Effectiveness and impact of networked communication interventions in young people with mental health...

Patient Education and Counseling 85 (2011) e108–e119

E-Health

Effectiveness and impact of networked communication interventions in youngpeople with mental health conditions: A systematic review§

Steven Martin, Paul Sutcliffe *, Frances Griffiths, Jackie Sturt, John Powell, Ann Adams, Jeremy Dale

Health Sciences Research Institute, University of Warwick, Coventry, UK

A R T I C L E I N F O

Article history:

Received 3 August 2010

Received in revised form 28 October 2010

Accepted 21 November 2010

Keywords:

Communication

Technology

Young people

Mental health

A B S T R A C T

Objective: Examine the effectiveness and impacts of the networked communication technologies used by

health care professionals for the treatment of adolescents/young adults with mental health disorders.

Methods: Nine electronic databases were searched. Quantitative and qualitative study designs were

included, technologies were described and a narrative synthesis of all included studies was undertaken.

Results: 20,925 papers were identified from which 12 interventions met the inclusion criteria. Three

categories of networked communication were identified: email and/or web-based electronic diary

(n = 6); videoconference (n = 5); and virtual reality (n = 1). Three studies reported statistically significant

improvements in symptoms post intervention; all involved email communication. Patients were willing

to use networked communication in routine care in nine studies.

Conclusions: Networked communication technologies can increase the opportunity for communication

between patient and health care professionals. Limited improvements in quality of life and continuity of

care for patients were reported. Patients and health care professionals expressed some satisfaction with

technologies. Further research exploring concerns over privacy and security is needed.

Practice implications: Networked communication technologies have the potential to be a useful addition

to mental health services delivery, however the impact and effectiveness of these technologies is

inconclusive.

� 2011 Published by Elsevier Ireland Ltd.

Contents lists available at ScienceDirect

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jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

Networked communication technologies (NCTs) support thedelivery of education and self management interventions inhealthcare. These technologies are suitable for remote two-waycommunication and access to a service (e.g. practitioner, nurse andspecialist). Examples of networked communication include: socialnetworking sites (e.g. Facebook, MySpace); mobile/smart phone;video- and tele-conferencing; Voice over Internet Protocol (VoIP)system (e.g. Skype); forums; email; short messaging service (SMS);and multi-media messaging services (MMS). The systematic reviewevaluated the effectiveness and impact of these technologies oncommunication between adolescents and young adults withdiagnosed mental disorder(s) and their healthcare professionals.The clinical and social impacts, acceptability and satisfaction ofnetworked communication technologies were also considered.

§ Disclaimer: I confirm all patient/personal identifiers have been removed or

disguised so the patient/person(s) described are not identifiable and cannot be

identified through the details of the story.

* Corresponding author at: Health Sciences Research Institute, Warwick Medical

School, University of Warwick, Coventry CV4 7AL, UK. Tel.: +44 0 2476 574505.

E-mail address: [email protected] (P. Sutcliffe).

0738-3991/$ – see front matter � 2011 Published by Elsevier Ireland Ltd.

doi:10.1016/j.pec.2010.11.014

Treating mental health conditions in adolescents and youngadults is a challenge for patients, parents and medical practi-tioners. Mental health disorders affect 12.8% and 9.65% of boys andgirls aged 11–15, respectively [1]. Neurotic disorders affect 13.3%of 16–19 year olds and 15.8% of 20–24 year olds, while obsessivecompulsive disorder (OCD) affects 0.9% of 16–19 year-olds and1.9% of 20–24 year-olds in Great Britain [2]. According to the RoyalCollege of Psychiatrists, anorexia affects approximately one in 150,15 year-old females, and one in 1000, 15 year-old males [3].

NCTs may be useful for health conditions that require closemonitoring, clinical assessment and early intervention to avoidadverse events. Adolescents and young adults are increasinglyusing these forms of technology in their everyday lives and UKstatistics show approximately 70% of 16–24 year-olds report dailyuse (only 4% had never used it) [4].

In previous reviews [5,6] the use of networked communicationswere proposed as pathways of action of several forms self-management interventions. The combination of information withadditional services (behaviour change support, decision support orpeer support) may allow the patient to more efficiently internalisethe interventions. The combination of enhanced self-efficacy withmotivation and knowledge may enable adolescents and youngadults to change their health behaviours, which may in turn,change clinical outcome.

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S. Martin et al. / Patient Education and Counseling 85 (2011) e108–e119 e109

There is a growing interest in whether NCTs can be used bypatients with mental health disorders to communicate with theirhealthcare professionals [5,6]. The challenge remains to assesswhether the introduction of networked communication devicesinto everyday mental health care can complement or enhancetraditional forms of communication.

We evaluated the effectiveness, patient level impact, patient andclinician satisfaction of NCTs associated with meeting healthcareneeds of adolescents and young adults with diagnosed mentalhealth disorders. We addressed the following research questions:

1) What is the impact of networked communication technolo-gies on that patients and outcomes for mental health disorders?

2) What are the essential components of an effective networkedcommunication technology?

3) What are the benefits of networked communication thatface-to-face consultations cannot provide?

4) How satisfied are patients and healthcare professionals withusing networked communication technologies?

2. Method

2.1. Search strategy

An iterative procedure was used to develop the searchstrategy, with input from clinician advisors (psychiatrist,general practitioner, mental health nurse) and an informationspecialist.

A comprehensive search of nine electronic bibliographicdatabases (MEDLINE, EMBASE, ASSIA, Sociological abstract, SocialStudies abstract, PsycINFO, Cochrane Database of SystematicReviews, Dissertation Abstracts, Current Controlled Trials) as wellas hand searches of key journals was undertaken and completed inMay 2009 following the general principles recommended inPRISMA guidance [7].

2.2. Search terms

The inclusion of keywords for ‘‘mental health’’ resulted inrelevant papers being omitted; therefore the final search strategywas kept broad (i.e. no keywords for specific mental healthconditions) to capture all available literature. A combination offree-text and thesaurus terms were used. We combined ‘‘technol-ogy’’; ‘‘communication’’ and ‘‘population’’ search terms (see Table1 for details).

