The implementation and use of telehealth in mental healthcare

<p dir="ltr"><b>Aim: </b>The use of telehealth in mental healthcare (“telemental health”) has grown exponentially in the past four years, stemming from its rapid and widespread adoption during the COVID-19 pandemic. The aim of the thesis is to learn from this implementation of telemental health to inform its successful and sustained use going forward.</p><p dir="ltr"><b>Methods: </b>Four distinct, yet related, studies were conducted to achieve this aim. Firstly, a mixed methods systematic review explored patient and provider perspectives on the factors influencing the implementation of remote mental health consultations. Subsequently, to facilitate an in-depth exploration of these factors, a qualitative study elicited diverse stakeholder perspectives of the implementation of remote mental health consultations during the COVID-19 pandemic. Having identified a lack of research on telehealth in child and adolescent populations, a cross-sectional survey study examined the perspectives of caregivers of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) of telehealth. Finally, given the need to identify solutions to reduce digital barriers to accessing telehealth, a scoping review mapped the research on training activities for service users in the use of telehealth.</p><p dir="ltr"><b>Results: </b>The mixed methods systematic review identified seven themes relating to patient and provider perspectives on factors influencing the implementation of remote mental health consultations. Reported factors were mapped to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability of remote consultations was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers.</p><p dir="ltr">The subsequent qualitative study described six themes relating to the most relevant constructs of the CFIR. Providers and managers described varying levels of success with implementation, citing complexity and incompatibility with existing workflows as barriers to adoption. Providers’ access to resources, guidance, and training were notable facilitators. Service users, providers, and managers perceived remote mental health consultations to be satisfactory, but not equivalent, to in-person care in terms of quality. Whilst a return to in-person services was mostly preferred, participants acknowledged a potential adjunct role for remote consultations in certain circumstances.</p><p dir="ltr">The cross-sectional survey study of 112 caregivers of children and adolescents with ADHD found that the majority of respondents (n = 91, 81.3%) would be willing to use telehealth for their child’s future appointments. Of the 61 (54.5%) participants with experience of telehealth, the majority reported that they were at least satisfied with telehealth (n = 36, 59%), whilst approximately half of participants rated the quality more poorly than in-person visits (n = 31, 50.8%). The most common reasons selected for wanting to use telehealth included saving time (n = 76, 67.9%), improvements to the family routine (n = 56, 50%), and reducing costs (n = 51, 45.5%). Reasons selected for not wanting to use telehealth included not being able to receive hands-on care (n = 63, 56.3%), belief that the quality of care is poorer than in-person consultations (n = 56, 50%), and distraction of the child during telehealth visits (n = 50, 44.6%).</p><p dir="ltr">The scoping review mapped the evidence from 13 studies describing training activities for service users in the use of telehealth. Telehealth training was commonly described as once-off pre-telehealth visit phone calls to service users, facilitated primarily by student volunteers. Older adults were the most common target population for the training. Overall, training was feasible and well-received by service users, and studies mostly reported increases in rates of video visits following training. There was limited and mixed evidence that training improved service users’ competency with telehealth.</p><p dir="ltr"><b>Conclusion: </b>Successful adoption and sustained use of telemental health involves understanding and addressing the beliefs of providers, considering the preferences and needs of service users, adequately resourcing organisations, and increasing accessibility for underserved populations.</p>