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The COVID-19 pandemic and its mitigation measures and impacts, such as shelter-in-place orders, social isolation, restrictions on freedoms, unemployment, financial insecurity, and disrupted routines, have led to declines in mental health worldwide and concomitant escalating demands for mental health services. Under the circumstances, electronic mental health (e-mental health) programs and services have rapidly become the “new normal.”
The aim of this study was to assess key characteristics and evidence gaps in the e-mental health literature published in relation to the COVID-19 pandemic via a scoping review and bibliometric analysis.
We conducted a search of four academic databases (ie, MEDLINE, Embase, PsycInfo, and CINAHL) for documents published from December 31, 2019, to March 31, 2021, using keywords for e-mental health and COVID-19. Article information was extracted that was relevant to the review objective, including journal, type of article, keywords, focus, and corresponding author. Information was synthesized by coding these attributes and was then summarized through descriptive statistics and narrative techniques. Article influence was examined from Altmetric and CiteScore data, and a network analysis was conducted on article keywords.
A total of 356 publications were included in the review. Articles on e-mental health quickly thrived early in the pandemic, with most articles being nonempirical, chiefly commentaries or opinions (n=225, 63.2%). Empirical publications emerged later and became more frequent as the pandemic progressed. The United States contributed the most articles (n=160, 44.9%), though a notable number came from middle-income countries (n=59, 16.6%). Articles were spread across 165 journals and had above-average influence (ie, almost half of the articles were in the top 25% of output scores by Altmetric, and the average CiteScore across articles was 4.22). The network analysis of author-supplied keywords identified key topic areas, including specific mental disorders, eHealth modalities, issues and challenges, and populations of interest. These were further explored via full-text analysis. Applications of e-mental health during the pandemic overcame, or were influenced by, system, service, technology, provider, and patient factors.
COVID-19 has accelerated applications of e-mental health. Further research is needed to support the implementation of e-mental health across system and service infrastructures, alongside evidence of the relative effectiveness of e-mental health in comparison to traditional modes of care.
Mental illness is widespread worldwide. Depression and anxiety are the two most common mental health conditions, affecting 4.4% and 3.6% of the world’s adult population, respectively [
COVID-19 was first reported in Wuhan, China, on December 31, 2019, and on March 11, 2020, the World Health Organization declared the disease a global pandemic [
Mental health data suggest that COVID-19 has exacerbated the mental health crisis [
As the COVID-19 pandemic continues, electronic mental health (e-mental health) is rapidly becoming the “new normal” [
With the onset of COVID-19, the potential benefits of the use of e-mental health programs have been greatly reinforced by the need for mental health services to adapt to social distancing and stay-at-home measures. This has propelled e-mental health into widespread use in developed countries in favor of face-to-face therapies. By mid-2020, more than 80% of high-income countries had shifted to e-mental health technologies to replace or supplement in-person mental health consultations [
Electronic mental health (e-mental health) technologies [
In this study, e-mental health evidence has accelerated since the onset of the COVID-19 pandemic, as indicated by the sharp increase in the number of publications in “telepsychiatry” in 2020 (
Investigate the key characteristics of publications in the e-mental health literature since the start of the COVID-19 pandemic (ie, from 2020 onward).
Identify the key topics covered by this body of literature in order to determine potential evidence gaps.
Analyze characteristics in the most influential publications, as indicated by Altmetric and CiteScore data.
Examine the future directions for research and practice in the e-mental health field, both during the COVID-19 pandemic and beyond.
Increase in publications during 2020 (blue) and trendline (dotted blue), based on publications in MEDLINE using the search term “telepsychiatry” in titles or abstracts.
The review followed a predetermined protocol, developed in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [
Four academic databases (ie, MEDLINE, Embase, PsycInfo, and CINAHL) were searched from December 31, 2019, to March 31, 2021. The search strategy consisted of terms pertaining to eHealth (eg, “eHealth” and “telehealth”), more specific terms related to e-mental health (eg, “m-mental health”), common mental disorders (eg, “anxiety” and “depression”), and COVID-19. The search strategy was adapted for each database as necessary (see
Articles were included if they were (1) in the English language, (2) peer-reviewed journal articles, (3) discussed the application of e-mental health (theoretical or applied), and (4) were published following the onset of COVID-19 (from December 31, 2019). No restrictions were placed on the target population or setting. Studies were excluded if they did not focus on e-mental health, they were book chapters or conference proceedings, or the full text was not in English.
