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The COVID-19 pandemic has required psychiatric and mental health professionals to change their practices to reduce the risk of transmission of SARS-CoV-2, in particular by favoring remote monitoring and assessment via digital technologies.
As part of a research project that was cofunded by the French National Research Agency (ARN) and the Centre-Val de Loire Region, the aim of this systematic literature review was to investigate how such uses of digital technologies have been developing.
This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was carried out in the MEDLINE (ie, PubMed) and Cairn databases, as well as in a platform specializing in mental health, Ascodocpsy. The search yielded 558 results for the year 2020. After applying inclusion and exclusion criteria, first on titles and abstracts and then on full texts, 61 articles were included.
The analysis of the literature revealed a heterogeneous integration of digital technologies, not only depending on countries, contexts, and local regulations, but also depending on the modalities of care. Notwithstanding these variations, the use of videoconferencing has developed significantly, affecting working conditions and therapeutic relationships. For many psychiatric and mental health professionals, the pandemic has been an opportunity to build up their experience of remote care and, thus, better identify the possibilities and limits of these digital technologies.
New uses of such technologies essentially consist of a transition from the classic consultation model toward teleconsultation and make less use of the specific potential of artificial intelligence. As professionals were not prepared for these uses, they were confronted with practical difficulties and ethical questions, such as the place of digital technology in care, confidentiality and protection of personal data, and equity in access to care. The COVID-19 health crisis questions how the organization of health care integrates the possibilities offered by digital technology, in particular to promote the autonomy and empowerment of mental health service users.
The spread of digital technology in health systems is a major and irreversible phenomenon, a source of changes that are only just beginning. Initiated several decades ago in the field of psychiatry and mental health care, the development of digital technologies has been increasing for several years [
The COVID-19 pandemic has highlighted the potential of these technologies, which have led to digital uses on an unprecedented scale in psychiatry. In particular, the pandemic revealed the contributions of these technologies to ensuring continuity of care while annihilating the risk of viral transmission in the context of an outbreak. As they allow remote monitoring of some patients, these technologies have been used in a wide range of strategies to reduce the risk of transmission of SARS-CoV-2. They have also made it possible to carry out interventions responding to needs that are specifically related to the epidemic, whether it be support for frontline health professionals or care for patients with COVID-19. The use of teleconsultation, previously in mental health care and psychiatry in its early stages, has massively increased in response to the health crisis and among measures that have been implemented to contain it [
Mental health and psychiatric care specifically provide a central place to the therapeutic relationship. In this context, our attention is focused on the impact of digital technologies as a “relational artifact“ (ie, the way they reconfigure care relationships).
The objectives of this study were (1) to describe the uses of digital technologies at the time of COVID-19 and their impact on professional practices in psychiatry and mental health and (2) to understand the place of digital technologies in the organizational adaptations linked to the COVID-19 epidemic, but also to identify how this specific context questions the modalities of care.
This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [
A systematic literature search was carried out in two databases, MEDLINE (ie, PubMed) and Cairn, and a specialized mental health platform, Ascodocpsy; all included articles met the inclusion criteria. Search terms were defined by articulating keywords, which were previously defined from dictionaries of synonyms and thesauri
After a preliminary exploratory search, all authors agreed on the inclusion and exclusion criteria. To be included in the literature review, articles had to meet the following criteria: deal with the use of digital technologies as a response to the pandemic context and be related to the field of mental health care or psychiatry. On the other hand, the following were excluded: articles documenting the impacts of COVID-19 on mental health and psychiatry in general, adaptations of the health care offering carried out independently of the digital possibilities, and uses of digital tools in mental health and psychiatry independent of the COVID-19 outbreak.
In order to benefit from international experiences in an unprecedented context where many countries were simultaneously confronted with the same challenges, we chose not to exclude references based on geographical criteria.
Search terms used to find articles for this review.
Database | Thesaurus | Search terms |
PubMed |
Yes | (“coronavirus” OR “covid-19” OR “sars-cov-2”) AND (“mental health worker” OR “psychiatry” OR “mental health professional” OR “psychiatrist” OR “psychologist” OR “psychiatric nurse” OR “e-professional in psychiatry” OR “e-mental health”) |
Cairn | No | (“covid-19” OU “sars-cov-2” OU “coronavirus”) ET (“psychiatrie” OU “santé mentale” OU “psychologue” OU “infirmier en psychiatrie” OU “pair-aidant” OU “médiateur de santé pair” OU “e-professionnel de la psychiatrie”) |
Base SantéPsy (Ascodocpsy) | Yes | Base set contains “covid-19” ET (“psychiatrie” OU “santé mentale” OU “psychologie” OU “hôpital psychiatrique”) |
The search yielded a total of 558 documents, 39 of which were duplicates that were excluded. The first two authors (HK and JGB) preselected references by applying the inclusion and exclusion criteria on abstracts and agreed to select 91 articles. A careful reading of the documents resulted in the exclusion, after consultation, of 30 more articles. Therefore, a total of 61 references were selected (
Flowchart of article selection for this review.
