The Effectiveness of Tele Mental Health

Shelly Iskandar

, Steven Saputro

, Syifa Nabilah

, Tania

, Tiara Syafitri Putri

, Vimal Chander

Mutiara Utami

Department of Psychiatry, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung

Faculty of Medicine, Universitas Padjadjaran, Bandung

Keywords: tele mental health, telepsychiatry, telemedicine, effectiveness.

Abstract: Background: The emergence of 2019 novel coronavirus (2019-nCoV) in Wuhan, China in December 2019

has caused coronavirus disease (COVID-19) and created a confusing situation. COVID-19 is considered

responsible for an increase in psychological problems including anxiety, depression, and even mass hysteria.

However, along with these conditions, orders to minimize direct contact and time spent in public were

implemented to prevent the spread COVI-19, so many psychiatrists turned face-to-face care to tele mental

health. This paper will provide the effectiveness of tele mental health compared with face-to-face care in

regards to psychiatric services in a setting of quarantine or isolation. A manual search was conducted to select

articles published between 2005 and 2020 using the PubMed database. We included full-text articles

published in English that reported the effectiveness of telepsychiatry in a setting of quarantine or isolation.

Among 557 articles, only 5 studies met all criteria and were included in the review. These articles reported

the effectiveness of tele mental health for those who are in a setting of quarantine or isolation. Tele mental

health helps those who need psychiatric services, but are not able to have a face-to-face consultation. This

review shows equivalent overall effects between tele mental health or face-to-face care in psychiatric services.

While the results are equivalent, few studies were obtained. Thus, more research is needed to establish

equivalence.

1 INTRODUCTION

The emergence of 2019 novel Coronavirus (2019-

nCoV) in Wuhan and the pandemic COVID-19

announcement from the World Health Organization

(WHO) in March 2020, has changed the world rapidly

and evoking multiple responses. (Coronavirus

disease, 2019; Chen JA,et al.2020; Moring JC, et

al.2020) It has infected more than 100 nations around

the world and had been declared as public health

emergency.(Health UDo,2019) As part of spreading

mitigation, the Centers for Disease Control and

Prevention (CDC) recommend limiting outdoor

movement and practicing social distancing.(Mark

É,et al.2020) This restriction may provoke stress and

in the end worsen mental health condition over time.

(Whaibeh E,et al 2020) This can be seen from the

elevating of anxiety, depression, mass hysteria,

posttraumatic stress disorder (PTSD) and negative

societal behaviors rates.(Ćosić K,et al.2020; Duan L

and Zhu G,2020)

There are the hindrance in mental health

treatment, and the consequences are lost work

productivity, unemployment, homelessness, marital

and parenting problems, domestic violence, drug and

alcohol abuse, suicides and others.(Ćosić K,et

al.2020; Tanielian TL,et al.2008) The increasing

demand for mental health services become a potential

risk of creating a global public mental health crisis.(

Ćosić K,et al.2020)

A survey conducted by Centers for Disease

Control and Prevention (CDC) shown that in June

2020, 40% of Americans reported struggling with

mental health or substance abuse problems.( Mark

É.,et al 2020) Quarantine, isolation, trauma

experienced by frontline workers, victims and their

family also create a challenges for healthcare

providers, including mental health provider.(

Whaibeh E,et al 2020)

Despite the adverse repercussions that have

occurred, mental health services must still be done.6

To meet the needs, many mental health center had to

adopt new strategies to ensure continuity of

treatment.(Moring JC,et al.2020) Tele mental Health

has a potential in addressing the psychological

problems of this condition. (Whaibeh E,et al 2020)

296

Iskandar, S., Saputro, S., Nabilah, S., Tania, ., Putri, T., Chander, V. and Utami, M.

The Effectiveness of Tele Mental Health.

