Crisis and Post-Crisis Virtual Mental Health Care: A Scoping Review

SEARCH STRATEGY

We selected search terms and databases for the review based on the expertise of our team and in consultation with a librarian. Based on commonly used terms and terms found in the literature, search terms were generated for variations of the following concepts: (1) virtual care, (2) mental health, and (3) crisis or emergency. The search terms were tried in different combinations, and the results were compared for volume and relevancy. Given the variability in terminology used on the topic, the final search string was kept broad to ensure maximum inclusion: ((tele* OR video* OR virtual* OR hospital-at-home) AND (psych* OR mental health OR suicide) AND (crisis* OR acute care OR urgent OR emergen* OR hospital*)).

PubMed, PsycINFO, CINAHL, and ProQuest databases were queried using the search string above. Parameters were applied to each database search, including limiting searches by title and abstract, English- and French-language publications, and date range from January 1, 2018, to June 30, 2024. There were no limits on age criteria. Citations from each database were imported into the online Covidence review management software.

ELIGIBILITY CRITERIA AND LITERATURE SELECTION

We established a set of eligibility criteria prior to screening citations (see Table 1). The task of screening citations was shared by all three authors. For each citation, at least two authors independently screened each citation by title and abstract. Overall agreement across raters was 96.3%, with interrater reliability between reviewer pairs ranging from a Cohen’s kappa of 1 (perfect agreement) to 0.38 (fair agreement) ¹⁸ ; however, articles were reviewed in a nonrandom fashion. Any disagreements were resolved by discussion with the entire study team, and eligibility criteria were revised or added as needed. Studies that potentially met the inclusion criteria were then screened by full text. Any uncertainty about article selection based on full-text review was discussed with the entire study team, while full-text articles that met criteria were included in the review.

OPEN IN VIEWER

Table 1.

Inclusion and Exclusion Criteria

INCLUSION	EXCLUSION
Literature that reports on the accessibility, delivery, and/or outcomes for at-home virtual mental health crisis care.	A substantial portion of the service is in person (i.e., in-person care at a hospital, clinic, and emergency department).
Article describes a program(s) providing direct care using virtual technology to individuals at home or another non-health care setting.	The patient is experiencing a mental health crisis secondary to a medical condition (e.g., brain injury, cognitive impairment, cancer, type 1 diabetes, COVID-19 survivors, and chronic pain due to multiple sclerosis).
Literature that describes program(s) that support individuals of any age in a mental health crisis (i.e., psychiatric or psychosocial distress).	Domestic abuse and child abuse are not considered mental health crises (e.g., a child reporting distress or maltreatment to a hotline).
The service is for emergency/acute/crisis intervention situations and intended as an intervention to conduct a crisis assessment, reduce future crisis care use, or serve as an alternative to hospital or other in-person facility admission (e.g., crisis stabilization unit).	Interventions that focus exclusively on substance use disorders are not considered interventions for mental health crises.
A structured program where the patient is recruited directly from a crisis setting (program initiates immediately during the crisis presentation or following discharge from the crisis setting).	The service provides ongoing support for a chronic psychiatric or mental health condition.
Literature published in peer-reviewed journals, article preprints, reviews, meta-analyses, published conference proceedings, and theses.	A structured program where the patient is recruited from a noncrisis setting (e.g., outpatient psychotherapy treatment).
Crisis line must go beyond the typical hotline triage and de-escalation and provide some more comprehensive assessment and intervention or follow-up.	The article does not describe a mental health crisis intervention.
Intervention must have clinician involvement—exclude studies that are exclusively an app or self-help resource.	Articles from newspapers or news sources.
Includes some evaluation to support its use, which can be as basic as volumes of service use or analysis of barriers/facilitators of implementation, or more robust evidence of effectiveness.
Virtual day hospital programs that take referrals from crisis settings.

DATA CHARTING

Two authors (S.S. and J.L.) extracted information from the full texts included in the review. The selection of variables for data extraction was based on recommendations from Arksey and O’Malley, ¹⁶ information related to the review’s objective, and study team discussion and included: “Authors/Year/Country,” “Objective(s),” “Data type,” “Design,” “Goal,” “Setting,” “Components,” “Frequency,” “Duration,” “Provider group,” “Total sample size,” “Population,” “Comparison,” “Recruited from,” “Relevant results.”