2.3. Inclusion and exclusion criteria

2.3.1. Types of studies

All study designs (qualitative, quantitative randomized experi-mental, quantitative non-randomized controlled, quantitativeobservation, and mixed methods) [8] were included if published

Table 1Search strategy.

‘Technology’ search terms:

telemedicine; remote consultation; telecare; ehealth; e-health; e-learning; elearning

computer communication network$; communication aid; interdisciplinary communi

short messaging service; virtual clinic$; online clinic$; on-line clinic$; internet; worl

technology; electronic communication$; digital divide; e-mail; email; telehealth

‘‘Communication’’ search terms:

health behaviour; health education; patient education health care delivery; adolesce

to health; child health care; self efficacy; social support; health promotion; self care

‘‘Population’’ search terms:

child$; teen$; paediatr$; pediatr$; boy$; girl$; youth$; schoolchild$; school child$; k

high school$; peer group$; highschool$; schoolage; school age$; young adult$; youn

further education; undergraduate$; college student$; university student$; universitie

An iterative procedure was used to develop the search strategy, with input from clinic

information specialist.

in the English language before May 2009. Commentaries, letters,editorials, previous reviews and conference proceedings wereexcluded.

2.3.2. Participants

Adolescents and young adults (study mean age 12–25 years)diagnosed with any mental health disorder defined by theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [9]. Diagnosis had been made by a qualified healthcareprofessional. Studies that contained at least 80% of participantswith clinically diagnosed mental health disorders were included.We excluded studies whose primary objective was focussed onsubstance misuse and learning difficulties, although these condi-tions may be present in our sample populations as co-morbidities.

2.3.3. Intervention

Studies with a primary aim of treatment of a mental healthcondition were included. Studies that dealt with prevention wereexcluded. All forms of technologies which involve at least two-waycommunication between young people with mental healthconditions and healthcare professional were included. Interfaceswhich only involve parent and child, only clinicians or only peer-to-peer communication were excluded. Studies evaluating Com-puterised Cognitive Behavioural Therapy (CCBT) use were exclud-ed from this review [10].

2.3.4. Outcome

A broad consideration of all outcome measures was adopted.Outcomes reported in the included papers were clinical outcomes(e.g. symptom alleviation), patient level impacts (e.g. improvedhealth behaviours), patient and health care professional satisfac-tion and costs.

2.4. Data extraction strategy

All titles and abstracts were screened for inclusion by either SMor PS, a random selection of 20% of papers were screened by bothreviewers. All papers identified at the abstract sift were screenedby both reviewers and data extracted by SM. A third reviewer (JS)resolved any disagreements about inclusion. Seventeen studyauthors were contacted to clarify missing data; complete answerswere received from seven, partial responses from five, and noresponse from five authors. Where insufficient information wasprovided, or an author did not respond, the paper was excluded.

2.5. Quality assessment and evidence synthesis

The broad range of NCTs and outcomes prevented meta-analysis from being undertaken. A narrative synthesis and qualityassessment using Mixed Methods Appraisal Tool (MMAT) [8] ispresented (Table 2).

; reminder system$; online system; interactive health communication;

cation; mobile phone; social network; facebook; myspace; virtual world;

d wide web; interactive health; computer assisted therapy; information

nt health; health care system; health knowledge, attitudes, practices/; attitude

; attitude to computers; physician-patient relations

id$; adoles$; minors$; under ag$; juvenile$; pubescen$; secondary school$;

g person$; young people; student$; sixth form$; higher education;

s/; college$

ian advisors (psychiatrist, general practitioner, mental health nurse) and an

S. Martin et al. / Patient Education and Counseling 85 (2011) e108–e119e110

3. Results

3.1. Search results

The search revealed 20,925 papers, 15,488 did not meet ourinclusion criteria at title sift and there were 2205 duplicates. 3232abstracts were screened, 342 papers were read in full, with 12interventions (in 13 papers) included for review (Fig. 1). Twopapers [12,13] report the same intervention, with unclear reporteddifferences between study samples.

3.2. Description of studies

a) Sample characteristicsTwelve interventions involving 180 young people

(Males = 117, Females = 63) with mental health conditions(4 = mixed sample, 1 = Bulemia Nervosa, 3 = Anorexia Nervosa,1 = Self Harming, 1 = Post Traumatic Stress Disorder, 1 = Atten-tion-Deficit Hyperactivity Disorder (ADHD), 1 = OCD. Twopapers [13,14] only measured ‘satisfaction’. Study sizes rangedfrom 1 to 136 (Mean = 34.6, SD = 50.6) however 11 studiescontributed only 44 patients in total. Four studies involved onlyone patient [15–18] and three studies included three patients[19–21]. In addition, 18 patients withdrew and 47 patientsdropped out of these studies [11,12,22]. The mean age ofpatients across the 13 studies ranged from 12 to 22 years(Mean = 17.5, SD = 3.742).

b) Study characteristicsStudies took place in the UK (n = 2), USA (n = 6), Netherlands

(n = 2), Canada (n = 1), Italy (n = 1), and Norway (n = 1). Threecategories of NCTs were identified from the 12 interventions: emailand/or web-based electronic diary (n = 6), videoconference (n = 5),and those that adopted virtual reality (n = 1). The oldest includedstudy was published in 1999 [18] the most recent published in2008 [16,22].

Table 2MMAT quality assessment.

Lohr

2007

[20]

Miller

2006

[16]

Roy

2008

[17]

Yager

2001

[21]

Yager

2003

[22]

Lange

2002

[13]

La

20

[1

Type 1 1 1 1 1 2 2

Question

1.1 Y N Y Y N – –

1.2 Y N Na N N – –

1.3 Na N Na Na N – –

1.4 Na Na N Na N – –

1.5 Na N N N Na – –

1.6 Na N Y Y N – –

2.1 – – – – – Y Na

2.2 – – – – – Na N

2.3 – – – – – Y Y

3.1 – – – – – – –

3.2 – – – – – – –

3.3 – – – – – – –

3.4 – – – – – – –

4.1 – – – – – – –

4.2 – – – – – – –

4.3 – – – – – – –

Key: Type: 1. Qualitative; 2. Quantitative randomised; 3. Quantitative nonrandomized;

Y = Yes; N = No; NA = not appropriate/applicable.

