1 PATIENTS’ EXPERIENCES OF USING TELEMEDICINE FOR THE TREATMENT OF DEPRESSION IN PRIMARY CARE by Sarah Boughton B.Sc.N., Thompson Rivers University, 2019 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING – FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2025 © Sarah Boughton, 2025 ii ABSTRACT This integrative review examines the growing prevalence of depression, a leading cause of primary care visits in Canada, and the need for accessible treatment options such as telemedicine. Despite substantial evidence supporting the widespread adoption of telemedicine in primary care, including for treating depression, research on patient experiences with telemedicine for depression remains limited. This integrative review aims to explore patients' experiences of using telemedicine for the treatment of depression in primary care to identify areas for enhancing the quality of care. The key findings reveal several themes influencing patient experience: the therapeutic relationship, the environment of care delivery, individualization of treatment approaches, accessibility of telemedicine, and the level of knowledge patients possess regarding telemental health. The findings have implications for primary care providers, including nurse practitioners (NPs), in optimizing the delivery of telemedicine for depression. Limitations of this review include a restricted number of studies that specifically focused on depression. Further investigation is needed to gain a deeper understanding of patient experiences with telemedicine for depression treatment. iii TABLE OF CONTENTS Abstract ii Table of Contents iii List of Tables v List of Figures vi Glossary of Terms vii Acknowledgement ix Introduction 1 Chapter One Background Depression Primary Care Telemedicine Patient Experience Purpose Statement/ Research Question 2 2 2 4 5 6 Chapter Two Methods Design Search Strategy Inclusion and Exclusion Criteria Critical Appraisal Data Analysis 7 7 7 8 8 9 Chapter Three Findings Search Results Themes The Impact of the Therapeutic Relationship Environmental Influences on Patient Experience Individual Factors Affecting Patient Experience Accessibility of Telemedicine and its Influence on Experience Influence of Patient Knowledge on Telemedicine Experience 10 10 11 11 15 16 18 20 Chapter Four Discussion Enhancing the Therapeutic Relationship Establishing a Safe and Supportive Environment The Need to Individualize Delivery Addressing Accessible and Equitable Telemedicine Care Enhancing Patient Understanding Implication of Findings for Practice Limitations 22 23 24 24 26 26 27 29 Conclusion 30 References 32 iv Appendix A Search Strategy 41 Appendix B Critical Appraisal 49 Appendix C Data Extraction 56 v LIST OF TABLES Table A1: Search Terms 41 Table B1: Critical Appraisal: Cohort Study 40 Table B2: Critical Appraisal: Qualitative Data 50 Table B3: Critical Appraisal: RCTs 52 Table B4: Critical Appraisal: Systematic Review 53 Table B5: Critical Appraisal: Mixed Methods 54 Table B6: Grading Scale 55 Table C1: Literature Matrix 56 Table C2: Thematic Analysis 73 vi LIST OF FIGURES Figure A1: CINAHL Database Search 42 Figure A2: Medline Database Search 44 Figure A3: APAPsycInfo Database Search 46 Figure A4: PRISMA Diagram 48 vii GLOSSARY OF TERMS Depression: Depression is a common mental health condition and mood disorder that can affect daily functioning, including relationships, work, and school (Government of British Columbia, 2023; World Health Organization [WHO], 2023). It presents with psychological and physical symptoms such as low mood, loss of interest, fatigue, sleep disturbances, and pain (Gaynes, 2024). Diagnosis may involve DSM-5 criteria (American Psychiatric Association, 2013) or screening tools such as the PHQ-9 (Gaynes, 2024). Mental Health: Mental health is a complex concept referring to an individual’s state of mental well-being and ability to cope, work, and interact or contribute to society (WHO, 2022b). Mental health conditions include a multitude of mental disorders, including psychosocial disabilities (WHO, 2022b). Patient Experience: Patient experience includes the range of interactions patients encounter with the healthcare system, such as with the healthcare system, care plans, and healthcare providers (Agency for Healthcare Research and Quality, 2025). Primary Care: Primary care is the first point of contact with the health system, typically provided by family doctors or nurse practitioners (HealthLink BC, 2024). Primary care includes services like prescription renewals, routine checkups, health screening, and chronic disease management (HealthLink BC, 2024). Telemedicine: Telemedicine is the delivery of health care services through technology, including internet, video, and audio connection (Allen, 2022; Balestrieri et al., 2020). Telemedicine typically involves telecommunication between a provider and a patient located in a hospital, clinic, or home (Guiana et al., 2021). The health service may be private or government-based (Guiana et al., 2021). Synonyms for telemedicine include telehealth, telecare, and virtual care (Allen, 2022; Canadian Institution for Health Information, 2023). viii Telemental Health: Telemental health refers to the delivery of mental health services by providers through telemedicine, including phone or video modalities (National Institute of Mental Health, 2023). These services may include assessments and interventions such as medication or therapy (National Institute of Mental Health, 2023). Telemental health is also commonly referred to as telepsychiatry (National Institute of Mental Health, 2023). ix ACKNOWLEDGEMENT I would like to express my gratitude to everyone who contributed to the completion of this integrative review. To my academic mentor Dr. Nicola Waters for the valuable feedback and encouragement in the process, as well as to my colleagues and peers for their insightful discussions and support. A special thank you to my husband for his constant support throughout the last two years of studies and to my dog, whose constant companionship and much-needed outdoor distractions contributed to my well-being throughout this journey. Lastly, thank you to my friends and family for your continuous encouragement and support. 1 INTRODUCTION In Canada and worldwide, the mental health of the general population has been declining (Stephenson, 2023), with depression being one of the most prevalent conditions (Centre for Addiction and Mental Health [CAMH], 2024; WHO, 2022a). General practitioners are often the first point of contact for patients seeking mental health care, with depression treatment being a leading reason for primary care visits (Stephenson, 2023). Access to mental health care remains a persistent challenge for patients. In Canadian primary care settings, barriers such as provider shortages have led to extended wait times, often deemed too long for effective mental health treatment (Moroz et al., 2020), which can worsen prognosis (Du et al., 2021; Kraus et al., 2019). Since the beginning of COVID-19, telemedicine has expanded significantly, improving access and reducing wait times for patients with depressive disorders (Canadian Institute for Health Information, 2023; Posselt et al., 2024), though notable challenges remain (Maher et al., 2022). The use of telemedicine for mental health services has become more prevalent in primary care (Bushey et al., 2020; Fountaine et al., 2022), with nurse practitioners (NPs) well-positioned as primary care providers to deliver depression treatment through telemedicine. For telemedicine to be successfully implemented in the long term, further exploration is needed, particularly into key factors such as patient perceptions (Allen, 2022). Limited understanding exists regarding patients’ experience of virtual care for the treatment of depression. A comprehensive review of existing literature is necessary to investigate patients’ experiences of telemedicine for depression treatment provided in primary care to identify strategies to enhance quality of care. 2 CHAPTER ONE: BACKGROUND Depression One in eight people are living with a mental health illness worldwide, with depression being one of the most common conditions (WHO, 2022a; CAMH, 2024). In Canada and other countries, the mental health of the general population has been declining over the past decade, with a large increase in depressive symptoms as a result of the COVID-19 pandemic (Stephenson, 2023). Depressive disorders are an emerging health topic due to their prevalence and burden on society, as well as patient suffering and disability (Guiana et al., 2021; Posselt et al., 2024; Rushton et al., 2020). There is a high prevalence of suicide risk and ideation in patients with depression (Echelard, 2021). In Canada, it is estimated that 12 individuals end their lives by suicide per day, averaging 4,500 deaths per year (Public Health Agency of Canada, 2023). Depression is linked to an increased risk of early death, not only due to suicide but also from comorbidities such as cardiovascular disease, stroke, heart attacks, diabetes, and certain types of cancer (Echelard, 2021; Kessler, 2012). This is because of the well-established correlation between depression and other physical health conditions (Echelard, 2021; Kessler, 2012). The consequences of untreated depression are therefore severe, ranging from substance abuse to physical illness and suicide (New England Medical Group, 2022). Given the rising prevalence and severe consequences of depression, further research into innovative approaches, early intervention, and treatment accessibility is crucial to improving patient outcomes and reducing its societal burden. Primary Care The shortage of primary care providers is another critical issue in Canada exacerbated by the pandemic and is a considerable barrier to accessing mental health care (Stephenson, 2023; Zhang, 2024). General practitioners serve as the primary point of contact for patients seeking mental health care, with appointments for depression treatment being among the 3 most frequently scheduled in primary care (Stephenson, 2023). In Canada, family physicians and NPs fulfil this role, with other professionals, such as pharmacists, providing support at later stages (Canadian Institute for Health Information, 2023). Primary care providers are often the main providers for treating patients with mild to moderate mental health problems such as depression and are responsible for ensuring high-quality care, which is often not possible with the lack of resources and extended wait times (Finazzi et al., 2023; Kolaas et al., 2023). A 2022 study by Statistics Canada suggests that for Canadians who met the diagnostic criteria for mental health conditions, including depression, half did not seek mental health care and the half who did reported unmet needs from the mental health care received (Stephenson, 2023). It is essential to mitigate barriers to accessing the healthcare required for patients with depression (Guiana et al., 2021). Provider shortages contribute to extended wait times, which has implications for effective mental health treatment (Moroz et al., 2020). Extended wait times for depression care can worsen symptoms, increase the chronicity and severity of the condition, and result in less effective treatment outcomes once care is accessed (Du et al., 2021; Kraus et al., 2019). Medication is the treatment most frequently provided by primary care practitioners (Kivi et al., 2015; Du et al., 2021) and is the most recommended therapy for severe depression (Kennedy, Parikh, & Grigoriadis, 2023). Cognitive Behaviour Therapy (CBT) has also been identified as a first-line treatment for mild to moderate depression, and the combination of pharmacotherapy and CBT has been shown to be more effective for the treatment of depression than either approach alone (Kennedy, Parikh, & Grigoriadis, 2023). However, provider shortages greatly affect accessibility to this type of treatment (Du et al., 2021; Santucci et al., 2014). With the rising number of patients with depression in need of mental health care and the prolonged wait times of accessing primary or specialist mental health care (Canadian Mental Health Association, 2024; Stephensen, 2023), there is a need 4 for innovative solutions for treatment delivery to decrease patient suffering (Barceló-Soler et al., 2023; Dialynas et al., 2024; Posselt et al., 2024) such as telemedicine. This integrative review aims to investigate the use of telemedicine for the treatment of depression in primary care. Telemedicine Telemedicine has emerged as a promising intervention for expanding access to mental health care, particularly for patients with depression, by utilizing digital technologies to support remote assessment, diagnosis, and treatment (Allen, 2022; Guaiana et al., 2021; Posselt et al., 2024). Telemedicine is the delivery of health care services through technology, including internet, video, and audio connection (Allen, 2022; Balestrieri et al., 2020). Telemedicine typically involves telecommunication between a provider and a patient located in a hospital, clinic, or home (Guiana et al., 2021). The health service may be private or government-based (Guiana et al., 2021). Telemedicine may be an alternative or adjunct to inperson treatment (Haun et al., 2023). Integrated care has been increasingly used in primary care practice, including mental health care (Bushey et al., 2020; Fountaine et al., 2022). The use of telemedicine for mental health care may be referred to as telepsychiatry and is currently used in Canadian healthcare by some healthcare providers (Echelard, 2021; Guaiana et al., 2021). A key feature of telepsychiatry is its application by providers in various stages of depression care, such as assessment, evaluation, diagnosis, management, and follow-up (Echelard, 2021). Telepsychiatry via video communication may be a well-suited care model for assessing depression, which entails verbal and visual cues from the patient (Guaiana et al., 2021; Lambert & Wertheimer, 2016). Telemedicine has also largely expanded since COVID-19 and can help improve access to care for Canadians (Canadian Institute for Health Information, 2023). While digital interventions may increase accessibility