Reference details, including abstracts, were downloaded into the reference management software EndNote X9 (Clarivate), exported to Microsoft Excel, and divided among the research team for title and abstract screening. Two reviewers (IM and LAE) independently reviewed 5% of the titles and abstracts; interrater reliability between the two reviewers was high (κ=0.95, 95% CI 0.77-1.00;
A customized data extraction workbook was developed in Microsoft Excel. The workbook was piloted by each of the four reviewers with a subset of papers (n=10). Issues in consistency of data entry and usability of the template were then discussed, and modifications were made accordingly. Key information extracted included the following: article characteristics (ie, authors, date of publication, country of residence of the corresponding author, and journal name); article keywords, as supplied by the authors of the paper; and article type (ie, empirical, nonempirical, protocol, or review). For empirical studies (ie, studies that present an analysis of primary or secondary data in their results), information on study design (ie, quantitative, qualitative, or mixed methods) and methods (eg, surveys and interviews) were also extracted. In addition, article titles, abstracts, and keywords were searched for terms to identify papers with specific subpopulations of interest (eg, children, adolescents, veterans, and the elderly) and specific mental disorders (eg, depression, anxiety, posttraumatic stress disorder [PTSD], and substance abuse), as well as articles with a focus on issues or challenges related to the use or uptake of e-mental health in the context of COVID-19 (eg, barriers, privacy, and ethics).
Altmetric data were selected as the most appropriate measure of an article’s impact or influence because of the recency of this literature [
Articles were grouped together based on common attributes in the data (eg, article type). The country of the corresponding author was coded by income classification based on the World Bank’s definitions of gross national income per capita per year. The three categories were low (<US $1045), middle (US $1046-$12,695), and high income (>US $12,696) [
Key topic areas were identified through an analysis of article keywords. These were extracted by the research team and were then cleaned and checked for consistency. Derivative terms (eg, “health care” and “healthcare”) were amalgamated. Each keyword was reviewed and inductively classified by two authors (LAE and IM) into key topic and subtopic areas using the structure and definitions outlined in
The search retrieved a total of 2418 publications. After removing duplicates, 1506 remained for title and/or abstract review. Following title and/or abstract screening, 1023 publications were discarded as they did not meet the inclusion criteria. Based on the full-text assessment, a further 127 publications did not meet the inclusion criteria, resulting in 356 publications included in this review (see
Search and review strategy.
A summary of the key characteristics of the included articles is presented in
Summary of key characteristics of included publications.
Classification | Papers (N=356), n (%)a | |
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United States | 160 (44.9) |
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Australia | 28 (7.9) |
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India | 27 (7.6) |
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United Kingdom | 20 (5.6) |
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Canada | 17 (4.8) |
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Other | 104 (9.2) |
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High income (>US $12,696) | 297 (83.4) |
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Middle income (US $1046-$12,695) | 59 (16.6) |
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Low income (<US $1045) | 0 (0) |
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Nonempirical | 225 (63.2) |
|
Empirical | 99 (27.8) |
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Review | 20 (5.6) |
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Protocol | 12 (3.4) |
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Quantitative methods | 68 (68.7) |
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Mixed methods | 21 (21.2) |
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Qualitative methods | 10 (10.1) |
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Anxiety (including posttraumatic stress disorder) | 71 (19.9) |
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Depression | 48 (13.5) |
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Substance abuse disorders (including addiction) | 17 (4.8) |
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Psychotic disorders (including schizophrenia) | 16 (4.5) |
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Suicide | 13 (3.7) |
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Eating disorders | 11 (3.1) |
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Children and/or adolescents | 90 (25.3) |
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Older adults and/or the elderly | 20 (5.6) |
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Veterans | 17 (4.8) |
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Health professionals | 15 (4.2) |
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Telephone or videoconferencing | 142 (39.9) |
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Smartphone apps | 43 (12.1) |
|
Support groups | 6 (1.2) |
aColumns may not equal 356 due to missing values and overlap in some categories.
Date of publication by article type.
Of the 225 nonempirical publications, most were commentaries or opinion pieces (n=106, 47.1%), with a further 49 (21.8%) classified as descriptive case studies, 36 (16.0%) as letters to the editor, 22 (9.8%) as unstructured reviews, 10 (4.4%) as editorials, and 2 (0.9%) as unstructured protocols (
Overall, the empirical studies focused on the uptake and effectiveness of e-mental health initiatives in providing mental health care during COVID-19. The nonempirical descriptive case studies outlined the processes and challenges of the rapid conversion to telehealth for a particular mental health service, while nonempirical commentary or opinion pieces more broadly outlined policy changes, issues, and challenges to e-mental health and offered guidance to clinicians (see
Corresponding authors were predominantly from high-income countries, with almost half of the 356 included outputs coming from the United States (n=160, 44.9%), followed by Australia (n=28, 7.9%), the United Kingdom (n=20, 5.6%), and Canada (n=17, 4.8%). Notably, our study identified a number of publications from middle-income countries (n=59, 16.6%), with most of these being from India (n=29, 7.6%) and China (n=9, 2.5%) (
Examples of included studies.
