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

Background Remote interventions known as telemental health care increased in use due to the COVID-19 pandemic when social distancing requirements were in place. Whilst there is some evidence regarding the cost-effectiveness of telemental health prior to the pandemic, there is a need for further evaluation due to the increase in remote care. Aims To systematically review the literature to explore whether remote mental health care interventions are cost-effective in terms of incremental cost per quality adjusted life year and in relation to condition specific outcomes compared to usual care or an alternative intervention. Method A multilayer search strategy was conducted to build on the searches of a previous systematic review, as well as including grey literature and economic models. Six databases (PubMed, EMBASE, Cochrane Central, PsychINFO, CINAHL, and EconLit) were searched for literature relating to the cost effectiveness of telemental health. Quality appraisal was conducted for all included studies, and findings were synthesised using narrative synthesis. Results 7386 studies were identified of which 59 met our inclusion criteria and were included in the synthesis of findings. 45 studies were rated as very good or excellent quality. Of the 59 included studies, 40 indicated that the telemental health intervention was cost-effective, whilst a further 16 suggested the intervention had potential to be cost-effective, but there was some uncertainty in the findings. Three studies reported that the intervention was not cost-effective. Conclusions This evidence will be used to inform practice in the UK as we respond to and recover from the COVID-19 pandemic.

Implementation strategies for telemental health: a systematic review (preprint)

Background The COVID-19 pandemic resulted in a rapid shift from traditional face-to-face care provision towards delivering mental health care remotely through telecommunications, often referred to as telemental health care. However, the manner and extent of telemental health implementation have varied considerably across settings and areas, and substantial barriers are encountered. There is, therefore, now a need to identify what works best for service users and staff and establish the key mechanisms for efficient integration into routine care. Objective We aimed to identify investigations of pre-planned strategies intended to achieve or improve effective and sustained implementation of telemental health approaches, and to evaluate how different strategies influence implementation outcomes. Methods A systematic review was conducted, with five databases searched for relevant literature using any methodological approach, published between January 2010 and July 2021. Studies were eligible for inclusion if they took place in secondary or tertiary mental health services and focused on pre-planned strategies for achieving or improving delivery of mental health care through remote communication between mental health professionals or between mental health professionals and service users, family members, unpaid carers, or peer supporters. All included studies were assessed for risk of bias. Data were synthesised using the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies and the taxonomy of implementation outcomes. Results A total of 14 studies were identified which met the inclusion criteria. A variety of implementation strategies were identified, the most commonly reported being ‘Train and educate stakeholders’. All studies reported using a combination of several implementation strategies. Conclusions Using a combination of implementation strategies appears to be a helpful method of supporting the implementation of telemental health. Further research is needed to test the impact of specific implementation strategies on implementation outcomes.

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

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, adoption and perceptions of telemental health during the COVID-19 pandemic: a systematic review (preprint)

Background: Early in 2020, mental health services had to rapidly shift from face-to-face models of care to delivering the majority of treatments remotely (by video or phone call or occasionally messaging) due to the COVID-19 pandemic. This resulted in several challenges for staff and patients, but also in benefits such as convenience or increased access for people with impaired mobility or in rural areas. There is a need to understand the extent and impacts of telemental health implementation, and barriers and facilitators to its effective and acceptable use. This is relevant both to future emergency adoption of telemental health, and to debates on its future use in routine mental health care. Objective: To investigate the adoption and impacts of telemental health approaches during the COVID-19 Pandemic, and facilitators and barriers to optimal implementation. Methods: Four databases (PubMed, PsycINFO, CINAHL and Web of Science) were searched for primary research relating to remote working, mental health care, and the COVID-19 pandemic. Preprint servers were also searched. Results of studies were synthesised using framework synthesis. Results: A total of 77 papers met our inclusion criteria. In most studies, the majority of contacts could be transferred to a remote form during the pandemic, and good acceptability to service users and clinicians tended to be reported, at least where the alternative to remote contacts was interrupting care. However, a range of impediments to dealing optimal care by this means were also identified. Conclusions: Implementation of telemental health allowed some continuing support to the majority of service users during the COVID-19 pandemic and has value in an emergency situation. However, not all service users can be reached by this means, and better evidence is now needed on long-term impacts on therapeutic relationships and quality of care, and on impacts on groups at risk of digital exclusion and how to mitigate these.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: a co-produced framework analysis (preprint)

BackgroundThe prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in accessing good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable. MethodsWe conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants experiences and views regarding telemental health during the pandemic was identified and extracted. Data collection and analysis used a participatory, coproduction approach where lived experience researchers, clinical and academic researchers contributed to all stages of data collection, analysis and interpretation of findings. FindingsParticipants experiences and preferences regarding telemental health care were dynamic and varied across time, settings, and individuals. Participants preferences were shaped by the reason for contacting providers, their relationship with the care provider, and both parties access or acceptability to use remote technology. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important new challenges around safety and privacy in online settings, and gave examples of good remote care strategies, including scheduling regular phone calls and developing guidelines about how to access remote care tools. DiscussionParticipants in our study and previous literature have highlighted advantages of telemental health care, as well as significant limitations which hinder mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and to support staff in making effective and collaborative use of relevant technologies.