TYPES OF VIRTUAL ASSESSMENTS AND INTERVENTIONS

Virtual programs were categorized into three types based on their function and objective(s): those offering crisis assessment and/or intervention (going beyond the standard triage and de-escalation aim of crisis hotlines), those providing a home-based alternative to hospital or other inpatient facility with high-intensity intervention, and those providing post-crisis intervention following discharge after a visit to an ED or other crisis center.

CRISIS ASSESSMENT AND INTERVENTION

A total of 22 publications^19–39,63 describe comprehensive virtual assessments of mental health needs and/or intervention that includes extensive therapeutic interaction. Evaluations focused on at least one of the following areas: feasibility/acceptability (n = 14),^{19,21–29,33–36} user characteristics (n = 8),^{19,20,23,30,32,38,39,63} outcomes (n = 6),^{19,21,28,31,34,38} cost-effectiveness/savings (n = 1), ²⁸ and social interaction experiences between providers and patients (n = 1). ³⁷ Of the studies that focused on outcomes, these included service use outcomes,^28,34,38 call characteristics, ¹⁹ program satisfaction, ²¹ and mental health services access. ³¹ Most crisis assessment services were for adults only (n = 8),^{22,24,26,28,29,32,33,38} six services were for all ages (both youth and adults),^{21,31,39,61,63} and four services were for youth only.^20,23,34,36 Five services described did not explicitly specify the age range of the recipient population.^{19,25,27,30,35} Target populations ranged from youth and adults experiencing acute distress, mental health complaints, psychosocial issues, or suicidal crises^{19,24,26,28–32,35,37–39,63} to individuals with diagnoses of moderate to severe mental health problems. ²² Two other services targeted health care workers experiencing mental health crises.^21,33 Similarly, the youth assessment services targeted minors experiencing mental health crises^23,36 as well as children with various psychological disorders. ²⁰ Special populations targeted included individuals experiencing mental health crises who are in contact with the police ²⁷ and high school students at risk of suicide. ³⁴

Patients of the virtual crisis assessment services were mostly recruited from the community (i.e., the general public; n = 13) with no referral necessary.^{19,24,25,28–32,35,36,39,63} The remainder of virtual crisis assessment services received referrals from a variety of sources (n = 8).^{20–22,26,27,33,34,37} More specifically, patients of the virtual crisis care (VCC) program in rural South Dakota, USA, were recruited by law enforcement from the community or from prisons as the service is initiated by law enforcement. ²⁷ Three more virtual crisis assessment services recruited patients from mixed settings (i.e., inpatient and outpatient).^22,26,37 Patients (as well as caregivers, i.e., parents) for the virtual crisis consultation service at the child and adolescent psychiatry department of the Reims University Hospital ²⁰ were recruited from referrals from health care professionals (doctors, psychologists, nurses). The Hospital–School–Community Telepartnership (HSCT) program recruited students from participating school districts. ³⁴ The mobile app called Ruh Sagligi Destek Sistemi-Mental Health Support System for telepsychiatry service recruited health care workers registered with the Ministry of Health (and their children) in Turkey, ²¹ while a crisis helpline in Mexico recruited frontline health care workers who work with patients infected by COVID-19. ³³

Of the 22 publications describing virtual assessment services, 17 used the telephone as a way of communicating with patients,^{19,20,22,24–26,28–33,35,37–39,63} 9 described using video,^{21,24,27,28,31,35–38} and 4 described using text/email.^21,31,35,39 Two services reported in-person clinic visits as part of the program in addition to the virtual contact.^24,31 The duration of virtual assessments varied between services. Most studies did not specify the duration of assessment services.^{19–23,25,26,28–32,35,63} The duration of the remainder of assessment services was usually about 30 min^24,28,36,37 or between 60 and 90 min.^33,34,38 For the most part, frequency of clinical contact was not specified for the assessment and intervention services (n = 14).^{19,21,24–31,35,37,63} The frequency of clinical contact for the remaining assessment services varied between 1 and 12 contacts/sessions per caller, patient, or student.^{20,22,23,33,34,36,38}