to care for patients with depressive disorders, 5 including reduced wait times (Posselt et al., 2023), the telemedicine approach is not without challenges (Maher et al., 2022). Digital interventions for mental health care, such as digital CBT, have been identified as an innovative solution for reducing wait times in mental health care (Andersson et al., 2019; Barceló-Soler et al., 2023; Lattie et al., 2022; Posselt et al., 2024). CBT may be self-guided, professionally guided, or a combination of both (Hegerl & Oehler, 2020; Lattie et al., 2022; Posselt et al., 2024). Evidence also highlights ongoing challenges with the use of digital CBT in primary care, including unclear reasons for drop-out and low patient compliance (Andersson et al., 2019; Du et al., 2021). Uncertainties and reservations from both patients and providers surrounding the use of telemedicine remain despite evidence for efficacy and advantages from various studies (Balestrieri et al., 2020; Castro et al., 2020; Maher et al., 2022; Haun et al., 2024; Powell et al., 2017; Petersen et al., 2020; Regueiro et al., 2016; Rushton et al., 2019; Rushton et al., 2020). Even with the increasing use of telemental health globally, these concerns pose challenges to its implementation (Rushton et al., 2020). As the first point of contact in healthcare, primary care is expected to widely adopt telemedicine, with tele-interventions playing a significant role in shaping future practices, and successful long-term implementation will require further examination of key factors such as patient perceptions (Allen, 2022). This review aims to explore these factors, including the benefits, challenges, and patient acceptance of telemedicine in primary care mental health treatment. Patient Experience Understanding patient attitudes toward healthcare implementations has been identified as essential to adopting and participating in care interventions (Rushton et al., 2020). Research to date has primarily focused on practitioners’ experiences of telemedicine for mental health services, with a gap in the literature for identifying patients’ experiences. Allen (2022) argues that studying patient perceptions as a secondary outcome or as quantitative 6 measurements only may result in superficial findings and suggests that a more in-depth examination of patient experience may be achieved through studying qualitative data (Allen, 2022). While research has provided valuable insights into patients' experiences with telemedicine (Maher et al., 2022), including positive perceptions of digital mental health interventions (Patel et al., 2020; Posset et al., 2024), deficiencies remain in understanding the complex factors that influence the acceptance and utilization of telemental health services (Allen, 2022; Finnazi et al., 2023). There is a specific gap in the literature regarding patients’ experiences of telemental health for the treatment of depression. Further examination of existing patients’ perspectives on the use of telemedicine for depression can produce valuable and pertinent insights for practice (Maher et al., 2022). Patients’ experiences are a key indicator of quality healthcare and examining such can guide recommendations for improvement (Bastameijer et al., 2019). This review aims to explore this gap by examining what is known about patient perspectives on telemedicine and provide insights that can inform best practices and improve the quality and accessibility of digital mental health interventions. Purpose Statement/ Research Question The purpose of this integrative review is to examine the gaps identified above by investigating what is known about patients’ experiences of using telemedicine for the treatment of depression. The specific question that will be answered is: What are patients’ experiences of using telemedicine for the treatment of depression in primary care? Understanding patients’ experiences can help improve quality of care in telemental health and enhance strategies to manage depression, promoting better patient outcomes. An awareness of factors influencing acceptability and engagement in telemental health for patients with depression is essential for primary care providers to deliver high-quality mental health care. 7 CHAPTER TWO: METHODS Design This integrative review follows the methodology outlined by Whittemore and Knafl (2005). This method ensures the thoroughness of the integrative review process as it incorporates diverse forms of data (qualitative and quantitative) and provides a guiding framework for the literature review process, including the literature search, data appraisal, data analysis, and presentation of findings. Search Strategy A comprehensive search strategy was used. Three electronic databases: CINAHL, Medline, and APAPsycInfo were searched. Each database was individually searched using a combination of key subject headings and search terms with Boolean operators related to depression, telemedicine, patient experience, and primary care (see Appendix A for the detailed search strategy including search terms). A preliminary search helped to identify key search terms (See Table A1). Following the multiple search strategies suggested by Whittemore and Knafl (2005), hand searching was done through both Google and Google Scholar using identical search terms to add to the comprehensive approach. The first 50 articles were scanned for relevance. A PRISMA flow diagram adapted from Page et al. (2020) was used to demonstrate and track the search process (see Figure A4). Zotero, a reference management tool (Corporation for Digital Scholarship, 2023), was used for citation management, removing duplicates, and screening article titles and abstracts for relevance. Full texts were reviewed for inclusion/exclusion criteria and further relevance to the research question. Inclusion and exclusion criteria were applied throughout the process when applicable. 8 Inclusion and Exclusion Criteria Inclusion and exclusion criteria were applied as part of the search strategy to keep results relevant (Whittemore & Knafl, 2005). The initial search included a data range of publications from 2020-2024. This was done intentionally to account for the widespread implementation of virtual care since the beginning of the COVID-19 pandemic (Braund et al., 2023). High-income countries were chosen as inclusion criteria, as they are most relevant to primary care practice in Canada, and the evaluation of the country's status was confirmed by using the World Population Review (2024) source. The study population included adults aged 18-65. Variables exist within the adolescent and older adult populations, including symptomology, treatment, and unique barriers or experiences with technology use (Rameraz et al., 2024; Rice et al., 2019; Pywell et al., 2020), which is not the focus of this particular review. Exclusion criteria included major medical comorbidities, which may reduce the generalizability of results (Melnyk & Fine-Out-Overholt, 2023). Mental health conditions as a general concept within studies that did not specify, mention, or include depression were also excluded for irrelevance. Systematic or literature reviews were limited to the most relevant, and primary research was included, as suggested by Whittemore & Knafl (2005), to achieve a maximal quantity of primary sources. Non-relevant articles were removed due to not incorporating primary care, depression (i.e. mental health as a general concept), telemedicine, or patient experience, which are this review's central concepts and purpose. Articles that did not meet the inclusion criteria were removed throughout the process. Critical Appraisal All included articles were first critically appraised for quality using various tools that were selected based on appropriateness to the type of study, including the Critical Appraisal Skills Programme [CASP] (2024) and the Mixed Methods Appraisal Tool (Hong et al., 2018). Various tables were created to capture the components of the critical appraisal and can 9 be found in Appendix B (See Tables B1-B5). A grading system was also applied to the studies to further determine the quality of data, adapted from the GRADE working group (Atkins et al., 2004) and Melnyk & Fine-Out-Overholt (2023), which took into account the study type and level of evidence (Melnyk & Fine-Out-Overholt, 2023) (See Table B6). Data Analysis Data analysis comprised of extracting relevant data from each study including method, relevant results, implications for practice, and strengths and limitations (Coughlin & Sethares, 2017; Toronto & Remington, 2020; Whittemore & Knafl, 2005). Data extraction was organized into a literature matrix table (See Appendix C), contributing to a systematic approach (Ghazal et al., 2020). The tables from both the critical appraisal and data analysis reflect a presentation of findings (Whittemore & Knafl, 2005). Braun and Clarke’s thematic analysis framework (2006) was used to analyze the data extracted from the literature. Braun and Clarke’s thematic analysis is most commonly used for qualitative data but is still appropriate for identifying themes from various sources of literature (Popay et al., 2006; Toronto & Remington, 2020). Findings were coded, organized, and grouped into themes. Coding was initiated in the literature matrix, and organization and grouping were accomplished through the development of a table (See Appendix C). 10 CHAPTER THREE: FINDINGS Search Results The initial search generated 560 articles. The 114 duplicate articles were then removed prior to screening. Titles and abstracts were then screened for relevance and 403 articles were removed. The remaining 43 articles were assessed for eligibility by reading the full texts, and 32 were removed after applying inclusion/exclusion criteria and assessing relevance. Two articles were removed due to being inaccessible. The final sample consisted of 11 articles. The search results are depicted in a PRISMA diagram (See Figure A4). The final search results of existing literature for patient’s experiences of telemedicine for the treatment of depression revealed a larger number of qualitative data compared to quantitative including one systematic review (Guaiana et al., 2021), one cohort study (Kolaas et al., 2023), one mixed methods study (Haun et al., 2023), six qualitative studies (BarcelóSoler et al., 2023; Du et al., 2021; Finazzi et al., 2023; Maher et al., 2023; Posselt et al., 2024; Rushton et al., 2020), and two randomized control trials (RCTs) (Balestrieri et al., 2020; Bushey et al., 2020). Due to the nature of primarily qualitative data, the grading of data quality appraisal resulted in mostly moderate grading accounting for the hierarchy of literature (Melnyk & Fine-Out-Overholt, 2023), grading system (Atkins et al., 2004) and critical appraisal (See Table B6). Only four studies focused on depression independently (Balestrieri et al., 2020; Barceló-Soler et al., 2023; Guaiana et al., 2021; Posset et al., 2020), while four studies observed depression and/or anxiety (Du et al., 2021; Haun et al., 2023; Kolaas et al., 2023; Rushton et al., 2020), two studies examined depression amongst mental health as a general condition (Finazzi et al., 2023; Maher et al., 2022), and one study examined depression, pain, and/or anxiety (Bushey et al., 2020). Pain was not excluded as a major medical comorbidity, 11 as depression and pain are closely linked, and depression can both cause and worsen pain (Harvard Health, 2017). Themes The Impact of the Therapeutic Relationship on Patient Experience The therapeutic relationship between patients and providers consistently emerged as a key theme reported by participants that influenced their experience with telemedicine interventions for depression or mental health (Ballesteri et al., 2020; Barceló-Soler et al., 2023; Du et al., 2021; Finazzi et al., 2023; Haun et al., 2023; Posselt et al., 2024; Rushton et al., 2020). The patient-provider relationship was found to influence patient motivation, with positive relationships enhancing engagement and negative relationships diminishing it. Du et al. (2021)’s qualitative study examined 33 adult patients’ experience and acceptance of online CBT programs for the treatment of depression and anxiety in Scotland. The environment of CBT delivery was dependent on the local health authorities' resources within different regions of Scotland and could include a medical clinic, community centre, library, hospital or home (Du et al., 2021). Participants identified that a lack of provider support contributed to feelings of frustration and reduced help-seeking behaviours. Most patients expressed a desire for healthcare provider contact during the CBT teletherapy for emotional support, motivation, reassurance, and to discuss progress and treatment plans or follow-up. Patients who preferred the clinic environment reported an appreciation for the personal or human interaction it offered while completing the online CBT intervention. Varying levels of human or provider support were identified with the differing environments (Du et al., 2021), contributing to a potential selection bias (e.g. remote vs city) and measurement bias, which may reduce the validity and generalizability of the study’s findings (Melnyk & Fine-Out-Overholt, 2023). Finazzi et al.’s (2023) qualitative-interpretative phenomenological analysis examined nine adult participants with depression and other common mental health conditions who 12 experienced remote CBT therapy from a primary care provider by telephone or video. Most patients reported an overall preference for in-person therapy, noting the therapeutic relationship and reading body language or nurture of human contact (Finazzi et al., 2023). Video delivery was reported as closer to in-person therapy, feeling more personal and less isolated compared to phone-call delivery (Finazzi et al., 2023). This study had a small sample size, and only 33% of the study participants had depression, which may limit the generalizability. It was also conducted during the COVID-19 pandemic, which produced unique variables, as noted by the authors Finazzi et al. (2023). Barceló-Soler et al. (2023) also examined a CBT digital intervention in a qualitative study of 41 adult participants with mild to moderate depression in the primary care setting. The intervention included either a therapist-guided online CBT intervention or a completely self-guided online CBT intervention for depression. Feelings of isolation and dropout risks were reported when follow-up or responsiveness from providers was lacking, especially in self-guided programs (Barceló-Soler et al., 2023). Genuineness from the provider and a partnership were all reported by most participants as important for intervention acceptability (Barceló-Soler et al., 2023). Some participants seemed to emphasize that human interaction was better than digital programs regarding feeling understood (Barceló-Soler et al., 2023). In contrast, Balesteri et al.’s (2020) cluster randomized trial examined patient satisfaction scores among 98 adults with moderate depression, comparing provider-patient encounters in a telemedicine group versus a treatment-as-usual control group. Participants in the telemedicine group reported greater comfort communicating with providers compared to the in-person control group, leading to a more positive experience. Similar to Bushey et al.’s (2020) RCT, blinding of participants and providers was not possible in Balesteri et al.’s study due to the nature of telemedicine. This may impact the validity of the study’s results (Critical Appraisal Skills Programme, 2024-c). 