Introduction

Social distancing guidelines and safety regulations during the COVID-19 pandemic created significant disruptions in healthcare delivery, including postponing elective and routine procedures.1 These mandates put a strain on the traditional model of healthcare delivery in the United States. Patients were unable to get traditional face-to-face care, which was a driving factor in institutions switching to online modalities following demand for these services. In response to this, the US healthcare system adapted their modes of service delivery to ensure they were following public safety rules and guidelines provided by the Center for Disease Control.2

Prior to 2020, telemedicine was on a steady upward trajectory, but the absolute integration and use were low.3 An analysis of private insurance data showed that telemedicine accounted for 0.3% of all interactions between March and June of 2019, but that number jumped to 23.6% between March and June of 2020.4 Several important changes were made by the US Department of Health and Human Services to the Health Insurance Portability and Accountability Act (HIPAA) that allowed for the development of telehealth services. These changes were prompted by the Centers for Medicare & Medicaid (CMS) temporary expansion of telehealth benefits on March 17, 2020.5 This important policy change allowed for Medicaid/Medicare insurance coverage of telehealth services using virtual conferencing platforms. Consequently, this led to an incorporation of technology into routine checkups and specialized care and away from traditional in-person care.1 The shift into virtual service delivery during the COVID-19 pandemic not only impacted routine and specialized healthcare but also behavioral health settings.6 This change, while necessary to meet increased needs for mental health services during the pandemic, meant providers were forced to adapt at a rapid pace.7

Transitioning to a telehealth modality can be a challenging endeavor for nearly all stakeholders involved (ie, institutions, providers, patients, etc.). However, healthcare organizations focused on realizing these institutional changes by acquiring new equipment and providing training to healthcare providers, which allowed for patients to utilize telehealth services in a manner that could meet the demands created by COVID-19 in routine healthcare and specialized services, such as behavioral healthcare. In making these large-scale service modality changes, healthcare institutions faced numerous barriers and facilitators for their transition to virtual care delivery models. Successfully incorporating modality changes for behavioral healthcare delivery had additional challenges resulting from the unique and specialized nature of behavioral healthcare and complex psychological disorders, which often require intensive interpersonal communication, observation of both verbal and non-verbal cues, and privacy to share intimate details between patient and provider. 

Borghouts et al,8 defined digital mental health interventions (DMHIs) as the translation of psychosocial interventions into digital formats, whether these are self-guided interventions, virtually supported applications, or traditional psychotherapy transitioned into a digital format. Due to the efficacy and cost-effectiveness of DMHIs, there is great potential for a reduction in stigma, expanded capacity, and extended rural reach.9 A key to the success of DMHIs is ensuring they are accessible to the target population.10 The authors identified three core constructs associated with user engagement with digital mental health interventions, which we will use interchangeably with virtual behavioral health interventions. These included “user”, “program”, and “technology/environmental” related constructs that either facilitated or presented a barrier to these changes in modality type and service delivery. The Borghouts et al8 framework was used to guide the current study. Moreover, Borghouts et al8 argued that these types of interventions have the potential to reduce existing barriers to traditional care and increase access to mental health support and resources. This is particularly relevant in geographic regions that typically have lower rates of access to traditional face-to-face mental healthcare, such as rural areas.9 DMHIs also have the potential to reduce disparities in access to mental healthcare by overcoming various barriers (eg, greater distances needed to travel to appointments due to a shortage of mental health providers, unreliable transportation, lack of anonymity, and stigma).9 A systematic review was recently conducted by this current team of researchers. In a previously published paper, Elliott et al,2 synthesized literature to identify the terminology associated with modality changes in behavioral health care delivery as a result of COVID-19 pandemic safety protocols in the United States. While examining the literature, we identified further potential levels of analysis; specifically, the reported barriers and/or facilitators related to changes in modality delivery during the pandemic, and whether pandemic-initiated adoptions were permanent or temporary based on the type of services changed, resources available, support for reimbursement for newly adopted delivery modalities and the specific needs of various patient populations. This review was therefore the second in a series of publications that examined pandemic-induced changes to care delivery using the PRISMA methodology. Consequently, while there may be some overlap of data (articles) analyzed for this review and the first PRISMA review conducted by this research team, the focus of the two reviews is different as the first article is aimed at identifying the variability in terminology used to define modality delivery and this article aims to identify the barriers and/or facilitators related to a modality change adoption. Additionally, the current review was grounded in Borghouts8 (2021) theoretical model, which outlines the specific constructs associated with adopting new technologies of care delivery.