Questions: 1.1. Do the researchers state a qualitative objective or question?; 1.2. Is there

there a description of the context of the study and how findings relate to the context?; 1.

Are the qualitative data collection and analysis processes described?; 1.6. Do the researc

and/or an appropriate sequence generation?; 2.2. Is there clear description of the allocatio

and low withdrawal/drop-out (below 20%)?; 3.1. Selection (before data collection): Are p

confounders?; 3.2. Comparability (addressed by data analysis): Are the participants in t

(control for) the difference?; 3.3. Exposure: Do researchers provide the evidence of an ab

acceptable response rate (60% or above)?; 4.1. Is the sampling and sample justified?; 4.2.

standard)?; 4.3. Is there (i) a control for confounding variables when applicable, and (

c) Study qualityFrom the MMAT [8] criteria the current review included: five

qualitative studies [15,16,19–21]; three randomised experimentalstudies [11,12,22]; and five quantitative observational studies[13,14,17,18,23]; see Table 2.

4. Networked Communication Technology Interventions

The following section provides a description of all studyinterventions.

4.1. Email and/or Web-based electronic diary

Seven identified interventions used e-mail, with or withoutweb-based discussion [11,12,16,19–22] to communicate betweenthe patient and health care practitioner. Four studies used email aspart of regular therapy; two used the online written evidencesubmitted by the patients (email correspondence, electronic diary)to provide education and self-management feedback [11,12].While two utilised email correspondence as an adjunct to face-to-face consultations [16,19]. Email was suitable if a relationshipbetween health care practitioner and patient was established priorto treatment, but some disorders were not suitable, such as severedepression and dementia [19].

Two interventions used email for communication betweenpatient and clinician for the treatment of eating disorders [20–22].No standardised protocol was used for conducting these sessions.Healthcare providers were attempting to elicit history, identifynegative thoughts and feelings, and encouraging health eating andpositive behaviours from the email and electronic diaries. Trainingrequirements were not reported [11,12,16,19–22]. Healthcareprofessionals had quick and more frequent contact with patients,more expressive forms of messaging and an advanced transparen-cy of interactions [19–21].

nge

03

2]

Robinson

2008

[23]

Elford

2001

[15]

Himle

2006

[18]

Kopel

2007

[14]

Myers

2006

[24]

Riva

1999

[19]

2 4 4 4 4 4

– – – – – –

– – – – – –

– – – – – –

– – – – – –

– – – – – –

– – – – – –

Y – – – – –

N – – – – –

N – – – – –

– – – – – –

– – – – – –

– – – – – –

– – – – – –

– Y N Y Y N

– Na Y Y Y Y

– Y Na Y Na Na

4. Quantitative observational.

a description of an appropriate qualitative approach or design or method?; 1.3. Is

4. Is there a description of the participants and a justification for the sampling?; 1.5.

hers describe their reflexivity?; 2.1. Is there clear description of the randomization

n concealment and/or blinding?; 2.3. Is there complete outcome data (80% or above)

articipants recruited to the intervention and control groups in a way that minimized

he intervention and control group comparable or do researchers take into account

sence of contamination?; 3.4. Is there complete outcome data (80% or above) or an

Do the researchers describe and justify measurements (origin and/or validity and/or

ii) an acceptable response rate (60% or above)?.

The reasons for exclusion, at full paper, were: par�cipants too old (n = 109); par�cipants too

young ( n = 14) non -return of informa�on query (n = 4) or par�al return of informa�on (n =

4) (at least 2 a�empts were made to make contact with authors); Missing either pa�ents or

clinician involvement, n = 11); reviews (n = 20); non -communica�on (n = 17); no n-diagnos ed

par�cipants (n = 38); topic non -mental health (n = 13); non -primary research (n = 28); non -

treatment interven�ons (i.e. preven�on, n = 43); CCBT only (n = 1); substance use (n = 7) and

non-Engli sh language (n = 16); we also iden�fied (n = 2) duplicates.

Potentially relevant

studies identified and

screened for retrieval

N = 20,925

Total abstracts

screened

N = 3232

Studies included in

this review = 12

Duplicates

N = 2205

Studies rejected at title

sift

N = 15,488

Studies rejected at

abstract sift

N = 2890

Total full papers

screened from search

N = 342

Studies rejected at full paper

sift criteria

N = 330

Fig. 1. Summary of study selection and exclusion. The reasons for exclusion, at full paper, were: participants too old (n = 109); participants too young (n = 14) non-return of

information query (n = 4) or partial return of information (n = 4) (at least 2 attempts were made to make contact with authors); Missing either patients or clinician

involvement, n = 11); reviews (n = 20); non-communication (n = 17); non-diagnosed participants (n = 38); topic non-mental health (n = 13); non-primary research (n = 28);

nontreatment interventions (i.e. prevention, n = 43); CCBT only (n = 1); substance use (n = 7) and non-English language (n = 16); we also identified (n = 2) duplicates.


4.2. Video-conferencing or tele-conferencing

Five studies used video-conference or tele-conference (voiceonly interface) interventions; three studies [13–15,17,23] exploredthe potential for videoconferencing to be used in conductingtelepsychiatry and treatments for OCD and ADHD. In two papersthe technologies were used with patients who had difficultyaccessing (e.g. due to geographical location) their regularhealthcare providers [14,23]. In one study the care model wasconsultative, did not engage with crisis care, and communicationwas between the hospital-based practitioners a youth correctionalfacility [23]. In the other study the intervention uses interactive

voice response systems to direct patients through the educationalprogram [17]. Treatment was alongside face-to-face clinician-guided therapy. Several training sessions were required for oneintervention [23] otherwise training were not reported [13–15,17].Healthcare professionals had more frequent contact with patients,however, clinicians focussed more on verbal than visual commu-nication during the consultation [17].