13 Haun et al.’s (2023) qualitative study found that an emerging relationship and growing rapport with a mental health provider contributed to a positive therapeutic relationship and were key factors shaping patients’ experiences with telemedicine for treating depression and/or anxiety. As part of a randomized feasibility trial, 20 adults with depression and/or anxiety participated in semi-structured interviews and were assigned to either an integrated care group, receiving five video-based interventions in addition to usual care, or a treatment-as-usual, in-person care group. Posselt et al.’s (2024) recent study conducted semi-structured interviews to examine 17 adult patients’ perspectives on the acceptance of digital therapeutic treatment for depressive disorders within primary care. Findings revealed that participants mentioned that a trusting therapeutic relationship promotes the acceptability of digital interventions and treatment recommendations. The results aim to contribute to further development of telemedicine acceptance. While strengths included interviewing patients with depression exclusively, the study examined patients’ intention to use digital interventions, not the actual implementation, which may differ from the real-world application and was a noted limitation by the authors (Posselt et al., 2024). Provider competence was acknowledged as influential to the therapeutic relationship (Rushton et al., 2020) and highlighted as essential to the perceived contribution to the effectiveness of digital treatments for depression (Posselt et al., 2024). Rushton et al.’s (2020) qualitative study also used semi-structured interviews to explore the experiences of 28 adult patients with common mental health conditions, including depression, of telephone-based interventions. Negative patient experiences with telephone-delivered mental health care were reported by some participants to be associated with individual practitioner issues, such as provider conduct and poor communication skills, rather than the treatment modality (Rushton et al., 2020). While in the same study, many participants claimed their positive experiences 14 were associated with a skilled practitioner. Challenges unique to telemedicine, such as the absence of body language, were identified as barriers to effective communication, diagnosis, treatment plan, and rapport-building (Rushton et al., 2020). The study sample included participants who were waiting to receive, currently receiving, or had recently received a telemedicine intervention. The waiting-to-receive group is similar to Posselt et al. (2024) study of examining the intention to treat, while the other groups receiving or having received the telemedicine intervention may present more meaningful data. Participants consistently identified the therapeutic relationship with their providers as a key factor shaping their experience with telemedicine interventions for depression and mental health care. Positive experiences related to the therapeutic relationship were reported to result in increased comfort in communication (Ballesteri et al., 2020; Haun et al., 2023), intervention acceptability (Barceló-Soler et al., 2023; Rushton et al., 2020), meaningful clinical improvement (Barceló-Soler et al., 2023), and treatment outcomes (Haun et al., 2023). Participants also identified attributes from providers that contributed to a positive therapeutic relationship, including compassionate and professional care (Finazzi et al., 2023; Haun et al., 2023), genuineness (Barceló-Soler et al., 2023), collaboration and partnership (Barceló-Soler et al., 2023; Finazzi et al., 2023), empathy (Finazzi et al., 2023; Posselt et al., 2024), competency (Finazzi et al., 2023; Rushton et al., 2020) taking the time to listen, confidentiality, warmth, acknowledgement of work, and challenge for change (Finazzi et al., 2023). Participants also identified negative determinants of the patient-provider relationship in the telemedicine context (Barceló-Soler et al., 2023; Du et al., 2021; Finazzi et al., 2023; Rushton et al., 2020). Time constraints (Finazzi et al., 2023), non-compatibility, and absence of body language (Rushton et al., 2020) were identified as leading to negative experiences with the therapeutic relationship. 15 Environmental Influences on Patient Experience Environmental factors influencing both positive and negative patient experiences with telemental health care surfaced as a recurring theme in the data analysis (Du et al., 2021; Haun et al., 2023; Maher et al., 2022; Posselt et al., 2024). Maher et al.’s (2022) qualitative study used semi-structured interviews with 14 adults experiencing common mental health conditions, including depression, who had received telephone or video teletherapy in the past year. Participants highlighted the comfort and privacy of home-based sessions, which fostered a sense of safety and relaxation, enhancing engagement. However, the authors acknowledge a risk of recall bias due to the reflexive nature of the study (Maher et al., 2022). Du et al. (2021) examined patient acceptance and experiences with online CBT for depression and anxiety delivered across varied environments including clinics, community centres, and homes. While this variability provided a broader view of how different settings impact engagement, it also introduced potential measurement bias such as fluctuating levels of privacy and distractions. Most participants preferred home-based options, citing privacy, decreased vulnerability, enhanced confidentiality, and reduced concerns about stigmatization, all of which positively influenced treatment engagement (Du et al., 2021). Haun et al.’s (2023) qualitative study examined participants with depression and/or anxiety and their experience with integrated telemedicine in primary care with video interventions and treatment as usual. The location was in a primary care setting, including for the video interventions, allowing for a controlled environment. Participants reported that the familiarity of these settings positively influenced their experience, which, like home environments described by Du et al. (2021), contributed to feelings of comfort and safety, enhancing engagement in telemedicine sessions (Haun et al., 2023). Despite these positive experiences, several environmental barriers were noted. A lack of privacy was seen as a significant obstacle to open communication and increased feelings of 16 vulnerability (Maher et al., 2022; Du et al., 2021), while interruptions, connectivity, and other technological issues were reported as frustrating and distracting factors that negatively impacted session engagement and overall experience with electronic platforms (Haun et al., 2023; Maher et al., 2022). Some participants also reported that electronic platforms could intensify feelings of depression or mental health challenges (Posselt et al., 2024), and one participant with depression noted that prolonged time at home negatively impacted their mental health (Maher et al., 2022). Overall, findings included that positive environmental factors such as the privacy and comfort of home-based telemedicine sessions were found to enhance patient engagement and foster a sense of safety and relaxation (Du et al., 2021; Haun et al., 2023; Maher et al., 2022). Conversely, barriers including a lack of privacy, technological disruptions, and feelings of isolation, were reported as challenges that negatively impacted communication, engagement, and overall patient experience with telemental health care (Maher et al., 2022; Posselt et al., 2024). Individual Factors Affecting Patient Experience Individual patient characteristics and preferences were found in many studies to influence factors related to patient experience of telemedicine treatment (Barceló-Soler et al., 2023; Bushey et al., 2020; Du et al., 2021; Finazzi et al., 2023; Posselt et al., 2024). In Posselt et al.’s (2024) qualitative study, participants' reports of intention to use digital interventions for the treatment of depression were dependent on the stage of disease and personal coping strategies. There were suggestions of telemedicine interventions being more helpful in the earlier stages of depression, contributing to a more positive experience (Posselt et al., 2024). Participant reports also indicated that periods of good health may reduce the perceived need for treatment (Posselt et al., 2024), while highly depressive phases can create barriers, such as low energy levels negatively impacting the ability to engage with digital 17 therapies (Posselt et al., 2024). While intention to use has been discussed previously as not as comprehensive as real-life application, Du et al.’s (2021) qualitative study examining patient acceptance and experiences with online CBT for depression and anxiety in various settings confirmed similar findings of low energy during depressive episodes having a negative impact on patient experience with telemedicine interventions. Du et al. (2021) also reported that some participants preferred completing online CBT in a clinical setting, valuing the structure it provided to help maintain engagement, especially during periods of low motivation or when dealing with challenging home environments. Conversely, other patients preferred home-based sessions due to concerns about stigmatization and the need for greater privacy and confidentiality (Du et al., 2021). A lack of these factors in clinical settings often led to feelings of vulnerability, which negatively impacted treatment engagement (Du et al., 2021). Finazzi et al. (2023) also found in their qualitative study examining participants with depression and other common mental health conditions through remote, provider-delivered CBT therapy that while some participants preferred structured approaches over open-ended therapy, others favoured open-ended methods (Finazzi et al., 2023). Posselt et al. (2024)’s study also found that standardization was a potential influencing factor in patient experience, stating that some participants viewed digital treatment as too standardized, pointing out that depression is complex and unique for each individual (Posselt et al., 2024). In Bushey et al.’s (2020) RCT examining adult primary care patients with chronic pain, depression, and/or anxiety, participants from both the telemedicine and nontelemedicine groups reported a need for a more tailored, personalized approach to telemedicine intervention to contribute to positive experiences and outcomes. The sample of Bushey et al.’s (2020) participants consisted primarily of male veterans, potentially reducing the generalizability of these results. Comorbid pain may also make it difficult to isolate the 18 specific results for depression. Addressing individual concerns, as opposed to generic ones, was also reported as having an influential and positive influence on participant’s personal motivation to engage in treatment in Barceló-Soler et al.’s (2023) qualitative study examining CBT digital interventions whose study sample included depression specifically but consisted primarily of middle-aged women. Telemedicine treatments, such as online CBT therapy or tailored and relevant materials (i.e., for depression), were reported as strong influencers to a positive experience for participants in both Barceló-Soler et al.’s (2023) and Finazzi et al.’s (2023) qualitative studies. Irrelevant materials and excessive homework were reported to be associated with negative impacts on participants' experience with telemedicine treatment (Finazzi et al., 2023). Many studies highlight that the anonymity of telemedicine and digital interventions was reported as beneficial by participants, helping them feel more comfortable sharing, avoiding stigma or judgement, and accessing care they might otherwise have avoided (Barceló-Soler et al., 2023; Posselt et al., 2024; Rushton et al., 2020). Specifically, telephone interventions and the lack of visuals were seen by some participants as less intimidating for communication (Finazzi et al., 2022; Maher et al., 2022). Some participants also identified anonymity as less personalized, negatively impacting their experience or willingness to share (Finazzi et al., 2022). Overall, positive and negative influencing factors of individualization on participant’s experience with telemental health interventions for depression included stage of disease or health status (Du et al., 2021; Posselt et al., 2024), structure (Du et al., 2021; Finazzi et al., 2023), and standardization (Barceló-Soler et al., 2023; Bushey et al., 2020; Finazzi et al., 2023; Posselt et al., 2024). Accessibility of Telemedicine and Its Influence on Patient Experience Accessibility unfolded as a common influencer of patient experience for telemedicine treatment for depression (Barceló-Soler et al., 2023; Bushey et al., 2020; Du et al., 2021; 19 