The purpose of this PRISMA review was twofold: 1) to identify barriers to behavioral health modality changes implemented across healthcare settings and institutions across the US in response to the COVID-19 pandemic (March 2020 – May 2022); 2) to identify facilitators of healthcare modality changes implemented across healthcare systems and institutions in the United States during the COVID-19 pandemic (March 2020 – May 2022). The expanded adoption of telehealth utilization during this time provides an important opportunity for researchers and clinicians to further investigate factors associated with the implementation and use of technology-based health services for patients in clinical settings that may not have traditionally used these modalities. In addition, gaining a better understanding of barriers and facilitators for technology-based health services adoption can help provide greater clarity around the challenges and opportunities faced by institutions, practitioners, and unique patient populations. Thereby potentially impacting the application and acceptance of such services across healthcare systems, relevant stakeholders (eg, patients and providers), and demographic groups (eg, rural communities).  

Method

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 methodology and matrix. Studies included in this review were written in English, conducted in the United States only, focused on mental health modality changes related to COVID-19 response, and published between March 11, 2020 – June 16, 2023. Keywords included were included “COVID-19” OR “pandemic” AND “Telehealth” OR “behavioral health” OR “psychotherapy” OR “counseling” OR “psychiatry” OR “mental health care” OR “health care delivery” both in the abstract with limiters of scholarly peer-reviewed journals. The “full text” searching criteria was not used as it allowed for discovery of the most relevant articles. Full-text articles not recovered were interlibrary loaned from other universities.

To meet the research needs of this study, eight databases were individually searched to identify the articles for review: APA PsycArticles, APA PsycINFO, EBSCOhost Psychology & Behavioral Sciences Collection, PubMed, Scopus, CINAHL, ProQuest Central, and Web of Science. These databases were selected as the key databases for psychological research available to the searcher and representing a wide range of journals. Potential search limitations include dates of searching and geographic limit to only the United States location.

Publications from March 11, 2020, to June 16, 2023, were included due to the specifics of the COVID-19 pandemic shutdown specifically in the United States and the last date of database searching. Due to different regulations, systems, and governmental restrictions, only studies or reports from the United States were used.

Inclusion Criteria

Studies were included if they (1) included behavioral health modality changes implemented during the Covid-19 pandemic, (2) specifically mentioned a barrier or facilitator to the modality change, (3) were only focused on studies or reports specifically in the United States, and published in English. Titles, article metadata including keywords, abstracts, and geographical location of the study were scanned to identify appropriate articles.

Data Extraction and Synthesis

A three-round screening process was used for exclusion screening to identify the most appropriate articles and eliminate bias and reader fatigue. An affinity matrix was used by all researchers to identify and codify themes within each article. The first two rounds of full-text screening exclusion criteria included: no modality change implemented, studies not based in the United States, not correct article type, not within the correct time parameters, and not focused on mental health or germane to the research topic. The third round of screening exclusion criteria focused on articles that specifically discussed a barrier or facilitator related to a modality change.

Any conflicts were resolved with a third reviewer. The qualitative nature of this thematic analysis may limit the generalizability of the results. This was accounted for by using a grounded theory framework.11 Several authors were involved in initial coding and used a team approach during intermediate and advanced coding. To control any potential bias, such as theoretical sensitivity, in the subjective interpretation of articles into themes, we engaged various content experts from interdisciplinary fields (ie, health policy and administration, clinical psychology researchers, and clinicians) and employed a consensus approach. Utilizing the Sciwheel reference management system, the university accessible databases, and interlibrary loan, the full text of all identified articles was accessed using a collective process. Researchers used Microsoft Teams for the collection of data, organization of files, and team meetings. Microsoft Excel was used for data collection and to categorize each article based on inclusion criterion and fit with each construct and subconstruct.

