The pros and cons of telemental health care

New research led by the National Institute for Health & Care Research (NIHR) Mental Health Policy Research Unit (MHPRU) at King's College London and University College London (UCL) has shown that certain groups of people benefit from the freedom of choice that telemental health care care provides, but this is not true for all.

The research, published today in the Interactive Journal of Medical Research, investigates which telemental health care approaches work (or do not work), for whom, in which contexts, and through which mechanisms. Telemental health care was found to be effective overall, but researchers highlight that there is no "one size fits all."

Telemental health care (or telemedicine) is mental health care—patient care, administrative activities and health education—delivered via "telecommunications technologies," e.g., video calls, telephone calls or SMS text messages. It has become increasingly widespread, as it can be useful in providing care to service users in remote communities, or during an emergency restricting face-to-face contact, such as the COVID-19 pandemic.

The study found telemental health care can be effective in reducing treatment gaps and barriers, by improving access to mental health care across different service user groups (e.g. adult, child and adolescent, older adults, and ethnic minority groups) and across personal contexts (e.g., difficulty accessing services, caring responsibilities or conditions). However, it is crucial that providers consider that there are a set of key factors which lead to variations in people's responses to telemental health care; for example, variations in access to a private and confidential space, ability to develop therapeutic relationships, individual preferences and circumstances as well as internet connection quality.

King's researcher Dr. Katherine Saunders from NIHR MHPRU, and the joint lead author, said, "We live in an increasingly digital world, and the COVID-19 pandemic accelerated the role of technology in mental health care. Our study found that while certain groups do benefit from the opportunities telemental health care can provide, it is not a one size fits all solution. Receiving telemental health care requires access to a device, an internet connection and an understanding of technology. If real world barriers to telemental health care are ignored in favor of wider implementation, we risk further embedding inequalities into our healthcare system."

Important limitations have been reported that implementing telemental health care could risk the reinforcement of pre-existing inequalities in service provision. Those who benefit less are people without access to internet or phone, those experiencing social and economic disadvantages, cognitive difficulties, auditory or visual impairments, or severe mental health problems (such as psychosis).

Professor Sonia Johnson from UCL, who is Director of NIHR MHPRU and a senior author, adds, "Our research findings emphasize the importance of personal choice, privacy and safety, and therapeutic relationships in telemental health care care. The review also identified particular service users likely to be disadvantaged by telemental health care implementation. For those people, we recommend a need to ensure that face-to-face care of equivalent timeliness remains available"

The authors suggest the findings have implications across the board of clinical practice, service planning, policy and research. If telemental health care is to be widely incorporated into 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.

Professor Alan Simpson from King's, and Co-Director of NIHR MHPRU, concludes, "As well as reviewing a huge amount of research literature, in this study we also involved and consulted with many clinicians and users of mental health services. This included young people, those that worked in or used in-patient and crisis services, and those who had personal lived experience of telemental [health care] throughout the pandemic. This gives this research a relevance that will be of interest to policy makers, service providers and those working in and using our services."

Merle Schlief, joint lead author from NIHR MHPRU at UCL, said, "Working entirely online to conduct this study gave us access to experts and stakeholders who we simply would not have been able to include if we had been working in person, including people living and working internationally, and those who would have been unable to travel. This highlights one of the key strengths of technology."

The authors recommend that guidelines and strategies be co-produced with service users, and caution that frontline staff are needed to optimize telemental health care implementation in real-world settings.