Introduction
There is now considerable evidence that there has been an increase in prevalence of mental health problems since the COVID-19 pandemic. A systematic review and meta-analysis of observational studies, published from January 1st 2020 to July 11th 2020 and spanning 32 countries, reported global prevalence estimates at 28.0% for depression; 26.9% for anxiety; 24.1% for post-traumatic stress symptoms; 36.5% for stress; 50.0% for psychological distress; and 27.6% for sleep problems (Nochaiwong et al. Reference Nochaiwong, Ruengorn, Thavorn, Hutton, Awiphan, Phosuya, Ruanta, Wongpakaran and Wongpakaran2021). The findings indicate the prevalence of common mental health disorders is higher during the pandemic compared to pre-COVID-19. A study by Steel et al., based on 174 surveys across 63 countries from 1980 to 2013 estimated lifetime prevalence was 29.1% for all mental disorders, 9.6% for mood disorders, 12.9% for anxiety disorders, and 3.4% for substance use disorders (Steel et al. Reference Steel, Marnane, Iranpour, Chey, Jackson, Patel and Silove2014). A prospective online study assessing health anxiety/somatoform disorder, general anxiety disorder, panic disorder, OCD, and depression reported prevalence of any of these disorders was 50.6%, much higher than pre-pandemic (Munk et al. Reference Munk, Schmidt, Alexander, Henkel and Hennig2020). In a cross-sectional study of 15,037 people in Germany, participants reported a significant increase in depression and anxiety symptoms, and distress, while health status deteriorated since the COVID-19 outbreak (Bäuerle et al. Reference Bäuerle, Steinbach, Schweda, Beckord, Hetkamp, Weismüller, Kohler, Musche, Dörrie and Teufel2020). These trends indicate the mental health problems which health systems face since the pandemic. Studies of long-term psychiatric morbidities after previous pandemics support this hypothesis. In a retrospective cohort study of SARS survivors, the prevalence of any psychiatric disorder at 30 months post-SARS was 33.3% (Mak et al. Reference Mak, Chu, Pan, Yiu and Chan2009).
The impact of this phenomenon on population health is further compounded by the extent to which the capacity for health systems to make new diagnoses may have been impacted. In the UK, a retrospective cohort study of data from 47 GPs reported a 50% reduction in first diagnoses of anxiety disorders and depression between March 1st and May 31st 2020, and a 39.1% reduction in first prescriptions of SSRI’s (Williams et al. Reference Williams, Jenkins, Ashcroft, Brown, Campbell, Carr, Cheraghi-Sohi, Kapur, Thomas, Webb and Peek2020).
How primary care can address the needs of people experiencing mental health disorders has always been important, but is especially the case now. Internationally, proposed initiatives to enhance primary care of mental health disorders in the post-pandemic era include United Nations policy: ‘COVID-19 and the Need for Action on Mental Health’, advocating for investment in remote mental health interventions and in mental health reforms to shift care towards community services (United Nations 2020). In Ireland, the policy document ‘Psychosocial Response to the COVID-19 Pandemic’ proposes a six-layered care framework (HSE 2020), with level four involving primary care providing one-to-one supports to reassure, promote well-being and resilience. ‘Population Mental Health Perspective’ is a similar initiative, using primary, secondary and tertiary interventions (Boden et al. Reference Boden, Zimmerman, Azevedo, Ruzek, Gala, Abdel Magid, Cohen, Walser, Mahtani, Hoggatt and Mclean2021). GPs will require further training in early detection of ‘at-risk’ individuals, and providing them with rapid interventions (HSE 2020, Boden et al. Reference Boden, Zimmerman, Azevedo, Ruzek, Gala, Abdel Magid, Cohen, Walser, Mahtani, Hoggatt and Mclean2021). Early career psychiatrists composed a ‘Mental Health Preparedness and Action Framework’ modelled on the WHO-Global Influenza Preparedness Plan, to guide development, implementation and evaluation of mental health interventions during and post-pandemic. If this is implemented and suitably resourced, it is postulated to reduce the impact of the mental health epidemic (Ransing et al. Reference Ransing, Adiukwu, Pereira-Sanchez, Ramalho, Orsolini, Teixeira, Gonzalez-Diaz, Pinto da Costa, Soler-Vidal, Bytyçi, El Hayek, Larnaout, Shalbafan, Syarif, Nofal and Kundadak2020).
