Introduction

The COVID-19 pandemic posed a challenge: meeting the growing demand for medical care while maintaining physical distance [1]. An increased number of mental health problems associated with the lockdown of children and adolescents was documented [2]. Caregivers of children with special needs, on the other hand, also faced increased levels of stress, anxiety, and depression [3]. This crisis prompted a shift in healthcare delivery from face-to-face to virtual consultations [4,5,6,7]. Previously, telemedicine adoption was slow due to barriers such as patient and provider resistance, security and privacy concerns, lack of regulations, and technical limitations [8,9,10,11,12].

There are studies supporting the use of mental telehealth, but most are focused on its applicability and acceptability [11,13]. During the pandemic, participants expressed gratitude for these virtual consultations, but evidence of their efficacy is still developing [11]. Some comparative studies have found no significant differences in clinical outcomes between face-to-face and virtual treatments [14,15,16].

Considering that 22.5% of the child-adolescent population already had psychiatric disorders before the pandemic, coupled with existing barriers to mental healthcare, telehealth is a valuable option to improve access and quality of care. However, studies assessing the feasibility and limitations of telehealth in local settings are lacking [7,17].

Given the above, this study aims to know the perspective of therapists and patients regarding the use of telehealth in a child and adolescent mental healthcare unit of a public service in the Valparaiso Region, Chile.

Methods

Study design

The approach of this study was that of grounded theory in its constructivist version. This theory allows us to establish inductively, systematically, and iteratively understand how the participants mean and organize their daily experiences. Using this analysis model, we sought to establish emergent categories to access the participants' perspectives on the use of mental telehealth in a child and adolescent unit of a public healthcare service [18]. For this purpose, two focus groups with professionals and 16 in-depth interviews with users, including adolescents and children’s main caregivers, were conducted. For both the focus groups and the in-depth interviews, semi-structured scripts were prepared with the topics of interest for this study.

Investigators

The group of researchers comprised a clinical team and an advisory team. The clinical team was composed of five female members of the same Child and Adolescent Mental Healthcare Unit. Four of them were child and adolescent psychiatry residents at the University of Valparaiso, in their second and third years, with an average age of 32 years. This team also includes a psychiatrist with teaching and assistance functions, with seven years of permanence in this unit and 11 years of experience in clinical research. The advisory team was comprised of two researchers, male and female, with an average age of 52 years and 25 years of research experience. Both are psychologists and university professors, with no connections to the group of professionals or the patients under investigation. They reviewed the study design, interview scripts, and focus groups. In addition, together with the clinical team, they participated in the data analysis.

Participants

In the sample selection process, therapists and patients participating in remote mental healthcare were sought. In the group of therapists, psychiatrists, and psychologists were invited to participate, and all of them accepted. In addition, a social worker was included because of her family’s therapeutic work (Table 1).

Regarding the users, a list was requested with all those currently in mental health care. A diverse sample of ages and diagnoses was sought for convenience, defining a first selection of 16 users, eight aged 13 years or more, and eight aged 12 years or younger. In the latter group, the responsible adult (mother, father, or grandmother) was interviewed [19,20]. Patients were randomly selected from the list according to age, and subsequently, the treating psychiatrists were consulted about the diagnoses. Once the selection of users had been made, the residents made telephone contact with the users and their relatives to invite them to participate in the study. All of them agreed to participate (Table 2). Users attended by the research team were excluded from participating. This is because the interviews were conducted by the Child and Adolescent Psychiatry residents of the University of Valparaíso, who attend to patients under supervision. For this study, participants attended by the professional team of the hospital’s child and adolescent unit were sought.

All participants, both therapists and users, were informed of the reasons for the study and agreed to be included in it by signing the informed consent or assent form, according to their age. This research was approved by the Scientific Ethical Committee of the Valparaiso San Antonio Health Service, labeled Ord. 1285 01/09/20.

Data collection

Focus groups with professionals: a semi-structured script was prepared to guide the conversation focused on the experience of providing telematic care. The topics addressed were the media and therapeutic setting, the relationship in remote care, the advantages and disadvantages of mental telehealth, user profiles, and general experience. The starting question was "How was your experience of remote care?" waiting for different topics to appear spontaneously, and then asking more specific questions, for example, "Do you think that the services were useful for the patient?

This semi-structured script allowed sufficient flexibility to accommodate emerging themes in the development of the focus groups. It also made it possible to ensure the revision of the defined topics to be addressed in each of the focus groups.

The focus groups were conducted simultaneously in August 2020, with a duration of 90 minutes. The moderators were the four residents of the research team. They were conducted in videoconference mode. The sessions were recorded and then transcribed for later analysis.

