Principal Findings
Trends in Publication and Usage of Terms
There has been an increasing interest in CMH publications in the past decade. This can be explained by the fact that CMH research has been influenced continuously by novel technological interventions and the growth in ICT usage, especially with the appearance of Web 2.0 between 2003 and 2004 [202]. Web 2.0 introduced an architecture of participation [203], focusing on social interactions and collective intelligence [204]. These changes were accompanied by a significant increase in the number of internet users worldwide [205] as well as ownership and usage of smartphones [206] and computers [207-209]. This has also impacted the use of ICT, which has been incorporated in many fields, including transport [210], tourism [211], education [212], virtual work teams [213], and health care [214].
An increase in the number of publications in the field of CMH could have also been influenced by the changes in the general literature. There has been a shift from paper copies to electronic copies, which significantly increased the accessibility to published studies, particularly open access publications [215]. Consequently, the research evaluations performed by peers became reliant on different bibliometrics [216]. The productivity of researchers has mainly been measured by bibliometrics (eg, journal’s impact factor [217,218] and researcher’s h-index [219]), which is impacting hiring processes, academic promotion, and funding decisions [219,220]. This puts more pressure on researchers to produce more publications in the literature, particularly publications indexed in Scopus.
The earliest term used in the selected CMH studies was telemental health, which falls in the same group of terms as telemedicine and telepsychiatry. These terms have been used to describe remote health care and informatization of some elements of the health care process since the 1990s [221,222]. The term telemental health has rarely been used in recent years as e-mental health began emerging since 2006.
The term eHealth was introduced in the late 1990s. It was defined at the 7th International Congress on Telemedicine and Telecare in London at the end of November 1999 by John Mitchell as “a new term needed to describe the combined use of electronic communication and information technology in the health sector” and as “the health industry’s equivalent of e-commerce” [223]. Although previously used terms were linked to medical professionals, eHealth was found to be driven by nonprofessionals, namely, patients (or consumers) [224]. Many journals after the introduction of eHealth changed their names to include it; for example, the Telemedicine Journal added an “and eHealth” to its title. Nevertheless, publications were not including the term eHealth, and researchers preferred to use more specific terms such as medical informatics, telemedicine, and electronic patient records, which are considered more meaningful than the generic term eHealth [223]. This might explain its late and delayed emergence in the literature.
The trend of publications also showed an increasing use of the term m-mental health, primarily since 2010. The expansion in the use and ownership of smartphones [225] brings new opportunities for the mental health care industry to face some of the most pressing global challenges and make mental health care more accessible, faster, less expensive, and better [226]. Studies have proven the interest and willingness of people with mental health issues to try mobile solutions [73,227]. Hence, it is expected that m-mental health will continue to attract the attention of CMH researchers and practitioners.
The term digital mental health has been used since 2011. This term is associated with the use of recent and advanced technologies, such as sensors [228] and machine learning techniques, and it has been used as a modern synonym for e-mental health, especially since 2017. It must be noted that researchers use different terms to refer to the same concept, and, in many studies, authors use more than one term, which might occasionally create confusion, especially in cases in which known definitions of each term overlap. Consequently, there is a need for a broad term such as connected mental health to encompass the different terms used. Although connected health has become an established field [20], we did not find the use of such a term in mental health care. To the best of our knowledge, this is the first study that uses this term to refer to the use of ICT in mental health.
Publication Channels
Most of the selected papers (238/289, 82.3%) were published in scientific journals. Publishing in a rigorous scientific journal is based on a set of ethics and rules [229] that can result in the production of high-quality content. This result could have been impacted also by the choice of digital library. More journals than conference proceedings in CMH might have satisfied the criteria of Scopus indexation. There are also many scientific journals that are categorized in health informatics. This encourages researchers to conduct studies suited for journals and indicates a particular level of maturity in the field from a quantitative perspective. Articles published in journals tend to be more detailed and extensive. Conferences are also an important venue for publications. Conferences with proceedings provide fast tracking of publication to keep researchers and practitioners up to date with the latest findings. The first identified publication in the selected studies, which appeared in 2003, was a book. Books are used to introduce or provide a detailed overview of a topic.
Research Types and Empirical Types
The multidisciplinary nature of the CMH field and its various subareas resulted in a high ratio of exploratory research and reviews compared with other types of research, such as solution proposals, validation, and evaluation research. The diversity of the identified empirical evaluation types points to the uncertainty regarding adequate methods to evaluate CMH solutions. There is a need for evidence-based studies that will verify the efficiency of CMH interventions, create accurate results for future research, and identify challenges that need to be addressed. Most of the selected studies (152/289, 52.5%) were not evaluated empirically, which can be linked to the fact that a large number of empirical evaluation studies in the health informatics field have not been published [230]. Most of the remaining studies were empirically evaluated through experiments (52/289, 17.9%), primarily owing to their controlled environments. Case studies are more suited for sensitive problems such as mental health issues and would be more beneficial for the growth of the field, as they help identify many issues that can be faced in real-life implementation of ICT interventions. However, only 2.4% (7/289) of the selected studies were evaluated empirically through case studies. Questionnaires represented an important part of the empirical evaluation methods of the selected studies (36/289, 12.4%) used mainly in exploratory research (104/289, 35.9%) to investigate perspectives and attitudes toward the use of technology for mental health and on advantages, challenges, and limitations of CMH. Questionnaires are useful tools for data collection as they can be formulated to collect significant amounts and various types of data and can be delivered through various means to reach large groups of people.