There have been many studies involving interventions to improve the psychological impact of medical pandemics. These interventions include Psychological First Aid (Yue et al. Reference Yue, Yan, Sun, Yuan, Su, Han, Ravindran, Kosten, Everall, Davey, Bullmore, Kawakami, Barbui, Thornicroft, Lund, Lin, Liu, Shi, Shi, Ran, Bao and Lu2020), Cognitive Behavioural Therapy (CBT) programmes and mobile-delivered interventions (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020), internet-based self-help interventions (Wei et al. Reference Wei, Huang, Lu, Hu, Zhou, Hu, Chen, Huang, Li, Wang, Wang, Xu and Hu2020) and physical activity and mindfulness meditation (Green et al. Reference Green, Huberty, Puzia and Stecher2021). These interventions mainly involved COVID-19 positive patients or frontline healthcare workers, but could be adopted in primary care, as will be explored in this paper.
The requirement to physically distance during the COVID-19 pandemic has increased utilisation of tele-healthcare in general practice in Ireland (Homeniuk and Collins Reference Homeniuk and Collins2021) and internationally (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021, Pierce et al. Reference Pierce, Perrin, Tyler, McKee and Watson2021). Increased use of telemedicine can be expected post-COVID-19, in line with Ireland’s two strategies promoting technology in healthcare: Sláintecare (HSE 2019) and the 2013 e-Health policy (HSE 2013, Homeniuk and Collins Reference Homeniuk and Collins2021). Studies are included which evaluate the effectiveness of telemedicine as an intervention to enhance care of mental health disorders in primary care.
Essentially there is a need for increased research into interventions which can improve GP care of mental health disorders post-COVID-19. The literature at present mainly focuses on mental health interventions for COVID-19 inpatients, frontline healthcare workers, or those presenting to psychiatry departments. GP interventions are mainly in relation to increased use of telemedicine in general, not specific to mental health. We aim to address this knowledge gap by examining the extant literature on interventions to enhance the care of mental health disorders among patients attending primary care since the COVID-19 pandemic.
Methods
To gain a comprehensive overview of the literature in relation to interventions which may improve the treatment of mental health disorders post-pandemic, a scoping review methodology was chosen. This scoping review was conducted from May to June 2021, using the six-stage framework described by Arksey and O’Malley (Reference Arksey and O’Malley2005) to collate existing literature, identify key findings and outline current research gaps in this area.
Stage 1: Identifying the research question
The COVID-19 pandemic has led to a reported rise in mental health disorders globally. Due to the important role of general practice as the gateway for treatment of mental health disorders in the community, it is necessary to research interventions which could improve care offered post-pandemic. Therefore, the objective of this scoping review was to examine the literature for effective interventions which could be implemented to enhance GP care of mental health disorders post-COVID-19. We formulated the following research question: ‘What interventions may be used to improve GP care of mental health disorders post-COVID-19?’
Stage 2: Identifying relevant studies
A preliminary search of key databases was performed, using multiple search terms to create a reading list. From this, keywords were identified and medical subject heading (MeSH) terms were generated. The electronic databases used in the searches were ‘PubMed’, the ‘Cochrane Library’, ‘PsycINFO’, ‘Google Scholar’ and the WHO ‘Global Research on COVID-19’ database. The search terms were grouped, with results requiring reference to one or more search term in each of the following categories: Interventions, General Practice, Mental Health Disorders, COVID-19 (See Fig. 1). We chose not to limit the study search by year as research on interventions implemented during other pandemics would be useful to study. Several additional articles of relevance were identified by ‘hand-searching’ from references found on databases mentioned above.
Fig. 1. Search strategy for PUBMED and PsycINFO.
Stage 3: Selecting studies
The initial search identified 139 studies with an additional nine studies added from hand-searching references from key literature.
A title and abstract review was then conducted to identify relevant articles, followed by full-text reviews. The ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)’ flow diagram below (Fig. 2) outlines the selection process. The literature was included irrespective of study design/methodology, therefore a variety of study types and reviews are included.
Fig 2. PRISMA flow diagram.
Once the initial search was performed, four duplicates were removed. Endnote 20 software was used to track and group studies, manage citations and remove duplicates. Studies were included if they were considered to examine the research question, if they were published in English and if the full article was available.