Authors (year) | Country | Article type | Article classification | Specific populations | Specific disorders | Article aim |
Pierce et al (2020) [ |
United States | Empirical | Quantitative survey of 2691 psychologists | Veterans | Anxiety | To examine the amount of psychologists’ telepsychology use before the COVID-19 pandemic, during the pandemic, and anticipated use after the pandemic, as well as the demographic, training, policy, and clinical practice predictors of these changes |
Steinberg et al (2020) [ |
United States | Empirical | Quantitative and qualitative survey of 51 pediatric psychologists | Children and adolescents | General | To examine the uptake of transitioning pediatric psychology services to meet mental health needs in response to a worldwide public health crisis, and to call attention to psychologists’ perceived benefits and challenges related to providing pediatric mental health services during the pandemic |
Patel et al (2020) [ |
Ireland | Nonempirical | Descriptive case study | The elderly | General | To discuss the transition and challenges faced in rapidly implementing telehealth in a rural psychiatry-of-old-age service in the northwest of Ireland |
Haque (2020) [ |
United States | Nonempirical | Perspective | Mental health professionals | General | To discuss policy changes due to the COVID-19 pandemic and to highlight what mental health providers should consider for future delivery and implementation of telehealth programs |
Global trends for publishing articles on electronic mental health applied to COVID-19.
The 356 included articles were spread across 165 different journals, which were primarily focused on mental health, but varied in scope. Most of the journals had a reported CiteScore in Scopus (n=138, 83.6%), with scores ranging from 0.3 (Psychiatric Times) to 25.2 (The Lancet Psychiatry). A total of 3 articles (1.8%) were published in The Lancet Psychiatry [
Of the 242 publications with reported Altmetric data, almost half were ranked in the top 25% of all outputs scored by Altmetric (n=118, 48.8%). Altmetric Attention Score values ranged from 1 to 282 (mean 13.33, SD 30.04); though similar to CiteScore values, there was variation in Altmetric metrics by article type, with empirical studies (mean 14.10, SD 29.22), nonempirical articles (mean 13.6, SD 32.77), and reviews (mean 11.9, SD 14.11) having higher Altmetric scores than protocol papers (mean 5.4, 4.39). The publication with the highest Altmetric score was a nonempirical contribution by Kozloff et al, which outlined the adverse mental health consequences and virtual mental health service delivery options for people with schizophrenia during COVID-19, with an Altmetric Attention Score of 282, placing it in the 98th percentile of outputs of the same age [
The most influential publications based on Altmetric data.
Authors (year) | Country | Title | Journal | Altmetric Attention Scorea | CiteScoreb | Article type |
Kozloff et al (2020) [ |
Canada | The COVID-19 global pandemic: Implications for people with schizophrenia and related disorders | Schizophrenia Bulletin | 282 | 12.2 | Nonempirical |
Torous et al (2020) [ |
United States | Digital mental health and COVID-19: Using technology today to accelerate the curve on access and quality tomorrow | JMIR Mental Health | 197 | 1.3 | Nonempirical |
Ben-Zeev et al (2020) [ |
United States | Augmenting evidence-based care with a texting mobile interventionist: A pilot randomized controlled trial | Psychiatric Services | 146 | 4.6 | Empirical |
Rahman et al (2020) [ |
United Kingdom | The NIMHc global mental health research community and COVID-19 | The Lancet Psychiatry | 124 | 25.2 | Nonempirical |
Zhou et al (2020) [ |
Australia | The role of telehealth in reducing the mental health burden from COVID-19 | Telemedicine Journal and e-Health | 124 | 4.6 | Nonempirical |
aAltmetric data from Altmetric Explorer as of June 2021. All scores were in the top 5%.
bCiteScore in Scopus as of June 2021.
cNIMH: National Institute of Mental Health.
The topmost influential publications—defined as those with Altmetric Attention Score values in the top 25% of all research scored by Altmetric, and/or CiteScore values of ≥5—were identified. Based on this definition, close to half of our 356 included publications were classified as influential (n=165, 46.3%). The 165 influential articles were broadly reflective of the countries and country incomes previously reported (high-income countries defined here: n=143, 86.7%).