4.3. Virtual reality

One paper adopted a virtual reality communication device fortreatment of anorexia nervosa [18] and the collection of clinical


data. The intervention assessed stimuli that could elicit abnormaleating and dentified that virtual reality can be used to improvemotivation, body satisfaction and awareness. Training require-ments were not reported.

5. Main outcomes

5.1. Clinical outcomes

Seven papers (six interventions) measured clinical outcomes.Six [11,12,17,18,22,23] showed improvement, while three studies[11,12,22] showed statistically significant improvements (p < .05).

One intervention [11,12] found participants in the experimen-tal condition (n = 13) improved significantly (p < .05) compared towaiting-list controls (n = 12). A total of 80% of treated participantsshowed clinically significant improvement after treatment forconditions ranging from anxiety, depression, somatisation, sleep-ing problems and profile of mood states. One study recruited asample of youths fulfilling the diagnostic criteria for BulemiaNervosa [22]. At follow-up (13/97) of the intervention group hadlost their diagnosis (n = 8 email based treatment [eBT] and n = 5self-directed writing [SDW]). There was no significant change inthe either Beck Depression Inventory (BDI) or Bulemia Investiga-tory Test (BITE) scores over time. There was no significant effect ofeither SDW or eBT compared to waiting list controls and nosignificant difference between eBT and SDW. Change in desiredBMI correlated positively with two categories: positive emotion(r = 0.44, p < 0.01) and positive feelings (r = 0.42, p � 0.01). Noother outcome measure correlated significantly with linguisticinquiries and word count (LIWC) categories. In the four yearsfollowing this study 6.2% were referred to specialist services,several participants were advised to see doctor due to vomiting,one participant’s depression score increased substantially aftereBT, and one participant was hospitalised following overdose andwithdrew.

5.2. Patient level impacts

Six papers measured patient level impacts and reportedbeneficial therapeutic effects from written communication as partof synthesis between both the electronic and face-to-face therapy[11,17–22]. Seven papers suggest that networked communicationinterventions increased the frequency of contact between patientand clinician [15,16,18–21,23], however only one scored well onthe MMAT quality assessment [23]. One paper compared theintervention outcomes and written word analysis [22] andreported positive correlations between the written words andBulemia investigatory test (Table 3).

No patients reported significant negative effects from email orfrom increased frequency and duration of contact [20,21]. Yagerfound email reports required patients to be constantly aware oftheir behaviours and of ‘being in therapy’. Benefits include:providing details through email frees time in face-to-face session;and increased frequency and amount of direct contact betweenpatients and clinicians. Some patients devoted considerable timecomposing emails to clinicians allowing more expressions inconsultations.

Two papers looked at the process of written communication[16,19]. Email enabled patient’s time to process information, and toselect words they use carefully, resulting in a different but effectivemodel of care [16]. This produced disinhibitory effects withdisclosure of health information and an increased perceivedcontrol and articulation of emotions on behalf of the patients.Written communication as part of therapy, allowed ‘storyrecounting’ [19]. Both studies [16,19] reported concerns overpossible unwanted disclosures to third parties due to a lack of

computer privacy, and discussed changes in the therapeuticrelationship (reduced formality and increased transparency), asthe therapy was not clearly framed, bounded and based on localityand time.

Motivation was seen to be an important contributor [17,18,22].The patient presented a high degree of motivation to change and areduction in avoidance behaviours and grooming habits. Compari-son scores also revealed a significant reduction in body dissatis-faction and patient reports improvement in peer-to-peercommunication. Robinson [22] reported the treatment systemsused in their study improved health care engagement as 83.7% ofthose involved in the study had never been treated before and83.3% agreed they would accept treatment with online or face-to-face therapy. The system eBT was associated with gaining control.

5.3. Clinician satisfaction and costs

Two studies [13,14] reported levels of clinician satisfaction aftertreatment for range of conditions. Only one study reported costs[14] finding that the delivery of telemedicine is cheaper than travelcosts, for those in remote locations. Kopel [13] evaluated thetechnical and general satisfaction of urban (CHW) and ruralclinician. In the analysis concerning the CHW clinicians 47% ratedease of use of equipment as ‘fair’ with 49% rating it as ‘good’ or‘excellent’. Anxiety was measured and 99% did not feel ‘anxious’, or‘slightly anxious’ because of equipment. Sound and video qualitywas rated sound quality as ‘poor’ (74% and 86% respectively).Overall quality was seen as ‘poor’ or ‘fair’ (82%). However 94% ratedsatisfaction with system compared to face-to-face as ‘adequate’ or‘almost as good’. Of the rural clinician’s involved in the study 100%would recommend the service to someone else. Similarly, Elford[14] found psychiatrists were either ‘very satisfied’ or ‘satisfied’with the telepsychiatry intervention. Miller [15] found thatvideophone enabled enhanced interaction between health careprofessionals involved in a mutual patient.

6. Discussion and conclusion

6.1. Discussion

The observed heterogeneity of interventions and patient groupsis a limitation in drawing robust conclusions. The majority ofpapers did not measure or report the clinical and behaviouraloutcomes. The reported technologies appear to offer patients alimited improvement in quality of life, continuity of care andaccess, and improvements in patient–clinician communication;however these gains were matched with concerns over privacy,security and limited evidence to suggest a range acceptabilitylevels and financial implications which makes evaluation of theircost effectiveness difficult.

The evidence dealing with email and web-based discussionappears to be more reliable and rigorous. Patients, health careproviders and others involved (such as parents and carers)expressed satisfaction with these technologies. However no papersreported outcomes relating to: transparency of care; deliveryguidelines; or equity in access to health care.

6.2. Conclusion

The current systematic review is the first to evaluate the impactof networked communication between adolescent and youngadults with mental health disorders and health care professionals.The following section will synthesise the results to address the fourkey research questions.

a) What is the impact of networked communication technolo-gies on mental health outcomes?