Findings were reviewed by a second reviewer, and a finalised list of studies was agreed.
Stage 4: Charting the data
Once all relevant articles were identified (n = 29), to facilitate comparison and thematic analysis, the following data was charted from the articles:
First author, year of publication,
Study title,
Study population,
Journal/publication,
Study location
Study aim/topic,
Intervention,
Study design,
Outcome measures,
Major findings.
Stage 5: Collating, summarising and reporting results
An overview of the literature is detailed in Table 1 below, summarising and charting the results. This will be discussed further in the results section.
Table 1. Interventions to improve care of mental health disorders post-COVID-19
Stage 6: Consultation
In line with recommendations by Levac et al., (Levac et al. Reference Levac, Colquhoun and O’Brien2010) studies were also included and excluded according to advice received during consultation with experts in the field of mental healthcare and research.
Results
The initial database searches identified 148 records. After four duplicates were removed, reviewers screened the remaining 144 records by title and abstract, during which 109 records were excluded. 35 articles met the inclusion criteria and were selected for full-text review. Following full-text review, six records were excluded due to a lack of relevance or unavailability of the full-text article, leaving 29 records which examined interventions that could be implemented to enhance GP care of mental health disorders post-COVID-19. The search process, as guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), is summarised in Fig. 2. Data were extracted from the final selection consisting of 29 records which met the eligibility criteria for the review.
Description of included studies
A variety of study types are included, with some articles including more than one study type. Six studies used randomised control designs (RCT), five used qualitative interviews and seven used surveys, some of which were cross-sectional, online or by telephone. Others include systematic reviews (n = 4), observational studies (n = 3), retrospective case/chart notes review (n = 2), a quantitative quasi-experimental pre-test/ post-test design (n = 1), consensus study (n = 1), a quality improvement project (n = 1) and narrative review (n = 1).
The majority of studies were conducted in the USA (n = 12), Europe (n = 6) and China (n = 5). Four systematic reviews were included providing international data. Single studies from Israel and New Zealand were included. The sample sizes of studies ranged from 14 to 350,966 participants. Most studies examined adult participants.
Study populations and settings
Specific study populations varied between studies, with most including members of the public (n = 13), healthcare professionals (n = 9), individuals with pre-existing mental health conditions (n = 4), COVID-19 positive patients (n = 3), older adults (n = 2) and other specific groups (n = 2; including an ethnic minority and military service members). The majority of interventions took place in community or primary health care settings (n = 23). Others took place in COVID-19 hospital wards (n = 2). Interventions reported in systematic and narrative reviews covered each of these settings (n = 4). One study focused on policy development.
Improving identification of mental health disorders in general practice
Interventions in general practice to improve identification of mental health disorders arising from the pandemic are essential, and have been reported in three included studies (Ahmad et al. Reference Ahmad, Wang, Wong and Fung2020, Kaufman-Shriqui et al. Reference Kaufman-Shriqui, Navarro, Raz and Boaz2021, Sivan et al. Reference Sivan, Halpin, Hollingworth, Snook, Hickman and Clifton2020). A RCT reported the effectiveness of an interactive pre-consultation health risk assessment tool for common mental health disorders (Ahmad et al. Reference Ahmad, Wang, Wong and Fung2020). The C19-Yorkshire Rehabilitation Screen (C19-YRS) tool was developed with referral criteria to determine management of individuals with sequelae of COVID-19, including mental health disorders, and can be completed over the phone with a GP. (Sivan et al. Reference Sivan, Halpin, Hollingworth, Snook, Hickman and Clifton2020). It has been recommended that GPs should adopt specific interventions to improve identification of and support for individuals at increased risk of anxiety and declining nutrition status post-pandemic. (Kaufman-Shriqui et al. Reference Kaufman-Shriqui, Navarro, Raz and Boaz2021). Interventions recommended include provision of appropriate diagnostic instruments, staff training and raising awareness. (Kaufman-Shriqui et al. Reference Kaufman-Shriqui, Navarro, Raz and Boaz2021).