Finazzi et al., 2022; Guaiana et al., 2021; Haun et al., 2023; Maher et al., 2022; Posselt et al., 2024; Rushton et al., 2020). In Barceló-Soler et al.'s’ (2023) qualitative study of a digital CBT intervention for patients with depression in primary care, the general consensus from participants was that the digital CBT was easy to use, including features of lay terms and uncomplex instructions, contributing to a positive experience (Barceló-Soler et al., 2023). Despite this finding, the population of primarily middle-aged women in urban areas potentially reduces the generalizability of these results to more diverse populations, including those with lower levels of digital literacy. User-friendly platforms were also identified as an influence on patient experience by Bushey et al.’s (2020) and Haun et al.’s (2023) studies. Posselt et al.’s (2024) qualitative study identified potential challenges for individuals with limited digital skills, as adapting to digital treatments required more effort, which was reported as a potential barrier to use, especially during highly depressive phases. Other participants reported that digital health interventions may be less demanding in terms of time and energy compared to in-person options, offering greater convenience and flexibility, particularly during periods of lethargy (Posselt et al., 2024). Comfort with technology was also identified as an influencing factor on patient experience with telemedicine for the treatment of depression in Haun et al.’s (2023) and Maher et al.’s (2022) qualitative studies. Comfort with technology, such as video consultations, was reported by participants as positive, allowing them to express their emotions openly (Haun et al., 2023). Participants highlighted the benefits of telemedicine’s flexibility and convenience, such as the ability to stay at home, schedule appointments around personal commitments like childcare or work, and revisit information as needed (Rushton et al., 2020; Barceló-Soler et al., 2023). While faster access to care and a decrease in weight times were reported in some studies (Haun et al., 2023; Posselt et al., 2024; Rushton et al., 2020), other studies had cases 20 of longer wait times for intervention implementation, which were found to negatively impacted participants experience (Du et al., 2021; Finazzi et al., 2023). Technology performance and stability (Maher et al., 2022) and access to devices or technology (Maher et al., 2022; Guaiana et al., 2021) were also described as influencing factors to experience with telemedicine. While some participants did not view minor connectivity issues as major obstacles (Haun et al., 2023), others found connection problems distracting, which negatively affected their treatment experience (Finazzi et al., 2022). Access to reliable technology platforms with minimal technical issues was identified as essential to avoid negative impacts on overall experience (Maher et al., 2022). In summary, factors related to accessibility that participants reported as having a positive impact on patient experience included faster access to care (Haun et al., 2023; Rushton et al., 2020), decreased weight times (Posselt et al., 2024), user-friendly platforms (Barceló-Soler et al., 2023; Bushey et al., 2020; Haun et al., 2023), schedule flexibility (Barceló-Soler et al., 2023; Du et al., 2021; Posselt et al., 2024; Rushton et al., 2020), greater convenience (Posselt et al., 2024), less energy requirements (Posselt et al., 2024), and decreased travel times (Guaiana et al., 2021). Factors related to accessibility that participants reported as having a negative impact on patient experience included longer wait times (Du et al., 2021; Finazzi et al., 2023) and technology issues (Finazzi et al., 2023; Maher et al., 2022). Influence of Patient Knowledge on Telemedicine Experience Participants’ knowledge of treatment was an additional arising theme on the influence of patients’ experiences of telemental health interventions (Du et al., 2021; Finazzi et al., 2023; Haun et al., 2023; Maher et al., 2022; Rushton et al., 2020). Patients with prior videoconferencing experience in Haun et al.’s (2023) qualitative study reported they were more likely to prefer consultations from home compared to those without such experience 21 (Haun et al., 2023). Most patients from Du et al.’s (2021) qualitative study examining patients’ experience of online CBT programs reported not being fully informed by their general provider about the program or how it worked, leading to apprehension of the treatment and influencing patient experience even prior to treatment initiation. One participant with depression identified that a lack of knowledge can negatively contribute to early experience, including assumptions and decreased engagement in telemental health interventions (Finazzi et al., 2023). In Rushton et al.’s (2020) qualitative study examining patient’s perspective of telemental health treatment via telephone, participants reported initial apprehensions stemming from a lack of understanding of telemedicine treatment can lead to negative assumptions such as being given inferior treatment or having no choice in treatment options. In general, as treatment and understanding of telemedicine progressed, the group tended to indicate a noticeable change in perspective with a more positive view regarding telemedicine and its potential efficacy (Rushton et al., 2020). Many studies found that participants reported that uncertainty or being uninformed can lead to treatment apprehension (Maher et al., 2022; Rushton et al., 2020; Du et al., 2021; Finazzi et al., 2023). 22 CHAPTER FOUR: DISCUSSION This integrative review aimed to explore existing knowledge on patients' experiences with telemedicine for treating depression. The review synthesized the findings of 11 studies on patient experiences with telemedicine for the treatment of depression. The reviewed studies primarily employed qualitative methodologies, highlighting the subjective experiences of patients. The results illustrated both positive and negative factors shaping the patient experience of telemedicine for the management of depression in primary care, with key findings centring on the therapeutic relationship, the environment of care delivery, individual patient factors, accessibility of telemedicine, and patient’s level of understanding of telemedicine treatment. With the rise in depressive disorders (Stephenson, 2023) and growing adoption of telemedicine in primary care (Bushey et al., 2020; Canadian Institute for Health Information, 2023; Fountaine et al., 2022; Posselt et al., 2024), understanding factors that shape patients' experiences with telemedicine for depression is crucial for generating practical insights (Maher et al., 2022) to enhance patient engagement in telemedicine interventions (Du et al., 2021; Finnazi et al., 2023; Haun et al., 2023) and ultimately improve patient outcomes and ensure high-quality telemedicine care. Of the 11 included studies, only four examined depression in isolation and the remaining seven looked at depression with other mental health conditions. While it is known that depression commonly coexists with other comorbidities (Echelard, 2021; Kessler, 2012), and efforts were made in the exclusion criteria to control for this, only physical comorbidities were excluded as the lack of available data did not allow for the exclusion of comorbid mental health conditions such as depression and anxiety. This lack of data may impact the generalizability of this review's findings (Melnyk & Fine-Out-Overholt, 2023) to broader populations rather than focusing on depression in isolation. 23 Enhancing the Therapeutic Relationship for Improved Patient Outcomes Overall, a majority of the primary studies that were examined revealed that the therapeutic relationship between patients and providers was a key factor influencing patient experiences with telemedicine for depression, affecting motivation, engagement, and treatment outcomes (Ballesteri et al., 2020; Barceló-Soler et al., 2023; Du et al., 2021; Finazzi et al., 2023; Haun et al., 2023; Posselt et al., 2024; Rushton et al., 2020). Positive relationships fostered communication, intervention acceptability, and clinical improvement, with provider attributes such as empathy, professionalism, and collaboration contributing to this dynamic (Barceló-Soler et al., 2023; Finazzi et al., 2023; Haun et al., 2023). However, challenges unique to telemedicine, including the absence of body language, lack of provider responsiveness, and time constraints, were reported as barriers to effective therapeutic relationships, potentially leading to feelings of isolation and reduced help-seeking behaviour (Du et al., 2021; Finazzi et al., 2023; Rushton et al., 2020). Provider competence was also identified as influential to the therapeutic relationship (Rushton et al., 2020). This evidence underscores the importance of prioritizing patient-provider relationships in telemedicine to optimize treatment quality, engagement, and outcome. The importance of the therapeutic relationship on patient engagement and outcomes in any healthcare encounter is a wellknown concept (Bova et al., 2021; Chipideza et al., 2015; Dorr Goold & Lipkin, 1999; Steele Gray et al., 2024), especially in mental health care (Laranjeira, 2021) and therefore is an expected finding. This aligns with findings from studies in this review that emphasize the importance of optimizing the therapeutic relationship in telemedicine healthcare encounters (Du et al., 2021; Maher et al., 2022). Strategies for primary care providers to foster a positive therapeutic relationship may include taking additional time to build rapport, especially compared to an in-person appointment, meeting patients in person before implementing telemedicine interventions 24 when possible, using teletherapy intermittently or alongside in-person visits (Finley et al., 2024). Additionally, strategies such as using essential communication and active listening skills that demonstrate compassion, such as validating patients' experiences, can help strengthen the therapeutic relationship in telemental health care (Glass & Bickler, 2021). Establishing a Safe and Supportive Environment Overall, environmental factors were found to influence patient experiences with telemental health care, with familiar and private settings like home enhancing comfort, safety, and engagement (Du et al., 2021; Haun et al., 2023; Maher et al., 2022). However, barriers such as lack of privacy, interruptions, connectivity issues, and technological challenges were also reported as negatively impacting patient sharing, engagement, and overall experience (Du et al., 2021; Haun et al., 2023; Maher et al., 2022). These findings illustrate that the suitability of telemedicine may be context-dependent. Primary care providers should work to establish a safe and comfortable setting for mental health telemedicine encounters. As presented by Mishkin et al. (2023) in their review article on addressing privacy in telemedicine, providers can help mitigate privacy concerns in patients’ home environments by adhering to scheduled appointment times, allowing patients to plan for a secure or private location, and by encouraging the use of headphones to added confidentiality. Additionally, ensuring a safe and supportive telemedicine experience requires considering each patient’s unique needs, which will be explored in the following section. The Need to Individualize Delivery Multiple studies used in this integrative review align with the foundational knowledge that telemental health interventions should be individualized to enhance patient acceptability and engagement in treatment (Du et al., 2021; Finazzi et al., 2023; Kolaas et al., 2023). Individual patient characteristics, such as disease stage, health status, and personal preferences, were found to significantly influence the telemedicine experience, with some 25 patients preferring structured therapies and others favouring more open-ended approaches (Barceló-Soler et al., 2023; Du et al., 2021; Finazzi et al., 2023; Posselt et al., 2024). A tailored, personalized approach to treatment that included relevant materials and addressed individual concerns was seen as enhancing engagement and outcomes, while standardized approaches could hinder participation (Bushey et al., 2020; Barceló-Soler et al., 2023). Anonymity in telemedicine was reported as both beneficial for reducing stigma and fostering comfort, but some participants felt it reduced their personal connection, affecting their willingness to engage (Finazzi et al., 2022; Maher et al., 2022; Posselt et al., 2024). These findings suggest that telemedicine interventions for depression are highly influenced by individual patient characteristics and preferences. Personalization in treatment, including the flexibility to tailor approaches based on disease stage, health status, and patient preferences may enhance engagement and treatment outcomes. Additionally, while anonymity in telemedicine can reduce stigma and increase comfort, it may also detract from the sense of personalization and trust, which are important for fostering an effective therapeutic relationship. Existing literature states that an individualized approach is essential to patient-centred care in mental healthcare (Edgman-Levitan & Schoenbaum, 2021), and patient-centred care is the well-known cornerstone of quality healthcare (British Columbia Ministry of Health, 2015). Achieving individualized telemental healthcare and delivering patient-centred care should ultimately involve including the patient in the decision to use telemedicine (Jørgensen et al., 2023). This can involve discussing the patient's goals and preferences at the start of an appointment or during an initial consultation. Additionally, this discussion should address the patient’s access to telemedicine to ensure feasibility. 