Feasibility of Accessible Video Mental Healthcare Triage and Assessment

This study aims to describe the immediate psychiatry (IP) service, patient population, and patient flow, as well as investigate the experiences, acceptability, and feasibility of the IP triage service implemented in Region Stockholm, Sweden.

Patients aged 18 years and older who were registered at participating primary care centers were eligible to access the IP through a regional healthcare app. IP comprised a brief digital screening followed by a 45-minute video consultation with a mental health professional. The study will employ a mixed methods design with data from medical records, patient surveys, interviews with the IP team, and clinician acceptability questionnaires. The quantitative data will be analyzed via descriptive statistics, and the qualitative data will be analyzed via content analysis.

Study Design, Setting, and Ethical Considerations This pilot study, initiated in May 2022, was conducted at a psychiatric clinic affiliated with Karolinska Huddinge Hospital, in collaboration with eight primary care centers in southern Stockholm, Sweden. Data collection occurred from December 19, 2022, to June 30, 2023. The study was ethically approved by the Swedish Ethical Review Authority (2022-03893-01) and adhered to ethical guidelines. Participants were informed about the study's purpose and procedures, with an option to opt out at any time without affecting their care.

The specific research questions were as follows:

1. How many patients received IP, on the basis of the selected recruitment strategy?
2. What were the subsequent care needs in primary and psychiatric care settings identified for patients after using the service?
3. What were the demographics of participants included in the study, such as age, gender, type of psychiatric problems?
4. How did the participants rate their psychiatric concerns in terms of the type of symptoms, symptom severity, symptom onset, and symptom duration?
5. How did the IP team assess patients' psychiatric symptoms and suicidality?
6. How did the participants rate their satisfaction with the IP?
7. Did patient groups recommended for subsequent care in primary and psychiatric care differ in terms of demographics and clinical aspects explored in C-F?
8. How did the IP team experience their work with the intervention?
9. How did participating primary care centers rate the acceptability of IP?

Recruitment Process Participants were recruited through multiple channels including information on the participating primary healthcare websites, posters, verbal information from healthcare providers, and local advertisements. Recruitment was limited to Swedish speakers due to the app's language and logistical issues with interpreter availability.

Participants Inclusion criteria required participants to be 18 years or older and registered with one of the eight participating primary healthcare centers. No exclusion criteria were applied, enabling the study to include patients with both subclinical and severe psychiatric symptoms.

Intervention and Procedure The Immediate Psychiatry (IP) service was delivered entirely through the "Alltid Öppet" app, which provided patients with a digital pathway to book consultations and complete brief screenings. After consultations, patients were invited to fill out a satisfaction survey. A flowchart of the patient journey was developed to visualize the process. The service was developed through an agile, collaborative approach and monitored weekly by a multidisciplinary team. A detailed service manual was produced, covering protocols for risk assessment, consultation procedures, and patient referrals.

Intake, Screening, and Patient Satisfaction Patients completed a brief psychiatric screening upon registration. After the screening, they could schedule a 45-minute video consultation with a mental health professional, without specific professional matching. Post-consultation, patients were provided with a link to an anonymous satisfaction survey.

Team Organization and Competencies The IP team was multidisciplinary, consisting of psychiatrists, psychologists, psychiatric nurses, a mental health therapist, and administrators. The team had a wide range of experience in general psychiatric care, social psychiatry, and suicide prevention.

Consultation Consultations were guided by a semi-structured interview process adapted for this study. Professionals gathered patient histories, screened for psychiatric symptoms, domestic violence, suicidality, and substance use, and collaboratively developed preliminary care plans with patients.

Clinical Documentation Each consultation was documented in a semi-structured format in the electronic medical record system. Preliminary diagnoses, care plans, suicide risk assessments, and other relevant information, such as experiences of abuse, were recorded following the clinic's standard procedures.

Subsequent Care and Referrals Consultations resulted in referrals to primary or psychiatric care, self-help recommendations, or no further action. Patients were responsible for scheduling follow-up appointments, with support from the healthcare system via the app.

Data Collection and Patient Flow Patient data, including demographic information, preliminary diagnoses, and actions taken, were collected through self-reports and medical records. Patient flow was monitored through the app and medical records.

Screening of Psychiatric Concerns A brief 9-item screening tool was used to assess psychiatric symptoms, history, and current use of medications. This tool was developed to facilitate early information gathering and reduce patient burden during intake.

Medical Records and Data Exports The Operational Support team within Region Stockholm Healthcare provided data exports from medical records, which included patients' demographic information, diagnoses, and suicide risk assessments.

Patient Satisfaction Survey The satisfaction survey utilized a 5-point Likert scale to assess multiple dimensions, including the ease of consultation, staff competence, and likelihood of recommending the service.

IP Team Interviews To capture staff experiences, three semi-structured interviews were conducted with IP team members at the end of the intervention period. These interviews focused on roles, patient interactions, and decision-making processes.

Clinician Acceptability at Primary Care Centers Healthcare professionals who received referred patients were surveyed using the Acceptability of Intervention Measure (AIM) to assess the acceptance and perceived usefulness of the IP service.

Data Analysis Descriptive statistics will be used to summarize patient characteristics. Fisher's Exact Test and the Mann-Whitney U Test will be applied for group comparisons. Missing data will be handled through imputation based on mean values. Qualitative content analysis will be used for interview data, involving systematic coding and theme development.

Eligibility Criteria:
Inclusion criteria:

* Adult patients
* Knowledge of Swedish language
* Access to internet
* Belonging to Primary care in Southwest of Stockholm Region
* Seeking help for acute psychiatric symptoms

Exclusion criteria:

* Younger than 18 years old
* Not meeting inclusion criteria