Results Frequency Rates 

The initial search resulted in 445 articles. Figure 1 provides the schematic flow of the sample identification and selection process. Forty-nine articles were used to identify barriers and facilitators to behavioral health modality changes during the COVID-19 pandemic. Table 1 shows the frequency at which barriers and facilitators were discussed across articles used in our analysis. These were described using a model of barriers and facilitators in patient engagement with telehealth following the restrictions imposed by the COVID-19 pandemic, which was proposed by Borghouts et al.8 For more information regarding the articles used in the current study, Table 2 shows the total sample selected and gives an overview of the sample data. Constructs and subconstructs presented in this paper can be found in Figure 2.

Table 1 Barriers and Facilitators of Modality Change Adoption Occurrence Frequencies

Table 2 Study Sample-Article Title, Authors, and a Summary of Findings 

Figure 1 Depicts the preferred reporting items for rapid reviews and meta-analysis (PRISMA) and the four stages of a PRISMA review. It also presents where studies were located, exclusion criteria, and the number of studies used in the review.

Figure 2 Presents an amended model, incorporating a novel administrative construct into the Borghouts model.

User-Related Constructs

The user-related factors predominantly center on individual attributes, encompassing personal perspectives, skills, and past experiences with the digital modality being utilized for care. Just over one-third of the articles (34.69%) discussed facilitators18,20,39 and barriers19,20,22,28,29,31,32,37,39,41,44,49,55–58,61 concerning user constructs. Subconstructs focused on demographic variables, mental health status, beliefs, mental health and technology experiences, as well as the integration of intervention into everyday life. It is important to note that there were no articles that fit under the personal traits sub construct.

Demographics Variables

This subconstruct primarily focuses on the sociodemographic factors of an individual, specifically encompassing personal attributes. Among the identified literature, three articles described barriers,19,49,57 while none addressed facilitators associated with demographic variables. The barriers centered around economics and insurance for patients. Not all healthcare facilities accepted Medicaid for telehealth services, disproportionately impacting those with a low socioeconomic status who would otherwise be unable to afford mental health care during the pandemic. The restrictions posed by costs in accessing mental health care initially increased during the change in modality, as there were disparities caused by differences in insurance policy reimbursement. These varying policies may have been a product of the sudden and immediate shift in modality.

Mental Health Status

Factors pertaining to the present mental health condition of the user, including the nature and intensity of symptoms, fall under the mental health status construct. Four articles highlighted barriers29,32,44,61 with none providing insights into facilitators associated with mental health status. The transition to an internet-based modality posed challenges associated with mitigating patients presenting factors (ie, aggression, paranoia, physical and cognitive limitations, etc.) particularly when addressing therapy interfering behaviors on a smaller screen.

Beliefs

The user’s beliefs concerning technology, mental health, and mental health services are encompassed within this subconstruct. Among the articles reviewed, one article highlighted both barriers and facilitators associated with beliefs.37 The article mentioned patients’ preference for in-person appointments. During the change in modality most care switched to the use of online appointments. Chief complaints of online appointments were centered around difficulties in building connections through online platforms. On the facilitator side, this article highlighted patients’ beliefs in favor of telehealth which were focused on therapeutic space. Specifically, patients commended for having the ability to choose a safe space for themselves to engage in therapy as opposed to going to a therapy office.

Mental Health and Technology Experiences

This subconstruct relates to the user’s past engagements with technology, mental health technology, and mental health services, as well as their competencies in digital or mental health literacy. The examined literature included eight articles that focused on barriers, while none of the articles mentioned facilitators associated with experiences involving mental health and technology.22,28,32,41,49,56,58,61 Technology literacy was the primary barrier cited across the articles. Inability or limited proficiency in technology literacy can obstruct the navigation of online interventions typically associated with the change in modality. Those with low technology literacy can experience difficulties in engaging in online behavioral health sessions, potentially leading to disengagement.

Integration into Life 

The integration into life subconstruct assesses the user’s capacity to allocate time and space for utilizing the intervention and seamlessly incorporating it into their routine or daily life. Within the body of literature examined, five articles outlined barriers,20,29,31,39,55 and three articles18,20,39 described facilitators associated with the integration into one’s life. Challenges in securing childcare during appointments and dealing with distracting workspaces emerged as the primary barriers. Alternatively, facilitators revealed that other patients did not have to find childcare, faced fewer work-related time constraints, and were not limited by transportation issues for appointments.