26 Addressing Accessible and Equitable Telemedicine Care Accessibility was found to be a common factor influencing patient experiences with telemedicine for depression, with positive aspects including faster access to care, flexible scheduling, user-friendly platforms, and reduced travel times (Barceló-Soler et al., 2023; Haun et al., 2023; Posselt et al., 2024). Digital health interventions were seen as less demanding in terms of time and energy, offering greater convenience, especially during depressive phases, though challenges arose for those with limited digital skills or connectivity issues (Posselt et al., 2024; Maher et al., 2022). Comfort with technology and access to reliable devices were also found to be essential in ensuring a positive treatment experience (Haun et al., 2023; Maher et al., 2022). The findings suggest that accessibility plays a critical role in shaping the patient experience with telemedicine for depression. Accessibility may also be taken into consideration for an individualized approach and patient-centred care. While it has been identified that telemedicine is a strategy to improve access to health care (Canadian Institute for Health Information, 2023), including for depressive disorders (Posselt et al., 2023), it is also known that it is not without obstacles (Maher et al., 2022). These findings emphasize the need to address digital divides and ensure accessibility features are considered to provide equitable, effective telemedicine care. A strategy for providers to improve the accessibility of telemental health is by engaging in health policy changes, such as advocating for standardization and regulatory frameworks that prioritize privacy, userfriendly platforms, and service coverage to remote areas (Alis Behavioral Health, 2025). Enhancing Patient Understanding to Reduce Treatment Apprehension It was identified that participants’ knowledge of telemedicine treatment influenced their experiences, with prior videoconferencing experience leading to a preference for home consultations, while lack of information or uncertainty contributed to treatment apprehension (Haun et al., 2023; Du et al., 2021). As patients became more familiar with telemedicine, 27 their perceptions generally became more positive, highlighting the importance of clear communication from providers to reduce initial apprehension (Rushton et al., 2020; Finazzi et al., 2023). The findings suggest that patients' prior knowledge and experience with telemedicine play a crucial role in shaping their attitudes and engagement with treatment. These results also highlight the importance of clear communication and education from healthcare providers to reduce uncertainty and enhance patient confidence in telemedicine, ultimately fostering better engagement and positive treatment outcomes. The background search conducted for this integrative review identified that uncertainties for patients exist surrounding the use of telemedicine despite the known advantages, leading to treatment apprehension (Castro et al., 2020; Petersen et al., 2020; Rushton et al., 2019; Rushton et al., 2020). Providers can enhance patient knowledge and understanding of treatment by engaging patients with open-ended questions to assess comprehension and address concerns, using lay terms, and offering a summary of the discussion to ensure clarity (Agency for Healthcare Research and Quality, 2020). Implication of Findings for Practice The findings from this review offer practical implications for primary care providers, who are at the forefront of caring for patients with depression (Stephenson, 2023), including through telemedicine interventions (Bushey et al., 2020; Fountaine et al., 2022). Nurse practitioners can play a key role as primary care providers in delivering quality care for the treatment of depression in telemedicine by enhancing the cornerstones of healthcare, including the therapeutic relationship, patient-centred care, advocacy, informed consent, and provider competency. NP provider competencies include developing a therapeutic relationship that prioritizes client needs in all practice settings (British Columbia College of Nurses and Midwives [BCCNM], 2018). NPs can adapt to establish and maintain a therapeutic 28 relationship for telemedicine and determine the most appropriate mode of care to meet the patient’s needs (BCCNM, n.d.) in order to provide patient-centred care. Strategies that NPs can implement to enhance the therapeutic relationship in telemental health care include pursuing additional education and training (Glass & Bickler, 2021). A strategy identified as critical to the therapeutic relationship in telemental health care by Glass and Bickler (2021) involves telemental health providers engaging in self-reflection to recognize personal biases, cultivate cultural humility, and develop a more authentic approach that enhances cultural awareness and inclusivity (Akyil et al., 2017; D’Arrigo et al., 2017; Perkins et al., 2019; Watson, 2019). This strategy, in turn, strengthens the therapeutic relationship in telemental health between patient and provider, ensuring a more tailored and effective response to individual needs (Akyil et al., 2017; D’Arrigo et al., 2017; Watson, 2019). By cultivating an inclusive and culturally aware approach, NPs can enhance the delivery of high-quality care that is both patient-centred and responsive to the unique needs of each individual. Adapting interventions to meet the individual needs of patients and ensuring they are informed about healthcare services, including access and treatments, aligns with the standards of practice for NPs (BCCNM, 2020-a), and is directly applicable to telemedicine for the treatment of depression. Adapting interventions to meet patients' individual needs is an ongoing process that requires continuous evaluation to address health disparities and ensure equitable care across diverse patient populations (Ezeamii et al., 2024). To enhance patient engagement and reduce apprehension in telemedicine care for depression, NPs can follow the principles for giving valid informed consent for telemedicine interventions, which is both an ethical and legal responsibility (BCCNM, 2020-b). NPs can ensure informed consent for telemental health by avoiding assumptions of implied consent and clearly explaining the benefits and risks of interventions or consultations beforehand (Mondal et al., 2020). 29 NPs as advocates is a core competency (BCCNM, 2024) and can address issues related to the accessibility of telemedicine for the treatment of depression to provide equitable care. NPs can advocate by actively participating in shaping health policies that support telemental health initiatives, ensuring that regulations facilitate its accessibility (Garber et al., 2023). Provider competency may also include an NP using clinical judgement to ensure they possess the right skills for technology and communication (BCCNM, n.d.) to provide high-quality telemedicine care for mental health patients. Part of the responsibility for high-quality healthcare lies with the primary care provider to ensure they are equipped with the necessary tools, knowledge, and competency to provide effective telemedicine care for depression. As discussed, this may involve providers pursuing additional education or training of telemedicine and telemental health (Glass & Bickler, 2021). Future research evaluating effective and available training for primary care providers and telemental healthcare should be explored. Limitations The limitations of this integrative review include the lack of specific literature on depression. Despite efforts to control for comorbidities through exclusion criteria, only physical conditions could be excluded due to insufficient data if excluding comorbid mental health conditions. The generalizability of the findings is further constrained by the variation in telemedicine modalities (e.g., CBT, video, or telephone). Additionally, most studies were of moderate quality, lacking any high-quality research, which may be influenced by the qualitative nature of the studies, which was necessary for an in-depth examination of this concept (Allen, 2022). The participant diversity, being limited to adults, and potential biases from self-reporting tools (i.e. response bias, social desirability bias) (Haun et al., 2023) also limit the findings. Future investigations into telemedicine for depression specifically are needed to better understand this growing intervention. 30 CONCLUSION Mental health has been steadily declining in Canada and globally, with depression emerging as one of the most common conditions (CAMH, 2024; Stephenson, 2023; WHO, 2022). Primary care providers are often at the forefront of mental health care (Stephenson, 2023), yet access to a provider remains a challenge (Moroz et al., 2020). The consequences of untreated depression range from substance abuse and physical illness to suicide (New England Medical Group, 2022). The expansion of telemedicine may improve access for patients with depressive orders (Canadian Institute for Health Information, 2023; Posselt et al., 2024), and successful long-term implementation requires exploration into key factors like patient perceptions (Allen, 2022). Limited understanding exists regarding patients’ experience of virtual care for the treatment of depression. This integrative review contributes to the low level of literature on determining what is known about patients’ experiences of telemedicine for the treatment of depression in primary care. The results illustrated both positive and negative factors shaping the patient experience of telemedicine for the management of depression in primary care, with key findings centring on the therapeutic relationship, the environment of care delivery, individualization of treatment approaches, accessibility of telemedicine, and the level of knowledge patients possess regarding telemental health. Understanding factors that shape patients' experiences with telemedicine for depression is essential to enhance patient engagement in telemedicine interventions (Du et al., 2021; Finnazi et al., 2023; Haun et al., 2023) and improve patient outcomes by ensuring high-quality telemedicine care. 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SSRN Electronic Journal. https://doi.org/10.2139/ssrn.4839693 41 Appendix A Search Strategy Table A1 Search Terms Concept: Search terms: Mental health/ Depression "mental health" OR "mental health disorder*" OR "mental health illness" OR depression OR "mood disorder*" OR "depression disorder*" OR “depressive disorder*” OR "depressive episode*" OR "major depressive disorder*" OR "depressive symptom*" OR “major depression” Telehealth telehealth OR telemedicine OR “virtual care” OR “e-health” OR “E-mental health” OR telepsychiatry OR “remote consultation” OR telecare OR telenursing OR telepsychiatry OR “mental health teletherapy” OR ‘telemental health” OR “digital health” Primary Care “primary health care” OR “primary care” OR “primary care nurse practitioner*” OR “nurse practitioner*” OR “primary care provider*” OR “primary healthcare provider*” OR “primary mental health care” OR” primary care service*” OR “general practitioner*” OR “family physician*” OR “family medicine*” OR “primary care physician*” OR “family nurse practitioner*” Patient Experience “patient Satisfaction” OR satisfaction OR “client satisfaction” OR “patient experience*” OR experience OR “patient perspective” OR “patient-reported outcomes” OR “patientreported measure*” OR “patient attitude*” OR “patient preference*” Note. This table displays the search terms used in database searches. Search terms were gathered during the preliminary search, including MESH headings and key search terms. 42 Figure A1 CINAHL Database Search 43 Note. The final CINAHL database search was executed on Dec. 11, 2024. All search terms are included with the appropriate Boolean operators, and results can be seen on S18. 44 Figure A2 Medline Database Search 45 Note. The final Medline database search was conducted on Dec. 11, 2024. All search terms are included with the appropriate Boolean operators, and results can be seen on S19. 46 Figure A3 APAPsycInfo Database Search 47 Note. The final APAPsycInfo database search was carried out on Dec. 11, 2024. All search terms are included with the appropriate Boolean operators, and results can be seen on S16. 48 Figure A4 PRISMA Diagram Note. A PRISMA flow diagram was created and utilized as part of the literature search strategy for this integrative review to identify studies. PRISMA flow diagram has been adapted from Page et al. (2020)’s PRISMA flow diagram for systematic reviews. 49 Appendix B Critical Appraisal Table B1 Critical Appraisal: Cohort Study Citation (Author, year) Method Sample Aim of Study Relevance to Capstone Validity of Results + Methodology (/8) Report of Results (/3) Relevance of Results (/3) Final Score (/14) + grading Kolaas et al. (2023) single-group prospective cohort study Adults >18 with at least moderate depression and/or mild/moderate anxiety scores (PHQ-9 or GAD-7) for clinical sample and mild depression or anxiety scored for the subclinical sample. N=91 Evaluate the feasibility of telepsych intervention via video based on CBT for common mental health problems, including depression and anxiety, in the primary care setting. -Primary care -Depression (not exclusively) -Patient perspective (satisfaction) -Telehealth intervention 7 2 3 12/14 Note. Adapted from the CASP Checklist for cohort studies (Critical Appraisal Skills Programme, 2024-a) *single cohort study Moderate 50 Table B2 Critical Appraisal: Qualitative Data Citation (Author, year) Method Sample Aim of Study Relevance to Capstone Validity of Results + Methodology (/6) Report of Results (/3) Relevance of Results (/1) Final Score (/10) + grading BarcelóSoler et al. (2023) Qualitative Ages 20-60 with one participant >60 years old with mild-moderate depression N=41 Evaluate a digital CBT intervention for patients with mild to moderate depression in a primary care setting. - Digital intervention - Depression -Primary care - Patient experience of online intervention/program 6 2 .5 8.5 Du et al. (2021) Qualitative Patients with anxiety and depression, ages 18-61 N= 33 Examine patients’ experiences and acceptance of an online CBT program, particularly exploring the point of referral, access to treatment, and support for depression and anxiety. -Primary care setting -Patients with depression -Digital intervention (telecare) -Patient experience 6 Qualitative- interpretative phenomenological analysis Participants ages 2254 referred by GP with mild to moderate health issues including depression (3) , anxiety (4), PTSD (1), OCD (1) N=9 Evaluating patient experiences of accessing, receiving, and completing remote tele-psych treatment provided by primary care services during COVID-19. -Patient experience -Primary Care -Tele-mental health -Depression (limited) 6 Qualitative Age >18 and previous experience of receiving teletherapy (phone or video) during COVID-19 pandemic by primary care Examine experiences of adult mental health primary care service users with teletherapy to inform future use -Includes depression but not exclusive -Aim of study is relevant to capstone. 