Evidence for telehealth group-based treatment: A systematic review

Abstract

Background

Interest in the use of telehealth interventions to increase access to healthcare services is growing. Group-based interventions have the potential to increase patient access to highly needed services. The aim of this study was to systematically review the available literature on group-based video teleconference services.

Methods

The English-language literature was searched using Ovid MEDLINE, PubMed, PsycINFO and CINAHL for terms related to telehealth, group therapy and support groups. Abstracts were reviewed for relevance based on inclusion criteria. Multiple study types were reviewed, including open-label, qualitative and randomised controlled trial study designs. Data were compiled regarding participants, study intervention and outcomes. Specific areas of interest were the feasibility of and satisfaction with telehealth technology, as well as the effect of video teleconference delivery on group dynamics, including therapeutic alliance.

Results

Forty published studies met the inclusion criteria and were included in the review. Six were randomised controlled trials. Among the studies, there was a broad range of study designs, participants, group interventions and outcome measures. Video teleconference groups were found to be feasible and resulted in similar treatment outcomes to in-person groups. However, few studies were designed to demonstrate noninferiority of video teleconference groups compared with in-person groups. Studies that examined group process factors showed small decreases in therapeutic alliance in the video teleconference participants.

Conclusions

Video teleconference groups are feasible and produce outcomes similar to in-person treatment, with high participant satisfaction despite technical challenges. Additional research is needed to identify optimal methods of video teleconference group delivery to maximise clinical benefit and treatment outcomes.

Keywords

Group psychotherapy group therapy support groups telehealth telemedicine videoconference

Introduction

Telemedicine is a rapidly growing field that holds much promise for improving access to healthcare and reducing healthcare costs. Telemedicine allows for the delivery of healthcare services to persons in remote and rural areas who may otherwise not have access to healthcare. As technology has become increasingly available to the public, there is increased demand on the part of healthcare consumers for more technologically based healthcare interventions.¹

Telehealth and telemental health are broad concepts that encompass many options for technology and methods of healthcare delivery, including mobile device applications, remote monitoring, online content, synchronous videoconferencing and asynchronous communication.² In the setting of telemental health, the area of greatest interest has been the use of live, interactive video teleconference (VTC) between a patient and a healthcare provider. It is well established in the literature that VTC visits can be used to provide high-quality diagnostic assessment and treatment for various mental health conditions.³

Telemental health has been shown to be highly feasible and acceptable across different patient types, including diverse populations, adults, older adults and children.^4,5 Telemental health has been used to diagnose and treat various health conditions, including depression and anxiety, as well as to provide support to patients and caregivers with co-occurring medical diagnoses such as diabetes mellitus, heart disease, and cancer.^4,6 Most studies in telemental health have focused on assessment or treatment provided to individuals, whereas the literature regarding group-based treatment is limited.² VTC group-based treatments consist of one or more group therapists or facilitators providing an intervention to a group of participants at a distance. VTC groups may be either single point-to-point or multipoint design (Figure 1). In single point-to-point design, group members are all located in one remote VTC group room; in multipoint design, group members meet in the virtual group environment from individual remote sites.

Figure 1.

Features of video teleconference (VTC) group design.

Group-based treatments have the potential benefit of expanding patient access to trained specialists in addition to allowing group members to find commonality and feel less isolated. In a review of information and support interventions for caregivers of people with dementia, only group-based interventions were shown to significantly decrease depression among caregivers.⁷ In addition, structured group interventions have been shown to decrease distress and improve quality of life in patients with cancer.⁸ Combining group-based treatment with VTC offers the potential for expanding availability of support services, reaching those isolated in remote areas, and reducing costs. However, because group treatments incorporate the interpersonal dynamics between facilitators and group members and between fellow group members, group treatment may provide unique challenges to the remote delivery of care. It is possible that VTC groups may hinder the development of a therapeutic alliance or interfere with the facilitator's ability to observe and respond to group interactions.

It remains unclear whether group psychotherapy or medical support groups can be provided via VTC with results comparable to face-to-face group treatment.⁹ Only one systematic review has been published, on the related topic of telehealth delivery of home-based support groups;¹⁰ the examination of 17 research articles showed that home-based VTC support groups were feasible, showed similar outcomes to in-person groups, and maintained group process factors. Thus, there is a substantial gap in the available literature concerning several important questions regarding the use of telehealth groups, which the current study aims to examine: (a) is group-based psychotherapy or a support group intervention via VTC as effective as similar in-person treatment? (b) do specific group processes differ between face-to-face and VTC groups? and (c) are group participants and providers satisfied with VTC technology? This current review expands on the one previous review by including both home-based and facility-based groups and by reviewing open-label and randomised controlled trials (RCTs). The overall aim of this study was to consolidate the available literature on group-based treatments that were delivered via VTC, and to examine feasibility and outcomes of group-based VTC treatments.

Methods

Search strategy and inclusion criteria

The databases Ovid MEDLINE (1946 to February 2018), PubMed, PsycINFO (1987–2018), and CINAHL were searched using the keywords group therapy, support group, group psychotherapy, self-help groups, videoconference, mhealth, mobile phone, smartphone, ehealth, remote group, telehealth, telepsychiatry, telemedicine, remote consultation, video visit, virtual visit, videotelephone, telepsychology, ehealth and econsult. Studies were included if they were open-label trials or RCTs published in English-language peer-reviewed journals and were performed in adult populations (age>18 years). A ‘telemental health intervention’ was defined as services provided by a trained professional to a group of participants. For study inclusion in our review, the intervention had to be provided by VTC format. Studies were excluded if they did not include a VTC intervention, such as studies with only text-based or telephonic communication. Studies were allowed if they included additional forms of telehealth interventions such as online chat interface or asynchronous discussion forums, as long as there was a primary VTC group component. Studies that incorporated both in-person and VTC sessions were excluded.

The titles and abstracts of the articles identified in the search were screened by one author for pertinence to the topic. Full texts of the selected studies were then retrieved and read in detail. The bibliographies of identified articles were reviewed to determine other potentially relevant articles not previously identified (Figure 2).

