Introduction

Psychiatric disabilities may occur as a result of mental illnesses such as bipolar disorders, schizophrenia, anxiety, and depressive disorders, as well as neurodevelopmental disorders such as autism spectrum disorder, global developmental delay, intellectual developmental disabilities (IDD), specific learning disability, and attention-deficit/hyperactivity disorder (Emmawill, 2022).

The rehabilitation process focuses on utilizing available opportunities according to a person’s strengths while acknowledging limitations for optimal functioning. In India, rehabilitation initiatives started in large government mental hospitals. Mental health rehabilitation centres primarily exist in non-governmental organizations (NGOs) and a small number of government and private hospitals (Chavan & Das, 2015; Kumar et al., 2014; Thara & Patel, 2010).

Psychiatric rehabilitation is a therapeutic approach that encourages people with mental illness and intellectual disabilities to develop their inherent capacities through learning and environmental support. Psychiatric treatment (pharmacological and psychological) controls psychiatric symptoms; psychiatric rehabilitation focuses on functioning and role outcomes. The new focus of rehabilitation is on wellness and optimum quality of life (Bachrach, 1992).

Psychiatric Rehabilitation Services (PRS) at NIMHANS also caters to day boarders, inpatients, and persons with IDD from the nearby Government Children’s Home for the Mentally Retarded (CHMR). They are engaged productively in ROSes Cafe and various sections, including bakery, printing, candle making, weaving, plastic moulding, tailoring, arts & crafts, carpentry, and leather (Roy et al., 2022).

Tele-rehabilitation can be defined as a spectrum of services that facilitate rehabilitation, or recovery-focused services, using telecommunication and internet-based communication services (Jayarajan et al., 2020). The most commonly used modalities of tele-rehabilitation are smartphones, webcams, and video conferencing. By implementing tele-rehabilitation models in India, health professionals are reaching the unreached and are in a much better position to provide interventions for people with communication disorders and mental health issues (Gupta, 2020).

Vocational training efforts are likely to be affected, due to the COVID-19 pandemic, and retraining may present a challenge. However, this can be minimized to a certain extent by home-based rehabilitation strategies, provided these are planned well in advance. There may be circumstances in which the routine daily activities established through rehabilitation are disrupted and are challenging to restore. The additional, unexpected burden on family caregivers would increase caregiver stress and affect caregiving (Roy et al., 2022).

In the Psychiatry Rehabilitation Service, NIMHANS, 113 patients have utilized the rehabilitation services as day boarders until Feb 2020. In view of the COVID-19 pandemic, the daycare Centers were closed during the pandemic. As a part of tele-rehabilitation, videos on activities of daily living were prepared and shared with the patients through the Google Meet platform on the computer. Live demonstrations were also conducted concurrently. However, tele-rehabilitation being a new trend, only 10–15 patients took advantage of the service. Some of the challenges faced by the patients were sharing a single device with other family members, difficulty affording a smartphone, difficulty availing various data packages, and difficulty accessing the technology.

Aim

This systematic review aims to explore the end-user’s perception of facilitators and barriers in accessing psychiatric tele-rehabilitation services.

Methods

After identifying the need and objectives for the current review, inclusion and exclusion criteria for selecting literature were prepared. PJ screened titles, abstracts and selected articles that met the inclusion criteria. SLG and TSK reviewed the full texts of these articles and excluded papers that did not meet the inclusion criteria. The authors discussed any discrepancies and arrived at a consensus. The review was carried out using different search strategies and various databases. The collected studies were checked for clarity and content before including in the review. Systematic review articles were not included in the review as per the exclusion criteria, and also those findings were mentioned succinctly. Data were extracted from the reports, and the findings were categorized based on similarity and aggregation of the categories to produce a comprehensive set of results. Full-text articles in the English language published from 2003 in peer-review journals were included.

Inclusion criteria were as follows

  • Perception of facilitators and barriers to psychiatric tele-rehabilitation services from 2003 to 2022.

Exclusion criteria were as follows

  • Insufficient data, and inadequate information on the research methodology.

  • Systematic reviews.

  • Abstracts and unpublished studies.

Electronic Database Searching

Various electronic databases like Web of Science, Scopus, PubMed, Research Gate, Science Direct, ProQuest, Springer, Wolters-Taylors, Elsevier, PsycINFO, Google scholar and Wiley online library were used to search the relevant articles. The following search terms include “IDD,” “Serious mental illness,” “Schizophrenia,” AND “Tele-rehabilitation,” AND “Online rehabilitation,” AND “Rehabilitation interventions,” AND “Mental health rehabilitation,” AND “Web-based interventions,”.

Data Extraction and Quality Assessment

The extracted data were assessed based on eligibility criteria. The experimental studies were evaluated based on relevance, appropriateness, clarity, and methodology. Those studies that were not meeting the criteria were excluded (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram showing the selection of review articles

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Analysis

The steps involved in the analysis of the studies were:

Stage 1: Preliminary Organization of Studies

The relevant articles were studied and tabulated under these headings: author, journal, country, approach, study design, sample size, tools, technique, and significant findings.