Among the 165 most influential publications, 124 had author-contributed keywords, with a total of 273 unique keywords in this subset of papers. The frequency with which these keywords were used together on a publication is visually depicted in the network of co-occurring keywords (
Network of co-occurring keywords in 165 of the publications with Altmetric values in the top 25% or CiteScore values of ≥5. Each circle (node) is a keyword, and each line (edge) represents co-occurrence. The size of each node indicates the number of times a keyword was used. Colors represent different topic areas. CBT: cognitive behavioral therapy; mHealth: mobile health; PTSD: posttraumatic stress disorder.
Although many of the 356 articles focused on mental health broadly, describing concerns relating to the effect of the pandemic on stress (n=78, 21.9%), loneliness or isolation (n=34, 9.6%), and general well-being (n=23, 6.5%), other studies focused their attention on specific mental disorders. A total of 71 of the 356 included articles (19.9%) were concerned with anxiety disorders (see
A large proportion of the 356 included articles described the application of e-mental health via telephone and/or videoconferencing during COVID-19 (n=142, 39.9%), as well as the use of smartphone apps (n=43, 12.1%) and support groups (n=6, 1.7%) in assisting people during times of need. For example, the review by Strudwick et al identified 31 smartphone apps and 114 web-based resources, including telephone support, virtual peer support groups, and discussion forums, that could be used to support the mental health of the Canadian public [
A number of articles identified particular at-risk populations who would require greater care and/or more resources to overcome barriers to access e-mental health during the pandemic. A total of 90 articles out of 356 were focused on children and/or adolescents (25.3%) (see
There appears to be a general consensus in the literature that younger children and older adults, who may be less familiar with technology, may find it more difficult to access the benefits of e-mental health [
A further 15 articles (4.2%) were specifically concerned with the mental health impact of COVID-19 on health professionals themselves. For example, Cheng et al outlined a peer support project offering support from mental health professionals overseas to frontline health care workers in Wuhan, China, via a popular smartphone app [
A total of 68 papers out of 356 (19.1%) identified issues and challenges associated with e-mental health in the context of COVID-19. An inductive thematic analysis identified that many issues and challenges were highlighted, with complexities present at the patient, clinician, technological, treatment, ethical, organization or service, and broader system levels (see
Summary of issues and challenges identified in the literature. e-mental health: electronic mental health.
At the technological level, included articles discussed how the rise in videoconferencing during COVID-19 has raised security concerns, as some platforms can be easily hacked or viewed by others [
A mixed methods study on the perspectives and experiences of mental health professionals reported on their need for robust, secure, user-friendly technology and better logistical and technical support [
Despite most people now having internet access, the “digital divide” was still viewed as an issue in some articles for certain patient and consumer groups, such as the elderly, veterans, those of lower socioeconomic status, those with cognitive impairments or vision or hearing difficulties, and those still having access issues and poorer digital competence [
At the broader system level, several articles pointed to changes in regulation and reimbursements that have enabled clinicians practicing in a wide range of settings to quickly adopt e-mental health solutions for both existing and new patients struggling with the pandemic’s impact [
Although it has been only 18 months since the start of the pandemic, this review identified that the total number of articles on e-mental health quickly thrived, with nonempirical articles peaking in June 2020 and empirical articles emerging later and becoming more common as the pandemic progressed. The location of articles was predominantly in high-income countries (ie, the United States, Australia, the United Kingdom, and Canada), reflecting general trends previously identified in the e-mental health literature [
Our bibliometric analysis indicated that the e-mental health literature during COVID-19 has had above-average influence, with almost half of the articles being ranked in the top 25% of all output scores by Altmetric and having an average CiteScore across articles of 4.22. Nonempirical articles (eg, commentaries or opinion pieces) received a notable amount of attention; articles of this type surged early in the pandemic, so elevated influence may reflect researchers and clinicians searching for new information on e-mental health, guidelines, evidence-based practice, and other relevant developments at an uncertain time and when empirical studies were limited.