6 Finazzi et al. (2023) Maher et al. (2023) Moderate 2.5 1 9.5 Moderate 3 .5 9.5 Moderate 3 .5 9.5 Moderate 51 or psych mental health services in Ireland. N = 14. Posselt et al. (2024) Rushton et al. (2020) Qualitative Qualitative Age >18 with mild to moderate depression receiving current treatment from a GP N= 17 Examine patient’s perspectives of digital therapeutic treatment for depressive disorders within primary care to contribute to further development of telemedicine acceptance. -Depression -Patient Experiences -Digital Interventions (telemedicine) -Primary care/general practitioners 6 Age 18-69 with anxiety, depression, anxiety and depression, or other with experience from telemental health therapy via telephone in last 12 months since start of study N=28 Examine patient’s perspectives of tele-mental health treatment via telephone to identify areas for improvement/change -Common mental health problems (Depression and anxiety) seen in primary care -Tele-mental health via telephone intervention -Patient views/experiences 6 3 1 10 Moderate Note. Adapted from the CASP Checklist for qualitative studies (Critical Appraisal Skills Programme, 2024-b). 3 1 10 Moderate 52 Table B3 Critical Appraisal: RCTs Citation (Author, year) Method Sample Aim of Study Relevance to Capstone Validity of study design (/3) Methodologically sound (/5) Report of Results (/3) Relevance of Results (/2) Final Score (/13) +grading Balestrieri et al. (2020) cluster randomized trial Ages 18-65 with moderate depression (PHQ-9 >11 and IDS-SR >26) Evaluate the impact of clinical decision support systems (CDSS) and telemedicine interventions in treating patients with depression in primary care settings. Secondary outcome = patient satisfaction (experience) with the provider-patient interview/ encounter (telemedicine group vs treatment as usual/ control group) 3 2 3 2 10/13 N= 98 *Consideration: Blinding not feasible due to the nature of telemedicine intervention Moderate Studying patients with depression and primary care practice setting. Bushey et al. (2020) RCT > 18 years old with clinically significant pain and at least moderate depression or anxiety Examining participant acceptability of telecare and self-management modules in management of pain, depression, anxiety Depression, primary care patients, patient experience, telecare management provided by a nurse-physician team 1.5 2 *Consideration: Blinding feasibility challenging due to the nature of telemedicine intervention N=294 Note. Adapted from the CASP Checklist for RCTs (Critical Appraisal Skills Programme, 2024-c). 2 1 6.5 LowModerate 53 Table B4 Critical Appraisal: Systematic Review Citation (Author, year) Method Sample Aim of Study Relevance to Capstone Validity of study design, methodology (/5) Report of Results (/2) Relevance of Results (/3) Final Score (/10) +grading Guaiana et al. (2021) Systematic Review Patients age >18 with MDD (Major depressive disorder) Aim to provide a systematic review on telepsychiatry interventions for MDD to assess acceptability and patient satisfaction, efficacy, and cost-effectiveness. -Age >18 -Depression -Patient experience (satisfaction) -Telecare 5 1 3 9 Note. Adapted from the CASP Checklist for systematic reviews (Critical Appraisal Skills Programme, 2018). Moderatehigh 54 Table B5 Critical Appraisal: Mixed Methods Citation (Author, year) Method Sample Aim of Study Relevance to Capstone Quality screening (/2) Qualitative Data Evaluation (/5) Quantitative Data Evaluation (/5) Mixed Methods Evaluation (/5) Final Score (/17) +grading Haun et al. (2023) qualitative study within a randomized feasibility trial Adults, mean age 45.3 y.o with depression and/or anxiety N=20 Assess patient’s views of the integration of telemedicine through the use of video consultation including: 1. Implementation- delivery and reception of video consult intervention 2. Mechanism of impactimprovements in mental health from video consults 3. Context: external factors influencing delivery of video consult intervention (barriers + facilitators) Patients with depression, primary care setting, patient experiences, and telemedicine. 2 5 4 4 15 - Examine patient’s lived experiences of telemedicine via video consultation for treatment of depression and/or anxiety Note. Adapted from the Mixed Methods Appraisal Tool (Hong et al., 2018). Moderate *Qualitative dominant (quantitative method described but actual study discussed elsewhere) 55 Table B6 Grading Scale Grading Scale High Confidence in the results; further research unlikely to alter confidence Moderate Confident that results are mostly accurate; new studies could change perspective Low Unsure about accuracy of the results; further research likely to have substantial impact on conclusions Very Low Uncertain about results; further research very likely to have substantial impact on conclusions Grading Considerations: Critical Appraisal CASP Scoring/Checklist or MMAT Level of Evidence Systematic Review> RCTs > Non-randomized controlled studies> Cohort> Qualitative Note. Adapted from the GRADE working group (Atkins et al., 2004) and Melnyk & Fine-Out-Overholt (2023). 56 Appendix C Data Extraction Table C1 Literature Matrix Citation (Author, year) Method Results (Relevant Findings) Implications for Practice Strengths and Limitations Quality of Evidence Codes/ Themes Balestrieri et al. (2020) Cluster Randomized Trial - Little difference in patient satisfaction rates of telemedicine experience of patient-provider encounter including provider-patient relationship and treatment results, compared to treatment as usual group (control group) - The telemedicine group reported a higher rate of comfort in communication with providers during the medical interview process compared to the control group -Study suggests that subjective experience of patients may be associated with effectiveness of telemedicine interventions for the treatment of depression -Primary care providers may have little motivation to add additional telemedicine tools to practice due to time constraints and patient load. - Sample size was smaller than anticipated (due to participant criteria), contributing to a large CI and lower precision of the estimate of proportion. - Self-reported measures may have implications for sensitivity and specificity. -Results may not be generalizable to patients with mild depression Moderate Blended therapy BarcelóSoler et al. (2023) Qualitative Main themes: Bond: - Feeling understood: Participants seemed to emphasize that a human interaction was better than the digital program when it came to "feeling understood." - Genuineness: participants identified the genuineness of the professional’s efforts in the creation of the intervention and therapeutic relationship was influential to meaningful clinical improvement - Goal setting as an activity from the i-CBT was reported by participants as important for motivation to achieve improvement of symptoms for depression and observe progress of treatment. Participants also noted that insufficient support in this area could hinder progress and lead to dropout. Sufficient support Strengths: -Based on data from participants in a randomized controlled trial (RCT), ensuring systematic data collection from individuals with direct experience of depression and treatment. -Focus on Working Alliance: Examining the therapeutic relationship in digital interventions is innovative and Moderate Therapeutic relationship Therapeutic relationship Anonymity Accessibility Individualization Blended therapy 57 -Partnership: (between patient, computer program, provider) trust and “warmth” are important for program use/acceptability. - Feelings of isolation and risk of dropout reported if no follow-up from a mental health provider - Reported that a lack of responsiveness from the program (i.e. self-guided components) highlighted the importance of responsiveness from a provider required to express feelings and seek guidance - Anonymity: Participants expressed a value for the anonymity of the digital intervention to reduce stigma or judgment of mental illness Goals: - Goal setting as an activity from the iCBT was reported by participants as important for motivation to achieve improvement of symptoms for depression and observe progress of treatment. Task: - Personalized motivation was reported as influenced by content addressing their individual concerns (as opposed to generic which was seen as less beneficial) - Usefulness of intervention: Participants expressed that parts of the online program increased engagement and openness and had practical application, such as changing their way of thinking or learning new skills. from providers may aid in helping patients with goal setting through digital intervention programs such as CBT. -Recommending iCBT programs that are easy to use and contain individualized interventions, as well as offering guidance when needed. adds to the limited research on this topic, especially in lowintensity internet-based programs. -Practical Implications: The study identifies actionable areas for improvement, such as the importance of goal-setting and professional support, which can inform future program design. Limitations: -Participant sample mainly consists of middle-aged women in urban areas, reducing representativeness and limiting generalizability to broader populations. -Excludes individuals with low technology affinity, potentially overlooking the needs of those who might benefit from digital interventions. 58 - Complementary: all patients reported that although the i-CBT was a useful tool, it was not seen as a complete replacement for a healthcare professional. Usability Heuristics (properties of digital intervention programs) - Accessibility: flexibility with personal schedule, revisit information - Ease of Use: general consensus from participants that the i-CBT was easy to use including features of lay terms and uncomplex instructions. - Self-directed: was seen as helpful for fostering responsibility and independence in the therapeutic process. While generally positive, it was noted that strong willpower was essential for it to be effective. - Interactivity: Participants felt the digital intervention program was lacking, leaving them with unanswered questions about its theoretical aspects and unaddressed concerns they couldn't express. - Aesthetic appeal: was reported as adding to a more pleasant experience, influencing motivation -Overall, general positive opinions for the use of i-CBT programs, however may not be a replacement for healthcare professional interventions. Bushey et al. (2020) RCT -Participants generally reported overall satisfaction with telehealth interventions - Higher satisfaction reported in the group receiving automated and comprehensive - Customizability for individual patients: tailored approaches to the implementation of telemental health interventions Strengths -Innovative care delivery methods: The study employed innovative methods that allowed Lowmoderate Accessibility Individualization 59 telecare (interaction with provider) as well as a higher rate of helpfulness scores regarding self-directed modules (including depression module) -The most common suggestion from the automated intervention group was for interaction with a provider including for feedback -Recommendations from participants for all technical methodologies included improvement in ease of navigating resources to make them more userfriendly -Participants from both groups reported a suggestion for a more tailored or personalized approach to telemedicine interventions i.e. some patients prefer more frequent reassessment and some patients prefer less -Combined tele-intervention with provider interactions and guidance (oversight, monitoring, feedback) -Personal interactions between providers and patients may enhance outcomes and patient satisfaction for the long-term assessment of specific symptoms, including depression, pain, and anxiety. -High completion rates: A large percentage of participants completed the intervention and the 12-month surveys. - Balanced response rates: the response rates, including for open-ended questions, were consistent across groups, allowing for balanced comparisons Limitations: Limited generalizability: -The sample primarily consisted of male veterans, raising questions about applicability to non-veteran or more diverse populations. - Pain AND depression, less generalizability of results - Lack of a placebo group: The absence of a true placebo group restricts the ability to distinguish treatment effects from spontaneous improvement or nonspecific attention effects. - Active comparator design: The design may have reduced the magnitude of differences between treatment groups compared to trials with a control group. Blended therapy 60 Du et al. (2021) Qualitative Key themes of patient experience identified regarding referral, information and accessibility to the CBT program, and identified challenges: Information dissemination -Most patients reported not being fully informed from their general provider about the CBT program including how it worked leading to apprehension of the treatment. Expectations and impact of waiting -Patients reported longer than expected wait times for the implementation of the intervention, expressing that this was unacceptable and delayed treatment and negatively impacted patient outcomes (i.e. impacts of anxiety and depression such as work leaves) -Expressed importance of accessibility Influence of Location on Experience -Some patients reported preference for completing online CBT program