Program-Related Construct

Overall, relatively few of the articles used in our analyses were grouped into the Program construct (12/49; 24.48%), based on the type of barriers14,16–18,22,27,45,48,51 and facilitators12,33,40 reported. This construct is related to the type of treatment and/or the content offered through the digital mental health intervention.8 The program-related subconstructs broadly include attitudes and beliefs about the program (eg, perceived usefulness), the level of guidance they received in navigating the program/intervention, and how the program contributes to feelings of social connectedness, or not.14,16–18,22,27,45,48,51 Other subconstructs from the program-related construct are not reported in this paper due to the poor fit between those and themes identified in our analyses. These included type of content, perceived fit, and impact of intervention.

Perceived Usefulness 

This subconstruct refers to the user’s experience with an intervention and their perceptions of whether the intervention would be useful to them. Only one article fits into this subconstruct.40 Authors of this paper surveyed whether substance use treatment centers were using telehealth services (ie, telephone and video health technologies for screening, assessment, treatment), other demographic variables (eg, rurality, type of SUD treatment), and projected intent to use telehealth services after COVID-19. Their findings found significant associations between perceived usefulness and future intent to use those telehealth services, as well as perceived usefulness and perceived ease of use.

Social Connectedness 

One important factor that contributes to user engagement with a digital intervention is the level at which participants feel socially connected. There were 10 articles that discussed this topic. The findings suggest that the lack of social connectedness in virtual modality delivery was consistently cited as a barrier in the transition from in-person service delivery (9/10). Examples of this included articles which described difficulties in building a therapeutic alliance with clients via telehealth,14,16–18,22,27,45,48,51 whereas one article33 described an easier process of building rapport and trust when working with children who had autism spectrum disorder. Those authors cited the reasons as an increased ability for children to share and discuss their likes and interests (eg, artwork, stuffed animals) that were in their personal physical environment, which also helped the clinicians learn more about the children than they normally could without bringing in those materials and information from the children's homes.

Technology and Environment Related Constructs 

A significant portion of the reviewed literature (37/49; 73.47%) discussed barriers13–15,17,18,21,22,26,29,31,34–36,37–39,41,42,44,45–47,49–53,55–59,61 and/or facilitators12,23,30,40,41,50,54 concerning technology and the environment. As the onset of the pandemic began, technology rapidly became the solution to the continuum of mental health care. The abrupt paradigm shift in modality brought with it both advantages and disadvantages to patients and providers. The technology and environment-related factors dive into the multifaceted dimensions surrounding the utilization of technology and implementation, encompassing subconstructs such as technology-related factors, privacy and confidentiality, and implementation. Additionally, none of the articles selected fit under the social influence subconstruct.

Technology-Related Factors 

Within this subconstruct, the primary focus was on the technology utilized to deliver the intervention. In most cases, this included the platform on which an intervention was delivered (ie video-conferencing applications, phone calls, web portals, and online programs). A notable majority of the articles (28/37) discussed technology-related factors. A total of six articles mentioned facilitators12,23,25,40,41,50 and 22 articles highlighted barriers.13–15,17,22,34–39,41,42,46,47,49,50,52,53,55–57 Instances included articles that outlined challenges in technology infrastructure for the patient14,17,22,34,35,37–39,41,46,47,49,50,52,53,55–57, and provider13–15,17,34–36,42,57 with emphasis on accessibility, ease of use, and reliability of the technology being some of the most common issues. The presence of diverse technological options25,40,41,50 allowed for custom solutions to different needs as well as enhancing the adaptability of the technology. On the provider side, comprehensive training in technology utilization12,23 equipped providers with the necessary skills to integrate technology into practice.

Privacy and Confidentiality

The central emphasis of this subconstruct surrounds data storage and sharing, specifically, in terms of the comfort levels of users in revealing sensitive details during an intervention. Eleven articles highlighted language pertaining to privacy and confidentiality,18,22,26,38,42,49,51,55,58,59,61 all of which were considered barriers. The primary focus of these articles predominantly centered around issues on the utilization of data,42,55,58,59 protection of private data,18,38,42,49,55,61 and safety.22,26,55,58 Key considerations included protocols, ethical, and legal aspects surrounding data usage, encompassing discussions on data ownership, control, and security. 

