A Systematic Literature Review on e-Mental Health Solutions to Assist Health Care Workers During COVID-19

Abstract

Background:

e-Mental health is an established field of exploiting information and communication technologies for mental health care. It offers different solutions and has shown effectiveness in managing many psychological issues.

Introduction:

The coronavirus disease 2019 (COVID-19) pandemic has critically influenced health care systems and health care workers (HCWs). HCWs are working under hard conditions, and are suffering from different psychological issues, including anxiety, stress, and depression. Consequently, there is an undeniable need of mental care interventions for HCWs. Under the circumstances caused by COVID-19, e-health interventions can be used as tools to assist HCWs with their mental health. These solutions can provide mental health care support remotely, respecting the recommended safety measures.

Materials and Methods:

This study aims to identify e-mental health interventions, reported in the literature, that are developed for HCWs during the COVID-19 pandemic. A systematic literature review was conducted following the PRISMA protocol by searching the following digital libraries: IEEE, ACM, ScienceDirect, Scopus, and PubMed.

Results and Discussion:

Eleven publications were selected. The identified e-mental health interventions consisted of social media platforms, e-learning content, online resources and mobile applications. Only 27% of the studies included empirical evaluation of the reported interventions, 55% listed challenges and limitations related to the adoption of the reported interventions. And 45% presented interventions developed specifically for HCWs in China. The overall feedback on the identified interventions was positive, yet a lack of empirical evaluation was identified, especially regarding qualitative evidence.

Conclusions:

The COVID-19 pandemic has highlighted the importance and need for e-mental health solutions for HCWs.

Introduction

After its first outbreak in Wuhan, China, coronavirus disease 2019 (COVID-19), a highly infectious disease, has spread to all regions of the world. Evidence suggests that COVID-19 is transmitted through close contact and droplets.¹ By June 6, 2020, the disease has infected >6,416,828 people, and caused >382,867 deaths worldwide.² The spread of COVID-19 has created a rapidly evolving situation that required global safety measures.³ The pandemic scenario lead to extra work loads on the frontline health care workers (HCWs), who have been heroically providing care to COVID-19 patients.⁴ HCWs are working long hours and are exposed to fatigue and other stressors such as fear of infection.⁵ Human-to-human transmission of COVID-19 has occurred among HCWs.⁶ As of early June 2020, there has been >69,761 U.S. HCWs who tested positive for COVID-19 with 368 deaths.⁷ In Italy, 10% of the total infected cases were HCWs.⁸

HCWs face several ethical and moral dilemmas that add on to their psychological stressors.⁹ HCWs often have concerns on how to balance their ethical duty to provide care for patients, against their fear of contracting the disease and transmitting it to their families. These concerns are further fueled by the limited availability and inequitable distribution of personal protective equipment.^10,11 HCWs struggle also with balancing their own physical and mental health against the call of duty.⁹ They sometimes find themselves in situations wherein they might have to make the agonizing decision of depriving critical patients who are unlikely to survive of ventilatory support and to allocate it to less critical patients with better chances of survival.

The aforementioned stressors have a significant impact on the HCWs' mental health. A meta-analysis of 13 cross-sectional studies¹² reported that a high proportion of HCWs experienced significant levels of anxiety, depression, and insomnia caused by the COVID-19 pandemic.¹² In Italy, a study¹³ including 1,379 HCWs reported key mental health outcomes including post-traumatic stress disorder (PTSD) symptoms, severe depression, anxiety, insomnia, and stress. In Germany, doctors reported an elevated prevalence of depressive and anxious symptoms.¹² There have also been several cases of suicide due to the COVID-19 outbreak among HCWs.¹⁴ A top emergency room doctor, who was impacted by the devastating scenes of COVID-19 patients, at a Manhattan hospital, has committed suicide.¹⁵ The COVID-19 situation had also a high impact on nurses, who spend the most time with patients and are the most vulnerable to suicidal feelings.^16,17 In Italy, two nurses have committed suicide: one after testing positive to COVID-19 and one while waiting for the results.¹⁶ In Britain, a young nurse took her own life while treating COVID-19 patients.¹⁶