Figure 2.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram. VTC: video teleconference.

Data collection

Relevant information from each study was summarised by one author using a data extraction sheet based on predetermined categories. These included sample size, target population, study design, technology factors (including software type and Internet speed), type of treatment intervention and outcome measures.

Results

Among 214 unique studies initially identified in the search, 40 met the inclusion criteria (Figure 2, Table 1).^9,11–48 Six of these studies used an RCT study design, with VTC compared with an equivalent face-to-face intervention.^{9,11,12,15,17,18} Three of these RCTs were designed to demonstrate noninferiority of the telemedicine intervention vs a face-to-face intervention.^9,12,18 Five studies used nonrandomised group selection for VTC vs a face-to-face group, with participant location or participant preference determining group selection.^22–25,41 Twenty-three studies were pilot, feasibility or qualitative studies with no control group.^{23–25,27–40,42–50} Three studies used a wait-list or no-treatment control group.^14,20,21 One study compared group VTC treatment vs a text-based chat group intervention, with group selection based on participant preference.²⁶

Table 1.

Characteristics of group-based VTC studies.

Study	Design	Participants	n	Technology factors	Treatment intervention	Goals	Overview of findings	QoE
Frueh et al., 2007¹² and Frueh et al., 2007¹³ secondary analysis	RCT: FTF vs VTC	Veterans with PTSD	VTC = 17 FTF = 21	Computer-based video conferencing (ViaVideo, Polycom); bandwidth, 384 kbit/s	CBT for PTSD, 14 week, then 3 monthly sessions	Noninferiority on outcome measures and service delivery perception	No differences in treatment improvement. FTF group reported more comfort with therapist and more likely to complete homework; no group differences in therapist competence and adherence to CBT	I
King et al., 2009¹¹	Randomised pilot study: VTC vs FTF	Opioid-dependent patients	VTC = 20 FTF = 17	Software updates provided to participant home computer by IT technician. Internet-based video conference platform (not named)	Manual-guided relapse control therapy, 2 sessions/week for 6 weeks; the same group content provided in person or via Internet connection	Treatment adherence and completion, positive drug screen, patient satisfaction, VTC group asked about preference for in-person vs Internet-based group	No group differences in treatment adherence, completion, or drug use; both groups showed high satisfaction; Internet group reported strong preference for Internet delivery (appreciated greater convenience and privacy); 13 participants withdrew related to IT concerns	I
Marhefka et al., 2014¹⁴	RCT: VTC group vs WLC	Women with HIV	VTC = 36 WLC = 35	Private room in clinic site with computer, dedicated high-speed Internet line, Cisco E-20 video phone, on-site liaison	6 2-h Sessions; Healthy Relationships educational program	Sexual Risk Behavior Assessment for Adults; Client Satisfaction Questionnaire-8; participant reports of sexual activity; participant satisfaction	No group differences in preventing unprotected sex; participants were highly satisfied with intervention; intervention group had fewer occasions of unprotected sex; most participants rated sound and image quality as good or excellent	I
Morland et al., 2004¹⁵	RCT: VTC vs FTF	Veterans with PTSD	VTC = 9 FTF = 8	Clinician at 1 site, participants all in remote conference room with VTC units (ViewStation V.35, Polycom); bandwidth, 512 kbit/s (frame rate, 30 frames/s); clinician travelled by plane to provide FTF groups	Coping skills, 8 sessions	Patient satisfaction, clinician satisfaction, information retention	Large attrition, participants only completed 4 sessions on average; no significant differences between groups	I
Morland et al., 2010⁹ (and Greene et al., 2010¹⁶ secondary analysis)	RCT: Noninferiority RCT to in-person or VTC groups	Male veterans with PTSD and anger problems	VTC = 61 FTF = 64	Participants met as a group for both conditions; on-site observer for the remote groups	12-Session manualised CBT intervention	Decrease in anger symptoms, process indicators (alliance, adherence, attrition, and satisfaction); group process indicators: GTAS, CPOSS-VA	Both groups showed improvement in anger and PTSD symptoms; VTC noninferior for anger management; few technical difficulties with VTC; GTAS subscales showed lower self-therapist alliance in VTC group	I
Morland et al., 2011¹⁷	RCT: VTC vs FTF	Male veterans with PTSD	VTC = 6 FTF = 7	TANDBERG 800 Model Health Care System VTC system; onsite observer in remote location	Cognitive processing therapy; weekly sessions for 6 weeks	Clinician-administered PTSD scale, process indicators including therapeutic alliance; Telemedicine Satisfaction and Acceptance Scale	VTC did not decrease participant confidence in treatment outcomes or satisfaction with services; high acceptance and satisfaction rates; no significant group differences	I
Morland et al., 2014¹⁸	RCT: noninferiority design, VTC vs FTF	Male veterans with PTSD	VTC = 46 FTF = 50	TANDBERG 880 Model Healthcare VTC system; participants met as a group for both conditions	12 Sessions of cognitive processing CBT	Improvement in PTSD symptoms: clinician-administered PTSD scale, process variables including group therapeutic alliance; CPOSS-VA	Comparable decrease in PTSD symptoms; comparable process indicators; no sessions cancelled due to technical difficulties; high satisfaction with VTC format	I
Vranceanu et al., 2016¹⁹	RCT: Active treatment vs placebo control group, both VTC	NF	Active = 32 Control = 31	Skype (no additional information on connectivity or participant location)	Relaxation Response Resiliency Program for NF	Physical health and psychological QoL using the World Health Organization QoL abbreviated instrument	Highly feasible, accepted by patients, and associated with improvement in multiple QoL domains	I
Zernicke et al., 2014²⁰	RCT: VTC vs WLC	Any cancer diagnosis + completed treatment in past 3 years	30 in each group	eMindful Inc.; headsets and webcams provided; tech support available; participants connect from home	Mindfulness-based cancer recovery program	Feasibility; improvement in measures related to QoL, spiritual well-being, mood, and posttraumatic growth	Most patients satisfied with intervention; decreased mood and stress symptoms; increased spirituality	I
Azar et al., 2015²¹	Pilot RCT: VTC vs delayed-intervention control	Obese men	32 per group	Encrypted web-based VTC software; participants provided HD web camera and microphone	12 Weekly small groups; diabetes prevention program	Weight loss	Intervention group lost more weight than controls; technical difficulties with audio quality	I
Batastini and Morgan 2016²²	Nonrandomised trial: VTC vs FTF vs NT	Male inmates in seclusion	VTC = 24 FTF = 12 NT = 13	Polycom VTC system; up to 6 participants on split screen; participants in separate rooms	CBT coping skills group; weekly for 6 weeks	Symptom Checklist 90-Revised, measures of criminal thinking styles, Client Satisfaction Questionnaire 8, Working Alliance Inventory, and Intervention Group Environments Scale	VTC group was less accepting of facilitator; agreed less on the tasks and goals of the intervention vs in-person participants; VTC participants felt less cohesion within the group; no group differences on measures of psychological functioning and criminal thinking across the 3 groups	II-1