Interventions to increase support for GPs treating mental health issues
Many primary care professionals are overburdened at present, and cannot adequately meet increased psychosocial needs of vulnerable patients, therefore a ‘task shift’ approach may be taken. A study involving a new integrated primary care team, with the primary care physician collaborating with a behavioural health care manager and a psychiatric consultant to treat patients with mental health disorders had positive results (Birch et al. Reference Birch, Ling and Phoenix2021). In a RCT Community Healthcare Workers (CHW) provided psychosocial support, resulting in significant improvement in participants self-rated psychosocial health, and high participant satisfaction (Vanden Bossche et al. Reference Vanden Bossche, Lagaert, Willems and Decat2021). This shows the added value of CHW to alleviate mental healthcare burden in primary care settings .
Therapeutic interventions
In systematic reviews (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020, Yue et al. Reference Yue, Yan, Sun, Yuan, Su, Han, Ravindran, Kosten, Everall, Davey, Bullmore, Kawakami, Barbui, Thornicroft, Lund, Lin, Liu, Shi, Shi, Ran, Bao and Lu2020), psychosocial interventions implemented during medical pandemics were assessed. A study involving well-being workshops and CBT programmes improved well-being, anxiety and depression among Ebola clinic staff (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020). A RCT of arts-based therapies for children suffering from trauma due to the Ebola crisis resulted in significant stress reduction (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020). It is projected there will be increased population incidence of PTSD (post-traumatic stress disorder) following COVID-19 (Wells et al. Reference Wells, Morland, Wilhite, Grubbs, Rauch, Acierno and McLean2020), as has been reported after other medical pandemics (Mak et al. Reference Mak, Chu, Pan, Yiu and Chan2009). Interventions to improve PTSD primary care treatment include a brief CBT termed ‘Prolonged Exposure for Primary Care’ (Cigrang et al. Reference Cigrang, Rauch, Mintz, Brundige, Mitchell, Najera, Litz, Young-McCaughan, Roache, Hembree, Goodie, Sonnek and Peterson2017). Video teleconferencing can be used to effectively deliver prolonged exposure for primary care remotely (Wells et al. Reference Wells, Morland, Wilhite, Grubbs, Rauch, Acierno and McLean2020). Therefore this intervention could be adopted to the current telemedicine revolution.
Studies have found that engaging in meditation and physical activities can buffer against negative mental health impacts of COVID-19 (Green et al., Zhu et al., Liu et al.). A survey of CALM app users found decreases in physical activity and meditation habits were linked with increased stress and worry about COVID-19 (Green et al. Reference Green, Huberty, Puzia and Stecher2021). An observational study found lower levels of pandemic-related distress in mindfulness practitioners (Zhu et al. Reference Zhu, Schülke, Vatansever, Xi, Yan, Zhao, Xie, Feng, Chen, Sahakian and Wang2021). Progressive muscle relaxation was found to improve mental health outcomes in COVID-19 patients, lowering anxiety and improving sleep quality (Liu et al. Reference Liu, Chen, Wu, Lin, Wang and Pan2020). This intervention could be tested in general practice patients who present with anxiety and disturbed sleep post-COVID-19 (Liu et al. Reference Liu, Chen, Wu, Lin, Wang and Pan2020).
Telemedicine
The COVID-19 pandemic has made obvious the need for effective digital mental health care interventions (Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020). Several studies report increased use of telemedicine internationally during COVID-19 (Atmore and Stokes Reference Atmore and Stokes2020, Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021, Ramaswamy et al. Reference Ramaswamy, M., Drangsholt, E., Culligan, Schlegel and Hu2020, Verhoeven et al. Reference Verhoeven, Tsakitzidis, Philips and Van Royen2020, Wynn Reference Wynn2020). Telemedicine can be used for a broad range of consultation types, and its use has particularly increased in mental health service provision (Pierce et al. Reference Pierce, Perrin, Tyler, McKee and Watson2021, Wynn Reference Wynn2020, Atherly et al. Reference Atherly, Van den Broek-Altenburg, Hart, Gleason and Carney2020). Quality of care can be maintained when providing mental health care via telemedicine (Frank et al. Reference Frank, Grumbach, Conrad, Wheeler and Wolff2021). Telephone triage has become common in general practice, making necessary face-to face time more ‘focused and productive’ (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021). This is an intervention GPs are eager to continue post-pandemic (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021, Verhoeven et al. Reference Verhoeven, Tsakitzidis, Philips and Van Royen2020).