DOI: 10.5220/0010370502960300

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 296-300

ISBN: 978-989-758-500-5

Tele mental health is promising approach to reducing

the treatment gap for isolated patients to access

mental health provider.(Hubley S,2020) Tele mental

health may be an ideal solution to reduce the risk of

clinicians or patients being infected while still

providing the treatment.6 Tele mental health is the

provison of mental and behavioral health care at

distance, including psychiatric evaluations, therapy

(individual, group, family), psychoeducation and

medication management.(Whaibeh E,2020) The

objective of the current review was to provide an

overview of scientific publication on the

effectiveness of tele mental health compared to face

to face intervention for those who are in a setting of

quarantine or isolation.

2 METHODS

2.1 Search Strategy

A multi-step literature search was performed. First,

systematic searches were conducted in the PubMed,

which publised between 2005 and 2020. The search

was done using the following combinations of key

terms: tele mental health effectiveness OR psychiatric

telemedicine effectiveness OR telepsychiatry

effectiveness. We searched the reference lists of

retrieved articles. Then, abstracts identified by this

process were then screened and full-text articles were

inspected against the inclusion and exclusion criteria.

Studies were eligible for inclusion when the

following criteria were fulfilled.

1. Full-text articles published in English

2. Full-text articles reporting the effectiveness of tele

mental health.

The exclusion criteria were:

1. Reviews, meta-analyses, study protocols,

abstracts and any other non-original data;

2. Lacking a clear primary focus on the effectiveness

of tele mental health in quarantine/isolation

setting.

The level of evidence of each study was

determined using the Oxford Centre for Evidence-

Based Medicine 2011 definition.(Group

OLoEW,2011)

3 RESULTS

We reviewed 5 studies that met our inclusion and

exclusion criteria. For brevity and conciseness, as

extracted from the 5 reviewed articles as follows:

Namkee G. Choi et al (2014): Objectives is to report

both depression and disability outcomes of telehealth

problem-solving therapy (tele- psychotherapy via

Skype video call) for low-income homebound older

adults over 6 months post intervention. Tele mental

Health Domain: Tele psychotherapy via Skype video

call and phone call. N Sample: 158 participants (56 in

tele-PST, 63 in in-person PST, and 39 in care call).

Study Design: (i) Randomized control trial. Outcome

Evaluation: Hamilton Rating Scale for Depression

(HAMD), (ii) WHO Disability Assessment Schedule

(WHODAS). Conclusion: Both tele psychotherapy

and in-person psychotherapy were efficacious

treatments for low-income homebound older adults;

however the effects of tele- psychotherapy on both

depression and disability outcomes were sustained

significantly longer than those of in-person

psychotherapy. Limitations of Study: The sample was

small and limited to those who were willing to be

randomized to tele-psychotherapy and to those

without cognitive deficits and other mental health

conditions. Level of Evidence is 2.

Namkee G. Choi et al (2014): Objectives is To

evaluate clinical effectiveness of a brief, aging

service–integrated, videoconferenced behavioral

activation (tele-BA) treatment delivered by lay

counselors compared with videoconferenced

problem-solving therapy (tele-PST) delivered by

licensed clinicians and attention control (AC;

telephone support calls). Tele mental Health Domain:

Videoconferencing for tele-BA and tele-PST

Telephone for attention control (AC). N Sample: 277

participants. Study Design: Randomized Clinical

Trial. Outcome Evaluation: Hamilton Rating Scale

for Depression (HAMD). Conclusion: Compared

The Effectiveness of Tele Mental Health

297

with participants in the AC group, participants in the

tele-BA and tele-PST groups had significantly higher

response and remission rates and medium to large

effect sizes. Limitations of Study: (i) All participants

resided in a single, large metropolitan area, which

may limit generalizability of the findings to non-

metropolitan areas. (ii) The lack of a longer (ie,

beyond 9 months) follow-up period. Level of

Evidence is 2.