COVID-19 has challenged the health care systems worldwide and increased health care delivery issues, leading to more stress and fear among HCWs. e-Mental health can overcome the current barriers to health care delivery created by the pandemic. This article presents the results of a systematic literature review on available publications in the literature, which present developed e-mental health interventions for HCWs during the COVID-19 pandemic. The findings of this study could help raise the awareness about existing solutions for HCWs that could assist with their mental care during this pandemic.

METHODOLOGY

The objective of this article is to answer the following research question: what are the available e-mental health interventions, reported in the literature, that are developed for HCWs during the COVID-19 pandemic?

REVIEW PROTOCOL

This article follows the quality reporting guidelines set out by the preferred reporting items for systematic reviews and meta-analysis (PRISMA) group to ensure clarity and transparency of reviews reporting.¹⁸

Sources and search strings

The search process started on May 12, 2020, by consulting the following sources: IEEE Digital Library, ACM Digital Library, ScienceDirect, Scopus, and PubMed. The following search strings were applied to the titles, abstracts, and keywords of the articles for the automatic search of publications in the mentioned digital sources:

–“mental health” AND “healthcare” AND (“workers” OR “givers” OR “providers” OR “professionals”) AND “COVID-19”

–“mental health” AND (“doctors” OR “nurses”) AND “COVID-19.”

Eligibility criteria

After application of the search strings, publications characterized by the following exclusion criteria (EC) were excluded: EC1: studies published before 2020 and EC2: publications that do not include e-mental health interventions for HCWs.

The inclusion criterion (IC) was limited to publications that included e-mental health interventions for HCWs during the COVID-19 pandemic. An analysis was conducted by inspecting each article's title, abstract, and keywords. A total of 11 studies were identified after application of IC and EC as presented in Figure 1.

Fig. 1.

Selection process. EC, exclusion criteria.

Results and Discussion

MAIN FINDINGS

A total of 11 publications were selected and analyzed to identify e-mental health interventions for HCWs during COVID-19. Table 1 presents the identified interventions' types and descriptions.

Table 1.

Identified Interventions from Selected Publications

PUBLICATION	INTERVENTION'S TYPE	INTERVENTION'S DESCRIPTION
Cheng et al. [2020]²²	Social media application	Peer psychological support from overseas to health care professionals on the frontline of the COVID-19 outbreak utilizing the social media application WeChat.
Blake et al. [2020]¹⁹	e-Package	An evidence-based e-learning package on the psychological well-being of HCWs.
Rastegar et al. [2020]²³	Social media platform	A social media platform wherein senior medical students of Shiraz medical school instruct junior medical students in coping with the anxiety and stress brought by the COVID-19 pandemic under the supervision of expert faculty members.
Zhang et al. [2020]²⁶	Online platform	An online platform providing free mental health advice to anesthesia providers.
Wong et al. [2020]³⁶	Mobile apps	Use of the mobile apps: PTSD Coach and Headspace, for mental health care delivery for HCWs.
Chen et al. [2020]²⁴, Rajkumar [2020]²⁵, Huang et al. [2020]³⁰	Online resources and hotlines	Psychological interventions including online courses on mental health and psychological issues, a psychological assistance hotline team providing the needed care, an online screening inventory, and group activities to release stress.
Huang et al. [2020]³⁰	Videos, online games	Online mental health services that include short videos and online games.
Wu et al. [2020]³²	Online resources and hotlines	Online mental health care programs for HCWs developed by medical and psychology associations.
Ripp et al. [2020]³¹	Virtual care and hotlines	Psychological resources including virtual support groups, facilitated by social workers and psychologists, virtual mindfulness and yoga, and support hotlines.
Ping et al. [2020]²⁰	Online platform and hotlines	A modified psychological handbook (UC-19), available through a website and the online platform COVIDCare.