Digital interventions
Several included studies pointed to digital interventions that could be adapted to improve care of mental health disorders in general practice (Cheng et al. Reference Cheng, Casement, Kalmbach, Castelan and Drake2021, Kerst et al. Reference Kerst, Zielasek and Gaebel2020, Maldonado Reference Maldonado2021, Shapira et al. Reference Shapira, Yeshua-Katz, Cohn-Schwartz, Aharonson-Daniel, Sarid and Clarfield2021, Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020, Wei et al. Reference Wei, Huang, Lu, Hu, Zhou, Hu, Chen, Huang, Li, Wang, Wang, Xu and Hu2020, Weiskittle et al. 2021, Wells et al. Reference Wells, Morland, Wilhite, Grubbs, Rauch, Acierno and McLean2020). Digital CBT for insomnia (dCBT-I) has been shown to offer long-lasting protection across multiple health domains, increasing health resilience and lowering risk of depression during COVID-19 in adults with a history of insomnia and ongoing mental health symptoms (Cheng et al. Reference Cheng, Casement, Kalmbach, Castelan and Drake2021). Mobile phone interventions could be encouraged by GPs to promote mental health. All studies in a systemic review of smartphone treatment applications for depression reported decline in symptoms after the intervention (Kerst et al. Reference Kerst, Zielasek and Gaebel2020). A music therapy intervention delivered by mobile for hospital staff during COVID-19 reduced participant levels of sadness, fear, worry and tiredness (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020), and a study of supportive individual phone consultations between patients and nurses improved mood (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020).
Two studies reported the success of online mental health self-help interventions (Wei et al. Reference Wei, Huang, Lu, Hu, Zhou, Hu, Chen, Huang, Li, Wang, Wang, Xu and Hu2020, Maldonado Reference Maldonado2021). These results indicate internet-based interventions show rapid improvement in mood disturbance and should be considered in patients whose mental health has been negatively impacted by COVID-19 (Wei et al. Reference Wei, Huang, Lu, Hu, Zhou, Hu, Chen, Huang, Li, Wang, Wang, Xu and Hu2020). Group interventions via telephone/video to relieve loneliness and worry among older adults during COVID-19 have had positive results, enabling participants to practice coping techniques and providing opportunities for social interaction (Shapira et al. Reference Shapira, Yeshua-Katz, Cohn-Schwartz, Aharonson-Daniel, Sarid and Clarfield2021). 55.6% of clinicians surveyed about their experiences implementing a ‘Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic’ described it very/ extremely effective in addressing social isolation and COVID-related worry. All respondents reported interest in a modified version post-COVID. (Weiskittle et al. 2021). Group interventions for older people are relatively simple measures that could be implemented in the community. Other successful digital mental health interventions during COVID-19 include the Canadian ‘Text4Mood’ service and Germany’s ‘Coping with Corona: Extended Psychosomatic care in Essen’ (Yue et al. Reference Yue, Yan, Sun, Yuan, Su, Han, Ravindran, Kosten, Everall, Davey, Bullmore, Kawakami, Barbui, Thornicroft, Lund, Lin, Liu, Shi, Shi, Ran, Bao and Lu2020).
Telemedicine improves accessibility
Telemedicine may improve accessibility of mental health services. One study reported use of telehealth significantly improved attendance rates (p = 0.002) and reduced cancellations (p < 0.001) (Frank et al. Reference Frank, Grumbach, Conrad, Wheeler and Wolff2021). Telemedicine use overcomes barriers to care for families with limited resources, including inconvenient appointment times and securing childcare and transport (Frank et al. Reference Frank, Grumbach, Conrad, Wheeler and Wolff2021). Some practitioners believed internet-delivered interventions may be more accessible to young patients who have social phobia or feel stigmatised. ‘When it is easily accessible and without closed doors, I think it is not so shameful…, you don’t have to feel that it is something strange and stigmatising…’ (Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020).