in a clinic and stated they required a more structured approach to ensure engagement, especially in stated of low motivation or triggers from home environment. -Patients who preferred the clinic environment appreciated the personal or human interaction it offered. -Other patients reported a preference from home due to factors such as concerns about stigmatization, as well as the lack of privacy and confidentiality, leading to feelings of vulnerability, negatively impacting the treatment. Implications for Practice -Health policymakers across the world should evaluate the most optimal delivery of digital CBT for patients in primary care and standardize it - Increase knowledge of health care providers when referring patients for CBT therapy to inform patients fully - Individualizing patient treatments based on preferences and suitability for optimal engagement - Practitioners providing available support to patients during digital intervention including a therapeutic relationship to enhance patient engagement and treatment outcomes. Strengths -Primary care setting, study adds value to existing studies in primary care -Adequate sample size and data saturation achieved -Identified potential barriers for patient engagement and dropout Limitations: -Examines depression and anxiety (not just depression) -Rapid pace of change in technology may lead to new versions of the CBT program released before or post-study release - There was three patient withdrawals and challenging follow-up Moderate Knowledge informed/apprehension Accessibility Environment Therapeutic relationship Individualizing 61 -Most patients in the study reported a preference for a home option including factors such as privacy and schedule flexibility. Need for Improved Human Support -Most patients expressed a desire for healthcare provider contact during the CBT teletherapy for emotional support, motivation, reassurance, and to discuss progress and treatment plans or follow up. -Some patients found some sessions distressing and the lack of human support lead to feelings of a decrease in helpseeking. -It was noted that patient experience of patient-provider relationship had an impact on motivation (i.e. negative relationship, negative motivation/engagement and vice-versa) Desire for expanded support features (design) -Most patients reported need for additional support features to assist with questions and concerns during program -Patients reported frustration with not being able to communicate their feelings to the computers properly or further explain the answers they gave Finazzi et al. (2023) Qualitativeinterpretative phenomenological analysis Orientation to treatment Role of GPs: (referral process for remote CBT) -GPs were reported by patients as first point of contact and most referral - Therapeutic relationship: taking sufficient time to listen contributes to an accurate assessment of patients’ diagnosis and needs or management which may Limitation: - Only 33% of of the study participants had depression, may be less generalizable Moderate Knowledge Therapeutic relationship Accessibility 62 processes from the GP were identified as comfortable and efficient. -Contributing factors to this positive experience reported by patients included GPs taking the time to listen, while time constraints contributed to negative experiences. Expectations, feelings, mindset: - Participants identified the right timing, motivation, and mindset were facilitating factors in treatment engagement. - An initial expectation of treatment is influenced by adequate knowledge. A lack of knowledge can negatively contribute to assumptions and decrease engagement was identified by one participant with depression. -Long wait times or unawareness of wait time can also decrease engagement and patient acceptability as well as negative impact mental health outcomes. Treatment features -Helpfulness: The remotely delivered CBT modality (phone or video) was reported by all participants as helpful to mental health outcomes. -Some participants found the structured approach beneficial as opposed to openended therapy, while others preferred open-ended talk therapy. Remote delivery (barriers and benefits) -Benefits: easily adaptable, flexibility (i.e. working from home) -Barriers: connection problems and privacy issues, more distractions include referral for tele-therapy interventions. Contributes to person-centred care and patient empowerment - Individualized treatment may enhance patient acceptability and engagement of interventions -Role of GP: offering options, further mental health training for primary care providers, access point for referral to adjunctive therapies including tele-mental health interventions, providing all necessary information for expectations of treatment (informed consent) -During COVID-19 pandemic, presents unique set of considerations -Small sample and predominantly white females (less generalizability) -Unkown timing between participant interview and competition of treatment; potential recall bias Strengths: -Methodology able to assess unique participant experiences, insights, and specific factors in accessing/engaging in remote psych treatment -To ensure quality control, a second researcher independently assessed initial interviews, and all team members contributed to data analysis and transcript reviews. Reflective diary extracts were used to provide transparency about the researchers' subjectivity throughout the process. Environment Individualized care 63 - The majority of patients reported overall preference for in-person therapy, noting the therapeutic relationship and reading body language or nurture of human contact -Patients reported a preference for either phone call or video delivery -Video-delivery was reported as closer to in-person therapy, feeling more personal and less isolated -Phone delivery was described as less intimidating and easier to communicate. Change enablers -Materials: all patients reported the material was helpful. -Participants identified that homework should not be “excessive” for better engagement and that there should be awareness of varying learning styles should be -Individualized and relevant materials provided to patients (i.e. for depression) were reported as strong influencers for positive mental health outcomes. Therefor barriers included irrelevant materials and excessive homework. -Therapeutic relationship: all participants except for one reported the importance of the therapeutic relationship with the mental health provider during teletherapy. Positive factors on treatment intervention included: collaboration, empathy, competency, professionalism, confidentiality, warmth, acknowledgement of work, and providing 64 both compassion and challenge for change. Treatment Outcomes Overall, all participants reported they found the remote delivery of tele-mental health treatment helpful and would recommend it to others. Guaiana et al. (2021) Haun et al. (2023) Systematic Review qualitative study within a randomized feasibility trial Authors state that all studies examining patient acceptability and satisfaction for tele-mental healthcare showed no differences between telepsych and inperson treatment, and that some studies found that patients expressed greater satisfaction with telepsychiatry when televideo was the medium used. -Contributing factors: decreased travel times, increasing personal access to devices/technology Televideo as the medium for patients with depression may be an acceptable alternative to inperson mental health treatment. Patients’ perceptions of implementation Generally: -Most patients found video consultations feasible and user-friendly, and minor connectivity issues were not seen as major obstacles -Primary care providers (PCPs) may serve as key facilitators for video-based integrated mental health care -Mental health care models in primary care for the treatment of depression and/or anxiety that integrate telemedicine are Strengths: - Used RCTs (high level of evidence) - Comprehensive search strategy and focused topic Moderatehigh Accessibility Moderate Integrated/blended care Limitations: - Original intention of study was for a meta-analysis, yet there was not enough articles produced in search strategy - Different means of measuring patient satisfaction provided challenges for comparison - Populations studied were mostly Caucasian and male, reducing the generalizability of results - Hospital and outpatient (primary care) setting, less generalizable to primary care setting Limitations: - Depression AND/or anxiety, results generalized to both - Primary care patients located in a primary care setting, but psycotherapy treatment video consult was done by specialist (clinical psychologists with a Environment Provider competency Accessibility 65 -All patients were comfortable with video consultations which allowed them to openly express their emotions Other: -few patients reported distractions from interruptions in connectivity that impacted their engagement in the session -A substantial number of patients viewed video consultations as comparable to inperson visits -A few participants favoured video consultations over in-person and described them as less intense, while several patients expressed missing inperson interactions- all from suburban areas -Patients with prior videoconferencing experience were more likely to prefer consultations from home compared to those without such experience. Patient’s perceptions of impact on mental health - Patients reported positive impact of telemedicine intervention on needs and priorities and denied safety concerns (i.e. data security breaches) - With the progression of video consultations, rapport grew with the mental health clinician, increasing patient comfort - For most patients, the therapeutic relationship was a key facilitator to treatment outcomes including compassionate and professional care. - Fast access to a mental healthcare provider was also identified by patients as linked to positive patient experiences. -Primary care providers should apply integrated care models -Primary care providers should aim to provide a safe and familiar environment for conducting mental health telemedicine encounters -Primary care providers should be competent to assess wether patients require in-person appointments. diploma or master’s degree in psychotherapy training or resident doctor training for board certification in psychosomatic medicine and psychotherapy) - Small sample size - Self-reporting measures leave potential for social desirability bias, although mitigation was attempted - 20/23 participants of the telemedicine intervention agreed to partake in this qualitative study interviewing, leaving the possible assumption of negative experiences excluded from results - Trial ended prior to COVID-19, and do not include pandemic or post-pandemic-related factors Strengths: - Limitations and potential biases were attempted to be mitigated - Participants were contacted to confirm summary of data findings and agreed adequate reflection of experiences of telemedicine video intervention Therapeutic relationship 66 a key facilitator to positive mental health outcomes Patient’s perceptions of external factors influencing delivery of video consult intervention -Familiar environment was identified as a contributing factor to engaging in the video consult (home or a primary care practice setting video consulting with a specialist) Two key mechanisms influencing patient’s experience of telemedicine for the treatment of depression and/or anxiety: 1. Fast access to care 2. Emerging therapeutic relationship with mental health clinician Kolaas et al. (2023) Single-group prospective cohort study Overall Participant Satisfaction: On average, participants were somewhat satisfied with the tele-intervention (online cognitive behavioural courses) The average score (out of 32) on the CSQ-8 satisfaction scale was 21.8, which suggests more satisfaction than dissatisfaction. There was some variation in satisfaction: -The clinical group (those with more serious mental health scores) had an average score of 21.4. -The subclinical group (those with milder scores) had a higher average score of 23.0, indicating a slightly higher level of satisfaction. Previous Experience with Psychological Treatment: - Finding efficient methods to deliver accessible tele-mental health interventions such as CBT online courses for a large number of patients in primary care including those who suffer from depression, could improve access to first-line psychological treatments, enhancing the quality of mental health care and reducing unnecessary suffering. -Patient satisfaction or acceptance of tele-therapies may be influenced by knowledge of the intervention and efforts should be made to Strengths: - Primary care setting, conducted within regular patient workflow (adds to generalizability) - Amount of missing data was minimal (increasing precision of results) Limitations: - Lack of randomization and control group - Need to evaluate educational courses further in lower socioeconomic demographics - Qualitative component of patient experience/satisfaction missing (may give valuable insight into ratings) Moderate Accessibility Knowledge Individualization 67 Maher et al. (2022) Qualitative -People who had never had psychological treatment before had an average satisfaction score of 22.5. -Those who had previous treatment had a slightly lower average score of 21.3, indicating they were somewhat less satisfied than those with no prior treatment. Course Theme Ratings: Participants were asked how helpful they found each weekly cognitive behaviour course topic on a scale of 1 to 10: -Depression Satisfaction Rating: The average score for the "depression" theme course was 6.5 out of 10, which suggests that most participants found the content about depression to be somewhat helpful. communicate explanation of treatment -Tele-mental health interventions in primary care should be individualized to the patient - Same follow-up provider may have contributed to positive outcomes -Depression: staying home may have negative implications (i.e. staying in bed) - Overall view of teletherapy: Positive or generally positive: 9 responses (64.3%) Negative: 4 responses (28.6%) Video