Carlson et al., 2012²³	Nonrandomised trial, group selection by location: FTF vs VTC	Smokers, self-referred or by PCP	FTF = 370 VTC = 184	VTC equipment in up to 6 remote sites, each with local facilitator; main facilitators in auditorium with split screen showing 6 sites; ISDN lines transmitting at 384 kB/s	Smoking cessation protocol, 8 sessions over 15 weeks	Cessation rates; perceptions of telehealth	Smoking cessation rates similar for both groups; better than those typically achieved through websites or telephone counseling; VTC interfered somewhat with the FTF session; low completion rates of satisfaction surveys, but responses generally positive	II-1
Kearns et al., 2012²⁴	Nonrandomised trial: VTC vs FTF	Diabetes patients	VTC = 27 FTF = 39	Participants at 1 remote site using point-to-point ISDN line connection using an Intel ProShare video system with camera	Diabetes Self-Management Education, 1-h individual assessment and 6-h ‘Living With Diabetes’ class; follow-up class after 1 month	HbA_1c, Problem Areas in Diabetes Survey, Diabetes Treatment Satisfaction Questionnaire, Telemedicine satisfaction survey	HbA_1c levels improved slightly in each group, nonsignificant difference between groups; both groups had improved diabetes-related distress; diabetes treatment satisfaction improved for FTF but not VTC; high satisfaction with VTC format	II-1
Khatri et al., 2014²⁵	Nonrandomised trial: VTC vs FTF, group selection by participant preference	DSM-IV diagnosis of mood, anxiety, or adjustment disorder	VTC = 8 FTF = 10	Password-protected web platform, includes email, nonsynchronous discussion thread, VTC for group meetings, online handbook; study coordinator was main IT support	CBT group for 13 weeks	Improvement on BDI-II at 3 months; reliable adherence to a group CBT protocol	Reliable adherence in both groups; comparable improvement in BDI-II in both groups, many technical challenges	II-1
Marziali and Garcia, 2011²⁶	Nonrandomised trial: participant selection for VTC or Internet-based chat support	Caregivers of adults with dementia	VTC = 51 Chat group = 40	Caring for Me website and training manuals; computers provided for small percentage who needed them; webcams and audio headsets provided for all VTC participants	Chat group: text-based chat group with online resources Video group: 10 week online VTC support group	Reactions to using technology to access a healthcare intervention program and perceived usefulness of the intervention program	Chat discussion not used frequently; both groups showed improved self-efficacy and decreased distress related to specific caregiving tasks; VTC intervention was more effective in improving mental health status	II-1
Marziali and Donahue, 2006²⁷	Feasibility study: randomised to web-based intervention or no treatment control group	Family caregivers of older adults with neurodegenerative disease	66, unknown allocation details	Group members received computers and training to use ‘a password-protected Web site’ and a VTC ‘link for the support-group intervention’	10-Session manualised psychosocial support group, with 12 additional sessions run by group members	Feasibility; adherence to treatment strategies	Improvement in general health, depression; stress response to ADLs, IADLs, and difficult behaviours, and social support; VTC groups adhered to treatment goals; qualitative analysis of group themes in line with theoretical framework; no group differences in stress measures; high dropout rate from control group (54%)	II-2
Austrom et al., 2015²⁸	Feasibility; before-and-after study	Caregivers of adults with dementia	5	Cisco Movi program; group members provided with computer at home; research assistant provided IT support (remotely or in home); at least 200 kB/s speed	Psychosocial educational support group once a week for 6 months	Revised Scale for Caregiving Self-Efficacy, PHQ-9, GAD-7, caregiver-perceived health and QoL via the Short Form-36, postintervention focus group feedback	Decreased anxiety and depression symptoms; improvement in perceived physical health; improvement in self-efficacy; slight increase in overall caregiver burden; participants reported positive experiences and the desire to continue with further group meetings	II-3
Banbury et al., 2016²⁹	Feasibility; before-and-after study	Older adults with chronic medical conditions	52	Samsung Slate XE700T1A-A03AU 11.6-inch screen and docking station was supplied to each participant with a secure VTC platform	6-Week educational program on health literacy and chronic disease management	Qualitative, participant feedback	Background noise was disruptive; low lighting was a problem; need systems for facilitating communication; high-level IT support is needed	II-3
Chang et al., 2016³⁰	Feasibility; before-and-after study	Persons with recent loss of a loved one	4	Participants located at 1 of 5 remote sites; group facilitators located at the main site; Cisco Telepresence SX20 VTC equipment	Grief group, psychoeducational and support group format; 8 sessions	PHQ-9, Clinical Outcomes in Routine Evaluation-form B, semistructured interview to assess complicated grief, participant satisfaction survey	No change in quantitative measures; participants were highly satisfied; participants would have preferred ‘some in-person contact with the facilitators, preferably [at] the 1st session’	II-3
Collie et al., 2007³¹	Feasibility; before-and-after study	Women with breast cancer	27	Participants attended 1 of 4 support groups via a videoconferencing site near her (some > 50 miles); Polycom VTC unit and an Accord MGC-100 VTC bridge; high-speed telephone lines 384 bps	8 2-h Weekly support sessions run by a social worker	Qualitative interview, improvement on measures of anxiety and depression	Improvement in most measures; women reported feeling they had made strong emotional bonds; appreciated option for rural women; participants were positive about the technology; technical problems with lighting and lag time	II-3
Doorenbos et al., 2010³²	Cross-sectional study	Cancer survivors and caregivers (rural AI and AN)	50 participants sampled (32 returned surveys)	VTC to conference rooms, facilitated by university	Cancer 101 support group format	Telehealth Satisfaction Survey	Participants reported a high level of satisfaction	II-3
Frueh et al., 2005³³	Feasibility; before-and-after study	Men with alcohol abuse or dependence	18 (14 completers)	ViaVideo (Polycom) at 384 kbit/s; participants located in 1 remote site, with 2–7 participants per group session	8 Sessions of group therapy for substance abuse over 4 weeks	Qualitative satisfaction and acceptance, treatment credibility, attendance, CPOSS-VA, Treatment Credibility Questionnaire, Telemedicine Satisfaction and Acceptance Scale	High satisfaction with intervention and telemedicine; qualitative feedback about improving lighting and size of the video screen; participant feedback that it would be helpful to have an initial in-room session with the therapist	II-3