Table 3Summary of design, study and patient characteristics.

Study Design and patient characteristic Intervention and outcome measures

Elford (2001) [15]

Newfoundland

Design:

Quantitative observational

Inclusion criteria:

Children aged 4–16 years and had

been referred to see a child and

adolescent psychiatrist at the

Janeway Child Health Centre

and lived in the Western

Health Region

Number of participants:

11 children and 19

adolescents, 30 parents,

30 psychiatrists

Interventions:

Telepsychiatry

Duration of follow up:

NA

Power calculations:None reported

Exclusion criteria:Not reported

Numbers randomised:NA

Concurrent treatment:Unknown

Outcome measures:Primary outcomes:

Patient, parent and psychiatrist satisfaction

Secondary outcomes:

Patient travel costs and telepsychiatry costsMean age in years (SD):Child and adolescent

group = 13 (3)

Treatment duration:

One session

Results:

Psychiatrists were either ‘very satisfied’

or ‘satisfied’ with telepsychiatry. 28 of the

30 parents rated their satisfaction level as 5

(1 = lowest, 5 = highest), and two rated it 4.

All parents ‘liked’ the telepsychiatry

assessment and would use the system again.

29 parents preferred to use the telepsychiatry

system to travelling to see a child psychiatrist.

All 11 children ‘liked’ the telepsychiatry system.

5 out of 9 children liked the ‘television doctor’

better than the ‘real’ doctor; 4 had no preference.

Most of 19 adolescents were very satisfied or

satisfied with the system. 17 of the 19 adolescents

(89%) said they would prefer to see the psychiatrist

on the videoconferencing system to travelling for

an assessment, and the same number said that

they would use telepsychiatry again. Estimated

total travel cost for the 30 patients was $12,849,

an average of $428 per patient. The total cost of

the telepsychiatry service for the three-month

pilot was $12,575, or $419 per patient

Sex (female):

Child and adolescent

group = 21 males and

9 females

Himle (2006)

[18] USA

Design:


Condition:

OCD

Number of participants:1

Interventions:

Manualised CBT video-conference

Exposure and Response Prevention

therapy (ERP)


Not reported

Setting:

Not reported

Age, years (mean, SD):

19Concurrent treatment:

Not reported

Outcome measures:

Yale-Brown Obsessive Compulsive Inventory

(Goodman et al., 1989); Clinical Improvement

scale (NIMH, 1984); Work and Social

Adjustment Scale (Marks, 1986); Hamilton

Depression Rating Scale (Hamilton, 1960);

Working Alliance Inventory (Horvath &

Greenberg, 1989)

Sex (male/female):

Female

Treatment duration:

12 weeks

Results:

CBT for OCD can be effectly delivered via

videoconferencing ‘‘Patient experienced

substantial improvements’’. 100% treatment

retention suggests that videoconferencing

CBT has utility in the treatment of OCD.

VC associated with high ratings of treatment

satisfaction and therapeutic alliance. Patients

displayed a full range of emotive responses

Kopel (2007)

[14] Australia

Design:


Condition:

Non specific


136

Interventions:

Telepsychiatry

Service SatisfactionQuestionnaire

Patient Satisfaction Questionnaire


Not reported

Setting:

Telepsychiatry service


12.3 (3.9 SD)Concurrent treatment:

Regular treatment

Outcome measures:

Service Satisfaction

Patient Satisfaction

S. M

artin

et a

l. /

Pa

tient

Ed

uca

tion

an

d C

ou

nselin

g 8

5 (2

01

1)

e10

8–

e11

9

e11

3

Table 3 (Continued )


Sex (male/female):

Not reported

Treatment duration:

Not reported

Results:

Technology SatisfactionPatient Satisfaction58% responded

97% did not feel anxious, or slightly anxious

because of equipment

97% did not fee l the equipment interfered

with the session not at all or slightly

91% rated sound quality as good or excellent

95% rated video quality as good or excellent

96% rated the overall quality as good or excellent

91% rated satisfaction with system compared

to face to face as adequate or almost as good.

CHW clinician Satisfaction47% rated ease of use of equptment as fair

49% rated it as good or excellent



74% rated sound quality as poor

86% rated visual quality as poor

82% overall quality as poor or fair

94% rated satisfaction with system compared

to face to face as adequate or almost as good.

Rural clinician Satisfaction

74% responded

86% rated ease of use of equipment as good

or excellent



98% did not feel self-conscious or embarrassed

95% did not fee l the equipment interfered with

the session not at all or slightly

86% rated sound quality as good or excellent

18% rated sound quality as fair

87% overall quality as poor or fair

91% rated satisfaction with system compared to

face to face as adequate or almost as good

Lange

(2001, 2003)

[12,13]

Amsterdam

Design:Quantitative Randomised

2 (condition)�3 (time:

pre- postfollowup) design

Inclusion criteria:

Had experienced a traumatic

even at least 3 months ago


25

Interventions:

5 weeks, 10 writing sessions, two

45-minute sessions a week

First phase: self-confrontation. At the

start of treatment the participants

received on-screen psycho-education

about the rationale

of self-confrontation (exposure)

Second phase: cognitive reappraisal.

Participants received psycho-education

about the principles of cognitive

reappraisal

Third phase: sharing and farewell ritual.

Participants received psycho-education

about the positive effects of sharing


6 weeks after treatment (completed by 8

participants)

Power calculations:

Non reported

Exclusion criteria:

If participants had other

psychological conditions

other than posttraumatic

stress or pathological grief

Numbers randomised:

INTERVENTION: 13

CONTROL: 12

Concurrent treatment:

Not reported

Outcome measures:

Primary outcomes

impact of events scale

Secondary outcomes

Anxiety; Depression; Somatization; Sleeping

problems; Profile of mood states


22 years (SD 4:9; range

18–37 years)

Treatment duration:

5 weeks

Results:

Participants in experimental condition (n = 13)

improved significantly compared to

waiting-list controls (n = 12), on trauma-related

symptoms and general psychopathology.