Implementation

Implementation encompasses factors related to how the intervention was executed. A total of 13 articles highlighted implementation in some form. Twelve articles14,21,22,26,29,31,42,44,45,49–51 explored implementation barriers, while one article30 explored implementation facilitators. Examples of these included articles which examined issues in patient engagement,22,29,31,42,44,51 provider technology training,21,45,50 and licensure requirements,14,26,49 while one article30 described how the implementation of structured technology rollout programs helped ensure integration of technology into existing systems, which promoted successful adoption.

Administrative Construct 

Some of the articles collected (13/49; 26.53%) did not fit into any of the constructs proposed by Borghouts et al (“user”, “program/intervention”, “technology and environment”).6 Specifically, the data showed that there was an additional construct comprising articles related to implementation and administration of DMHIs and discussed administrative topics that impacted new modality adoption and engagement.14,16,18–20,22,24,29,33,38,43,49,60

Insurance/Reimbursement

Three articles identified insurance/reimbursement as important factors related to the adoption of new modalities of care delivery. Authors reported difficulty being reimbursed by insurance for telehealth services at the same rate as they would for in-person care.14,19,49 One article reported insurance/reimbursement as both a barrier and facilitator to adoption of a new modality.14 Specifically, the authors reported that while the administrative cost of navigating new lines for reimbursement was a challenge, the reimbursement rates for services provided by the newly adopted modality were at a higher rate than for the previous mode of delivery for the same service. Additionally, the new system of delivery and reimbursement (once adopted) was an easier administrative process to navigate and thus allowed them to continue seeing patients after the pandemic via this modality.

Difficulties Administering Therapy 

 A total of four articles cited examples of situations where the transition from in-person services to telehealth was met with challenges related to the nature of the mental illness and clinical presentation of the patients and consequently, increased difficulty in administering therapy via the new telehealth modality.22,29,33,38 Of the articles which included barriers related to the administration of therapy, there was mention of difficulties such as managing distractions and maintaining engagement with patients that had/were being treated for severe mental illness. These new modalities required providers to adapt to delivering care synchronously using technological platforms that they may not have been familiar with. 

Federal and State Policy Regulations for Providing Prescriptions 

Federal and state policy and regulations for providing prescriptions via a new modality of care delivery were also identified as barriers from the implementation and administrative perspectives.24,43,60 These articles discussed policy and regulations for medication-assisted treatment programs for individuals with opioid use disorders. They reported difficulty in transitioning to virtual or telehealth-related care due to the restrictions imposed by the Controlled Substances Act,62 which previously did not allow for prescription of opioids without a prior in-person medical evaluation. However, the Secretary of Health and Human Services declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). On March 16, 2020, the Secretary, with the concurrence of the Acting DEA Administrator, designated that the telemedicine allowance under section 802(54)(D) applies to all schedule II–V controlled substances in all areas of the United States.63 Following these changes, providers and administrators had to quickly navigate newly established short-term regulations that supported the adoption of new modalities of care delivery over a short period of time. Examples of these included facilitators such as using audio-only methods to reduce barriers to accessing care for individuals in opioid use disorder (OUD) treatment programs.

Workflow Issues 

Another implementation/administrative barrier identified by providers was workflow issues.16,18,20 Changes in delivery modality meant a change in process as there was more dependence on online communication within organizations and provider teams. These changes required new and innovative workflow parameters that were challenging to adopt and implement. Examples of workflow issues included timely communication of patient screening results to determine scheduling and rescheduling of appointments.20 In multi-site organizations, workflows had to be modified to meet the individual needs of each clinical setting.16 Lastly, authors discussed the increased difficulty in the ability to regularly consult with colleagues due to changes in location and no longer being able to readily access colleagues.18 Two of the articles discussed a change in procedure to interacting with patients in person which involved using more space in the facility to maintain social distance. However, this created a need for more staff to adequately cover the area.16,20  

Flexibility in Working Hours 

Three articles were grouped based on reporting increased flexibility in work hours as a facilitator to adoption of a new modality.12,30,33 Findings showed that through the adoption of telehealth services, it was not only beneficial to patients but also to staff who could save on commuting time and costs. This type of flexibility was viewed as a benefit that could combat high rates of turnover and burnout experienced by clinical staff during the pandemic. Additional examples for this subconstruct included articles which discussed the benefits of mental health providers being allowed more flexibility in scheduling clients, allowing for patients to have increased ease in scheduling and attending appointments (eg, appointments available after traditional work hours and on the weekends,30,33) and the ability to complete training that would have been inflexible and in person prior to modality changes virtually.12  