Lipman et al., 2011³⁴	Feasibility; before-and-after study	Poor, single mothers of a child age 3-9 y	2 pilot groups n = 15	Password-protected web platform; online message board and resource manual; computer, webcam and high-speed Internet provided	Weekly sessions for 10 weeks, supportive/ educational sessions	VTC session archived and reviewed for group process and adherence, follow-up interviews with participants, Center for Epidemiologic Studies Depression Scale	Qualitative reports of decreased isolation; increased knowledge of parenting, increased confidence; response to VTC format showed web-based format was less threatening and more convenient; no significant improvement on quantitative outcome measures	II-3
Lounsberry et al., 2010³⁵	Feasibility; before-and-after study	Allogeneic stem cell transplant patients, 0-3 y post transplant	19	Participants go to health centre near their home with VTC capability; up to 4 remote sites; support person sets up the group, then leaves	6 Weekly support group sessions	Functional measures, measures of QoL, spirituality and meaning making, distress, and positive growth	High attendance and satisfaction ratings; no improvement in QoL, spirituality and meaning making, distress, or positive growth	II-3
O'Connell et al., 2014³⁶	Feasibility; before-and-after study	Rural spouses of persons with atypical and early onset dementias	11	‘Group members each travelled to a local hospital-based site to use the videoconferencing equipment’	Emotional processing group; monthly meetings over 3 years	Qualitative, perceptions of caregivers	Group members valued feeling less alone	II-3
Tan et al., 2013³⁷	Feasibility; before-and-after study	Women veterans with chronic pain and comorbid depression or PTSD	34 (27 completers)	Polycom VSX 5000; T1 bandwidth; VTC between main hospital and 2 local clinics	5 Weekly group sessions and home practice with biofeedback device	PTSD Checklist, Center for Epidemiological Studies-Depression Scale 10, pain intensity measure, Medical Outcomes Sleep Measure, focus groups to assess participant response to VTC format	Statistically significant improvement in pain unpleasantness, pain interference, depressive symptoms, PTSD symptoms, and sleep disturbance; participants found the sessions as acceptable as in-person sessions	II-3
Campo et al., 2017³⁸	Feasibility	Young adult cancer survivors	21	Participants provided headphone for use with home computer; VTC with Cisco WebEx	8-Week Mindful Self-Compassion Program	>75% Attending 6-8 sessions; psychosocial outcomes related to resilience, body image, and self-acceptance	Feasibility goal was met; improvement in psychosocial outcomes; ‘the technological challenges were infrequent and minor’; high participant satisfaction	III
Rayner et al., 2016³⁹	Feasibility	Parents of children with life-threatening illness	13	Participant home computer or tablet; Go-to-Meeting software	5 Sessions of Acceptance and Commitment Therapy	Feasibility, measures of stress and psychological function	Feasibility demonstrated with 92% session attendance; high comfort level among participants with the VTC	III
Kinner et al., 2018⁴⁰	Feasibility	Ovarian cancer survivors	19	Home computer or tablet; Cisco WebEx and Zoom Video Communications; wireless Internet or 4G	10 Weekly sessions of stress-management intervention	Feasibility and acceptability, measures of mood, QoL, sleep, and social support	Feasible with 68% retention; participants highly satisfied; improvements in perceived stress and QoL; connectivity problems reported	III
Laitinen et al., 2010⁴¹	Feasibility, non-randomised	Persons at risk for type 2 diabetes	VTC = 33, FTF = 44	VTC from meeting room at their local health centre	4 Sessions of dietary counseling	Feasibility, satisfaction, metabolic measures	‘The proportion of subjects who received a lot of social support from other group participants was higher in the [VTC] groups than in the [FTF] groups’; no between-group differences on metabolic measures	II-1
Burkow et al., 2015⁴²	Pilot feasibility	Patients with COPD	10	Home television–connected computer with broadband Internet connection	9-Week pulmonary rehabilitation program with group exercise and self-management education	Feasibility, satisfaction based on semistructured interviews, QoL scale, System Usability Scale	Well accepted by participants; high satisfaction; technology was easy to use; one participant with problems with wireless Internet connectivity	III
Burkow et al., 2013⁴³	Pilot, feasibility, qualitative	Patients with COPD or diabetes	COPD = 5, diabetes = 5	Home television– connected computer (using the Residential Patient Device) with broadband Internet connection	8 Weeks of comprehensive pulmonary rehabilitation and diabetes self-management education	Feasibility, satisfaction based on semistructured interviews	Well accepted by participants; high satisfaction; good participant retention	III
Taylor et al., 2012⁴⁴	Qualitative; before-and-after study	Stroke survivors and caregivers	19	4-6 Participants at local site, 4-6 via VTC at 2 remote sites; local IT support provided	Moving On After Stroke, 18 sessions with 1-h discussion, 1-h exercise	Qualitative	Participants felt engaged and appreciated opportunity to participate; some reported feeling of being in the same room, but with loss of subtleties of interaction; poor video quality; more local technical support needed	II-3
Tsaousides et al., 2014⁴⁵	Feasibility; before-and-after study	TBI with emotional dysregulation	7	GoToMeeting, participants using personal computer	16 Sessions of EmReg (a CBT-based intervention combining didactic and experiential training)	Outcome measures related to emotional regulation, Satisfaction with Therapy and Therapist Scale, and exit interview	Participants had positive feedback about the format; some noted that VTC was less distracting than FTF; no improvement in clinical measures	II-3
Zhou et al., 2016⁴⁶	Feasibility; before-and-after study	Adult cancer survivors (diagnoses of breast, prostate, and blood cancers)	16	Tablet computer (iPad) for each participant to connect the Cisco WebEx VTC software. First session was in person at the recruitment site	4, 1-h Weekly group sessions, adapted from a CBT stress management intervention	Perceived Stress Scale, open-ended query regarding what participants liked and disliked about the program	Participants reported treatment-related barriers including difficulties with developing an emotional connection to other group participants, inability to focus on content, and technical difficulties (e.g. wireless connectivity disruptions); only slight improvements in perceived stress	II-3
Sander et al., 2009⁴⁷	Feasibility; before-and-after study	Caregivers of adults with TBI	15	Caregivers reported to a VTC centre and connected via University-based VTC network	6 VTC sessions, designed for a group format, but given individually due to logistical difficulties	Satisfaction and perceived utility	Generally positive response from participants; some difficulties with scheduling and access to teleconference rooms	II-3
Somers et al., 2015⁴⁸	Feasibility; before-and-after study	Patients with breast, lung, prostate, or colorectal cancer who reported persistent pain	25	Skype via an iPad with wireless data plan, provided to participants	4 Sessions of pain coping skills training	Outcome measures related to pain, distress, and physical symptoms; Brief Pain Inventory; participant rating of program quality and acceptability	Participants reported substantially decreased pain severity, physical symptoms, psychological distress, and pain catastrophising; high levels of completion and participant satisfaction	II-3