Effect sizes were large. 80% of treated

participants showed clinically significant

improvement after treatment

Sex (male/female):

9 males and 16 females

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Lohr (2007)

[20] Norway

Design:

Qualitative

Condition:

CASE 1: ‘‘range of mental

problems’’

CASE 2: Not reported



3

Interventions:

CASE 1: Email content of face-to-face

sessions and emailing concerns to

therapist.

CASE 2: use of email to request

appointments; discuss therapy; send

pictures of emotional importance.

CASE 3: therapist emailed patient with

problematic issue in preparation

for face-to-face sessions.


Not reported

Setting:




Age, years (mean, SD):21, 25, 25 identification to

case not given by author


CASE 1: ‘‘Weekly face-to-face

therapeutic sessions’’

CASE 2: Face-to-face CBT sessions

CASE 3: Psychoeducation with

therapist; face-to-face CBT sessions

Outcome measures:

Not reported

Sex (male/female):

CASE 1: Female

CASE 2: Male

CASE 3: Male

Treatment duration:




Results:

There are benefits of written communication

as part of therapy, if emails are structured

to allow ‘story recounting’.

There is an added ease with electronic

writing over paper-based due to the ease

in which analysis can be conducted of more

complex relapses. There are implications for

therapist-patient relationship, such as reduced

formality and increased transparency, as the

therapy is not clearly framed, bounded and

based on locality and time.

Miller (2006)

[16] USA

Design:

Qualitative

Condition:

ADHD


1

Interventions:

Multi-disciplinary consultation

using set-top videophone.


Not reported

Setting:

Rural outpatient

Age, years (mean, SD):12 Concurrent treatment:

Patient seen by clinical psychiatrist;

special educator; speech language

pathologist and school psychologist.

Outcome measures:

Not reported

Sex (male/female):

Non reported

Treatment duration:

Not reported

Results:

Videophone enabled enhanced interaction

between school personnel, medical and

health related professionals. Issues concerning

quality of audio and visual information

Myers (2006)

[24] USA

Design:


Inclusion criteria:

Youths in minimum security

juvenile correctional facility


115 youths

Interventions:

Telepsychiatry


Not reported

Setting:Minimum correctional facility

Numbers randomised:

NA


Pharmacotherapy

Outcome measures:

Primary outcomes

Utilisation, diagnoses and prescribed medications

were examine according to gender and age

Secondary outcomes

Satisfaction ratings

Power calculation: Nones Age, years (mean, CI):

Means were not reported:

33 youths aged 13 to

15 years; 82 youths

aged 16 to 19 years

Treatment duration:

A total of 115 youths were treated

with 279 telepsychiatry visits

(mean 2.4 visits per patient;

range 1 to 9)Sex (male/female):

87 males; 28 females

Results:

A total of 115 youths were treated over 279 visits, 2.4

per patient. Males outnumbered females (76% v 24%).

Diagnosis:

Comorbidity was common with average 2.4

disorders per youth

SUD was most common diagnosis (64%), followed by

ADHD (53%) that was less common in older girls (29%).

SUDs and ADHD frequently co-occurred across groups.

Depressive disorders (44%). Six youth developed

Adjustment Disorders secondary to their incarceration.

Medication:

Most common prescribed were antidepressants (42%),

stimulants and atomoxetine (36%). Males were more likely

to be prescribed ADHD medicartions. 20% did not receive

medication. Overall satisfaction with telepsychiatry visit

was high (4.16) (0-low, 5-high). Preference for face to

face was (3.07). Summary score of 3.97 for youths’

satisfaction with telepsychiatry.

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Table 3 (Continued )


Riva (1999)

[19] Italy

Design:

Qualitative

Condition:

Anorexia Nervosa


1

Interventions:

Experiential Cognitive Therapy,

assisted by clinical psychologist

Virtual Environment for Body Image

Modification (VEBIM 2)


Not reported

Setting:

In-patient eating

disorder program

Age, years (mean, SD):22


Not reported

Outcome measures:

MMPI 2; Multiphasic personality scale; Eating disorder

scale; Body satisfaction scale; Body image avoidance

questionnaire; Figure rating scale; Contour drawing

rating scale; Symptoms of anxiety related to food exposure

Sex (male/female):

Female

Treatment duration:

Approx. 8 weeks

Results:

Treatment resulted in increased bodily awareness.

Comparison scores reveal a significant reduction in

body dissatisfaction.

Reduction in avoidance behaviours and grooming habits.

Patient presented a high degree of motivation to change

Robinson (2007)

[23] UK

Design:Quantitative randomised

Inclusion criteria:DSM-IV diagnosis of BN (purging

or non-purging), BED or eating

disorder not otherwise specified

Participants were required to have

an email address from the college

studied

Competent in written English

Number of participants:154

Interventions:eBT

Participants were assigned an email

therapist who was a member of the

Specialist Eating Disorders Team. eBT

was provided by 11 therapists,

including nurses, psychologists,

psychiatrists, a family therapist

and one nurse manager

SDW

This intervention was designed to

examine the therapeutic effects of

writing with minimal therapist

intervention

Waiting list control

These participants were placed on

a waiting list. After 3 months they

were reassessed and offered either

eBT or SDW by random allocation

Duration of follow up:3 months

Setting:

University of London

Exclusion criteria:

Body mass index below 17.5 kg/m2,

Regular drug users within the last

3 months,

Engaged in deliberate self harm in

the same period

Pregnant

In specialist treatment for an

eating disorder.

Not currently students or staff

members at the college under

study.