COVID-19, coronavirus disease 2019; HCW, health care worker; PTSD, post-traumatic stress disorder.

Table 2 shows that only three studies (27%) included empirical evaluation of the presented interventions. All three studies reported positive outcome and results from the interventions' evaluations. Yet only one¹⁹ investigated different aspects of the intervention such as its acceptability, usability, engagement, and practicality. The other two were limited to reporting results on the interventions' outcome regarding the general impact on the users. This points to the lack of empirical evaluation of the available interventions for HCWs, which is necessary to investigate the compatibility of the proposed solutions with the HCWs' needs. COVID-19 has created a unique situation, which is why it is also important to empirically evaluate the interventions in the current actual settings and environment, which will help identify the issues that might be faced during similar crisis.

Table 2.

Empirical Evaluation of the Presented Interventions

STUDIES	EMPIRICAL EVALUATION	OUTCOME
Blake et al. [2020]¹⁹	An evaluation form of 20 question items to assess the fidelity and implementation qualities of the package, which was delivered to HCWs and health care students that were recruited for 3 days through professional networks. In total 55 participants (49 employees, 6 students) completed the evaluation.	The predefined success criteria of the evaluation were met for the fidelity assessment (both delivery and engagement), and implementation qualities (practicality, resource challenges, attitudes, acceptability, and usability), 82% of participants reported having used the information provided in the e-package in their work or home lives, and 100% anticipated they would use it in the future.
Rastegar et al. [2020]²³	A questionnaire was delivered to assess the initiative during the COVID-19 pandemic. The questionnaire is based on five questions on the impact of the intervention [30].	In total, 71% of participants believed the platform had a significant impact on helping them adjust faster to the situation.
Ping et al. [2020]²⁰	An initial evaluation of the handbook was conducted in a 1-month trial, in early February 2020, with 25 Hospital University Malaysia Sabah's nurses.	The nurses reported positive qualitative feedback regarding techniques presented in the handbook.

The empirical evaluations were also based on limited number of participants, which was reported as a limitation of the interventions in the studies.^19,20 Table 3 presents the challenges and limitations identified in the selected articles. Only six studies reported challenges and limitations of the interventions. Identified limitations include influence of political and social infrastructures of the countries, which is a critical aspect that varies from a country to another, and must be taken into consideration. Cultural beliefs can also be a limitation for the psychological interventions, as depending on the country and its culture, many topics can be considered inappropriate and should be avoided. Culture and beliefs are another crucial aspect that should be taken into consideration as well.

Table 3.

Interventions' Limitations and Challenges

STUDIES	CHALLENGES	LIMITATIONS
Cheng et al. [2020]²²	Owing to the settings of the used social media application WeChat, availability status of participants in the support group is not visible. Volunteered mental caregivers could not know who is connected, therefore, they started the sessions “blindfolded.” Consequently, the volunteers could not reach participants in the group, but instead waited for participants to reach out to them.	The intervention was created specifically for China's HCWs, and was influenced by the Chinese political and social infrastructure and cultural beliefs. Many topics raised in the sessions, such as religion-related topics, were considered inappropriate. Since the volunteers were from different countries, the difference in time zones was also reported as a barrier.
Blake et al. [2020]¹⁹	—	The evaluation was limited to a small sample of HCWs from the United Kingdom. Further evaluation studies on the e-package are needed, particularly including frontline HCWs with greatest exposure to COVID-19.
Rastegar et al. [2020]²³	Some students reported that they were not sure how to apply the information gained to their personal situation, and desired real and practical face-to-face consultation.	—
Chen et al. [2020]²⁴, Rajkumar [2020]²⁵	HCWs were reluctant to participate in the group or individual psychology interventions provided to them, even though they were showing signs of psychological issues. Interviews with 13 HCWs to investigate reasons of their refusal of the interventions showed that HCWs had strong concerns regarding fear of effecting their families, not knowing how to deal with patients refusing to cooperate with medical and safety measures, shortage of protective equipment, lack of rest, and dealing with patients' anxiety and panic.	—
Ping et al. [2020]²⁰	—	Limitation reported include lack of quantitative evidence, ethical consideration regarding confidentiality and risk management, and limitations of the delivery of UC-19 solutions through phone call, which might limit the availability of essential cues.