ADLs: activities of daily living; AES: Advanced Encryption Standard; AI and AN: American Indian and Alaskan Native; BDI-II: Beck Depression Inventory Second Edition; CBT: cognitive behavioral therapy; COPD: chronic obstructive pulmonary disease; CPOSS-VA: Charleston Psychiatric Outpatient Satisfaction Scale-VA PTSD Version; FTF: face-to-face; GAD-7: Generalized Anxiety Disorder seven-item scale; GTAS: Group Therapy Alliance Scale; HbA_1c: haemoglobin A_1c; HD: high-definition; HIV: human immunodeficiency virus; IADLs: instrumental activities of daily living; ISDN: integrated services digital network; IT: information technology; NF: neurofibromatosis; NT: no treatment; PCP: primary care provider; PHQ-9: Patient Health Questionnaire-9; PTSD: posttraumatic stress disorder; QoE: quality of evidence; QoL: quality of life; RCT: randomised controlled trial; TBI: traumatic brain injury; VTC: video teleconference; WLC: wait list control.

Target populations were variable among studies, with inclusion criteria based on common features such as cancer survivors, caregivers of adults with dementia, or veterans with posttraumatic stress disorder (PTSD) (Table 1).

There was substantial heterogeneity among the studies included for review, including the choice of participants, the intervention provided, and the measures used to assess outcomes. Eleven of the studies were primarily qualitative.^{26,27,29,32,36,43,44,47,49–51}

The methodological quality of the studies was assessed using the quality of evidence criteria of the US Preventive Services Task Force (Table 2).⁵²

Table 2.

Quality of evidence scale.

Rating	Criteria
I	Properly designed randomised controlled trial
II-1	Well-designed controlled trials without randomisation
II-2	Well-designed cohort or case-control analytic studies
II-3	Multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence
III	Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Source: Modified from US Preventive Services Task Force,⁵² which was developed with data from: Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121: 1193–1254.

Description of technology

There was immense variability in each study's description of the technology used for providing the VTC intervention. Several studies described the computer program or teleconference technology that was used. Some described whether technical support was provided either before the intervention or during the group sessions. Some studies specifically examined technical issues and the quality of videoconferencing interaction, whereas others were limited in providing this information. Only six studies reported Internet connectivity in kilobytes per second (kB/s), with speeds ranging from 200–512 kB/s.^{13,15,23,28,31,33} Five studies that collected information related to technical issues indicated that this was not a major concern during the course of their intervention.^{9,11,14,18,38} In other studies, several types of technical difficulties were described related to video quality,⁴⁴ audio quality,^21,25,29,49 low lighting^29,31,33 and VTC connectivity.^{25,31,40,42,46,49} Two studies identified a need for increased local technical support.^29,44

VTC sessions were provided with various group designs across studies, including single point-to-point groups and multipoint groups (Figure 1). In 21 studies, participants connected to the VTC with a multipoint design using a personal computer or tablet.^{11,19–21,25–29,34,38–40,42,43,45,46,48–51} Nineteen used either point-to-point or multipoint design with group participants gathering in one or more clinic locations where the VTC connection was provided by institutional teleconferencing equipment.^{9,12,14,15,17,18,22–24,30–33,35–37,41,44,47} For studies with participants at several different clinical sites, the number of participants at each location varied – that is, some remote sites would include face-to-face group participant interaction, whereas other sites would only have one participant each. In one study, the therapists delivered smoking cessation content to an in-person group, with simultaneous broadcast via VTC connections to other remote locations.²³

Description of psychological/supportive intervention

The studies included a broad range of psychosocial interventions, such as cognitive behavioural therapy, mindfulness training, coping skills training, and acceptance and commitment therapy. Studies included support groups for patients and caregivers with cancer, chronic pain, and neurodegenerative disorders (Table 1). There were also educational groups in the areas of diabetes, weight management and smoking cessation. Most studies were short-term groups of 6–14 sessions. One study was described as an emotional processing group and consisted of monthly meetings over the course of three years.³⁶