Interviews with patients and family members: all interviews were conducted by telephone. They began with an initial broad question regarding the experience of mental health care. Then, more specific questions were asked about the media and setting, the relationship in remote care, the advantages and disadvantages, and a general evaluation. Some of these topics were taken from emerging themes in the focus groups. The starting question was: "How was your experience with remote care?" and then probed through more specific questions. An example was "How did you feel when participating in the remote care services? As in the focus groups, the individual interviews combined a flexible approach to accommodate emerging themes while ensuring the review of the topics defined to be addressed in each of them.

The interviews were conducted between April and June 2021 by the residents of the research team, with an average duration of 25 minutes. None of the residents who conducted the interviews were direct caregivers to the patients. All interviews were recorded and transcribed for later analysis.

Analysis

Following the grounded theory procedures, two to four researchers coded the transcripts of the focus groups with the open coding system [18,21,22]. The coding process was developed with the ATLAS.ti software, version 8.4.5, consisted of assigning codes to expressions, in this case, those of the therapists, through an inductive process of constant comparison. This process was validated through a triangulation procedure of the analysis carried out with another researcher in all instances where no consensus was reached [23]. This involved working initially with provisional emerging codes and properties, which were consolidated as they became saturated in the iterative processes of coding and triangulation.

Once the coding was completed, the codes were classified into categories and subcategories to generate classification schemes that allowed the central topics of the telemedicine experience to be raised [18,21,22].

Subsequently, the patient interviews were coded following the same procedure described above. However, this time, the coding was guided by the codes, subcategories, and categories emerging from analyzing the therapists' focus groups. Although a first selection of 16 users was defined, it was not necessary to incorporate more interviews due to saturation.

Results

Therapist’s perspective

The descriptive analysis of the focus groups allowed us to extract four main categories:

1. History of mental telehealth.

2. Implementation of mental telehealth.

3. Mental telehealth from the therapist’s perspective.

4. Projections.

1. History of mental telehealth: This refers to the knowledge about mental telehealth before the pandemic and its expectations. Here, there is concern about the resources needed for its implementation, the lack of training, the scarcity of research in the area, and clear guidelines. It also recognizes doubts about the possibility of psychotherapy in this context and ethical questions related to this type of care.

2. Mental telehealth implementation: This section describes how care is carried out, both from a practical and therapeutic point of view. Changes in the framing of care are seen and how this may influence the therapist-patient relationship. Differences between remote care modalities are also described.

3. Mental telehealth from the therapist’s perspective: This category refers to the impact of the telematic modality of care on therapists and the potential risk to their mental health, resulting in a loss of boundaries between personal and work life. On the other hand, it points to the emergence of new resources in therapists, work teams, users, and families.

4. Projections of mental telehealth: It describes the current and future technical and clinical challenges, alluding to the need to adapt to new technologies in therapeutic care, to the changes derived from its use over time, and to the consequences of fewer face-to-face consultations. It also highlights the need to identify a profile of less suitable users for distance care.

Table 3 shows these categories, with the subcategories and codes extracted from the analysis. An illustrative vignette is provided for each category.

User’s perspective.

The descriptive analysis made it possible to extract three main categories:

1. Implementation of mental telehealth.

2. Mental telehealth users evaluation.

3. Projections of mental telehealth.

1. Implementation of mental telehealth: describes how care is carried out from the practical point of view, referencing the means of communication used and the environmental and family elements that condition its performance.

2. Evaluation of mental telehealth users: This includes users' positive or negative evaluations based on their experience with remote mental health care. It also includes the interviewees' comparisons between face-to-face and remote modalities, identifying advantages and disadvantages.

3. Projections refer to the possibility of maintaining mental telehealth in the future based on the user’s current and future preferred modality, their profile, and the difficulties identified in its implementation. These may be environmental, privacy-related, or technical and technological.

Table 4 shows these categories, with the subcategories and codes extracted from the analysis with illustrative bullets.

Discussion

Our study focused on the rapid transition to mental telehealth in the context of a healthcare crisis, with little previous research and no clear guidelines. In the process, we report shared experiences among therapists and users, reflected in three central categories: implementation of mental telehealth, perspectives of therapists and users, and projections of this modality.

The users' assessment of remote care ranges from acceptance and conformity to dislike. Our study attempts to detail the interviewees' experiences to understand this variation. For patients and therapists, the idea of patient profiles less suitable for this care modality emerges. Therapists and users coincide in pointing out the challenges of caring for young children and seriously ill patients. In particular, this is a topic widely studied in psychiatry and other healthcare areas [24,25,26].

