Effectiveness of Telehealth Interventions to Promote Mental Health Among Healthcare Professionals: A Systematic Review (Preprint)
Authors: Silva Simone Maria de Oliveira , Damasceno Kairo Silvestre Meneses , Santana Amália Ivine Costa , Coelho Julita Maria Freitas , Freitas Ruan Pablo Duarte , Júnior Argemiro D’Oliveira , Pimentel Rodrigo Fernandes Weyll , Ferreira Matheus dos Santos , Gomes Antonio Marcos Tosoli , Pimentel Magno Merces Weyll 
Published: January 2025

BACKGROUND

Summary
Introduction Telehealth interventions have been widely used due to their advantageous application characteristics, despite the lack of evidence of their effectiveness among healthcare professionals.
Objective: Investigating the effectiveness of telehealth programs aimed at healthcare workers.
Methods: This is a systematic review, searching the databases of Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Cochrane Register of Controlled Trials (CENTRAL CCTR/Cochrane Library) and Latin American and Caribbean Literature on Health Sciences (LILACS). Randomized clinical trials that investigated the efficacy of telehealth aimed at health professionals were included. The outcome analyzed was the improvement of mental health among healthcare professionals. The Revised Cochrane risk-of-bias tool for randomized trials 2.0 was applied to assess the risk of bias.
Results: Two randomized clinical trials with low risk of bias were analyzed. Two randomized clinical trials were analyzed, both with a low risk of bias. One study showed a significant difference in favor of the interactive platform’s intervention group after 6 months (- 0.96; 95% CI, -1.52 to -0.40) and 9 months (-1.14; 95% CI, -1.69 to - 0.58). In the other study, no significant difference was found between the groups after two weeks (- 0.04; 95% CI -0.11 to 0.04; P = 15). A subgroup analysis of participants taking psychotropic drugs showed a significant difference between the groups in favor of the app intervention group (-0.29; 95% CI -0.48 to -0.09; P = 0.004). In both studies, there was no significant difference between the groups for the Burnout and Stress outcomes.
Conclusions: There are initial evidences with a low risk of bias that telehealth is not effective in interventions for improving mental health of healthcare professionals.

OBJECTIVE

Investigating the effectiveness of telehealth programs aimed at healthcare workers.

METHODS

Study design
This is a systematic review following a checklist on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)[7] and it is registered on platform PROSPERO, CRD 42024567724.
Study search and selection strategy
The three databases as follows were selected to carry out the systematic review: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Cochrane Register of Controlled Trials (CENTRAL CCTR/Cochrane Library), Latin American and Caribbean Literature on Health Sciences (LILACS) and Virtual Health Library (VHL). The search was carried out in June 2024.
The initial selection was carried out using the titles and abstracts of the studies, and were evaluated by two authors, independently and blindly. The articles were read in their entirety and the studies included were selected. In cases of disagreement, this was resolved by the action of a third reviewer.
Eligibility Criteria
The choice of studies was made according to the PICOS strategy: (Population, Intervention, Control, Outcome, and Study Design):

•	Population: healthcare professionals
•	Intervention: at least one experimental group with synchronous or asynchronous telehealth, consisted of audiovisual programs in isolation.
•	Control: No interventions, in-person health interventions, placebo interventions, and any intervention without telehealth.
•	Outcomes: mental health assessed using validated instruments.
•	Type of study: Randomized clinical trials (RCTs)

Thus, the research question derived from the PICOS strategy consists of: Which telehealth interventions are effective for the mental health of health professionals?

Preliminary and pilot studies, abstracts published at conferences, articles with insufficient data on the results, and studies with participants other than health workers analyzed together with the population of interest were excluded.

Risk-of-bias assessment
The Cochrane Collaboration recommendations were used to assess the risk of bias for all randomized clinical trials using the RoB 2.0 tool (Revised Cochrane risk-of-bias tool for randomized trials) used by the Microsoft Excel program, consisting of five domains: Bias in the randomization process; Deviations from the intended intervention; Bias due to missing data; Bias in measuring outcomes; Bias in reporting outcomes. The risk-of- bias assessment was carried out by two independent researchers.
Data extraction
Data extraction from the included studies was performed using a standardized form adapted from the Cochrane Collaboration Checklist[8], extracted by two independent reviewers.

RESULTS

An initial search was carried out and 1779 studies were analyzed, and 2 RCTs were selected for qualitative analysis, totaling 1757 participants. The studies were conducted in Spain and the United States. The average age of the participants was 40 years, the ages range from 18 to 65 years, and gender division was approximately 80% women and 20% men. In both studies, the participants were health professionals, physicians, nurses, and nursing aides who were selected based on exposure to high-demand scenarios, such as the COVID-19 pandemic, and who showed signs of stress and Burnout at the start of the studies.
The assessment tools used in the analyzed studies were validated and widely used in the literature, ensuring the robustness of the measures. Outcomes were assessed by using Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Depression, Anxiety, and Stress Scale (DASS-21), Davidson Trauma Scale (DTS), Maslach Burnout Inventory Human Services Survey (MBI-HSS), Insomnia Severity Index (ISI), and General Self-Efficacy Scale (GSE). The baseline assessment period and last reassessment ranged from 2 weeks[2] and 6 to 9 months[9].

A study[9] implemented a digital engagement strategy, in which participants accessed an online platform that offered interactive content on mental health, with weekly mindfulness modules, stress reduction exercises, and virtual appointments with therapists. Participants were encouraged to use the platform for at least 20 minutes a day, over 4 weeks. Another study[2] used PsycovidApp, a mobile application designed to provide psychological support for health professionals during the pandemic. The app included features such as daily emotional state tracking, breathing exercises and guided meditation, and motivational messages sent automatically. The participants used the app for an average of 15 minutes daily for 6 weeks.

Regarding the outcomes of anxiety and depression, a study[9] showed a significant difference in favor of the intervention group after 6 months (- 0.96; 95% CI, -1.52 to -0.40) and after 9 months (-1.14; 95% CI, -1.69 to - 0.58). In the other study[2], no significant difference was found between the groups after two weeks (- 0.04; 95% CI -0.11 to 0.04; P = 15). However, in an analysis of the subgroups, a significant difference was observed between the groups in favor of the intervention group, in which the participants used psychotropic drugs, even before and during the study (-0.29; 95% CI -0.48 to -0.09; P = 0.004). In the two studies analyzed, there was no significant difference between the groups for the outcomes of Burnout and Stress.

Both studies showed a low risk of bias in all domains. In Domain 1 (Randomization), both studies used appropriate methods for random sequence generation and allocation concealment (computerized randomization with adequate concealment). In Domain 2 (Deviations from Intervention), adherence to interventions was high in both studies, and participants were not informed about their allocations, minimizing the risk of bias. In Domain 3 (Missing Data), follow-up loss rates were minimal, approximately 2% in the study by Agarwal et al. (2024) and 10% in the study by Fiol-deRoque et al. (2021), in addition, the missing data were duly treated. In Domain 4 (Outcome Measurement), the outcome evaluators were blind to the allocation of the groups and the scales used were validated. Finally, in Domain 5 (Outcome Selection), all pre-specified outcomes were reported in both studies, with no evidence of bias in the selection of results.

CONCLUSIONS

Based on this review, there are initial evidences with a low risk of bias that telehealth interventions are not effective in promoting mental health for healthcare professionals. Such results should be cautiously considered due to the limited number of studies included. Although telehealth is currently a safe and easily accessible resource, new robust clinical trials with longer observation times can contribute significantly to the growing literature on the clinical impact of telehealth on the mental health of health professionals.