Participant satisfaction and evaluation of technology

Participant satisfaction with the telemental health intervention was commonly assessed with satisfaction questionnaires and/or postintervention participant interview. There is no formally identified standard measure for assessing patient satisfaction with telemedicine interventions. Two studies used the Telemedicine Satisfaction and Acceptance Scale, an 11-item questionnaire developed to study participant perceptions about variables related to mode of service delivery.^18,33 None of the studies described whether this tool has been empirically validated. Some studies used individually developed patient satisfaction questionnaires. Other studies used qualitative methods to determine the participant experience with telemedicine, such as postintervention focus groups or semistructured interviews. All of the studies reviewed indicated that the participants had positive perceptions of the telehealth experience. Two studies reported that participants had concerns regarding low lighting or background noise that directly interfered with the VTC experience.^29,33 One study noted difficulty with scheduling and access to the VTC rooms.⁴⁷ Only one study identified patient acceptance as a barrier to implementation, reporting that nine participants withdrew from the study because they did not contact information technology support for necessary technology upgrades to their home computers.¹¹

Group process outcomes

Several studies were designed to specifically examine group process indicators to determine whether group process was affected by a VTC delivery method.^{9,17,18,22,45} Many of the pilot/feasibility studies primarily evaluated qualitative postintervention interviews to determine participants' perceived experience. Themes of these qualitative analyses indicated that group participants reported a positive group experience, wanted to continue group sessions, felt valued by group members and felt less alone.^28,36,44,46 In two of the studies, participants indicated that their group experience would have been improved by having at least one face-to-face interaction with the therapist at the beginning of treatment.^30,33 Studies that directly compared group process outcomes showed some mild differences between groups, with small decreases in therapeutic alliance and group cohesion in the VTC group vs face-to-face delivery.^9,12,22 These differences in group process indicators, however, did not appear to result in different treatment outcomes between the VTC and face-to-face groups. In two studies, participants indicated a preference for VTC over face-to-face interaction because it was less distracting and threatening.^25,34,45

Effectiveness of group-based intervention

All studies included in this review indicated generally positive clinical outcomes but were limited in drawing conclusions about efficacy of the group-based intervention because of the absence of randomisation and/or appropriate control groups. Across studies, there was general agreement that VTC groups were feasible and well accepted by participants. Several studies used quantitative measures and indicated general posttreatment improvement in anxiety and depression symptoms,^27,28,34 quality of life^19,35 and perceived stress.⁴⁶

Discussion

This literature review identified several fundamental questions regarding group treatment provided via telemedicine. First, is group-based psychotherapy or a support group intervention via VTC as effective as similar in-person treatment? This question would require the comparison of two treatment groups for which similar interventions were provided, with one condition given face-to-face and another provided remotely via VTC equipment. Only six studies examined this treatment condition in an RCT fashion.^{9,12,15,17,18,21} This is a field of study, however, in which randomisation can present technical and clinical challenges. In particular, telemedicine serves to bring healthcare to those who live in remote areas and do not have ready access to the types of academic centres where rigorous RCTs are often performed. Participants can be randomly assigned to a VTC versus in-person treatment only if they live in close proximity to the research centre or if the research centre can send providers to remote locations for in-person treatment. Therefore, true randomisation may not always be feasible or preferable. Additional factors such as patient preference and comfort with technology may be relevant to understanding the role of telemedicine for specific populations. Five additional studies directly compared a VTC group with a face-to-face group but did not include randomisation.^22–25,41 Among these 11 studies, both randomised and nonrandomised, no differences were found between VTC and face-to-face groups in terms of treatment outcomes, such as decreased PTSD symptoms or smoking cessation rates. Three of these studies were able to demonstrate through noninferiority analysis that VTC was equivalent to face-to-face delivery of the same intervention.^9,12,18 All three studies were performed among male veterans with PTSD. Additional studies in other populations would be beneficial, as would other group interventions of a similar design to show equivalence of VTC groups across various populations and conditions.

The second relevant clinical question to be considered is: do specific group processes differ between face-to-face and VTC groups? Four studies specifically evaluated measures of group process,^9,17,18,22 and one used a measure of satisfaction with therapy and the therapist.⁴⁵ These studies indicated mild decreases for VTC in factors related to alliance with the group or with the therapist. Batastini and Morgan²² indicated that participants in the VTC group were less trusting and accepting of the facilitator and felt less cohesion within the group. Morland and colleagues⁹ indicated that participants in the VTC group showed lower levels of self-therapist alliance. These differences in group process indicators were not associated with treatment outcomes in any of the studies. Several other noncontrolled studies used qualitative information provided by participants regarding their experience with a VTC group. In the study by Chang and colleagues,³⁰ participants believed that the care they received was just as good as face-to-face services. Collie et al.³¹ indicated that women felt they had made strong emotional bonds with other group members. In the study by O'Connell and colleagues,³⁶ participants stated that they valued feeling less alone as the result of attending the group. However, in one study among 16 adult cancer survivors, participants reported treatment-related barriers, including difficulties with developing an emotional connection to other group participants and persistent technical difficulties.⁴⁶ In two studies, participants reported that they would have preferred some component of in-person contact with the facilitators, preferably at the initial session.^30,33 Evidence is still limited as to the role of group process factors in relation to providing remote group treatment. Only a few studies directly examined group process indicators. There was no consistent use of standard measures to assess factors such as group cohesion and therapeutic alliance.

The potential effect of these differences in group organization and structure was not addressed directly in any of the studies. Currently, no evidence is available to suggest whether having all group participants physically located in one location, vs all participants only having remote access to each other, would influence treatment outcomes or group process factors such as adherence and therapeutic alliance. None of the studies addressed whether specific participant characteristics might contribute to a preference for different group organizational structures – for example, whether participants with certain types of physical or mental health challenges may feel more comfortable in settings without any face-to-face interaction.