The virtual assessment services are situated in a variety of settings. Six services are crisis helplines organized by university students and professors, a suicide prevention crisis center, and a collaboration between private and public care (the Kids Helpline did not specify where the clinical team is based; n = 6)^{26,30,33,35,39,63}; four services are involved with EMS (i.e., call center, dispatch center, and helpline)^28,29,32 or ambulance services (i.e., clinical support desk) ²⁵ ; two are teleconsultation services in a university hospital’s child psychiatry department ²⁰ and a collaboration between the Dominican Republic government and regulatory bodies for psychology and psychiatry ³¹ ; two are EDs^23,36; and one of each: a call-in center at a COVID-19 testing location at a medical center, ¹⁹ a mobile app with telehealth service, ²¹ a psychology department within a community mental health team, ²² a mental health center, ²⁴ a hub team staffed by clinicians from Avera eCARE, ²⁷ a decentralized on-call system established in regional psychiatry centers, ³⁷ and a crisis clinic facility. ³⁸ The HSCT program did not specify the setting where the intervention team is situated. ³⁴

Most virtual assessment services were staffed with multidisciplinary teams. The majority of publications described services staffed with psychology (i.e., psychologists, trainees, students, psychotherapists, licensed counselors or social workers, crisis workers, child development professionals, OTs; n = 15),^{19,21,22,24,26,30–36,38,39,63} followed by psychiatry (psychiatrists, residents, child and adolescent psychiatrists; n = 11),^{19–21,24,30,31,33–35,37,38} nursing (i.e., nurses, psychiatric nurses, mental health nurses; n = 6),^{24,28,36–38,63} and physicians (i.e., ED physicians, emergency physicians, anesthesiologists, general practitioners [GPs]; n = 3).^23,29,36

At the Yvelines Emergency Medical Services Dispatch Center (EMS-DC), in particular, anesthesiologists (and other physicians working there) are expected to have suicide risk assessment training based on the Risk–Urgency–Danger (RUD) approach. The RUD approach sets national guidelines and standards for suicide risk assessment and is adopted by EMS telephone dispatch centers in France. ²⁹ Some publications used generic terms without specifying the exact type of practitioner (i.e., behavioral health practitioners, mental health professionals, secondary triage practitioners, health sciences professors, health department professors; n = 4).^25,27,28,35 The goal of most virtual assessment services is to resolve crises^{19,20,22–24,26–35,37,39,63} (plus provide referral support^31,34 and reduce mental health morbidity and mortality during the COVID-19 pandemic ³⁵ ), followed by diverting ED visits^20,25,28,38 and diverting hospitalization.^20,27,28 The goal of the pediatric ED Virtual Care service at the Children’s Hospital of Eastern Ontario (CHEO) is to maintain access to care during the COVID-19 pandemic. ³⁶

Outcomes studied generally fell into four categories: user characteristics (n = 14),^{19,20,23,24,28,30–35,38,39,63} service usage (n = 10),^{22–26,32,34,35,38,39} service outcomes (n = 9),^{19,22,25–28,34,38,63} and service evaluation (satisfaction, feedback, scores, feasibility/acceptability, benefits and/or challenges; n = 13).^{21–29,33,35–37} Results of publications reporting on user characteristics focused on patient demographics and main complaints/reasons for presentation. The majority of virtual crisis service users were women (n = 9)^{19,24,28,31–35,39} and reported accessing virtual services for reasons involving anxiety (n = 6),^{19,28,31,32,35,63} depression/low mood (n = 4),^28,32,35,63 suicidal thoughts and behaviors (n = 3),^31,35,63 sleep problems (n = 3),^19,31,63 and interpersonal conflict (including conflict with family; n = 4).^20,32,35,39 Four publications reported that users were accessing virtual services for complaints and symptoms attributed to the COVID-19 pandemic (n = 4).^19,30,32,35 Three publications compared the demographics of virtual and in-person users accessing the same crisis services.^23,28,38 Youth accessing the CHEO ED virtually tended to present for reasons related to anxiety rather than depression and suicidal/self-harm thoughts and behaviors, and tended to be younger in age. ²³