Table 4 presents the targeted countries identified in the selected studies. It shows that 45% of the selected studies (5 of 11 studies) presented interventions that are developed for China's HCWs. Based on our search, most studies investigating the impact of COVID-19 on mental health of HCWs were conducted in China as well. Consequently, China is leading the literature on this topic. This can be related to the outbreak starting there. Other countries followed the same path and provided interventions for their HCWs' mental care, such as the United Kingdom, United States, and Canada with the mentioned interventions.

Table 4.

Country Information from the Selected Studies

STUDIES	COUNTRY	TOTAL
Cheng et al. [2020]²², Zhang et al. [2020]²⁶, Chen et al. [2020]²⁴, Rajkumar [2020]²⁵, Huang et al. [2020]³⁰	China	5
Blake et al. [2020]¹⁹	United Kingdom	1
Rastegar et al. [2020]²³	Iran	1
Wu et al. [2020]³²	Canada	1
Ripp et al. [2020]³¹	United States	1
Ping et al. [2020]²⁰	Malaysia	1
Wong et al. [2020]³⁶	Nonspecific to one country	1

Limitations of e-mental health interventions in general were also reported. They include ethical concerns regarding confidentiality and risk management, as it is possible that communication through such interventions to be observed by outsiders, without the knowledge of users or care providers, resulting in confidentiality and security issues.²¹ The limitations also include missing essential psychological cues, such as nonverbal cues, which might help the psychological care providers to better understand and communicate with the users. Use of Information and Communication Technologies for mental care delivery might also face certain challenges, such as the technological limitations of the solution used²² and unwillingness of patients to use such solutions, and their preference of traditional face-to-face approaches.^23
–25

Considering all issues that HCWs have to deal with, providing psychological aid might not be enough. Instead, global aid approaches, providing solutions for HCWs' issues in addition to psychological care, will be more effective, beneficial, and more acceptable by HCWs.^24,25

Summary of identified e-mental health interventions

A group of Chinese-speaking mental health professionals from the United States, Canada, and Australia formed a team to provide tele-peer-to-peer psychological support for the Wuhan HCWs using the social media platform WeChat. The team included 45 mental health professionals from different disciplines. The project started operation on January 24, 2020, the day after Wuhan was placed on lockdown. The project offered both group and individual support. The program was able to help 300 Wuhan HCWs. Preliminary results suggested that it was a beneficial intervention, as many of those who received support found the intervention helpful.²² WeChat has also been used in February 15, 2020, by the Chinese Society of Anesthesiology and Chinese Association of Anesthesiologists, to provide free mental health and advice to anesthesia providers. The program was capable of providing consultation to >200 persons per day.^26,27

A social media platform was created for students of Shiraz medical school in Iran. The initiative was first launched in 2015,²⁸ and is used during the COVID-19 pandemic to help medical students cope with the situation. The students were experiencing an unintended pause in their education, and some of them were collaborating with HCWs to deliver the needed care for COVID-19 patients. Therefore, they were exposed to numerous mental and emotional issues. The platform implemented a near-peer mentoring method, by having senior medical students instruct junior medical students in coping with the anxiety and stress brought by the COVID-19 pandemic. Senior students, under the supervision of expert faculty members, provided suitable solutions to psychological issues and supported junior students in managing their emotions. In total, 371 junior students joined the platform. Furthermore, 71% of the students reported that the platform had a significant impact on helping them adjust faster to the pandemic conditions.²³