The last question raised by this study is: are participants and providers satisfied with interventions using VTC technology? Several of the studies used structured interviews or internally developed patient satisfaction surveys to assess satisfaction with VTC technology. All the studies in this review indicated generally positive feedback from participants, with high ratings of satisfaction. Few studies surveyed the group therapists/providers with regard to their level of satisfaction with the use of technology. In some of the studies, it was clear that study participants would not have been able to receive the treatment at all had it not been provided via VTC. In other studies, the participants were randomly assigned to VTC or face-to-face treatment. It is reasonable to assume that participants' pre-existing preferences regarding in-person or remote treatment may have influenced their perceptions of VTC technology. Participants also interacted with the VTC technology in various ways. Some participants were located alone at home or in a clinic site. In other studies, patients were grouped together in a conference room at one remote site. In some conditions, group participants could see other group members on a split screen, whereas in other studies only the therapist was able to view all group members. Beyond the effect this may have on group process, there are also important implications for the use of technology, with more control of and technical support for groups located in clinical or research sites vs in a participant's home.

Limitations

There are several limitations of this review. Most studies were limited by small sample sizes or lack of control groups. Only four studies included a VTC treatment arm with more than 50 participants.^23,26,29,49 Six studies had 10 or fewer participants per treatment group.^{15,17,25,28,30,45} It was difficult to draw more specific conclusions regarding treatment effects of VTC because of the great variability between study methods, interventions, and target populations. Most studies were pilot/feasibility studies and therefore not designed to show statistically significant differences between VTC and in-person treatment. Because telehealth interventions represent an emerging field of study, there is a lack of consensus on the terminology to describe them. Terminology such as telehealth, telemental health, web-based, Internet-based, online and VTC can have variable meanings and are not used consistently across the literature. Therefore, it is possible that additional studies exist in the literature but were missed because of limitations of the search methods.

Conclusion

Telemental health group treatment has been shown to be feasible and is well received by participants. More rigorous studies, especially RCTs, are warranted to ensure that a group-based telehealth intervention is sufficiently equivalent to in-person treatment. The unique elements of group dynamics can be affected by a remote, VTC format; thus, this area requires specific study. It is possible that many group dynamics, such as group cohesion and therapeutic alliance, may not be adequately represented via a telehealth intervention. As noted in the limitations, many studies were not specifically identified as providing a group-based treatment and did not specifically examine group process factors. Additional research is needed to better understand factors that would enhance the delivery of VTC group treatment and mitigate possible negative effects on group process.

Telemental health interventions are greatly needed to improve access to qualified mental health providers. Given the limited availability of mental health providers, especially in remote or rural areas, it is reasonable to consider group-based treatment as a way to disseminate evidence-based care more broadly.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

References

Lungu

Sun

. Time for a change: College students' preference for technology-mediated versus face-to-face help for emotional distress. Telemed J E Health 2016; 22: 991–1000.

Grady

Myers

Nelson

et al.

Evidence-based practice for telemental health. Telemed J E Health 2011; 17: 131–148.

Hailey

Roine

Ohinmaa

. The effectiveness of telemental health applications: A review. Can J Psychiatry 2008; 53: 769–778.

Bashshur

Shannon

Bashshur

et al.

The empirical evidence for telemedicine interventions in mental disorders. Telemed J E Health 2016; 22: 87–113. .

Hilty

Ferrer

Parish

et al.

The effectiveness of telemental health: A 2013 review. Telemed J E Health 2013; 19: 444–454.

Kung

Rummans

et al.

Reducing caregiver stress with Internet-based interventions: A systematic review of open-label and randomized controlled trials. J Am Med Inform Assoc 2015; 22: e194–e209.

Thompson

Spilsbury

Hall

et al.

Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatr 2007; 7: 18.

Clark

Bostwick

Rummans

. Group and individual treatment strategies for distress in cancer patients. Mayo Clin Proc 2003; 78: 1538–1543.

Morland

Greene

Rosen

et al.

Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. J Clin Psychiatry 2010; 71: 855–863.

10.

Banbury

Nancarrow

Dart

et al.

Telehealth interventions delivering home-based support group videoconferencing: Systematic review. J Med Internet Res 2018; 20: e25.

11.

King

Stoller

Kidorf

et al.

Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling. J Subst Abuse Treat 2009; 36: 331–338.

12.

Frueh

Monnier

Yim

et al.

A randomized trial of telepsychiatry for post-traumatic stress disorder. J Telemed Telecare 2007; 13: 142–147.

13.

Frueh

Monnier

Grubaugh

et al.

Therapist adherence and competence with manualized cognitive-behavioral therapy for PTSD delivered via videoconferencing technology. Behav Modif 2007; 31: 856–866.

14.

Marhefka

Buhi

Baldwin

et al.

Effectiveness of healthy relationships video-group-A videoconferencing group intervention for women living with HIV: preliminary findings from a randomized controlled trial. Telemed J E Health 2014; 20: 128–134. .

15.

Morland

Pierce

Wong

. Telemedicine and coping skills groups for Pacific Island veterans with post-traumatic stress disorder: A pilot study. J Telemed Telecare 2004; 10: 286–289.

16.

Greene

Morland

Macdonald

et al.

How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. J Consult Clin Psychol 2010; 78: 746–750.

17.

Morland

Hynes

Mackintosh

et al.

Group cognitive processing therapy delivered to veterans via telehealth: A pilot cohort. J Trauma Stress 2011; 24: 465–469.

18.

Morland

Mackintosh

Greene

et al.

Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: A randomized noninferiority clinical trial. J Clin Psychiatry 2014; 75: 470–476.

19.

Vranceanu

Riklin

Merker

et al.

Mind-body therapy via videoconferencing in patients with neurofibromatosis: An RCT. Neurology 2016; 87: 806–814.

20.

Zernicke

Campbell

Speca

et al.

A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: The eTherapy for Cancer Applying Mindfulness Trial. Psychosom Med 2014; 76: 257–267.

21.

Azar

Aurora

Wang

et al.

Virtual small groups for weight management: An innovative delivery mechanism for evidence-based lifestyle interventions among obese men. Transl Behav Med 2015; 5: 37–44.