Michelle Lampman et al (2019): Objectives is to

to examine if self-reported access to primary care is

associated with actual patient wait times and use of

telephone visits, and to assess whether this

relationship differs by rural residence. Tele mental

Health Domain: Telephone visits. N Sample: 160,447

Veterans. Study Design: Cross sectional. Outcome

Evaluation: Telephone visits Conclusion: As actual

wait time for routine appointments increases,

Veterans served by clinics with a higher percent of

rural Veterans perceive telephone visits more

positively. Limitations of Study: Not stated by

authors. Level of Evidence is 3.

Amanda K. Gilmore et al. (2019): Objectives is to

test the usability of a mobile health intervention

targeting alcohol and drug misuse, suicide

prevention, posttraumatic stress symptoms, coping

skills, and referral to formal assistance for individuals

who have experienced sexual assault. Tele mental

Health Domain By application (SC-Safe) Interviews

were conducted through teleconferencing. N Sample:

13 participants. Study Design: Qualitative study.

Outcome Evaluation: (i) Sexual Experiences Survey.

(ii) The Patient Health Questionnaire (iii).

Posttraumatic stress disorders Checklist (PCL5) (iv)

Alcohol Use Disorders Identification Test (AUDIT-

C). (v) SC-Safe questionaire about application.

Conclusion: The participants indicated that SC-Safe

would be a helpful resource for individuals who

experience sexual assault due to the pervasive barriers

that these individuals face to accessing care.

Limitations of Study: (i) The current study included a

small sample of individuals to assess initial usability

of SC-Safe (ii) Future work is needed to understand

the post-SAMFE healthcare needs of men, sexual and

gender minorities, and different racial/ethnic groups..

Level of Evidence is 3.

Choi et al (2020): Objectives is to evaluate the

acceptance and preliminary efficacy of in-home

telehealth delivery of problem-solving therapy (tele-

PST) among depressed low-income homebound older

adults in a pilot randomized control trial designed to

test its feasibility and preliminary efficacy. Tele

mental Health Domain: Videoconferencing for tele-

PST Telephone. N Sample: 121 participants. Study

Design: Randomized control trial. Outcome

Evaluation: (i) Hamilton Rating Scale for Depression

(HAMD). (ii)Treatment Evaluation Inventory (TEI)

Conclusion: Almost all participants had extremely

positive attitudes toward tele-PST at the 12-week

followup. Tele-PST also appears to be an efficacious

treatment modality for depressed homebound older

adults and to have significant potential to facilitate

their access to treatment. Limitations of Study: (i) The

study period was rather short (24 weeks), so not able

to examine the relationship between long-term

treatment outcome and the treatment modality, as

well as cost analysis of tele-PST delivery versus in-

person PST delivery. (ii)The sample was limited to

older adults without cognitive and sensory deficits.

Tele-PST for older adults with cognitive and sensory

deficits, especially auditory and visual, may not be

feasible as such deficits can impair the ability to

interact with a therapist over a videoconference

connection. Level of Evidence is 2.

4 DISCUSSION

The COVID-19 has been a global health issue since

the number of cases increases throughout out many

countries. Patients with COVID-19 should be isolated

or quarantined. This condition allows the patients

having psychological problems. Since the patients are

limited to meet people, a technological revolution in

mental health care is approaching. The use of

technology to reach populations whom to be

quarantined allows the doctor and the patient are able

to communicate without face to face.

This systematic review evaluates the effectiveness

of of tele mental health compared with face-to-face

care in regards to psychiatric services in a setting of

quarantine or isolation. This review suggests that

using tele mental health care and face-to-face care

had equivalent overall effects. Almost all of the

associated technologies can be effectively used to

treat and evaluate mental disorders without

compromising the quality of service. This review

presents its discussion under the following headings

and subheadings.

4.1 Modalities

In conducting tele mental health, there are some

technologies that can be used such as:

 Videoconferencing and telephone

Videoconferencing omits presence physically

and some physical cues could not be assessed,

but overall the examiner was still able to

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observe the expressions of the client.

Telephone omits visual cues, but examiner was

still able to assed their expression by voices.