Patient and practitioner satisfaction with telemedicine
Patient satisfaction has been cited as the most important factor in the success of telemedicine initiatives (Ramaswamy et al. Reference Ramaswamy, M., Drangsholt, E., Culligan, Schlegel and Hu2020). A study of primary care patients revealed 79% were more likely to use telemedicine now than pre-pandemic (Atherly et al. Reference Atherly, Van den Broek-Altenburg, Hart, Gleason and Carney2020). Another study reported patient satisfaction with video visits was significantly higher than in-person visits (p < 0.001), through pre-COVID and COVID-19 periods studied (Ramaswamy et al. Reference Ramaswamy, M., Drangsholt, E., Culligan, Schlegel and Hu2020). Many studies have reported practitioner satisfaction with telemedicine (Weinland et al, Murphy et al, Pierce et al). Practitioners appreciated the variety telemedicine brought to their schedules, finding it a relief from challenges of face-to-face psychotherapy (Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020). GPs report telemedicine gives them greater control of their working day (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021). In a study of psychologists, 89.19% anticipated using telepsychology in their clinical practice, in contrast to 45.70% reporting they had never used telepsychology pre-pandemic. This indicates long-lasting changes in the use of telepsychology are likely post-COVID-19 (Pierce et al. Reference Pierce, Perrin, Tyler, McKee and Watson2021). There was greater use of telepsychology by clinicians who reported more telepsychology training and supportive policies (Pierce et al. Reference Pierce, Perrin, Tyler, McKee and Watson2021).
Barriers and facilitators to intervention implementation
Barriers to intervention implementation have been reported to include healthcare workers/ organisations lacking awareness of what is required to support their mental well-being, lack of equipment or time, and inadequate skills (Pollock et al. Reference Pollock, Campbell, Cheyne, Cowie, Davis, McCallum, McGill, Elders, Hagen, McClurg, Torrens and Maxwell2020). GPs have voiced concerns about telemedicine. Some consider continuing remote consulting at such high levels unsustainable (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021). They reported lack of clarity regarding thresholds for face-to-face consultations, and that telephone consulting at high volumes was more mentally intense and less satisfying, removing ‘…the most enjoyable part of their job – talking and touching and sensing patients in the room…’ (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021). Intercultural communication and language difficulties pose problems due to lack of non-verbal cues. (Verhoeven et al. Reference Verhoeven, Tsakitzidis, Philips and Van Royen2020, Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020). Other telemedicine concerns include that it would lead to ‘double doing’ and enforce already existing health inequalities by increasing access only for those with IT skills (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021).
Effective communication and having a positive, safe learning environment were facilitators to implementation. Personal knowledge or beliefs regarding the intervention can act as either barriers or facilitators to implementation (Pollock et al. Reference Pollock, Campbell, Cheyne, Cowie, Davis, McCallum, McGill, Elders, Hagen, McClurg, Torrens and Maxwell2020). A systematic review highlighted the importance of establishing an open entry system at primary care level for detection and intervention of mental health problems (Yue et al. Reference Yue, Yan, Sun, Yuan, Su, Han, Ravindran, Kosten, Everall, Davey, Bullmore, Kawakami, Barbui, Thornicroft, Lund, Lin, Liu, Shi, Shi, Ran, Bao and Lu2020). Two qualitative studies reported telemedicine was more effective when the therapeutic relationship had already been established between clinician and patient (Rowen et al. Reference Rowen, Giedgowd and Baran2021, Verhoeven et al. Reference Verhoeven, Tsakitzidis, Philips and Van Royen2020). Patient motivation and careful patient selection is critical, especially for specific interventions such as iCBT (Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020). Practitioners need more training to implement telemedicine effectively in practice to treat mental health disorders, and seamless technology is essential (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021, Pierce et al. Reference Pierce, Perrin, Tyler, McKee and Watson2021).