Numbers randomised:

INTERVENTION: 36

CONTROL: 34

T3: 27


Not reported

Outcome measures:

Primary outcomes

Diagnosis of eating disorder on the questionnaire

for eating disorders

Secondary outcomes

Beck Depression Inventory (BDI) (Beck, Ward, &

Mendelson, 1961) and Bulimia Investigatory Test

Edinburgh (BITE) (Henderson & Freeman, 1987);

Desired weight; Word count; Risk management

Power calculations:

Data from a pilot study of

23 participants

(Robinson & Serfaty, 2001)

indicated that 12 out of 16

participants improved

with eBT (i.e. 75%)

Assuming a 5% spontaneous

remission rate, at 80% and 90%

power at the 5% significance level,

22–30 participants would be

required in each group in order

to detect a significant difference

between an intervention and a

control group. As the present

study used three groups, the

total predicted study population

was 66–90

Age, years (mean, CI):

INTERVENTION: 24.5

(23–25.9)

CONTROL: 32.4

(29.7–35.1)Results:

At outset 100% fulfilled diagnostic criteria for an eating

disorder. At follow-up 13 of the intervention group has

lost their diagnosis (8 eBT and 5 SDW). There was no

significant change in the either BDI or BITE scores

over time. There was no significant effect of either

SDW or eBT compared to WLC and no significant difference

between eBT and SDW. Change in desired BMI correlated

positively with two categories: positive emotion (r = 0.44,

p<0.01) and positive feelings (r = 0.42, p�0.01). No other

outcome measure correlated sig. with LIWC categories.

53.5% who had received either eBT or SDW and who

replied to the question indicated they would be filling to

have face-to-face treatment.

53.5% indicated they would accept online therapy

83.7% indicated they would have other therapies

21% would accept both

83.7% had never been treated before.

83.3% agreed they would accept with online or face-to-face

therapy

eBT was associated with gaining control. 60% of comments

were positive

50% of SDW participants made positive comments

Sex (male/female):

INTERVENTION: 4/32

CONTROL: 34

T3: 27

Treatment duration:

3 months

Risk management:

Several participant were advised to see doctor

due to vomiting. One participants depression score

increased substantially after eBT. One participant was

hospitalised following overdose and withdrew.

This participant was scored ‘moderate’ depressed

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Roy (2008)

[17]

Country not

identified

Design:

Qualitative

Condition:

Depressed mood

Self-harming


1

Interventions:

CBT Via email

Email patient once a week, spending

an hour to develop email response

based on previous correspondence.

Diary

Patient asked to keep diary when

mood was low, anxious or

particularly good. Patient to rate

feeling on scale, where 10 is

most intense.


Not reportedSetting:

Secure unit

Age, years (mean, SD):17


Not reported

Outcome measures:

Not reported

Sex (male/female):

Female

Treatment duration:

Not reported

Results:

Email produced disinhibitory effects with disclosure of

health information. Increased perceived control and

articulation of emotions. Concern over lack of security

and confidentiality

Yager (2001)

[21]

USA

Design:

Qualitative

Condition:

CASE 1: Case has eating disorder

CASE 2: Case has eating disorder

CASE 3: Anorexia Nervosa


3

Interventions:

CASE 1: Almost Daily emails

regarding condition

CASE 2: Weekly emails

concerning activities

CASE 3: ‘‘regular email’’




CASE 3: Not reportedSetting:CASE 1: Outpatient

CASE 2: Outpatient


Age, years:CASE 1: 17

CASE 2: 18

CASE 3: 22Concurrent treatment:CASE 1: Paroxetine (?);

inpatient therapy; family

visits; bibliotherapy; elimination

of active exerceise; calorie-meal

plan. Developing bone densitometry.

CASE 2: patient also seen by student

health physician and psychotherapist


Outcome measures:CASE 1: Weight

CASE 2: Weight

CASE 3: Not reportedSex (male/female):

CASE 1: Female

CASE 2: Female

CASE 3: Female

Treatment duration:

CASE 1: 28 Weeks

CASE 2: circa 19 weeks


Results:

No patients reported significant negative effects from email.

Email increases frequency and time of contact between

patients, clinicians and therapeutic processes. There is a

positive emotional value due to patients engaging in

communication when needed/inspired. Quasi-daily

email reports require patients to be constantly aware of

their behaviours and of being in therapy.

Providing details through email frees time in

face-to-face sessions

Yager (2003)

[22]

USA

Design:

Qualitative

Condition:

CASE 1

Anorexia nervosa

Bipolar I disorder OCD

CASE 2

Anorexia nervosa

CASE 3

Bipolar disorder

Binge/purge anorexia nervosa


3

Interventions:

Email CBT


Not reported

Setting:

Out-patients (?)

Age, years (mean, SD):CASE 1: 21

CASE 2: 16

CASE 3: 13


CASE 1: Lamotrigine; Citalpram

CASE 2: weekly visits to

psychotherapist

CASE 3: Meets with psychiatrist and

therapist

Outcome measures:

Not reported

Sex (male/female):

CASE 1: Female

CASE 2: Female

CASE 3: Female

Treatment duration:

Not reported

Results:

Email increases frequency and amount of direct contact

between patients and clinicians. Patients

devote considerable time composing emails to clinicians

Some patients described feeling as having ‘‘virtually

constant access to their clinicians’’. Email allows

patients to more easily express themselves. Electronic

submission of calorie counts or symptom logs frees

up time in face-to-face sessions. Concern over

unwanted disclosures to third parties resulting from

lack of computer privacy

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Seven of the included studies reported improvements in youngadults’ mental health symptoms [12,16–21]. It was recognised thatthese changes correlated with the patient’s and clinician’smotivation to use the technologies [6]. There was a lack of highquality qualitative evidence, while response rates in experimentaland observation quantitative studies are weak (Table 2). Theimpact of NCTs on mental health is inconclusive.

b) What are the essential components of an effective networkedcommunication technology?

The provision of multi-modal communication (integration ofverbal, written and other non-verbal methods) between practi-tioner and patient seems to be important for recovery or reductionin symptoms in therapeutic relationships observed [12,16–21]. Byengaging more time in communication with patients, clinicianswere able to discuss the issues surrounding the conditions andpatients were better able to self-manage. Studies without writtencommunication elements also reported troubles with poor soundquality and/or fears over visual quality [13,14,23]. Whatever themode of intervention delivery it is important to note that there areidentified concerns over unwanted use of these technologies;principally regarding confidentiality resulting from lack ofcomputer privacy/security.