Similarly, adults accessing an EMS call center in Australia managed by mental health nurses via video telehealth tended to be younger and female compared with those adults who access the service by voice-only triage. ²⁸ Adults accessing the virtual assessments from the Crisis Response Center compared with those attending in person were more likely to be older and live farther away from the Center, and were less likely to be male, engage in suicidal behavior, abuse substances, or experience psychosis. ³⁸ Results of publications reporting on service usage typically focused on quantifying the number of sessions/visits attended by patients (n = 5),^{22,26,32,34,38} whether medication was prescribed to patients(n = 2),^24,34 and what patients’ preferences were for communicating with clinicians virtually (n = 2).^35,53 In regard to communication preferences, teen users of the Kids Helpline (KHL) liked communicating with providers by webchat and email more than phone calls. ³⁹ Similarly, adult users of the Autonomous University of Santo Domingo (UASD) COVID-19 Psychological Helpline preferred messaging on WhatsApp rather than taking phone calls. ³⁵ Results of publications reporting on service outcomes typically focused on the end result of crisis calls, visits, or sessions,^22,26,38 especially referrals (to hospitalization, mental health care, community providers such as therapists and psychiatrists; n = 3)^19,25,34 and pharmacological intervention or medication management.^34,63

Finally, results of publications reporting on service evaluation typically focused on user and provider satisfaction (or similar). Satisfaction ratings were generally high among both users and providers,^{21–24,26,28,33,35,36} and two of these studies concluded that the services were feasible and acceptable (i.e., crisis support call service organized by a Community Mental Health Team, helpline organized by the National Institute of Psychiatry and the National Autonomous University of Mexico).^22,33 Some studies collected qualitative feedback from users and providers, which revealed the benefits and challenges of virtual crisis assessments.^25,27,36,37 Benefits included efficient access to crisis support, improved documentation, mitigation of involuntary committal procedures, enhanced transparency for clinical assessments and decisions, and effective clinical gaze (provider–patient interactions during therapeutic encounters, i.e., emergency psychiatric consultations).^27,37 Challenges included high staff turnover, lack of in-person triage options, technical issues, network availability issues, and barriers to the acceptability of VCC (i.e., time constraints, insufficient staff support, and competence levels of clinicians).^25,27,36

HOME-BASED ALTERNATIVE TO INPATIENT CARE

A total of 16 publications^40–55 describe crisis interventions that are home-based alternatives to hospital or similar facility-based admissions and provide high-intensity care. These virtual interventions include partial hospital(ization) programs (PHPs; n = 6),^{44,47,52–55} a crisis stabilization unit (n = 4),^40,46,48,50 intensive outpatient programs^{41–43,45,51} (IOPs; n = 5 including a day program called the Adult Transitions Program [ATP] ⁵¹ ), and a crisis resolution home treatment team (CRHTT; n = 1; the Crisis Toolbox [CTB] ⁴⁹ ).

Thirteen studies evaluated intervention outcomes.^{40–43,45,47,49–55} The following outcomes were investigated: depression (n = 7),^{44,45,47,51,53–55} patient satisfaction (n = 6),^{47,49,52–55} visits/attendance (n = 3),^42,43,52 suicidality/self-harm (n = 2),^45,51 anxiety (n = 2),^47,51 safety (n = 2),^53,54 effectiveness (n = 1),^53,54 hospitalization (n = 1), ⁵² patient progress (n = 1), ⁵² post-discharge acute care use (n = 1), ⁴⁰ and patient-infant bonding (n = 1). ⁴⁴ Of the 13 studies, 7 also focused on feasibility/acceptability,^{42–44,50–52,54} 3 on user characteristics,^40,45,50 and 1 on cost-effectiveness/savings. ⁴⁰ Three other studies aimed to describe the implementation (i.e., feasibility/acceptability) of virtual crisis services (i.e., Yale New Haven Psychiatric Hospital’s telehealth group-based IOP and OP services, and vCSU).^41,46,48 Of these, one also focused on user characteristics. ⁴⁸