(Mohr D,et al.2011)

 Application

Applucation in the study had some limitation in

interaction, but strengthened by interview by

videoconferencing.( Whaibeh E,et al.2020)

4.2 Isolation or Quarantine Settings

There are some situations before that resembles the

condition caused by COVID-19 like:

 Homebound older

Social isolation is a state in which the

individual lacks a sense of belonging socially,

lacks engagement with others, has a minimal

number of social contacts and they are deficient

in fulfilling and quality

relationships.(Nicholson Jr NR,2009)

 Sexual assault

There are several systemic (e.g., access to

services), logistical (e.g., financial constraints),

and attitudinal (e.g.,stigma, confidentiality

concerns) barriers to accessing healthcare

services immediately after sexual

assault.(Gilmore AK,2019)

 Rurality

Rural residents have identified several barriers

to accessing care including distance, access to

transportation, and availability of services.

(Douthit N, 2015.) COVID‐19‐related social

isolation may be enforced by government

restrictions and/or due to an individual's fears

of infection. (Kato TA,2020) Both condition

almost similar.

4.3 Effectiveness

The advantages of tele mental health care include

improved access, reduced costs, flexibility, and

interactive sessions between clients and clinicians.(

Farrell SP,et al.2009; Tillfors M,et al.2008) Most

important things about tele mental health care are

skills to use technologies (both clinicins and clients),

good quality of equipments (both sofware and

hardware), good quality of internet services, and

evaluation of services.(Christensen H,and Hickie IB

2010) Another concerns are about marginalizing

clients with physical and cognitive disabilities who

are unable to use the equipment properly, making in-

person services as the only feasible choice.(Ybarra

ML,and Eaton WW 2005).

5 DISCUSSION

Our finding suggests that there were no significant

differences between participants receiving

telemedicine or face-to-face psychiatric services.

Tele mental health can effectively reduce psychiatric

symptoms, reduce cost. Therefore, it can be used as

an adaptable solution for COVID-19 pandemic

situation. Mental health providers providing this

service is advised to benefit from feedback collected

from clinicians and clients. Considering the potentials

of tele mental health care, further research is required

to optimize its current applications and to explore its

future promises.

REFERENCES

Chen JA, Chung W-J, Young SK, Tuttle MC, Collins MB,

Darghouth SL, et al. COVID-19 and telepsychiatry:

Early outpatient experiences and implications for the

future. General Hospital Psychiatry. 2020;66:89-95.

Choi NG, Marti CN, Bruce ML, Hegel MT, Wilson NL,

Kunik ME. Six‐month postintervention depression and

disability outcomes of in‐home telehealth problem‐

solving therapy for depressed, low‐income homebound

older adults. Depression and anxiety. 2014;31(8):653-

61.

Choi NG, Marti CN, Wilson NL, Chen GJ, Sirrianni L,

Hegel MT, et al. Effect of Telehealth Treatment by Lay

Counselors vs by Clinicians on Depressive Symptoms

Among Older Adults Who Are Homebound: A

Randomized Clinical Trial. JAMA Network Open.

2020;3(8):e2015648-e.

Christensen H, Hickie IB. Using e‐health applications to

deliver new mental health services. Medical Journal of

Australia. 2010;192:S53-S6.

Choi NG, Hegel MT, Marti CN, Marinucci ML, Sirrianni

L, Bruce ML. Telehealth problem-solving therapy for

depressed low-income homebound older adults. The

American Journal of Geriatric Psychiatry.

2014;22(3):263-71.

Coronavirus disease 2019 (COVID-19) Situation Report.

World Health Organization; 2020 (diunduh March 25,

2020). Tersedia dari:

https://www.who.int/docs/default-

source/coronaviruse/situation-reports/202AQ00324-

sitrep-64-covid-19.pdf?sfvrsn=703b2c40_2.

Ćosić K, Popović S, Šarlija M, Kesedžić I. Impact of human

disasters and Covid-19 pandemic on mental health:

Potential of digital psychiatry. Psychiatria Danubina.