The psychiatry department of the Second Xiangya Hospital of Central South University, the Hunan Psychiatric Center, and the National Center for Psychological and Mental Disease Clinical Medicine in China provided a detailed psychological intervention plan, which included online courses to guide medical staff in dealing with common psychological problems, and a psychological assistance hotline team that offered telephone counseling, online counseling, and video consulting. Moreover, an online screening inventory was also developed to help frontline medical staff acknowledge their possible mental issues.^24,29 However, this intervention was first met with reluctance from the HCWs themselves. After investigation, the intervention was redesigned to include the provision of a rest area, care for basic physical needs such as food, training on the care of COVID-19 patients, information on protective measures, leisure activities, and periodic visits to the rest area by a counselor. The results showed an improved satisfaction rate among HCWs toward the intervention. Outcomes from this initiative highlight the need for continuous feedback analysis and modification of such interventions, if they are not beneficial to HCWs.²⁵ The health committee of Sichuan, China, has also provided mental health services for HCWs. Besides online and telephone counseling, they adopted other innovative psychological interventions including short videos and online games.³⁰

In the United States, the Mount Sinai Health System (MSHS) identified three essential areas in promoting and maintaining the well-being of the MSHS workforce during the pandemic. One of which was developing a robust array of easily accessible psychosocial and mental health support options. In addition to their pre-existing mental health support resources, MSHS provided other resources including virtual solutions, such as virtual support groups, facilitated by social workers and psychologists, virtual mindfulness and yoga, and support hotlines.³¹

In Malaysia, the University Malaysia Sabah (UMS) has modified its ultrabrief psychological interventions (UBPI) handbook to be adapted specifically to the COVID-19 pandemic, and was named UC-19. The UC-19 psychological handbook contains a variety of psychotherapies and was delivered in two approaches. The first one is for occupational mental health in COVID-19, targeting HCWs, especially COVID-19 frontlines as well as the general public. The handbook was then shared to various other centers, and published online on a website to increase its availability. The second approach is through a web chat portal called COVIDCare, which is available for both the public and HCWs. The initiative also provided hotlines to deliver the necessary care. The psychological techniques presented in the UC-19 handbookwere evaluated in a trial including UMS nurses working on the COVID-19 frontline, who reported positive feedback. The online delivery approach of the handbook has also been receiving positive feedback from users of the platform.²⁰

In Canada, the Canadian Medical Association has launched the Provincial Physician Health Program. This program includes specific guidelines for each province of Canada. These programs include telesupport and care for HCWs and their families.^32,33 The Canadian Psychological Association has also invited all registered psychology practitioners to volunteer for providing psychological services to frontline HCWs. Moreover, they provided a list of mental health professionals who provide telepsychiatry services for HCWs.

In the United Kingdom, an evidence-based digital learning package, on psychological well-being for HCWs, was created by members of the University of Nottingham and the National Institute for Health Research.^19,34 The e-package provided educational content to targeted United Kingdom's HCWs, as well as health care academics and students. It included sections providing content on the psychological impact of COVID-19, suggestions on actions that team leaders can take to create psychologically safe work spaces for staff, information on the importance and methods of communication and social support, and methods of self-care. The e-package also included advice from experts in mental well-being as well as from those with direct pandemic experiences from the frontline. The proposed system had been accessed 17,633 times for the first 7 days of its launch. Users of the e-package were not limited to United Kingdom's HCWs, but included users from other regions such as the United States, Europe, and China, which was an indicator of its wider applicability. The e-package showed positive quality and usability results, and was found to be very helpful to HCWs.¹⁹

Mobile mental health apps have also been suggested to be tools that can provide support in a more informal manner. The PTSD Coach,³⁵ a mobile app developed by the U.S. Department of Veteran Affairs' (VA), National Center for PTSD, essentially for U.S. veterans, has been suggested to be effective for HCWs. It is based on cognitive-behavioral therapy. The app helps manage issues that HCWs might suffer from, such as stress, anger, anxiety, hopelessness, and sleep problems.³⁶

