frequent appointments to deal with challenges in remote working (eg, some service users struggling to stay focused). This was also used as a method to increase flexibility. Frequent contacts between sessions helped to build the therapeutic relationship.
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[43,51,56,86,108,109] |
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Outer setting: Information on whether the organization is networked with others, peer pressure to implement intervention, and external policies and incentives |
Implementation was commonly due to “stay at home” orders or national lockdowns, or a high level of COVID-19 cases in that area resulting in social distancing requirements. In the United States, health insurers did not always cover telemental health care, whereas in some European countries, insurance cover for telemental health terminated at the end of the first wave of infections. Telehealth service delivery was eased by the relaxation of policy and billing reimbursements during this time. Professional bodies facilitated transition to telehealth by posting guidelines on their websites to assist clinicians. Platform developers worked rapidly to increase capacity. Clinicians identified the need for a video tool that adheres to privacy standards and links with a technical helpdesk. There were also concerns over the reduction in services to support the physical health needs of mental health service users.
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[29,56,57,75] |
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Inner setting: Information on the structural characteristics, networks and culture of an organization, as well as the implementation climate (eg, capacity for change) |
|
[76,100,102,105] |
|
Staff characteristics: Information on the following psychological attributes and also on any effects of staff demographic and professional backgrounds |
There was some variation in acceptability of remote ways of working for staff depending on their therapeutic approaches. Telemental health take-up was dependent on perceived experience of patient (positive or negative), comfort with online platform, previous clinical experience. Some staff felt less confident about professional skills during online compared with in-person consultations, especially those with less clinical experience and those who perceived their patients disliked remote care.
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[43,52,111] |
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Process: Training provided and any processes put in place to support telemental health intervention, planning, and feedback on progress of implementation |
The transition to telemental health occurred usually over a short period. Training staff to use platforms was mentioned frequently, as was phoning service users to let them know about the transition to telemental health and how care would be provided going forward. Methods of staff training included courses, shadowing or observing senior colleagues, discussion within clinical teams, facility-level telehealth coordinators, clinical champions providing training, and webinars. Sources of information for staff: colleagues, government guidelines, prepared consent forms, posts on listservs, American Psychological Association, and other official guidelines. New workflows had to be developed to allow staff to access patient records remotely. Despite some training, staff reported lack of support and identified training needs across several studies regarding how to use online platforms and meeting privacy regulations.
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[7,28,44,45,50,59,61,62, 74,105,112,115] |
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Service user needs/resources: Statements demonstrating awareness of the needs and resources of those served by the organization (eg, barriers and facilitators and feedback) |
A commonly reported issue was access to technology, particularly among service users with diagnoses such as schizophrenia, service users with a lower socioeconomic status, and older adults (one study mentioned that older adults often lacked access to video software, so preferred phone calls). Concerns around privacy and confidentiality, and forming a therapeutic relationship may be more difficult when using remote care. Difficulties for service users to concentrate within a digital environment. Several studies mention the need for an agreed “Zoom etiquette” for service users, including attire, audio/visual setup, and reducing background distractions. Stable internet connection was a problem for some service users. Some clients benefitted from the distance created by online treatment, as they became less inhibited and less dependent on therapist.
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[50,62,77,86,98,116] |