positive, phone negative: 1 response (7.1%) - Quality of the teletherapy experience largely depends on factors beyond the practitioner's and participant's control. Key elements include privacy, distractions, comfort, the mode of delivery (phone or video), technology stability, and the ability to adapt to teletherapy, all of which influence its effectiveness. - Sufficient training is required for practitioners to develop teletherapy - Access to reliable teletherapy platforms with minimal technical issues to maintain session quality. Technological issues may have a negative impact on experience. -May be beneficial for practitioners to meet patients before teletherapy to develop therapeutic relationships to optimize telehealth delivery - Assessing the suitability of patients for teletherapy: communication style, comfort Strengths: -Use of semi-structured interviews allowed participants to guide conversation and uncover most relevant aspects of their experiences. - Nationwide recruitment provided a diverse participant pool, though demographic details were not collected. - Lack of a prior relationship between interviewer and participants helped reduce courtesy bias. -use of pseudonyms for participants may minimize social desirability bias. Moderate Therapeutic relationship Individualized care Environment Provider training/competence Accessibility Anonymity Privacy Blended therapy 68 Posselt et al. (2024) Qualitative - Early apprehensions due to uncertainty of telemedicine treatment or experience with technology, and home environment (i.e. privacy, distractions), and other individualized factors. -Teletherapy may be more effective as a complement to traditional in-person services rather than a replacement. Performance expectancies: Patient’s perspectives on how digital treatment may impact healthcare: - Not a substitute for in-person treatment and participants assumed a lower efficacy of digital treatment compared to inperson treatment - May improve access to care and wait times (most) which was identified to positive impact depression treatment - Some participants identified that anonymity of digital interventions is advantageous with mental health conditions to avoid stigma, and that admitting a mental disorder is challenging and such tools could ease this burden discreetly. - Provider competence in mental health counselling was identified as a large influencing factor in acceptance and efficacy of depression digital interventions - Provider guidance can help mitigate some barriers such as motivational support to enhance patient acceptance for depression digital interventions - Patient acceptance is linked with treatment efficacy and efforts should be made to improve patient acceptance Limitations: -uncertain of results from depressive patients specifically - influence of COVID-19 context, i.e. pandemic-related restrictions influence on participant’s views of teletherapy experience -lack of demographic data collection may limit availability to explore group differences. -predominantly female sample may reduce generalizability -risk of recall bias, participants discussed experiences from the previous year. -small sample Limitations: -Study examines intention to use digital interventions, not the application of telemedicine -Potential selection bias may exist for patients more digitally proficient or inclined Strength: -Exploration approach -Examined patients with depression in their natural environment -Modern (2024 publication) Moderate Accessibility Anonymity Provider competence Therapeutic Relationship Individualized care 69 - Some viewed the digital treatment as too standardized, pointing out that depression may be complex and unique for each individual (non-individualized) - A majority of participants reported that electronic platforms may be potential contributors to or intensifiers of mental health challenges and depression - Advantages of digital treatment that were identified included access to tools and information to improve selfmanagement of depression Patients perspectives on learning and operating the technology: - Digital health interventions were seen as less demanding in terms of time and energy compared to in-person options, making them particularly helpful during periods of lethargy; greater convenience and flexibility There were also potential challenges identified for individuals with limited digital skills or competencies in adapting the digital treatments, which required more effort GPs Patients perspectives on the influence of general practitioners on the digital intervention: - A trusting therapeutic relationship with the GP promoted acceptability of digital interventions (i.e. tx recommendations) - Empathy and provider competency were identified as essential to effective digital treatment for depression 70 Patient reports of intention to use digital interventions for depression Dependent on: - Stage of disease (may be more helpful in earlier diagnosis) - Personal coping strategies - Disease can negatively impact treatment intention: may not require during periods of “good health” and barriers to use during highly depressive phases (energy expectation); health status affects patient acceptance of digital tx -Patients acceptance of digital interventions for depression depends on the various identified factors Rushton et al. (2020) Qualitative Four main target areas for change were identified: 1. Patient knowledge and understanding of telemedicine treatment -Initial apprehension can stem from a lack of knowledge or understanding of the telemedicine treatment, including thoughts of being given an inferior treatment or not having a choice in treatment options due to long wait times for in person appointments. -In general, as treatment and understanding of telemedicine progressed, the group tended to indicate a noticeable change in perspective with more positive view regarding teletherapy and its potential efficacy -Therapeutic relationship was also a considering factor in the acceptability of telemedicine intervention -Improving patient knowledge and understanding at the start of treatment is essential for increasing acceptance and engagement with telephonedelivered care. -Critical communication skills of practitioners that were identified included active listening and ability to express compassion via telephone which may influence patient engagement, a trusting therapeutic relationship, and treatment efficacy, this may entail proper training -Empowering patients by making sessions more flexible, personalized, and less practitioner-led could enhance Strengths: -Used two theoretical models (TFA and TDF) to examine data and enhance understanding of patient acceptability and engagement in telephone treatment, greater specificity -Collaboration between an experienced qualitative researcher and a Psychological Well-being Practitioner research assistant enriched the analysis. Practitioner involvement helped link research findings to healthcare practice. Moderate Knowledge and Apprehension Accessibility Anonymity Environment Provider Competency Therapeutic Relationship Individualized care Limitations: -Retrospective accounts may reduce data accuracy and contribute to bias (i.e. recall bias) 71 -Lack of knowledge led to many presumptions and assumptions regarding telemedicine via telephone including inadequate practitioner competency 2. Patient and practitioner skills (proficiency) - Communication skills of both patient and practitioner was identified as a key factor in the efficacy of the telemedicine intervention - Lack of body language was identified as a negative contributing factor to the diagnosis, treatment plan, and therapeutic relationship - Critical communication skills of practitioners that were identified included active listening and ability to express compassion via telephone which may influence patient engagement, therapeutic relationship and treatment efficacy 3. Practical and environmental factors (context) - Participants stated benefit of flexibility and convenience with telemedicine including staying at home and finding appointment times around childcare or work schedules. - Faster access to mental health care was also a driving factor for accessibility - The anonymous nature of the teletherapy was reported by some participants as a positive feature where they felt more comfortable to open up and avoid judgement or stigma and may have not accessed care otherwise. engagement and reduce the perceived barriers of telephone treatment - Sample was predominantly white, British participants, limiting generalizability. - Did not specifically mention primary care but study examines common mental health conditions seen in primary care: Depression and Anxiety -Does not separate results for depression -Study took place prior to COVID-19 pandemic 72 4. Beliefs surrounding capabilities and consequences - Some participants initially had low expectations and doubts for telephonebased treatment which commonly improved with treatment progression - Many participants claimed their positive experiences were associated with a skilled practitioner -Negative experiences were often associated with individual practitioner issues such as compatibility or provider conduct (rather than the treatment modality) -Overall, telephone-based treatment was generally viewed as an effective and appropriate treatment -Overall, still a higher preference for face-to-face interventions compared to teletherapy. Note. Adapted from A Step-by-step Guide to Conducting an Integrative Review (Coughlin & Sethares, 2017; Toronto & Remington, 2020; Whittemore & Knafl, 2005). Themes and coding adapted from Braun and Clarke’s thematic analysis framework (2006). 73 Table C2 Thematic Analysis Theme Code/Theme Data (results) Subtheme: Positive/ negative influences on patient experience Factors that influence patient experience with telemedicine for the treatment of depression Therapeutic Relationship Positive: • • • • • • • Comfort in communication (Ballesteri et al., 2020; Haun et al., 2023) Emerging relationship/growing rapport (Haun et al., 2023) Compassionate, professional care (Haun et al., 2023) Genuineness, feeling understood (Barceló-Soler et al., 2023) Partnership important for intervention acceptability (Barceló-Soler et al., 2023) Taking the time to listen (Finazzi et al., 2023) Factors related to positive influence of therapeutic relationship on teletherapy: collaboration, empathy, competency, professionalism, confidentiality, warmth, acknowledgement of work, and providing both compassion and challenge for change (Finazzi et al., 2023) Negative: • • • • • Lack of body language (Rushton et al., 2020) Non-compatibility contributes to negative experiences (Rushton et al., 2020) ) Lack of support may lead to a decrease in help-seeking (Du et al., 2021) Time constraints (Finazzi et al., 2023). Lack of responsiveness (Barceló-Soler et al., 2023) Other (+/-) • Influence on acceptance of telemedicine intervention (Rushton et al., 2020) • Provider competence influence on therapeutic relationship (Rushton et al., 2020) • Impact on motivation (Du et al., 2021) Provider competence (part of therapeutic relationship) Positive: • • • Skilled practitioners linked with positive experience (Rushton et al., 2020) Active listening, compassion (Rushton et al., 2020) Empathy and provider competency essential for effective treatment (Posselt et al., 2024) Negative: • Provider conduct (Rushton et al., 2020) Other (+/-) • Communication skills (Rushton et al., 2020; 74 Environment Positive: • • • The comfort of home environment, safe, relaxed (Maher et al., 2022) Familiar environment (Haun et al., 2023) Privacy (Du et al., 2021) Negative: • • • • • Accessibility Lack of privacy can impact degree of sharing (Maher et al., 2022) and increase feelings of vulnerability (Du et al., 2021) Distractions, interruptions, frustration (Maher et al., 2022) Distractions from connectivity interruptions impacting engagement in session (Haun et al., 2023) Technological issues may have a negative impact on experience (Maher et al., 2024) Electronic platforms may be potential contributors to or intensifiers of depression (Posselt et al., 2024) Positive: • • • • • • Faster access to care (Haun et al., 2023; Rushton et al., 2020) and decreased weight times (Posselt et al., 2024) User-friendly platforms (Haun et al., 2023 Barceló-Soler et al. (2023; Bushey et al., 2020) Schedule flexibility (Posselt et al., 2024; Rushton et al., 2020; Barceló-Soler et al. 2023; Du et al., 2021) Greater convenience (Posselt et al., 2024) May require less energy (Posselt et al., 2024) Decreased travel times (Guaiana et al., 2021) Negative: • • • Limited digital skills or competency (Posselt et al., 2024) Barriers to use during highly depressive phases (energy expectation) (Possely et al., 2024) Long wait times ( (Du et al., 2021; Finazzi et al., 2023) Other (+/-) • Comfort with technology (Maher et al., 2022) • Technology stability (Maher et al., 2022) • Access to devices/technology (Guaiana et al., 2021) Individualization Positive • • • Relevant online CBT materials (Finazzi et al., 2023) Personalized, tailored approach to telemedicine interventions (Bushey et al., 2020) Individualized internet CBT content can positively influence personal motivation (Barceló-Soler et al., 2023) Negative • Irrelevant online CBT materials (Finazzi et al., 2023) Other (+/-) • Standardization (Finazzi et al., 2023; Posselt et al., 2024) • Patient preferences and needs (i.e. structure in a state of low motivation) Du et al. (2021) 75 • Anonymity (part of individualization) Stage of disease (Posselt et al., 2024) Positive • • • i.e. telephone lack of visuals was seen as a positive by some participants (Maher et al., 2022) Anonymous nature may increase comfort with sharing and decrease stigma/judgement (Rushton et al., 2020; Posselt et al., 2024; Barceló-Soler et al., 2023) Less intimidating for communication (FInazzi et al., 2022) Negative • Knowledge Less personalized (Finazzi et al., 2022) Negative • Uncertainty or being uninformed of telemedicine treatment can lead to apprehension (Maher et al., 2022; Rushton et al., 2020; Du et al., 2021; Finazzi et al., 2023) Note. Themes and coding adapted from Braun and Clarke’s thematic analysis framework (2006).