Both groups, therapists and users, pointed out that remote care involves greater parental participation, which is considered valuable when working with children and adolescents. They also agree in pointing out difficulties in terms of privacy and the influence of their environment on the sessions. Regarding time and space limitations, users and therapists state that there is a perception of greater willingness on behalf of the therapist. It is relevant that users evaluate this aspect positively, while therapists consider it a risk to their mental health with the loss of boundaries between personal and work life. At this point, therapists emphasize that they also experienced the pandemic with physical and emotional effects. Therapists also point this out in a review published in 2023, where they describe visual to physical fatigue, increased emotional vulnerability, and doubts regarding their abilities to maintain full-time attention [27]. Another study conducted in an Italian psychology center highlighted the perceived changes in the sense of professional identity. It also relieved some therapists' fear of a possible "unstable framing" through mental telehealth, as opposed to the usual formal framing, and how this could lead to a dissolution of the analyst’s role. At the same time, they pointed out the possibility of building a new form of real and virtual intimacy together with the analyzed users [28].

Despite the positive aspects that users recognize in mental telehealth, such as perceiving the professional’s help or feeling comfortable and listened to, no user preferred exclusively remote care in the future scenario. Without the pandemic context, users would opt for face-to-face or mixed care. This is similar to a systematic review of 39 mixed studies, which concludes that providers and patients supported a "hybrid" model of mental health care in the future, considering patient eligibility, preferences, and type of consultation [11]. Our work is also consistent with a qualitative study conducted in France with a sample of adolescents and caregivers. The latter indicates that the pandemic context facilitated the incorporation of mental telehealth. In turn, this study agrees that therapists and users positively valued the integration of parents in the sessions. This is consistent with our work, which even suggests generating a mixed system in which care for parents can be virtual and for children and adolescents face-to-face. It also mentions elements related to physical distance and its consequences, such as difficulty identifying non-verbal communication and bonding elements. Additionally, they coincide in identifying a profile of patients more suitable for this modality of care. For example, when there are phobic or avoidant symptoms, they would be more comfortable with the distant relationship, as opposed to patients with severe symptomatology and/or little bonding with the therapist. The study also proposes that, for some users, attending face-to-face interventions can be therapeutic in itself, which is in line with what was mentioned in our work [12].

The study raises ethical issues such as lack of privacy, the need for training in telemedicine, distrust when exposed to unknown professionals, crisis management, and inequity in access to mental healthcare. In addressing the inequity of access, challenges such as lack of coverage, lack of internet access, and being inexperienced with information and communication technologies are evident, which is consistent with a study on the North American reality [29]. Despite the above, some participants value the convenience of avoiding travel and allowing caregivers to assist other family members during the consultation, which is in line with efforts to reduce the gap in mental health care. This reflects the particular needs of each user.

In legal terms, our work raises concerns about the lack of guidelines for remote care, the security of platforms with no guarantee of sensitive data encryption, and the environmental conditions that affect care, especially for those who lack a quiet environment. It also coincides with the literature, which adds the use of informed consent, licensing, and regulations on drug prescribing [30,31].

The American Psychiatric Association and the American Telemedicine Association developed a guideline to provide effective and safe medical care. The guideline includes administrative, technical, and clinical considerations. For example, legal recommendations, use of protocols, informed consent, and patient and setting issues are presented [30]. This guide provides suggestions, which should be implemented according to the regulations of each country at that time. Nowadays, despite the existence of formal guidelines and recommendations on the use of mental telehealth, there is a lack of studies on the application of these guidelines.

Regarding the limitations of our study, we consider that, since it was carried out in a single mental health center, the results are focused on the local reality or could only be extrapolated to other centers with similar characteristics. Another limitation is that, among the patients interviewed, ten received telephone calls, three had the experience of making video calls along with other modalities, and only three were attended exclusively by video call, so most of the experience reflected in this study is related to telephone care and not by video.

It should be noted that the researchers were working at the same child psychiatry unit. This allowed for a closer knowledge of the research topic and generated questions more pertinent to the context in which it was developed; however, this could also introduce biases in the research. Finally, the data from users and professionals were collected at different times and, therefore, at different moments of the pandemic. This indicates a moment of less adaptation on behalf of the therapists to this modality of care.

Conclusions

In summary, this study provides a detailed overview of the telehealth transition in a child and adolescent mental healthcare service during the COVID-19 pandemic. It highlights the importance of communication between therapists and caregivers and the challenges and benefits of remote care. The results are relevant for mental health professionals and future care planning in similar situations. Similarly, these data are important for the adoption of mental telehealth as a daily care option.