Contributions of the Selected Studies
The largest number of the selected studies focused on investigating the advantages, benefits, risks, challenges, and limitations of CMH (106/289, 36.6%) as well as perspectives and attitudes of patients, clinicians, and various stakeholders toward CMH (57/289, 19.7%). An important part of the identified contributions was about tool-based techniques (70/289, 24.2%), whereas only a few studies represented frameworks, protocols, and models (14/289, 4.8%). This points to a level of ambiguity in the field as frameworks, protocols, and models are typically signs of clear understanding of a concept, its benefits, and its limitations. Tool-based techniques are usually relatively specific to one area of implementation and target a specific need, for instance, a mobile app for tracking mood changes or a website for evaluating levels of depression. Despite an increasing number of CMH publications, the types of research identified are primarily theoretical and hypothetical, indicating that researchers are still proposing their conceptual ideas for CMH. Only 4.4% (13/289) of the studies, categorized as others in Figure 3, addressed topics such as effectiveness, efficiency, usability, and quality of technological solutions for mental health care. The lack of publications on these topics is related to the aforementioned lack of empirical evaluation studies.
Mental Disorders and the Targeted Cohort
Most of the selected studies did not target a specific group of people (200/289, 69.2%). The remaining studies focused primarily on young people, adolescents, and children (33/89, 37%; 12/89, 13%; and 9/89, 10%, respectively). There was an overlap of age ranges among the categories, primarily owing to the existing overlapping of ages in the known definitions of the categories. The World Health Organization defines adolescence as the age range spanning from 10 to 19 years, youth as those aged between 15 and 24 years, and young people as the group covering the 2 categories from 10 to 24 years [231]. The adolescent group is further divided to include a subgroup of early adolescence (11-14 years) [232], which might be referred to by some authors as children. Targeting primarily the young category of patients can be explained by the fact that this category is characterized by the ownership of mobile devices, high usage of the internet and social networks, and familiarity with the use of technology, which makes it easy for them to become customers of CMH solutions.
On the basis of our findings, the young people category is the main target for studies on technological solutions for depression, anxiety, and related issues. These disorders are the third leading cause of death among adolescents and young adults, with a prevalence of approximately 4% in children and 10% to 20% in adolescents [233]. Other mental health issues such as body image issues, eating disorders, and sleep problems are also common among young people. Most mental health issues identified in this category could be linked to young people’s extensive use of social networks and living a digital life, making them disconnected from real life and absorbed in following other people’s lives and comparing them with their own lives. In many cases, this can cause them to feel worthless and disappointed with their lives, bodies, or achievements. Internet use has become an addiction for many young people, causing, among other problems, loss of sleep and high levels of loneliness [234] as well as many cyber-related mental problems [235].
Depression, followed by anxiety, was identified among most of the cohort groups, owing primarily to the increasing global expression of these disorders. The global population with depression increased by 18.4% between 2005 and 2015; similarly, the total number of people with anxiety increased by 14.9% between 2005 and 2015 [236]. Depression can occur as a result of other health problems, such as perinatal and postpartum depression among women [155,237] and common depression among cancer patients [238].
Many serious disorders such as schizophrenia, psychosis, and personality disorders were the subjects of many of the selected studies, pointing to the potential of using CMH not only for common mental disorders but also for more severe and complicated mental problems.
Most of the selected CMH publications addressed general mental well-being. Having more studies focusing on specific mental issues might help identify specific limitations and issues as well as highlight opportunities related to specific disorders. More studies should also focus on people in war zones as they are vulnerable to various mental problems and have more barriers to obtain mental health care, which CMH can help solve [239].
Countries in Which the Empirical Evaluations Were Conducted
Most empirical evaluations were conducted in developed English-speaking countries such as Australia, the United States, Canada, and England. This might be mainly owing to the advancement in research in these countries. In Australia, universities are considered world-leading in at least one area of research [240], and large investments are provided to research institutes [241]. There is an important research interest in health informatics in Australia [242]. Research in the United States is believed to be essential to the country’s economic growth. Therefore, the federal government has devoted a significant amount of funding for research [243]. The United States has many of the most accomplished individuals in the field of health informatics working in research projects and institutions specialized in the field [244]. Several developing countries have good ICT infrastructures and can benefit from different CMH interventions to solve several existing issues; however, limited research is conducted in developing countries. The same goes for war zones as only 2 studies addressed people in war zones: one conducted for Palestinian children [245] and the other addressed Syrian refugees in Germany, Sweden, and Egypt [106]. CMH interventions are solutions to overcome mental care barriers in developing countries and war zones. Research in this field should be shifted to countries that are most in need of CMH solutions.