EXAMPLES OF EXISTING E-MENTAL HEALTH INTERVENTIONS NOT REPORTED IN THE LITERATURE

There are many interventions that were not reported in the literature. Like the parachute project, which provides free teletherapy for the United States HCWs, it includes 500 volunteer therapists and covers 37 states.³⁷ And the HSPH COVID-19 online mental health forums, offered by Harvard University, where experts address psychological and physical issues related to the pandemic.³⁸ One of the forums focused on the impact of COVID-19 on the mental health of HCWs, and how their family and friends can support them.³⁹ Moreover, in the United Arab Emirates, the initiative “Mental Support Line” was launched by the national program for happiness and well-being in association with the “volunteers.ae” national campaign. The initiative includes trained volunteers including leading psychologists and mental health professionals, and provides a free hotline to support people with their mental health during the pandemic. The hotline can be used by HCWs and the public, and is available in both English and Arabic.^40,41

The VA's National Center for PTSD has developed the app COVID Coach, specifically to support self-care and overall mental health during the COVID-19 pandemic, the app is created for everyone, including veterans and service members, and provides self-directed coping, self-assessment, and mindfulness resources.⁴² Other than the mentioned apps, The VA's National Center for PTSD offers a variety of other apps, mainly developed to help manage PTSD, but can help with other related issues such as insomnia, mood changes, and anger.⁴³

Other examples of available mental care apps are Moodpath, ⁴⁴ Sanvello, ⁴⁵ and InnerHour, ⁴⁶ which target stress, anxiety, and depression. These apps provide features such as mental health assessment tests, guided relaxation, and breathing exercises. Apps can also be useful tools to deliver online psychiatric therapy with mental care professionals. Examples of such apps include Headspace,⁴⁷ which is now available for free to all U.S. health care providers with a National Provider Identification number³⁶, other examples of similar apps include BetterHelp,⁴⁸ ifeel,⁴⁹ and Online Therapy. ⁵⁰ Other than the mentioned apps, there is a wide range of mobile mental care apps that provide different mental care features, targeting mental issues such as PTSD,⁵¹ anxiety,⁵² and depression,⁵³ which HCWs might benefit from.

Developing countries are also aware about the importance of supporting HCWs' mental health, especially through e-mental health solution. For instance, Mohammed V University in Morocco has established the work psychology unit initiative, which is composed of four experienced psychologists, and offers free psychological consultations to Moroccan HCWs through phone calls. The unit receives ∼20 calls daily.⁵⁴

Conclusions

This study provides a systematic review on e-mental health interventions developed for HCWs during the COVID-19 pandemic. Eleven studies were selected. Results showed that the number of identified interventions was limited and covers only few countries, mainly targeting China's HCWs. This points to the need for more mental care interventions to help HCWs in other countries. A lack of empirical evaluation of available interventions was also identified, especially regarding quantitative evidence. And many limitations and challenges facing e-mental health solutions were extracted, including technological and cultural limitations, confidentiality, and risk management concerns, as well as attitudes of users toward the interventions. Developing e-mental health solutions for HCWs should be among the priorities of all countries with COVID-19 cases. Lessons should be learned from the current COVID-19 crisis and more attention should be given to e-mental health interventions. This study might be of interest for HCWs to find interventions that could be helpful for their mental care, as well as for developers and researchers interested in the topic. For future work, we plan to build on the outcome of this study to develop an e-mental health platform for HCWs.

Authors' Contributions

All authors contributed to the creation of the article. N.D. contributed to design, conception, acquisition and interpretation of data, classification of selected articles, drafting of the article, and revision. S.O. was involved in design, conception, drafting of the article, and critical revision. G.M. and I.T.D. carried out drafting of the article and critical revision. M.G. was involved in design and critical revision. M.A.J.I. made critical revisions. All authors read and approved this article.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

This study is part of the startup project (#31T131) funded by the UAEU (2019–2021).

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