The majority of virtual crisis interventions were for adult patients (n = 11).^{40,41,46–50,52–55} A minority of interventions were for both youth and adult patients (n = 4).^42,43,45,51 One intervention did not explicitly specify the age of users. ⁴⁴ Patients of the virtual crisis interventions were mostly recruited from mixed settings (i.e., inpatient/outpatient),^{43–45,47,50–55} followed by EDs/crisis clinics^40,46,48,49 and outpatient settings.^41,42 The interventions’ target populations were individuals experiencing mental health crises^40,43,48,49 and who are at risk of hospitalization,^50,51 or any patient requiring acute, intensive psychiatric treatment in a PHP setting. ⁵³ Target populations were patients with a wide range of mental disorders (i.e., mood disorders, anxiety disorders, psychotic disorders)^41,52 with high acuity^42,45,46 and/or comorbid conditions.^45,47 Some virtual interventions targeted specific populations including borderline personality disorder, ⁵⁴ major depressive disorder, ⁵⁵ and women with perinatal mood and anxiety disorders. ⁴⁴

Of the 16 publications describing components of the virtual crisis interventions, 14 included individual therapy^{40,43–49,51,53–55} and 12 included group therapy.^{41–48,51,53–55} Of the 12 publications including group therapy, 2 described a virtual outpatient intervention that is exclusively group-based and conducted over telehealth (i.e., telephone, virtual televideo, MyChart messaging/video).^41,42 Most virtual crisis intervention programs offered connection via video (n = 12),^{40,43,45–48,50–55} followed by telephone (n = 7),^{40,43,46,48–50,52} and/or text (n = 4).^40,46,50,52 One intervention (i.e., The Motherhood Center PHP) describes providing group and individual therapy over telehealth but does not specify if this is video- or phone-based contact. ⁴² Frequency of treatment/clinical contact (i.e., check-ins, individual therapy sessions, and group therapy sessions) varied between virtual crisis interventions. Contact frequency ranged from several times per week (n = 3)^43,45,51 to daily (n = 9).^{40,42,47,48,50,52–55} For two interventions,^44,46 the contact frequency was not specified. Duration of treatment also varied between virtual crisis interventions. Treatment duration ranged from 3 days ⁴⁰ up to 6 weeks.^43,52 For four interventions, the treatment duration was not specified.^42,44,47,49

The virtual intervention teams are situated in a variety of settings. These include a 24/7 walk-in crisis center with crisis stabilization unit,^40,46,48,50 IOPs at hospitals,^41–43 a company (i.e., Charlie Health, Inc.), ⁴⁵ and a day program at an academic medical center, ⁵¹ PHPs in hospitals,^47,52–55 a health care center (i.e., Motherhood Center of New York), ⁴⁴ and a Crisis Resolution Home Treatment Team (CRHTT) with no specified setting/location. ⁴⁹ The goal of most virtual crisis interventions is to divert hospitalizations (n = 13),^{40,43,45–55} resolve crises (n = 9),^{40–44,46,48–50} divert ED visits (n = 5),^{43,45,46,51,52} and/or avoid repeat ED visits (n = 4).^43,45,46,51 Most virtual crisis interventions were staffed with multidisciplinary teams.

The majority of publications described virtual programs staffed with psychologists, psychotherapy clinicians, clinical therapists, clinical counselors, mental health clinicians, or psychology students or fellows (n = 11),^{40,41,44,46,47,49–51,53–55} psychiatrists (or psychiatric trainees; n = 10),^{40,41,44,46–48,50,51,54,55} nurses or nurse practitioners (n = 4),^46,48,50,51 social workers (n = 3),^48,54,55 physician assistants (n = 3),^40,46,51 and an occupational therapist. ⁵¹ In some cases, publications used generic terms to describe clinical staff, crisis workers, or clinicians on multidisciplinary teams of virtual crisis interventions.^42,45,50,52

Studies generally reported results related to program acceptability/feasibility (including patient and provider satisfaction; n = 10),^46–55 symptom improvement (n = 8),^{44,45,47,51–55} patient attendance (n = 7),^{42,43,45,52–55} and patient characteristics (n = 3).^40,48,50 In terms of acceptability/feasibility, the vCSU had high levels of acceptability from providers ⁴⁸ and was deemed feasible for a variety of mental health crisis patients. ⁵⁰ Additionally, the vCSU received positive feedback from service users, families, and providers. ⁴⁶ vCSU providers thought the model worked well for more than half of the patients referred and identified several benefits for users (i.e., stabilization support, stay at home, more care options, better outcomes are possible). ⁴⁸