Discussion

The COVID-19 pandemic created increased demand for mental health services that required rapid engagement with virtual behavioral health modalities. In this review, barriers and facilitators associated with the adoption of virtual behavioral health care modalities during the COVID-19 pandemic were examined. This review included articles in a range of clinical settings, including community mental health, pediatric psychiatry clinics, perinatal care centers, inpatient psychiatry units, university training clinics, criminal justice environments, VA medical clinics, and hospital facilities. The researchers presented the diverse demographics served across these settings, encompassing various age groups, mental health conditions, and presenting issues. This study specifically addressed four domains: three focused on user engagement are further broken into user-related, program-related, and technology-related constructs, following a framework offered by Borghouts et al.8 In addition, we address a novel, fourth administrator/provider-related domain of virtual behavioral health modality changes. This approach was chosen because while pre-existing theories of technology acceptance could be relevant, they fell short of capturing the complexity of this rapidly evolving change.

Across the four domains reviewed, barriers were identified more frequently than facilitators. Identified barriers included financial and insurance challenges, such as disparities in insurance coverage and provider reimbursement for telehealth services, patient preference for in-person appointments, limitations in technology literacy among patients, unreliable internet services, difficulty building therapeutic rapport in telehealth modalities, privacy and confidentiality concerns, difficulties in engaging patients in telehealth services, navigating evolving federal and state policy regulations for prescribing controlled substances, and issues in transitioning workflow to fully or predominantly online modalities. In contrast, themes that emerged as facilitators across the four domains included patients’ belief in the usefulness of telehealth, accessibility of telehealth, ease of integration into daily life, increased reimbursement rates for providers during the COVID-19 pandemic, technology’s ability to allow physical distancing and safety, and flexibility in work hours for providers.

These results align with findings in the computer science literature, especially the Technology Acceptance Model (TAM),64 the Unified Theory of Acceptance and Use of Technology (UTAUT), and its extension of (UTAUT2).65 The TAM model emphasized perceived usefulness, perceived ease of use, and external variables which impact the adoption of any technology.66,67 The UTAUT and UTAUT2 models instead include “effort expectancy” which has been found to be critical in mobile health (mHealth) adoption.68 Likewise, facilitators like those we described have been identified in UTAUT as vital to mobile health apps.69 Although these models are detailed, a shortcoming of these models is that they do not truly encapsulate the complicated socio-cultural factors influencing mHealth utilization. Although each of these theories described previously had considerable overlap, none alone provides a comprehensive picture, and the Borghout model with an additional administrative-related construct was added.

The results also align with a similar systematic review that identified barrier and facilitator themes that were associated with satisfaction with telemedicine interventions and various health outcomes.70 The authors identified social support and convenience as common facilitator themes. Perceived ease of use, technology literacy, and increased connectedness were less frequent facilitators, and were related to satisfaction with telemedicine interventions more generally. There were similarities and differences with the findings in this recent review and the findings in the present review. In terms of differences, rather than a stand-alone theme, convenience would have been grouped with the integration into life subconstruct according to the Borghout model.8 In addition, technology literacy was not one of the most frequently reported facilitators.70 When looking at barriers, the findings align more closely. In both studies, technology literacy and confidentiality concerns were the most frequently cited. Preference for in-person appointments and perceived ease of use were also mentioned at similar rates. The two studies differed significantly in that workflow-related issues and insurance reimbursement for providers were the only themes that would be captured in administrative-related subconstructs in our proposed model, whereas the present review found these issues as well as therapy administration difficulties and regulatory hurdles. Conversely, flexibility in working hours emerged as a notable facilitator, suggesting that administrative adaptability could significantly improve telehealth delivery. This may be due to differences in research question and methodology. For example, the current study focused specifically on behavioral health modality changes, whereas the other recent review did not.70 Their medical focus also likely influenced their choice in using population and intervention variables, control groups, and outcomes (PICO) to orient their study. The focus on behavioral health modality changes allowed researchers in the current review to identify themes relevant to administrative/provider facing themes in behavioral health, such as difficulties administering therapy and federal and state policy regulations for prescriptions.