22.

Batastini

Morgan

. Connecting the disconnected: Preliminary results and lessons learned from a telepsychology initiative with special management inmates. Psychol Serv 2016; 13: 283–291.

23.

Carlson

Lounsberry

Maciejewski

et al.

Telehealth-delivered group smoking cessation for rural and urban participants: Feasibility and cessation rates. Addict Behav 2012; 37: 108–114.

24.

Kearns

Bowerman

Kemmis

et al.

Group diabetes education administered through telemedicine: Tools used and lessons learned. Telemed J E Health 2012; 18: 347–353.

25.

Khatri

Marziali

Tchernikov

et al.

Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: A pilot study. Clin Interv Aging 2014; 9: 765–770.

26.

Marziali

Garcia

. Dementia caregivers' responses to 2 Internet-based intervention programs. Am J Alzheimers Dis Other Demen 2011; 26: 36–43.

27.

Marziali

Donahue

. Caring for others: Internet video-conferencing group intervention for family caregivers of older adults with neurodegenerative disease. Gerontologist 2006; 46: 398–403.

28.

Austrom

Geros

Hemmerlein

et al.

Use of a multiparty web based videoconference support group for family caregivers: Innovative practice. Dementia (London) 2015; 14: 682–690.

29.

Banbury

Parkinson

Nancarrow

et al.

Delivering patient education by group videoconferencing into the home: Lessons learnt from the Telehealth Literacy Project. J Telemed Telecare 2016; 22: 483–488.

30.

Chang

Sequeira

McCord

et al.

Videoconference grief group counseling in rural Texas: Outcomes, challenges, and lessons learned. The Journal for Specialists in Group Work 2016; 41: 140–160. .

31.

Collie

Kreshka

Ferrier

et al.

Videoconferencing for delivery of breast cancer support groups to women living in rural communities: A pilot study. Psychooncology 2007; 16: 778–782.

32.

Doorenbos

Eaton

Haozous

et al.

Satisfaction with telehealth for cancer support groups in rural American Indian and Alaska Native communities. Clin J Oncol Nurs 2010; 14: 765–770.

33.

Frueh

Henderson

Myrick

. Telehealth service delivery for persons with alcoholism. J Telemed Telecare 2005; 11: 372–375.

34.

Lipman

Kenny

Marziali

. Providing web-based mental health services to at-risk women. BMC Womens Health 2011; 11: 38.

35.

Lounsberry

Macrae

Angen

et al.

Feasibility study of a telehealth delivered, psychoeducational support group for allogeneic hematopoietic stem cell transplant patients. Psychooncology 2010; 19: 777–781.

36.

O'Connell

Crossley

Cammer

et al.

Development and evaluation of a telehealth videoconferenced support group for rural spouses of individuals diagnosed with atypical early-onset dementias. Dementia (London) 2014; 13: 382–395.

37.

Tan

Teo

Srivastava

et al.

Improving access to care for women veterans suffering from chronic pain and depression associated with trauma. Pain Med 2013; 14: 1010–1020.

38.

Campo

Bluth

Santacroce

et al.

A mindful self-compassion videoconference intervention for nationally recruited posttreatment young adult cancer survivors: Feasibility, acceptability, and psychosocial outcomes. Support Care Cancer 2017; 25: 1759–1768.

39.

Rayner

Dimovski

Muscara

et al.

Participating from the comfort of your living room: Feasibility of a group videoconferencing intervention to reduce distress in parents of children with a serious illness or injury. Child Fam Behav Ther 2016; 38: 209–224.

40.

Kinner

Armer

McGregor

et al.

Internet-based group intervention for ovarian cancer survivors: Feasibility and preliminary results. JMIR Cancer 2018; 4: e1.

41.

Laitinen

Korkiakangas

Alahuhta

et al.

Feasibility of videoconferencing in lifestyle group counselling. Int J Circumpolar Health 2010; 69: 500–511.

42.

Burkow

Vognild

Johnsen

et al.

Comprehensive pulmonary rehabilitation in home-based online groups: A mixed method pilot study in COPD. BMC Res Notes 2015; 8: 766.

43.

Burkow

Vognild

Ostengen

et al.

Internet-enabled pulmonary rehabilitation and diabetes education in group settings at home: A preliminary study of patient acceptability. BMC Med Inform Decis Mak 2013; 13: 33.

44.

Taylor

Stone

Huijbregts

. Remote participants' experiences with a group-based stroke self-management program using videoconference technology. Rural Remote Health 2012; 12: 1947.

45.

Tsaousides

D'Antonio

Varbanova

et al.

Delivering group treatment via videoconference to individuals with traumatic brain injury: A feasibility study. Neuropsychol Rehabil 2014; 24: 784–803.

46.

Zhou

Partridge

Blackmon

et al.

A pilot videoconference group stress management program in cancer survivors: Lessons learned. Rural Remote Health 2016; 16: 3863.

47.

Sander

Clark

Atchison

et al.

A web-based videoconferencing approach to training caregivers in rural areas to compensate for problems related to traumatic brain injury. J Head Trauma Rehabil 2009; 24: 248–261.

48.

Somers

Abernethy

Edmond

et al.

A pilot study of a mobile health pain coping skills training protocol for patients with persistent cancer pain. J Pain Symptom Manage 2015; 50: 553–558.

49.

Banbury

Parkinson

Nancarrow

et al.

Multi-site videoconferencing for home-based education of older people with chronic conditions: The Telehealth Literacy Project. J Telemed Telecare 2014; 20: 353–359.

50.

Damianakis

Wilson

Marziali

. Family caregiver support groups: Spiritual reflections' impact on stress management. Aging Ment Health 2018; 22: 70–76.

51.

Marziali

Donahue

Crossin

. Caring for others: Internet health care support interventions for family caregivers of persons with dementia, stroke, or Parkinson's disease. Fam Soc 2005; 86: 375–383.

52.

U.S. Preventive Services Task Force. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions: report of the U.S. Preventive Services Task Force, Baltimore, MD: Williams & Wilkins, 1989.