Providers also identified challenges related to the vCSU model, which included staff and resource limitations, procedural issues, program limitations compared with routine care, and possible lack of program suitability for some patient demographics. ⁴⁸ Similarly, the Rhode Island Hospital Adult Partial Hospitalization Program (RIH PHP) received positive feedback. Both virtual and in-person users of the PHP reported being highly satisfied with the service.^53–55 Virtual users of the CTB program also reported high levels of satisfaction with the service, ⁴⁹ and virtual users of the Zucker Hillside Hospital PHP were as satisfied as in-person users with the service. ⁵² Like the Zucker Hillside Hospital PHP, virtual users of the Behavioral Health Partial Hospital Program (BHP) also had equally positive perceptions about the service compared with in-person users. ⁴⁷ Both user groups felt they were informed and treated respectfully and would recommend the program to others. ⁴⁷ Like the vCSU providers, virtual users of the BHP also identified advantages and challenges related to the service. ¹⁵

One advantage is increased access to treatment, and challenges include difficulty connecting with other patients in the program, technology issues, and difficulty establishing a therapeutic environment at home. ⁴⁷ In terms of symptom improvement, studies generally reported significant decreases in depressive symptoms, anxiety, suicidality, and self-harm.^45,51 When compared with in-person services, virtual services showed significant decreases in depressive symptoms, anxiety, suicidality, and overall mental health (i.e., coping, well-being, and functioning) that were equal or greater.^{44,47,52–55} In terms of attendance, studies generally reported increased appointment or session attendance^42,43,52 and fewer days missed ⁵⁴ for virtual service compared with in-person service. As well, studies reported increased treatment completion rates ⁵⁵ and lower hospitalization rates ⁵² for virtual programs compared with in-person programs.

The RIH PHP reported on length of stay (LOS) and noted a higher average LOS for virtual patients compared with in-person patients.^53–55 The vCSU ⁵⁰ also reported on LOS (4.9 days, range of 1–10) but did not compare it with the in-patient CSU. Other studies simply reported on completion rates of virtual programs. One virtual IOP reported a mean completion rate of 85.9% (standard deviation [SD] = 16.48), ⁴⁵ and one virtual day program (ATP) reported that 92% of virtual patients ⁵¹ completed the program.

Lastly, studies reported on the characteristics of patients who use virtual crisis interventions.^40,48,50 Studies of the vCSU, in particular, reported on patient demographics at admission ⁴⁰ and patient symptoms at assessment. ⁵⁰ Both studies reported the presence of depression, anxiety, suicidal/self-harm behavior, and psychosis/mania.^40,50 Psychosis/mania, in particular, was noted to be a significant predictor of transfer to hospital. ⁴⁰ Furthermore, the feedback of vCSU crisis clinicians led to the development of four patient profiles who are a good fit for the vCSU model ⁴⁸ ,p.7: (1) “barriers to care and ‘predictable’ mental health needs,” (2) “system-aware and avoidant,” (3) “high needs, system-naïve,” and (4) “acute and transient crisis.”

POST-CRISIS INTERVENTION

A total of seven publications^56–62 describe virtual follow-up programs offered following an ED or other crisis visit that are less intensive than in-patient alternatives. The post-discharge programs include the telephone follow-up (TFP) program, ⁵⁶ the telephone-based psychosocial intervention (TBPI), ⁶⁰ the virtual patient navigation program, ⁵⁷ problem-solving cognitive behavior therapy (PSCBT), ⁵⁸ the extended crisis follow-up (EFU) program, ⁵⁹ the Safety Planning Intervention (SPI), ⁶¹ and VigilanS. ⁶² Each study^56–62 aimed to evaluate the virtual follow-up care intervention. For most studies, the focus of evaluation was on outcomes,^{56,57,60–62} which included suicidal behaviors, self-harm, suicide attempts and reattempts, completed suicides, ED to hospital admission conversions, acute care utilization, and outpatient mental health visits. The focus of evaluation for the EFU ⁵⁹ and TBPI ⁶⁰ programs was acceptability/feasibility only, while the focus of evaluation for PSCBT ⁵⁸ was both feasibility and outcomes (i.e., depression, personal health, hopelessness, anxiety, suicidality, work and social adjustment, and health utility).