Outcomes to measure acceptability and/or feasibility
The majority of included studies utilised surveys or questionnaires which participants completed before and after completing an intervention, to measure the acceptability and/or feasibility of interventions. Many of these surveys incorporated validated scales including the ‘Seven-item Generalised Anxiety Disorder Scale’ (Kaufman-Shriqui et al. Reference Kaufman-Shriqui, Navarro, Raz and Boaz2021, Kerst et al. Reference Kerst, Zielasek and Gaebel2020, Maldonado Reference Maldonado2021, Rowen et al. Reference Rowen, Giedgowd and Baran2021, Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020, Zhu et al. Reference Zhu, Schülke, Vatansever, Xi, Yan, Zhao, Xie, Feng, Chen, Sahakian and Wang2021), the ‘Nine-item Patient Health Questionnaire’ (Birch et al. Reference Birch, Ling and Phoenix2021, Cigrang et al. Reference Cigrang, Rauch, Mintz, Brundige, Mitchell, Najera, Litz, Young-McCaughan, Roache, Hembree, Goodie, Sonnek and Peterson2017, Kerst et al. Reference Kerst, Zielasek and Gaebel2020, Rowen et al. Reference Rowen, Giedgowd and Baran2021, Shapira et al. Reference Shapira, Yeshua-Katz, Cohn-Schwartz, Aharonson-Daniel, Sarid and Clarfield2021, Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020), the ‘Post-Traumatic Stress Checklist-Civilian Score’ (Cigrang et al. Reference Cigrang, Rauch, Mintz, Brundige, Mitchell, Najera, Litz, Young-McCaughan, Roache, Hembree, Goodie, Sonnek and Peterson2017, Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020) and the ‘Revised Children’s Anxiety and Depression Scale’ (Weineland et al. Reference Weineland, Ribbegårdh, Kivi, Bygdell, Larsson, Vernmark and Lilja2020). The success of the intervention was interpreted from the score difference before and after the intervention. Another study used the ‘Patient-Reported Outcomes Measurement Information System’ and ‘The Patient Global Impression of Change Scale’ (Vanden Bossche et al. Reference Vanden Bossche, Lagaert, Willems and Decat2021). The ‘Self-Report Habit Index’ (SRHI) was used along with the ‘Perceived Stress Scale’, ‘Impact of Events Scale’ (IES) and ‘Hospital Anxiety and Depression Scale’ to assess the link between strength of physical activity and meditation habits and mental health (Green et al. Reference Green, Huberty, Puzia and Stecher2021). Similarly in another study, a questionnaire assessing frequency of mindfulness practice was completed together with GAD-7 and IES questionnaires (Zhu et al. Reference Zhu, Schülke, Vatansever, Xi, Yan, Zhao, Xie, Feng, Chen, Sahakian and Wang2021). The SRHI or similar scales used alongside measures of mental well-being is useful to highlight health promoting behaviours.
Many studies included qualitative interviews with participants. Common interview themes were identified, and used to assess the feasibility/ accessibility of the intervention (Murphy et al. Reference Murphy, Scott, Salisbury, Turner, Scott, Denholm, Lewis, Iyer, Macleod and Horwood2021, Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020, Weiskittle et al. 2021). Chart Reviews were also used, to assess clinician symptom detection (Ahmad et al. Reference Ahmad, Wang, Wong and Fung2020), investigate if appointment attendance differed with telemedicine use, and to check if EBI’s continued to be provided using telemedicine (Frank et al. Reference Frank, Grumbach, Conrad, Wheeler and Wolff2021). The ‘Working Alliance Inventory Scale’ was used to evaluate therapeutic alliance during a telemedicine intervention (Rowen et al. Reference Rowen, Giedgowd and Baran2021).
Discussion
Key findings
As COVID-19 infections continue to rise globally, it is anticipated that many interventions to address its mental health sequelae are ongoing and will continue to be evaluated in the months and years ahead. Research to date has predominantly focused on interventions to improve identification of mental health disorders, new or existing psychological therapies to treat these disorders, and the use of telemedicine to enhance the care GPs offer to this cohort of patients. Interventions studied that required active involvement of patients in their own care had positive results, and thus should be considered for patients with declining mental health stemming from the pandemic (Soklaridis et al. Reference Soklaridis, Lin, Lalani, Rodak and Sockalingam2020).
A key theme identified was the usefulness of digital mental health interventions. The surge of interest in and acceptance of digital tools among clinicians and patients precipitated by the global pandemic has offered an opportunity to explore their potential to enhance mental health care. Many studies documented success of online programmes, mobile applications and zoom group meetings to improve mental health. GPs should become familiar with these interventions and encourage patients to engage with them as an aspect of their care. In particular, small group meetings of older adults over video/phone have shown to improve mental health during the pandemic. This intervention should be considered not just in the immediate post-pandemic period but into the future, as loneliness and social isolation among older people were problems long before COVID-19.
Based on the findings from this review, it is recommended that encouraging participation in health behaviours including physical activity and meditation should be an important public health objective, and should be promoted by GPs. Interventions proven to be accessible and that reduce stigma are important. Delivering mental healthcare in primary care settings can reduce the stigma often found in speciality settings (Cigrang et al. Reference Cigrang, Rauch, Mintz, Brundige, Mitchell, Najera, Litz, Young-McCaughan, Roache, Hembree, Goodie, Sonnek and Peterson2017). Using telemedicine allows the patient to interact with their clinician from their own home, improving accessibility.