This literature review shows that, in the context of the current crisis and as professional practices need to adapt, publications have been produced at a rapid rate. The use of digital technologies appeared to be a crucial issue, which was addressed in 61 articles in the year 2020 alone.
The methodological quality of these contributions turned out to be quite poor, due to a lack of time and hindsight to carry out more rigorous work. About half of them (30/61, 49%) were feedback articles. They show the willingness of those involved in psychiatry and mental health care to share their experiences and innovations in the midst of the COVID-19 crisis. Such publications reflect an acceleration in the exchange of professional practices on an international scale. They used diverse methodologies, ranging from personal narratives to more collaborative and structured forms of feedback and analysis of experience. The presence of 8 (13%) reflection-based articles also shows the willingness of professionals to share their concerns. Another set of 14 (23%) articles were literature reviews, either narrative or systematic. In the end, of the 61 articles, only 9 (15%) were original research studies.
Selected articles included many countries, spread over five continents, which were simultaneously confronted with similar issues related to the use of digital technologies in response to the pandemic. The largest number of articles concerned Western and Northern Europe (n=24, 39%) and North America (n=23, 38%).
Characteristics and themes of the selected articles.
Characteristics | Studies (N=61), n (%) | References | |
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Experience feedback | 30 (49) | [ |
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Literature review | 14 (23) | [ |
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Study | 9 (15) | [ |
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Reflection | 8 (13) | [ |
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Europe | 24 (39) | [ |
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North America | 23 (38) | [ |
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Asia | 8 (13) | [ |
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Australia | 4 (7) | [ |
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Africa | 2 (3) | [ |
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Videoconferencing | 45 (74) | [ |
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Telephone | 27 (44) | [ |
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App | 10 (16) | [ |
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Connected device | 5 (8) | [ |
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Website | 4 (7) | [ |
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Artificial intelligence | 4 (7) | [ |
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Patients’ follow-up and care | 44 (72) | [ |
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Public support for COVID-19 | 9 (15) | [ |
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Group therapy | 8 (13) | [ |
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Assessment and diagnosis | 7 (11) | [ |
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Support for health professionals | 5 (8) | [ |
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Care of patients with COVID-19 | 5 (8) | [ |
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Staff meeting | 5 (8) | [ |
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Psychiatry in general | 29 (48) | [ |
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Psychology | 14 (23) | [ |
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Mental health promotion | 8 (13) | [ |
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Child psychiatry | 5 (8) | [ |
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Geriatric psychiatry | 5 (8) | [ |
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Community health | 4 (7) | [ |
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Forensic psychiatry | 3 (5) | [ |
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Addiction | 3 (5) | [ |
Most of the articles selected for this literature review (45/61, 74%) mentioned the use of videoconferencing. This technology has been used, in particular, in interventions with mental health and psychiatric professionals who provide care for patients with COVID-19 [
However, teleconsultation has been massively developed to ensure continuity of care. Videoconferencing has made it possible to maintain not only remote monitoring of patients, but also therapy groups [
In most psychiatric services, however, this switch to remote communication is not yet complete, forcing practitioners to determine which activities require face-to-face meetings and which ones can be done via videoconferencing [
As the number of remote consultations increased, prescription procedures have also been impacted. In order to limit the number of in-person appointments, practitioners have either used tele-prescription or opted for prescriptions covering a longer period. For treatments that require follow-up of specific clinical parameters, such as Clozapine, which involves monitoring blood counts, protocols have been made more flexible, sometimes allowing for a remote assessment of the clinical condition of patients [
In addition, 10 articles (16%) discussed connected apps and devices. In particular, their authors highlighted the relevance of connected apps and devices to assist remote monitoring during the pandemic [
Although the COVID-19 pandemic has stimulated the development of telepsychiatry on all continents, our review of the literature allowed us to glimpse variations between countries. In the United States, due to the removal of regulatory barriers, the shift to telepsychiatry has been massive and even total in certain units, as illustrated by numerous publications [
Within countries, these trends raise the issue of unequal access to digital technologies. Consequently, the development of telepsychiatry may disadvantage people living in poverty [
Moreover, many authors have reassessed the appropriateness of telepsychiatry depending on the patients and their disorders, which had already been documented in the literature [
Specific problems with the use of these technologies have arisen in certain fields, such as forensic psychiatry [
These numerous contributions found in the scientific literature, which were based on new experiments in the context of the COVID-19 pandemic, have added to the established knowledge about the relevance of telepsychiatry in different situations.