2020;32(1):25-31.

Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some

important barriers to health care access in the rural

USA. Public health. 2015;129(6):611-20.

The Effectiveness of Tele Mental Health

299

Duan L, Zhu G. Psychological interventions for people

affected by the COVID-19 epidemic. The Lancet

Psychiatry. 2020;7(4):300-2.

Farrell SP, Mahone IH, Zerull LM, Guerlain S, Akan D,

Hauenstein E, et al. Electronic screening for mental

health in rural primary care: implementation. Issues in

mental health nursing. 2009;30(3):165-73.

Gilmore AK, Davidson TM, Leone RM, Wray LB, Oesterle

DW, Hahn CK, et al. Usability testing of a mobile

health intervention to address acute care needs after

sexual assault. International journal of environmental

research and public health. 2019;16(17):3088.

Group OLoEW. " The Oxford 2011 Levels of Evidence."

Oxford Centre for Evidence-Based Medicine.

http://www cebm net/index aspx? o= 5653. 2011.

Health UDo, Services H. Secretary Azar declares public

health emergency for United States for 2019 novel

coronavirus. 2020 Jan 31. 2020.

Hubley S, Lynch SB, Schneck C, Thomas M, Shore J.

Review of key telepsychiatry outcomes. World Journal

of Psychiatry. 2016;6(2):269.

Kato TA, Sartorius N, Shinfuku N. Forced social isolation

due to COVID‐19 and consequent mental health

problems: Lessons from hikikomori. Psychiatry and

clinical neurosciences. 2020.

Lampman M, Stockdale S, Kaboli PJ, Jaske E, Wood GB,

Clinton WL, et al. The effects of telephone visits and

rurality on veterans perceptions of access to primary

care. The Journal of the American Board of Family

Medicine. 2019;32(5):749-51.

Mark É. Czeisler; Rashon I. Lane MEP, MD; Joshua F.

Wiley, PhD; Aleta Christensen, MPH; Rashid Njai,

PhD; Matthew D. Weaver, PhD; Rebecca Robbins,

PhD; Elise R. Facer-Childs, PhD; Laura K. Barger,

PhD; Charles A. Czeisler, MD, PhD; Mark E. Howard,

MBBS, PhD; Shantha M.W. Rajaratnam, PhD. Mental

Health, Substance Use, and Suicidal Ideation During

the COVID-19 Pandemic. United States: CDC; 2020.

Mohr D, Cuijpers P, Lehman K. Supportive accountability:

a model for providing human support to enhance

adherence to eHealth interventions. Journal of medical

Internet research. 2011;13(1):e30.

Moring JC, Dondanville KA, Fina BA, Hassija C, Chard K,

Monson C, et al. Cognitive Processing Therapy for

Posttraumatic Stress Disorder via Telehealth: Practical

Considerations During the COVID‐19 Pandemic.

Journal of Traumatic Stress. 2020.

Nicholson Jr NR. Social isolation in older adults: an

evolutionary concept analysis. Journal of advanced

nursing. 2009;65(6):1342-52.

Tanielian TL, Tanielian T, Jaycox L. Invisible wounds of

war: Psychological and cognitive injuries, their

consequences, and services to assist recovery.Rand

Corporation; 2008.

Tillfors M, Carlbring P, Furmark T, Lewenhaupt S, Spak

M, Eriksson A, et al. Treating university students with

social phobia and public speaking fears: Internet

delivered self‐help with or without live group exposure

sessions. Depression and Anxiety. 2008;25(8):708-17.

Whaibeh E, Mahmoud H, Naal H. Tele mental Health in the

Context of a Pandemic: the COVID-19 Experience.

Current Treatment Options in Psychiatry. 2020:1-5.

Ybarra ML, Eaton WW. Internet-based mental health

interventions. Mental health services research.

2005;7(2):75-87.

HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical

300