Stage 2: Categorizing the Studies Based on the Review Objectives

The studies were explored to gather data based on the goals and objectives of the review. Meta-aggregation was done to categorize collected data as per the objectives.

Stage 3: Summarizing the Findings

The significant findings were summarized.

Results

Overview of the Studies (Table 1)

Table 1 List of studies included in the review (n = 13)
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All the studies included in the review were published between 2003 and 2022 and used qualitative, quantitative, and mixed methods. The articles included in the review are listed in Table 1. The details are available regarding author, journal, year of publication, country, method, sample size, tools used, and the significant findings.

Discussion

This review helped the researcher understand the perception of tele-rehabilitation services among people with mental illness and intellectual developmental disabilities and their family caregivers and guardians. Much of the study has focused on the benefits, and challenges of tele-rehabilitation among people with mental illness and IDD and their family caregivers. The results identified were based on the facilitators and barriers in accessing tele-rehabilitation. The common themes identified in this review are (1) facilitators of tele-rehabilitation, (2) barriers of tele-rehabilitation, and (3) expectations in tele-rehabilitation. The studies included in this review were conducted across many countries in the world, but most of the studies were born in the United States of America (61.53%), and only one study was found in India. This is because tele-rehabilitation is utilized more in high-income countries compared to low-income countries. Barriers that can be taken into consideration in having access to tele-rehabilitation are: loss of resources, non-availability of a mobile phone or internet-enabled digital devices, loss of awareness, poor socio-economic conditions, loss of virtual skills, resistance to adapt to new technologies, and absence of technical support. Most of the studies were quantitative design in nature, and a very minimal number of qualitative studies and one mixed-method study were found relevant (Tables 2, 3).

Table 2 Frequency distribution and proportion of studies on the perception of tele-rehabilitation in people with mental illness and mild IDD (n = 13)
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Table 3 Frequency distribution and proportion of reviewed studies on various research designs (n = 13)
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Facilitators of Tele-Rehabilitation

A study reported that 41% of the respondents would be “very interested” in computer training (Salzer et al., 2003). Participants living with serious mental illness reported lower smartphone ownership rates (50%) compared with the general population (68%) (Naslund et al., 2016). A study identified the significance of success factors influencing healthcare personnel for tele-rehabilitation. The success factors include satisfaction and willingness, cost/financial benefits, and e-healthcare knowledge. Satisfaction with the current technology applied at healthcare institutions is likely to influence the willingness of healthcare personnel to accept tele-rehabilitation (Bahari et al., 2019). Participants expressed high satisfaction levels and found the technology easy to access (Glynn et al., 2010). A survey report identified that 83.5% of respondents were very comfortable using a computer (Brunette et al., 2017) A qualitative multiple case study reported that technologies could be valuable tools to support the rehabilitation and recovery of people with SMI (Catherine et al., 2015). The potential benefits of the internet as a source of information and support are consistent with the philosophy and spirit of peer support services, which embrace empowerment, shared decision-making, and peer exchanges of information and social support (Kelly et al., 2018).

Barriers of Tele-Rehabilitation

A systematic review identified the failure factors that include resistance to change, lack of knowledge, financial limitation, lack of awareness, less use of hardware and software, lack of skill optimization, connectivity issues, and less involvement in planning and training (Bahari et al., 2019).

Few patients reported the need for training due to their lack of familiarity with smartphones/tablets, and the poor mental health of patients can be a barrier (Pemovska et al., 2021). An Indian study reported that the challenges faced during tele-rehabilitation were: network issues and only one device at home for multiple users. They needed guidance and repeated instructions to use the Google Meet platform (John et al., 2022). A survey report shows that respondents don’t have a mobile, lack understanding/skills, have person-related barriers, use of mobile phone/internet device makes distressing/disturbing, breakdown of phones, cost, and fear of theft (Tobit et al., 2017).

A cross-sectional survey conducted in the USA reported that usage of computers, the Internet, and cell phone technology were observed low among veterans with serious mental illnesses. Out of 210 respondents, 87 participants reported not using the Internet, 21.0% did not know how to use a computer or to type, 17.6% cited financial barriers, 12.9% thought it was not helpful/not needed, and 7.1% had privacy concerns (Klee et al., 2016; Zeev et al., 2013). The challenges faced during tele-rehabilitation include a lack of technical skills, expensive data plans, and using the touchscreen and navigating to specific features (Hoffman et al., 2020).

Some of the participants provided additional feedback about their group experience, indicating that they had made lifestyle changes based on the knowledge they acquired in the DOORS group. They expressed a strong desire for more sessions to continue learning about digital health tools (Hoffman et al., 2020). 18% said that taking this survey was the first time they had used a computer to go online. A survey reported that 49% of respondents were interested in learning more about online forums that provide information and support for mental health issues (Brunette et al., 2017). A study reported that participants had feelings of surveillance by having the technology in the home (Oestergaard et al., 2022).