The findings indicating successful interventions incorporatewritten communication which seems to support the argumentsproposed by Pennebaker and Beall [24] who studied the effects ofwritten emotional disclosure on health. Evidence suggests thatdisclosing personal and health experiences to others over a longperiod of time may be related to disease processes (p. 274). Areview by Sloan and Marx [25] identified key theoretical conceptsin written disclosure; Inhibition Theory (explanation of the benefitsby catharsis); Cognitive-Processing Theory (patients gain insightinto what had happened to them); Self-Regulation Theory (writingabout the ‘best possible self’ improves health outcomes). A recentreview by Frattaroli [26] indicates that experimental disclosurecan be beneficial for psychological and physical health, and overallfunctioning. However many experimental disclosure interventionswere found not to be helpful for some patients. The success of theintervention was correlated to participant characteristics, forexample those who were very comfortable during disclosure andthose who were paid participants reported improved outcomes. Anexplanation of the therapeutic effects of electronic writtencommunication is not within the remit of this review. Furtherresearch exploring these correlations needs to be undertaken.

c) What are the benefits of networked communication thatface-to-face consultations cannot provide?

Multi-modal, and in particular written, communication along-side increased frequency and time of contact between patients andclinicians were important for patients engaging in behaviourchange [16,19–21]. Patients had time to prepare documents andclinicians had time to read them which resulted in more activeface-to-face sessions. These processes allowed patients to expressthemselves and construct more representative meanings of theirperceptions on treatment, condition(s) and concerns with in-creased articulations of emotions [16,19–21]. These interactionschanged the dynamic of the relationship and the structure ofconsultations became less formal and bounded.

d) How satisfied are patients and healthcare professionals withusing networked communication technologies?

Eight studies [13,14,16,17,19,21–23] reported patient satisfac-tion scores. Two studies [14,23] looked at patient satisfaction andone [14] at parental satisfaction. Studies [13,14,17,22,23] foundthat most of the children, adolescents and parents in the studieswere satisfied with the networked communication technologies.

Elford [14] reported that five out of nine children liked the‘television doctor’ better than the ‘real doctor’, while four had nopreference. Adolescents (17/19) said they preferred the videocon-

ferencing system than travel for an assessment, and the samenumber said that they would use telepsychiatry again. All parents’‘liked’ the telepsychiatry assessment and would use the systemagain. Kopel [13] found that 97% of patients did not feel ‘anxious’,or ‘slightly anxious’ because of the equipment. Satisfaction withthe system compared to face-to-face was ‘adequate’ or ‘almost asgood’ (91%). Whereas, other studies report less positive results;Robinson [22] found only 50% of Self Directed Writing groupparticipants made positive comments on the intervention web-portal. Myers [23] found there was a preference for face-to-face,rather than virtual/online, consultations. Miller [15] reported thatthere were a few issues surrounding quality and delays intransmission, but the patient reported good satisfaction.

7. Practice implications

Many forms of networked communication were shown toreduce symptoms and some of the complications of mental healthproblems and their use seem to improve the quality of the patient’sand health care professional’s encounters. The question remainswhether these technologies can compliment or enhance tradition-al consultations in specific patients. Many studies did not reporttraining, costs and use of equipment; both sound and visual qualitywere reported in studies and seen as poor. It remains unclearwhether this intervention type could be adapted for other health-care settings and chronic diseases.

8. Limitations

The current research area is rapidly changing; terminology andtechnologies have not become established and used routinely.Research evidence for the effectiveness of self care devices is notyet available for all NCTs currently in use [5]. As a result weidentified a relatively small number of technologies despite using abroad search strategy. The current review was limited to Englishlanguage publications; future reviews should include studies in alllanguages. The clinical and cost effectiveness of using NCTs toassist in the outpatient communication with young patients withmental health conditions also remains unclear.

9. Future research

The present study appears to demonstrate that NCTs maypositively affect clinical and personal outcomes in young patientswith diagnosed mental health disorders. Further research isneeded to explore further the acceptability and satisfaction issuesfor patients and clinicians, and determine whether technologiesare reliable, helpful and easy to use.

Future studies should clearly document the training needs ofpatients and providers to master the equipment and theimplications of implementing technology in mental care. AsGreenhalgh [27] argues these new technologies involve changesand adaptations in ‘roles, identifies and mutual expectations’,which are context dependent. Further research on the impact ofchanging the tasks and duties of the healthcare team as the newtechnologies are implemented (e.g. time tradeoffs), increasephysicians’ workload due to the learning process required,assistance to patients for technical support, need for organizationaland clinical protocol changes, is required.

NCTs are also being harnessed to support self-care andsymptom monitoring, for example the use of text messaging inbulemia [28] and in mood [29]. We did not include long-termdisease monitoring in this review which examined interventionswhich had a treatment focus. An area for future research is toinvestigate the value of mental health symptom monitoring usingelectronic tools.


10. Conclusion

Different forms of NCTs have the potential to be used by healthcare professionals and their young patients with mental healthdisorders. However, the breadth of study design and types oftechnologies reported makes the magnitude of benefit difficult todetermine. The review highlights the lack of high quality evidencesupporting more widespread implementation of NCTs at this time.Our conclusions are tentative due to considerable uncertainties atthe organisational level, the training needs for both patients andhealth care professionals and purchasing of these technologyproducts. Furthermore, this is a rapidly expanding area; with newtechnological products regularly entering the market. Despite this,the main focus of research appears to be on adults, with lessattention being made to younger people.

Conflict of interest

The authors declare that there is no actual or potential conflictof interest including any financial, personal or other relationshipswith other people or organizations within three years of beginningthe submitted work that could inappropriately influence, or beperceived to influence, their work.

Acknowledgements

This research was in part supported by the Warwick & CoventryPrimary Care Research (WC-PCR). We wish to thank SamanthaJohnson for her support and expert information specialist advice indeveloping the searches.

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