Comparison With Related Studies
The findings of this study are aligned with the findings of other studies related to CMH:
The identified increase in interest in the CMH literature was also reported in a literature review of e-mental health [133].
The identified lack of empirical evaluation of the proposed solutions was reflected in the findings of a meta-analysis on digital interventions for alcohol and substance use disorders, reporting limitations in the number of randomized control trials (RCTs) in that area [117]. Another review on RCTs on the effectiveness of occupational e-mental health concluded the need for more detailed and specific effectiveness research [246]. A narrative review on digital mental health in developing countries reported a shortage of studies on the effectiveness and cost-effectiveness of the investigated internet-based programs [166]. A review on the effectiveness of mobile apps reported a lack of clinically validated evidence on the efficiency of most available apps [191].
There was a lack of use of the term telemental health. Related findings were described in a review of the directions for videoconferencing and telemental health [247]. The review reported a limited number of RCTs in the field as well as methodologically flawed and limited research studies, which resulted in the research agenda of telemental health not being fully maximized [247].
Leading countries in the empirical studies selected were Australia and the United States, which are similar to findings from other reviews. A review reported that evidence for telemental health and web-based solutions are largely led by Australia [138]. Two reviews reported that most of their selected publications were found to have mostly originated in the United States and Australia [22,133], and a study [133] found that Australian e-mental health research was higher in diversity and quantity.
Limitations
This study has some limitations. This study did not include other digital databases. However, Scopus is widely considered to be the largest indexing digital library that includes publications from different disciplines [35]. This allowed us to identify different contributions in CMH research. It should be noted that Web of Science (WoS) was not considered as a recent study showed that slight differences exist between the scientific literature covered in Scopus and WoS Core Collection, which will result in a large number of duplicates [248].
The search strings were applied only to the titles to limit the sizes of the selection and to include only relevant and focused CMH publications, possibly omitting other candidate studies. However, we considered that if a paper’s principal focus was CMH, then at least one of the terms from the search strings could be expected to appear in the title, alleviating the risk of discarding relevant publications for this mapping study.
Other terms, particularly terms related to different mental health issues, might have been relevant for inclusion in the search strings, possibly impacting the results. However, our aim was to provide a high-level overview of existing CMH literature.
Other classification criteria might have been relevant to extracting further information from the selected studies, possibly affecting our findings. However, the principal aim of this systematic mapping study was to provide an overview of CMH literature, and the process and criteria presented in the Methods section fit this purpose.
The final study selection depended on the first two authors, ND and SO, who conducted the search process. The first author conducted a preliminary search in Scopus and constructed a preliminary selection of publications. The second author revised the selection. If a disagreement arose between the two authors on the exclusion or inclusion of a paper, then a discussion took place until an agreement was reached. It should be noted that the two authors have experience in conducting mapping studies and systematic literature reviews [228,249,250].
Conclusions
This paper conducted a systematic mapping study of 289 publications indexed in Scopus and provided an overview of the available literature on CMH research. CMH has the potential to overcome some of the mental health care delivery barriers by introducing and exploiting ICT in the process of mental health care. A total of 289 publications were selected, analyzed, and classified. The results showed that CMH is a promising research field that has gained increasing attention from researchers over the years. The frequency of the selected publications was influenced by the continuous developments in digital media and the use of ICT as well as the changes in literature evaluation methods, which mainly relied on bibliometrics. The results also showed that most of the selected CMH literature addressed general mental well-being; depression and anxiety were the mental disorders most addressed in studies on specific mental issues, which is in accordance with their global prevalence; young people were the most targeted cohort group as they are more familiar with digital solutions; exploratory research and reviews were the dominant research types found in the selected literature, which indicates that researchers are more focused on exploring possible venues of implementation of ICT in mental health care and constructing an understanding of the field; and most of the selected studies were not empirically evaluated. Moreover, the results showed that selected studies that were empirically evaluated were mostly conducted in developed countries. Screening of the selected studies that were reviews showed that they targeted specific cohort groups, specific mental disorders, specific types of solutions, or specific terms. To the best of our knowledge, this is the first mapping study that addresses the field of CMH as a whole, including all relevant terms and without excluding any specific criteria. On the basis of our findings, we recommend the following to researchers:
Shift attention to provide evidence-based solutions and studies, and empirically evaluate existing solutions in future CMH studies.
Focus on specific mental issues and cohort groups to better identify possible issues and limitations of the field.
Investigate CMH solution implementation in developing countries and war zones, which experience various mental care delivery barriers.
Use connected mental health as an englobing term for the exploitation of the different types of ICT in mental health care.
Practitioners can use this study to find tool-based studies for specific cohorts and/or mental disorders. They can also find studies related to the attitudes and behaviors of CMH users.
We believe that our study will provide researchers and practitioners with relevant information regarding the existing CMH literature as well as recommendations for future publications. For future work, we intend to develop a conceptual framework for sustainable CMH solutions.