A qualitative multiple case study report found the difficulties observed in tele-rehabilitation were the presence of anxiety, and pervasive thoughts hampered cognitive availability; low self-esteem and low confidence in one’s capacities, constant need for reassurance; and information processing difficulty (Catherine et al., 2015). A recent report documented that the challenges faced in tele-rehabilitation are that all requirements cannot be met; access and privacy may be a problem in resource-scarce settings; liaison with existing services is required, and organizations need to plan appropriately and reallocate resources (Jayarajan et al., 2020).

Expectations in Tele-Rehabilitation

Most employers hesitate to give jobs to people with mental illness. Patients and their family members who avail of rehabilitation services expect a simple job arrangement done through the institution. There is a mention in a study that consumers with the most significant disabilities have severe impairments that limit their capacity for employment outcomes, require ongoing assistance to find and maintain employment and can be expected to require multiple vocational rehabilitation (VR) services for an extended period of time (Embree et al., 2018). The current review findings are also supported by another study, which reported that psychiatric disability constitutes a severe societal burden in addition to human suffering. Because mental illnesses typically begin in adolescence or early adulthood, they interfere with education and job development, diminish human capital and undermine economic growth. The implementation challenges vary across countries concerning wealth, location, culture, and many other factors. Nevertheless, healthcare organizations and governments in all countries should have the common goal of helping people with the most severe illnesses have opportunities to live, work, socialize and participate fully in their communities. To do so, countries must strive to implement evidence-based, person-centred, culturally competent psychiatric rehabilitation (Drake 2017). The findings from the current review are in line with another study, which found that reimbursement and professional services for individuals seeking independent living, vocational rehabilitation, residential services or other community re-entry functions are not typically funded by medical insurance plans. Even in face-to-face rehabilitation settings, the payment is often made by an amalgam of country funding, state funding, state/federal vocational funds, grants and other sources. Stakeholders seeking reimbursement for tele-rehabilitation thus find themselves mired in a maze of non-profit and government-based organizations. Most funding for face-to-face rehabilitation services has traditionally been provided in the context of acute rehabilitation services (Pramuka and Roosmalen, 2009).

India needs to extend the reach of its telecommunications infrastructure with initiatives such as BharatNet for rural broadband to reach the neediest people. Governments should use telepsychiatry platforms to offer as many mental health services as possible without disadvantaging those without access to digital services. Many rehabilitation services can and should be delivered via telemedicine. Evidence for the delivery of mental health services suggests that telemedicine provides comparable and cost-effective care (Jayarajan et al., 2020). An Indian study indicated that as the healthcare system transitioned to virtual platforms during the pandemic, healthcare providers needed to help their patients embrace and get used to telehealth or mobile health technology (John et al., 2021).

Strength

This study gives a broad idea about the various success and failure factors while implementing psychiatric tele-rehabilitation practices in a new set-up. The identified factors that challenge and influence the access to tele-rehabilitation can equip the mental health professionals for the better outcomes of the person, and in the development of some interventions which help to reduce the factors and challenge the tele-rehabilitation, education, practice, research and mental health promotion policies.

Limitations

The authors could not find more articles on psychiatric tele-rehabilitation as it was a recent trend. So, only a limited number of papers were found in the field of psychiatric tele-rehabilitation. Recently, the COVID-19 pandemic caused people with mental illness to reach out the rehabilitation services through an online platform, since, we were left with no other options to avail of the services. Though generally, the tele-rehabilitation practices had begun many years back, either people were unaware of or not utilized much of it. Tele-rehabilitation was indeed a need of time to facilitate rehabilitation goals in people with mental illness. The review does not reflect on developing countries’ tele-rehabilitation practices (two studies were included) as studies from developed countries (USA) were included most. This could be because of a lack of studies from developing countries. Most people with mental illness in LAMIC (Low and Middle-income countries) do not have access to evidence-based treatments. This is due to chronic underinvestment and a severe shortage of mental health facilities and specialists (Asher et al., 2015). Two of the included studies (Glynn et al.; Catherine et al.,) have evaluated the feasibility of online programmes and usage of mobile devices, but the findings of the studies were supporting by the facilitators/barriers and are in line with this review.

This review was not registered with PROSPERO.

Quality assessment tools not used in this review.

Conclusion

The pandemic of COVID-19 provided an opportunity to use technology to its fullest extent across all fields. In the field of health as well, technology helps patients access their rehabilitation needs and goals. This review explored the perceived facilitators and barriers to accessing tele-rehabilitation from the patient’s perspective. There is a need to create awareness and train the patients and their caregivers on how to access tele-rehabilitation. Equal accessibility should be emphasized irrespective of rural or urban areas in tele-rehabilitation. Technology has to be made more accessible for patients to access. Studies on developing interventions to improve digital literacy among people with mental illnesses and their caregivers. Inclusion of tele-rehabilitation services in Psychiatric hospitals to reach the unreached and to make these services affordable/accessible.