The present review is unique in using the framework offered by Borghouts et al and including the additional construct of provider-facing/administrative themes, with a focus on behavioral health modality changes.

This review shows the importance of public health experts to consider technological, socio-cultural, and psychological factors involved in deploying mental health tools to hard- to- reach populations.70 Particularly in light of world events such as the COVID-19 pandemic, it is vital to include an interdisciplinary approach to overcome essential barriers in the use of technological artifacts utilizing human-centered design in order to address mental health needs, as we have seen applied to housing insecurity issues.71 By relying on interdisciplinary approaches, the models can be robust enough to develop roll out plans while remaining flexible for adaptation to respond to environmental challenges such as global pandemics and ever-changing policies and regulations.72

Limitations

As discussed in the Method sections, the generalizability of these results may be limited by the qualitative nature of this thematic analysis; however, this was accounted for by using a grounded theory framework.11 Nonetheless, future research using quantitative approaches such as questionnaires that are related to important clinical outcomes and attitudes may contribute to this area. The applicability and replicability of these findings may also be influenced by the cultural and social contexts that the researchers are inherently embedded in. For example, some articles could have been grouped into the demographic characteristics subconstruct such as socioeconomic status (SES), or insurance coverage, or into the environment subconstruct. Moreover, the barriers and facilitators identified in the present review emerged in the context of a unique global pandemic, which forced a modality switch to virtual behavioral health. Whether these barriers and facilitators persist post-COVID contexts in which virtual behavioral health options are encouraged and desired remains to be seen.

 Conclusion

This systematic review identified key barriers and facilitators to changing the modality of delivery for behavioral healthcare services during the COVID-19 pandemic, utilizing the Borghouts model as the primary framework. The findings of this study highlight the complex interplay of user-related, program-related, technology and environment-related, and administrative constructs in shaping the adoption and implementation of telehealth services, specifically within behavioral healthcare systems.

User-related constructs (34.69%) revealed that demographic variables, mental health status, beliefs, and experiences with mental health and technology significantly influenced engagement in telehealth. Economic and insurance barriers, a preference for in-person care, and challenges related to technology literacy were prominent obstacles. However, facilitators such as the ability to choose a safe space, reduced transportation needs, and fewer childcare and work-related constraints illustrated the potential benefits of telehealth.

Program-related constructs (24.48%) emphasized the dual role of perceived usefulness and social connectedness. While social connectedness was a barrier in some cases, it served as a facilitator for children who felt safer in their environments, indicating the nuanced impact of these constructs.

Technology and environment-related constructs (75.51%) were paramount in both enabling and obstructing telehealth adoption. Factors like technology access, privacy concerns, data storage, patient engagement, and provider training were critical. Effective implementation required addressing these challenges to enhance user engagement and satisfaction.

Administrative constructs (26.53%), newly introduced in this study, revealed additional barriers such as insurance reimbursement issues, therapy administration difficulties, regulatory hurdles, and workflow challenges. Conversely, flexibility in working hours emerged as a notable facilitator, suggesting that administrative adaptability could significantly improve telehealth delivery.

Overall, this study highlights the necessity for a multifaceted approach in addressing barriers and leveraging facilitators to optimize the delivery of behavioral healthcare services in a telehealth context. Policymakers, healthcare providers, and technology developers must collaborate to address these diverse factors, ensuring equitable access and effective utilization of telehealth services in the post-pandemic era. Additionally, this review builds upon previous research and gives a comprehensive overview of barriers and facilitators of modality change adoption by organizations which offered behavioral healthcare in the midst of COVID-19. Further research is warranted to explore the long-term impacts and potential strategies to overcome these challenges, ultimately enhancing the resilience and responsiveness of behavioral healthcare systems.

Acknowledgments

This paper is dedicated to Dr. Michael Morris, who was an excellent mentor, colleague, and friend. We would like to thank him for his years of service in education and acknowledge his role in initiating and managing this project.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Payments were made through grant funding ($900,000.00) from the Health Care Service Corporation (HCSC)- this is an unrestricted research grant awarded. The funder had no input or influence on the development of or conduct of the research presented in this manuscript. The project was partially funded through HCSC/BCBSTX, Affordable Cures Grant #1122327.

Disclosure

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 

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