The network analysis of author-supplied keywords identified key topic areas, which were explored further via our full-text analysis. Many articles focused broadly on mental health and well-being, with specific attention being paid to anxiety disorders, depression, substance abuse disorders, and psychosis. Children and adolescents were the most frequently identified in articles focused on specific populations, with other identified at-risk populations, including the elderly, veterans, and health professionals themselves. It was noted that younger children and older adults, who may be less familiar with technology, may find it more difficult to access the benefits of e-mental health. Frontline workers directly involved in the care of patients with COVID-19 have been identified as being at particularly high risk for mental health issues as a result of excessive workloads and work hours, insufficient protective equipment, feeling inadequately supported, as well as the high infection rate among medical staff [
Modalities of e-mental health largely focused on the application of “telehealth” via telephone or videoconferencing. However, there were also a number of articles reporting on the adoption of smartphone apps [
Since the start of the pandemic, both clinicians and patients have been required to gain both the skills and experience to adopt e-mental health solutions out of necessity, with a number of descriptive case studies being identified that inform the rapid conversion to e-mental health to continue to deliver care [
After any subsequent waves of COVID-19 subside, the key question is whether we are likely to remain in the “new normal,” in which telehealth remains a prominent vehicle for mainstream mental health treatment delivery [
Despite the swift adoption of the multitude of e-mental health apps and platforms that emerged during the pandemic, little is known about their immediate-, medium-, or long-term clinical value or the barriers to, and facilitators of, their uptake [
Some key research questions identified in the literature include the need to compare specific outcomes for in-person versus remote care related to specific mental health conditions, such as those with paranoia or other psychotic disorders and substance use disorders. Such conditions may pose unique challenges to management via e-mental health programs and services [
The strengths of this review are the inclusion of a broad range of articles, including nonempirical articles, reviews, and protocols. In addition to looking at the countries of origin, we also examined article influence and provided a novel keyword analysis with inductive thematic coding to identify key topic areas. Our thorough analysis of the key issues and challenges identified gaps in research to guide the next wave of research on e-mental health. The limitations of this review are primarily methodological. We chose to use CiteScore data because almost 85% of the identified journals had CiteScore information and almost 70% had reported Altmetric data, but not all journals have CiteScore data, nor do all articles have Altmetric Attention Score values available. Similarly, the keyword analysis could only be conducted on journal articles that provided keywords. To supplement this, we undertook an analysis of specific subpopulations, mental disorders, and issues or challenges within titles and abstracts for all publications. Although we included a broad range of journal articles (eg, commentaries, reviews, letters to the editor, and protocols), we did not include a grey literature search, which may have broadened our understanding of the e-mental health field since the pandemic began. Although we identified a relatively high proportion of articles from medium-income countries, our restriction to records in English and published works may have underestimated the true amount of literature emerging from low- and middle-income countries. Although, the inclusion of non-English studies can add substantially to the resources required to complete a review, we believe it could be important to include them in an updated search of the literature in this field in the future. The inclusion of conference abstracts in the updated search would also be beneficial, given the rapidly emerging nature of the topic.
Arguably, the COVID-19 pandemic is the defining moment for e-mental health adoption, with virtual care being likely to remain a prominent vehicle for mainstream mental health service delivery postpandemic. This review identified that many of the emerging e-mental health studies focused on the application of “telehealth” via telephone or videoconferencing, with notable interest in, and concern for, vulnerable populations, such as children, veterans, and health professionals as well as those with pre-existing mental health conditions, including anxiety disorders, depression, substance abuse disorders, and psychosis.
The rapid expansion of e-mental health services during the pandemic has been enabled by existing technology and swiftly implemented policies but has been challenged by numerous issues at the patient or clinician level and at the technology or treatment level, or due to factors at the ethical, organization or service, and broader system levels. Ensuring that the field advances beyond simply the sharp increase in publications documenting the use of e-mental health—and the concomitant interest by readers—to further accelerate access and quality of care beyond the pandemic will be the next big challenge.
Database search strategy using Ovid MEDLINE.
Coding structure and definitions for keyword classification.
Articles included in this study.
Extension for Community Healthcare Outcomes, All Ireland Institute of Hospice and Palliative Care
electronic mental health
lesbian, gay, bisexual, transgender, queer, questioning
mobile health
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews
posttraumatic stress disorder
We would like to thank and acknowledge Tamasha Jayawardena for assistance with data extraction and Mai-Tram Nguyen for editorial assistance. The work was supported by the organizations involved and research grants from the National Health and Medical Research Council (grants APP9100002, APP1134459, and APP1176620) and the Medical Research Future Fund (grant APP1178554).
This study was originally designed by LAE, IM, CP, and KC. Data extraction and screening was conducted by LAE, IM, and KC, with research assistance from SH. The first draft of the Results section was written by LAE, IM, KC, and CP. All authors provided critical feedback and helped shape the final manuscript.
None declared.