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09 December 2021

Review finds significant barriers in shift to remote mental health services during pandemic

New findings from research exploring mental health care provided by phone and video call during the COVID-19 pandemic.

Feature Student on laptop taking notes

A systematic review looking at mental health care provided by phone and video call (remote care) during the COVID-19 pandemic has shown that many service users were able to continue accessing some support but that the shift to remote care presented significant barriers to certain groups. Researchers are calling for further examination into the effects of telemental health on groups at risk of digital exclusion and for better evidence on long-term impacts.

The study, published in the Journal of Medical Internet Research reviewed a total of 77 primary research papers from five countries. It found that the implementation of telemental health services – provided by video, phone call, or messaging – allowed some continued support to a majority of service users during the COVID-19 pandemic and highlighted its value in emergency situations.

The benefits of remote care include increased convenience and accessibility for staff and patients and reduced travel costs. Additionally, some studies reported that more family members were able to attend family therapy or family education sessions since care was moved online.

However, the shift to telemental health also presented challenges, such as difficulties in picking up on non-verbal cues and establishing a strong therapeutic relationship. While the studies came from a variety of higher income countries, similar challenges tended to be experienced.

The study was carried out by researchers in the Mental Health Policy Research Unit at University College London (UCL) and King’s College London (KCL). The research was also supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King’s College Hospital NHS Foundation Trust, and by King’s Improvement Science, which is funded by King’s Health Partners and Guy’s and St Thomas’ Foundation.

Early in 2020, mental health services around the world had to rapidly shift from face-to-face models of care to delivering most treatments remotely due to the pandemic. Although this change was beneficial in many ways, it also resulted in several challenges for staff and patients.

Alan Simpson, Professor of Mental Health Nursing at the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care at King’s College London and Co-Director of the NIHR Mental Health Policy Research Unit

The study found that remote care was deemed less acceptable and presented more challenges for certain groups, including new patients, service users without a private space at home for therapy, service users with a schizophrenia diagnosis, severe anxiety or learning disabilities, children, older adults, and those from lower socio-economic backgrounds.

As telemental health was not commonly used in most services pre-COVID, staff had to rapidly adjust to a new way of working. Service users also identified certain needs and resources to enable them to effectively transition to remote care.

Sonia Johnson, Professor in the UCL Division of Psychiatry, Consultant Psychiatrist in Early Intervention for psychosis and Director of the NIHR Mental Health Policy Research Unit, explains:

'A commonly reported issue was access to technology. Problems such as a stable internet connection and interrupted communication could negatively impact the therapeutic relationship. We also found concerns raised by both clinicians and service users regarding safety, privacy and confidentiality in remote care, especially concerning if someone lived with an abuser.'

The needs of those at risk of digital exclusion are still largely underreported in the literature and should be made a priority for future research. We also found that studies included little information regarding the cost-effectiveness of telemental health implementation.

Fiona Gaughran, Professor of Physical Health and Clinical Therapeutics at King’s College London and Director of Research and Development at South London and Maudsley NHS Foundation Trust

The review also concluded that the majority of service users and clinicians wanted at least some appointments to be face-to-face once restrictions on in-person contact due to the pandemic had loosened.

This review has identified a need to understand the extent and impacts of telemental health implementation, and barriers and facilitators to its effective and acceptable use. More research into what works for who and in what context is required. This is relevant both to future emergency adoptions of telemental health, and to debates on its future use in routine mental health care.

Nick Sevdalis, Professor of Implementation Science and Patient Safety at King’s College London

Karen Machin, member of the NIHR Mental Health Policy Research Unit Lived Experience Working Group said:

'My biggest concern about remote care is that while we focus on the many advantages it might bring for some people and services, the challenges and problems may get minimised or overlooked. Well-intentioned actions, such as addressing inequalities of access, have the potential to undermine a personal choice not to use remote care. My concern is that people then effectively have no choice or might be seen as obstructive if they choose to refuse remote care.'

Dr Monika Badhan, Psychiatrist at Camden and Islington NHS Foundation Trust said:

'The COVID-19 pandemic has resulted in a necessary change in the way we think about service delivery in mental healthcare. My practice has evolved to include both in-person and remote reviews with consideration to safety, accessibility, and patient preference. Challenges in delivering remote care when suitable have included poor internet connectivity and lack of access to devices/data plans on both sides. Sometimes people are too unwell to engage in remote reviews.'

To read the full review, visit: Implementation, adoption and perceptions of telemental health during the COVID-19 pandemic: a systematic review.

In this story

Alan Simpson

Professor of Mental Health Nursing

Fiona Gaughran

Professor of Physical Health and Clinical Therapeutics

Lucy Goulding

King’s Improvement Science Programme Manager