The use of telepsychiatry, which makes it possible to reduce the risks of infection, has generated new conditions of practice for many professionals, defining both new possibilities and constraints. For independent practitioners, teleconsultation is no longer necessarily a freely chosen practice [
It should be noted that this new digital work experience has sometimes been associated with teleworking from home [
Professionals teleworking from home have been confronted with unprecedented situations of temporal and spatial juxtaposition of both their professional and personal lives. This juxtaposition requires “psychological work to differentiate between private and professional lives that is more costly than usual” [
Moreover, the use of digital technologies, especially as their use is improvised and unframed, is likely to lead to an increased workload. Professionals may be exposed to an accumulation of requests through multiple technologies: videoconferencing, telephone, email, and SMS [
Having experiences of care relationships reshaped by digital technologies in the context of this pandemic, psychiatric and mental health professionals have been using videoconferencing and the telephone to follow up on many patients. For health care providers, the COVID-19 crisis has been an opportunity to build up their experience of remote health care monitoring and, thus, better understand the possibilities and limitations of such digital technologies. This unprecedented context forced them to reinvent “relational mental health” [
Furthermore, although the effectiveness of telepsychiatry had already been documented [
The professionals were also led to discover the advantages of digital technologies. The use of videoconferencing can be an opportunity to better contextualize some information, since part of the patient’s environment is made visible [
Although telepsychiatry allows for a large number of follow-up consultations, several authors mentioned that the greatest difficulty was in establishing a therapeutic relationship without a prior face-to-face encounter [
Although already documented, the possibilities and limits of telepsychiatry were highlighted by the COVID-19 epidemic, illustrating how experience can help to gradually shape new therapeutic practices integrating digital technologies.
The profusion of articles identified in the framework of this literature review shows how much the COVID-19 crisis has raised issues about care practices in psychiatry and how they integrate the available digital technologies. Such integration proves to be heterogeneous, depending on local contexts and regulations, but also regarding the fields and modalities of care. The use of videoconferencing has had an impact not only on the working conditions of mental health and psychiatric professionals, but also on the care relationships they maintain with their patients. This sudden shift to remote care has prompted professionals to publish papers about their experiences with telepsychiatry, sometimes in a naive way, without building on pre-existing research.
The experience of videoconferencing, in a context where mental health and psychiatric professionals had not been prepared for it, calls into question the quality of care [
To guarantee the best conditions for confidentiality, special attention should be paid to the choice of digital technologies to be used. In the context of the current crisis, this choice has been little considered and is essentially based on pragmatic considerations. The use of new technologies requires special precautions, such as using headphones, consulting in a closed room, and disconnecting when absent [
The partial or total shift to remote consultations also raises the issue of equity in the provision of health care. Many professionals have been forced to identify vulnerable patients who require face-to-face encounters and those who can be monitored remotely [
In showing many professionals the potential of digital technologies, the COVID-19 crisis also revealed the extent to which their nonuse can be an ethical challenge. Digital technologies can reduce regional inequalities in access to health care [
However, while the use of teleconsultation has been significant, professional uses of apps and connected devices do not seem to have been as stimulated by the health crisis. According to some authors, the pandemic, nevertheless, made it urgent to use such tools in order to intervene on a large scale to relieve the mental health burden induced by the crisis [
The COVID-19 health crisis questions the organization of care and the way it integrates new possibilities offered by digital technology. The scientific publications that we have identified mainly addressed the issues related to teleconsultation, sometimes ignoring previous research. The impact of the use of digital technology on relationships between professionals is poorly documented. However, the use of digital technologies is reshaping the conditions of teamwork and allows for new modalities of interprofessional collaboration [
Digital technologies also question the place of users and their relatives in the organization of care. As a result of the increase in outpatient and remote follow-up during lockdown periods, many patients have become more autonomous in managing their mental health [
The COVID-19 pandemic has led to new uses of telepsychiatry, with the aim of ensuring continuity of care while limiting the risk of transmission of SARS-CoV-2. Such expansion was essentially characterized by the integration of videoconferencing as a new framework for consultation. Many mental health and psychiatric professionals started experiencing remote health care monitoring and assessment in a hurry and with no preparation. They have become familiar with the constraints, possibilities, and assets of care relationships in this type of context. These new conditions of professional practice have confronted them with ethical questions, such as equity in access to care. Existing research resources and data could be mobilized to enable these professionals to better leverage the benefits of digital technologies to complement face-to-face meetings. Further interdisciplinary work will be needed to better understand variations in digital technology uses across countries.
The use of digital technologies during the COVID-19 epidemic have shed light on the organization of mental health and psychiatric care, and about the place of users within this context of care. In a context where hospitals and health centers are no longer the only spaces where care and support are delivered, access to care and “decoding” the eHealth world constitute a pillar of tomorrow’s public health [
French National Research Agency
French National Hospital Program for Clinical Research
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
We thank the French National Research Agency (ARN) and the Centre-Val de Loire Region for funding our research.
WEH received speaker fees from Air Liquide, Eisai, Janssen, Lundbeck, Otsuka, UCB Pharma, and Chugai. WEH has received research grants from the Fondation de France and from the French National Hospital Program for Clinical Research (PHRC) that are unrelated to the submitted work.