Comparison with existing literature
Previous research has indicated that digital interventions are important in the COVID-19 era. A scoping review reported that technology-based interventions have been designed and implemented for mental health prevention and promotion during COVID-19, and highlighted the shift to telemedicine to provide mental health care (Safieh et al. Reference Safieh, Broughan, McCombe, McCarthy, Frawley, Guerandel, Lambert and Cullen2021). This paper also supported our finding that physical activity is associated with improved mental health outcomes (Safieh et al. Reference Safieh, Broughan, McCombe, McCarthy, Frawley, Guerandel, Lambert and Cullen2021). Sharing the Vision Ireland’s Mental Health Policy (2020) states that all service elements should include access to talk therapies as a first-line treatment option for most people who experience mental health difficulties (Department of Health 2020). As such, it is important that GPs have direct and increased access for their patients to trained providers of these services. Other practical strategies suggested to enhance provision of mental health services include clinic-based telehealth, linking patients with helplines and virtual medication management visits (Kopelovich et al. Reference Kopelovich, Monroe-Devita, Buck, Brenner, Moser, Fredrik, Harker and Chwastiak2021).
Methodological considerations
Adopting Arksey and O’Malley’s framework was beneficial, as it facilitated greater rigour and transparency in the research process. Our early literature review allowed a comprehensive set of search terms to be compiled. Further, we feel the decision to not limit our literature search by year was justified as it facilitated the potential inclusion of studies during other medical pandemics. However, the scoping review methodology itself gives rise to some limitations. We did not evaluate the study quality of the included literature, as scoping reviews do not include an assessment of study quality – the focus is on covering the range of work that informs the topic rather than limiting the work to studies that meet particular standards of scientific rigour. We also only included literature published in English, which may have excluded relevant studies in other languages. Furthermore, we acknowledge using the PRISMA extension for scoping reviews (PRISMA-ScR) (Colquhoun et al. Reference Colquhoun, Levac, O’Brien, Straus, Tricco, Perrier, Kastner and Moher2014) rather than the standard PRISMA guidelines may have added to the quality of the manuscript.
Future directions
While literature continues to be published on the mental health sequelae of COVID-19, literature reporting interventions to combat these issues remains lacking. More large scale primary research is needed in the general practice setting, to evaluate feasibility of mental health interventions. In our research, all studies reporting primary care therapeutic interventions have focused on psychological treatments. There is a lack of studies focusing on primary care biological treatments (psychiatric medications) as an intervention to enhance mental health post-COVID-19. This area needs to be explored going forward. As the pandemic is still ongoing, there is no concrete research conducted post-pandemic – we can only draw on interventions proven successful in people presenting with disorders arising during the pandemic, or from studies conducted after previous pandemics. When COVID-19 ends, there may be further negative mental health consequences as people struggle to return to normality. Research in this area must be continued over the coming months and years as we emerge from the pandemic, to gain a comprehensive view of interventions which can improve mental health post-COVID-19. Further research is additionally required to outline the impact of mental health primary care interventions post-COVID-19 in specialist populations such as in prisons and people with intellectual disabilities as these populations were disproportionately affected by the restrictions imposed by the pandemic (Gulati et al. Reference Gulati, Dunne and Kelly2020, Gulati et al. Reference Gulati, Fistein, Dunne, Kelly and Murphy2021). The challenge now posed to practitioners worldwide is facing up to the surge in mental health problems by keeping up to date with relevant research, and actively implementing interventions in their practice which can improve the mental health care they offer to their patients.
Conclusion
The mental health impacts of COVID-19 are only just beginning to manifest, and will have implications for healthcare systems for years to come. This review outlines studied interventions which could be implemented in general practice to enhance care of mental health disorders post-COVID-19. Studies highlighted the feasibility and effectiveness of digital mental health interventions and suggested that their use is likely to persist after the current pandemic. However it is important that digital mental health interventions are supported by requisite standards of evidence, funding, and data protection legislation. This review also established priority areas for future research, particularly in the area of biological treatments (psychiatric medications) for mental health sequelae of COVID-19. Further research is needed in the Irish general practice setting to determine which interventions are most effective in this setting.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
All authors have no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this review paper was not required by their local Ethics Committee.
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