Development of a Framework for the Implementation of Synchronous Digital Mental Health: A Realist Synthesis of Systematic Reviews

Abstract Background: The use of technologies has served to reduce gaps in access to treatment and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it's imperative to document the aspects related to their challenging implementation. Objective: To determine what evidence is available for synchronous digital mental health implementation and develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.Methods: The SPIDER framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020 were searched. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded theory approach with an emergent approach.Results: 21 systematic reviews were included in the study. The realist synthesis allowed the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: Hypothesis 1: These interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy. Hypothesis 2: These interventions reach populations otherwise unable to have access because they can be successfully delivered by non-specialists, which makes them more cost-effective to implement in health services. Hypothesis 3: These interventions are acceptable and show good results in satisfaction, because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.Conclusion: We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represented essential outcomes in the implementation process.Systematic review registration: PROSPERO (CRD420203811).