After years of slow and fragmented implementation of telemental health (TMH), the coronavirus disease (COVID-19) pandemic necessitated widespread adoption. With the initial state of public health emergency behind us, we are at a decision point on whether to continue with TMH or return to a largely in-person care model. In this qualitative study, we investigated clinicians' perspectives on advantages and disadvantages of TMH in outpatient mental healthcare as well as considerations for future implementation. We conducted 29 semistructured interviews with outpatient mental health providers. Data were analyzed using rapid qualitative analysis methodology. Advantages included increased utilization of services, improved therapeutic processes, and improved provider wellbeing. Providers, however, also noted that TMH has some disadvantages in terms of therapeutic processes and provider wellbeing, and they reported technology issues as an additional disadvantage. Overall providers reported they can provide high quality care via TMH, but indicated some patient populations and appointment types are a better fit for in-person services. Most providers preferred a hybrid model of care moving forward with reimbursement discrepancies and out-of-state licensure restrictions as barriers. They indicated that, as TMH becomes a mainstay in psychiatric care, training and professional guidelines will be important. Continued implementation of TMH alongside in-person care is likely to offer improved access and enhanced service quality when applied to the right patient populations and appointment types. Effective implementation may require policy and systems level support on equitable reimbursement rates, out-of-state licensure restrictions and professional guidelines for delivering TMH. Impact StatementThis qualitative study evaluated mental health clinicians' attitudes toward telemental health (TMH) after a period of use necessitated by the coronavirus disease (COVID-19) pandemic. Findings indicate that clinicians see substantial clinical advantages to continuing TMH services. Most clinicians, however, emphasized that some services should still be offered in person and infrastructure to support TMH usesuch as professional guidelines and reimbursement equity-will be essential moving forward.
Background While many digital mental health interventions (DMHIs) have been found to be efficacious, patient engagement with DMHIs has increasingly emerged as a concern for implementation in real-world clinical settings. To address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare with other treatments. Objective This scoping review aims to examine the state of reporting on intervention engagement in RCTs of mobile app–based interventions intended to treat symptoms of depression. We sought to identify what engagement metrics are and are not routinely reported as well as what the metrics that are reported reflect about standard engagement levels. Methods We conducted a systematic search of 7 databases to identify studies meeting our eligibility criteria, namely, RCTs that evaluated use of a mobile app–based intervention in adults, for which depressive symptoms were a primary outcome of interest. We then extracted 2 kinds of information from each article: intervention details and indices of DMHI engagement. A 5-element framework of minimum necessary DMHI engagement reporting was derived by our team and guided our data extraction. This framework included (1) recommended app use as communicated to participants at enrollment and, when reported, app adherence criteria; (2) rate of intervention uptake among those assigned to the intervention; (3) level of app use metrics reported, specifically number of uses and time spent using the app; (4) duration of app use metrics (ie, weekly use patterns); and (5) number of intervention completers. Results Database searching yielded 2083 unique records. Of these, 22 studies were eligible for inclusion. Only 64% (14/22) of studies included in this review specified rate of intervention uptake. Level of use metrics was only reported in 59% (13/22) of the studies reviewed. Approximately one-quarter of the studies (5/22, 23%) reported duration of use metrics. Only half (11/22, 50%) of the studies reported the number of participants who completed the app-based components of the intervention as intended or other metrics related to completion. Findings in those studies reporting metrics related to intervention completion indicated that between 14.4% and 93.0% of participants randomized to a DMHI condition completed the intervention as intended or according to a specified adherence criteria. Conclusions Findings suggest that engagement was underreported and widely varied. It was not uncommon to see completion rates at or below 50% (11/22) of those participants randomized to a treatment condition or to simply see completion rates not reported at all. This variability in reporting suggests a failure to establish sufficient reporting standards and limits the conclusions that can be drawn about level of engagement with DMHIs. Based on these findings, the 5-element framework applied in this review may be useful as a minimum necessary standard for DMHI engagement reporting.
BACKGROUND Digital mental health interventions (DMHIs) have been indicated as efficacious in clinical trial settings. However, in the wake of several large implementation studies, patient engagement with these interventions has emerged as a concern. In order to address engagement, we must first understand what standard engagement levels are in the context of randomized controlled trials (RCTs) and how these compare to other treatments. OBJECTIVE This systematic review aimed to synthesize data on intervention engagement in RCTs of mobile-application-based interventions intended to treat symptoms of depression. METHODS We conducted a systematic review of RCTs that evaluated use of a mobile-application-based intervention in adults with depression, for which depressive symptoms were a primary outcome of interest. We then extracted two kinds of information from each article: intervention details and indices of participant DMHI engagement. Key DMHI engagement data extracted included: (a) recommended intervention use as communicated to participants at enrollment; (b) method of app usage monitoring; (c) rate of intervention uptake among those assigned to the intervention; (d) level of app use metrics reported (i.e., number of uses and time spent using the app); (e) duration of app use metrics (i.e., weekly use patterns); (f) and number of intervention completers. RESULTS The systematic search retrieved 3137 results. 22 independent studies were eligible for inclusion. Within included studies, 13 evaluated an app intended to be used as a daily self-management/skill building tool; 5 evaluated an app intended to provide support in the context of clinician-administered care or to facilitate communication with clinicians; and 4 evaluated an app involving a discrete number of lessons/modules typically to be completed on a weekly basis. Only 64% of studies included in this review specified rate of uptake, defined as the number of participants randomized to the intervention condition who used the app at least once. Level-of-use metrics were also only reported in 64% of the studies reviewed (though not directly overlapping those reporting uptake). Approximately a quarter of studies (23%) reported duration-of-use metrics. Only half (50%) of studies reported the number of participants considered to have completed the app-based components of the intervention as intended or other metrics related to completion. CONCLUSIONS A number of basic metrics of intervention engagement were not routinely reported in RCTs included in this review. Such variability makes it impossible to draw conclusions about standard patient engagement levels with DMHIs. Additionally, this variability in reporting suggests a failure to establish sufficient reporting standards. Based on these findings, we suggest a five-element set of reporting guidelines of minimum necessary information when publishing RCTs of DMHIs. These include: (a) intervention instructions and retention criteria; (b) rate of uptake; (c) level of use; (d) duration of use; and (e) number of completers.
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