The study populations for virtual follow-up interventions consisted of adult patients or providers in four studies,^56,57,60,61 while the PSCBT intervention ⁵⁸ consisted of both youth and adult (i.e., ages 16–30) patients. Two studies^59,62 did not explicitly specify the age of patient populations. Most of the patient populations were recruited from EDs,^{56,57,59–62} while the patient population for PSCBT ⁵⁸ came from mixed settings including child and adolescent mental health services in EDs and hospital wards, community mental health services, and a local nonprofit organization. The target populations for the interventions were typically individuals who had presented to the ED for suicide attempts or self-harm and were discharged with high ongoing risk for suicide.^56,58–62 The target population for the virtual patient navigation program ⁵⁷ was individuals who received psychiatric consultations for mental health crises after presenting to the ED.

All seven publications^56–62 described virtual interventions that used the telephone to communicate with patients. In addition to the telephone, some of these virtual interventions also used video^57,58 and text or email. ⁶² Post-crisis interventions varied widely in terms of duration, ranging from 24 h ⁵⁹ to 12 months ⁵⁶ post-discharge; however, post-crisis interventions were most commonly up to 6 months in duration.^61,62 Virtual PSCBT, on the other hand, is 10–12 sessions in duration. ⁵⁸ In terms of frequency, most post-crisis interventions made contact with discharged patients on a weekly basis,^57,58,61 while some interventions left 1 or more months in between contacts with discharged patients.^56,62 Virtual interventions were operating from hospitals,^56,60 EDs,^57,61 a regional suicide prevention center, ⁵⁹ and regional EMS. ⁶² The PSCBT intervention was carried out by CBT therapists but did not specify from where the therapists were based. The remainder of the virtual follow-up interventions were performed by nurses,^56,62 behavioral health clinicians or counselors,^57,59 and/or psychologists or project staff with backgrounds in psychology or social work.^60–62 With the exception of the virtual patient navigation program, ⁵⁷ which aims to divert hospitalization, the goal of all other interventions is to reduce repeat suicide attempts or self-harm.^56,58–62

Most studies reported results related to treatment outcomes,^{56–58,61,62} and two studies reported on the feasibility and acceptability.^59,60 In terms of treatment outcomes (i.e., suicidal behaviors, depression scores), the results were mixed. For the TFP, ⁵⁶ no benefit of the intervention was found, with 23.6% of the intervention group reattempting and 0.5% completing suicide during the follow-up period, compared with 20.3% of the control group reattempting and 1.9% completing suicide over the same period. The TBPI program ⁶⁰ also showed no benefit of intervention, with no difference in suicide attempts within 30 days of baseline compared with the control group. PSCBT ⁵⁸ similarly reported negative results in that the RCT was not feasible for youth and young adults recruited from crisis mental health services for depression and self-harm based on stop-go criteria, recruitment, retention, and safety concerns.

On the other hand, positive results were reported for the virtual patient navigation program, which demonstrated significantly fewer instances of self-harm for the virtual patient navigation program compared with the control group over the follow-up period (−8.7%). ⁵⁷ Similarly, suicidal behaviors for the SPI ⁶¹ were significantly less likely to occur over the follow-up period for the intervention group compared with the control group (3.03 vs. 5.29%, odds ratio = 0.56; 95% CI: 0.33–0.95). VigilanS ⁶² also reported positive results in that the intervention group showed a greater downward trend in ED visits for suicide attempts after implementation of the intervention (−15.8%) compared with the period of time before implementation (−5.9%). Control groups showed either no change in suicide attempts or an increase in suicide attempts over the same period of time. In terms of feasibility and acceptability, the EFU program ⁵⁹ was deemed valuable by the psychiatry residents at the ED and the crisis counselors at the suicide prevention center. The residents and counselors discussed improving certain areas of the referral process, wanting to know more about the operations of the ED and the community program, and difficulties in identifying patients who are well-suited for the EFU program. ⁵⁹