Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews

Abstract

Background: The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation.

Objective: The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.

Methods: The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach.

Results: A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.

Conclusions: We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process.

Trial registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811.

International registered report identifier (irrid): RR2-10.12688/f1000research.27150.2.

Keywords: digital health; eHealth; internet-based intervention; mHealth; mental disorders; mental health; qualitative research; realist review; systematic reviews; telehealth; telemedicine.

Figure 1

Flowchart of the study selection process.

Figure 2

Risk of bias assessment of individual studies, according to AMSTAR-2. 1: Did the research questions and inclusion criteria for the review include the components of PICO (Population, Intervention, Control, Outcomes)? *2: Did the report of the review contain an explicit statement that the review methods were established prior to conduct of the review and did the report justify any significant deviations from the protocol? (critical item); 3: Did the review authors explain their selection of the study designs for inclusion in the review? *4: Did the review authors use a comprehensive literature search strategy? (critical item); 5: Did the review authors perform study selection in duplicate? 6: Did the review authors perform data extraction in duplicate? *7: Did the review authors provide a list of excluded studies and justify the exclusions? (critical item); 8: Did the review authors describe the included studies in adequate detail? *9: Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review? (critical item); 10: Did the review authors report on the sources of funding for the studies included in the review? *11: If meta-analysis was justified, did the review authors use appropriate methods for statistical combination of results? (critical item); 12: If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis? *13: Did the review authors account for RoB in individual studies when interpreting/discussing the results of the review? (critical item); 14: Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? *15: If they performed quantitative synthesis, did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? (critical item); 16: Conflict of interest declaration.

Figure 3

Results of the three hypotheses (H1-H3) of the realist synthesis. C: context (pink); M: mechanism (yellow); O: outcome (different colors for each hypothesis); CBT: cognitive behavioral therapy; QoL: quality of life.