Implementation Science of Telepsychotherapy for Anxiety, Depression, and Somatization in Health Care Workers Dealing with COVID-19

September 21, 2022 Editor

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Introduction

Worldwide, depression, anxiety, and health anxiety/somatization are among the leading mental health problems (MHP) of health care workers (HCWs) dealing with COVID-19 (HCW-COVID-19).^1–7 Given the need to minimize face-to-face interventions to reduce the spread of COVID-19 and taking advantage of technological developments, most mental health services during the pandemic have been provided remotely.⁸ In this sense, COVID-19 pandemic has led to a shift in psychological care provision toward telepsychotherapy, defined by Kaplan⁹ as psychotherapy conducted by a therapist at a location different from the patient’s through bidirectional communication technology supporting real-time interactivity in the audio, audiovisual, or text modalities.

Cognitive behavioral therapy (CBT) has proven to be effective in the treatment of these MHP in various contexts, including low- and middle-income countries,¹⁰ even if it is administered remotely¹¹ and during humanitarian crises.¹² Thus, according to the emerging field of implementation science of evidence-based practices (EBPs)—as opposed to the sciences for their development through clinical trials—nowadays, research should be oriented toward understanding the methods for promoting its incorporation into clinical practice.¹³

National efforts to identify and treat MHP in specific populations during COVID-19 provided an opportunity to measure the public impact of psychological EBPs and evaluate the most effective methods for achieving their implementation when interventions require the incorporation of significant changes in clinicians’ routine delivery methods (remote vs. face-to-face), patients, and circumstances (HCW-COVID-19). Common examples of these methods include strategies at the provider level (such as education/training, community engagement, and/or team-based coaching).¹⁴ Implementation studies therefore typically focus on the impact of specific strategies on the rates and quality of use of EBPs, the proportion of patients who attend a minimum number of treatment sessions, and/or the adaptations required to improve the implementation process.¹³

At the beginning of the COVID-19 pandemic in Mexico, the National Health System established a country-level strategy to identify and treat MHP in various populations, including HCW-COVID-19.³ A call was made for the voluntary participation of CBT psychotherapists interested in taking part in a collective effort to provide professional support for HCW-COVID-19. Thus, the main implementation strategy employed was community engagement, the leading theoretical and empirical paradigm for improving implementation of EBPs through partnerships between researchers and community (in this case service providers).¹⁵

Providers received training in the corresponding intervention manuals and data collection as well as supervision by a renowned Mexican psychologist, and engage in collaborative multidisciplinary teamwork with mental health specialists from various local institutions.

This involved the use of additional implementation strategies: (1) intervention systematization, which refers to the develop and format manuals and other supporting materials in ways that make it easier for clinicians to learn how to deliver the clinical innovation¹⁶; (2) development of electronic record systems to allow better assessment of implementation or clinical outcomes¹⁶ and given service providers personally involved in collecting data are more willing to use scientific evidence than their peers without such experience¹⁷; (3) education, referring to conduct educational meetings targeted toward different stakeholder groups (e.g., providers) to teach them about the clinical innovation¹⁶; (4) leadership engagement, defined as the recruitment, designation, and training of a leader for the change effort (in this case, the use of remote EBPs with HCWs)¹⁶; and (5) team-based coaching, which implied the creation of new clinical teams, adding different disciplines and different skills to make it more likely that the clinical innovation is delivered (or is more successfully delivered).¹⁶

The present study evaluates this implementation process and its clinical impact on HCW-COVID-19s anxiety, depressive, and somatic symptoms. We hypothesized that community engagement would guarantee the availability of sufficient professional resources, who would be equipped with the skills required to implement CBT through the intervention systematization, record systems, and education. Furthermore, these professional resources would be aligned with the goals and procedures of the program and its evaluation as a result of leadership engagement and team-based coaching (mainly with mental health specialists from the National Institute of Psychiatry). This strategy, in turn, would lead to positive implementation outcomes, including a high level of adoption of EBPs by clinicians, and therefore significant levels of patient satisfaction and clinical utility of the intervention.

The specific objectives were to determine (1) the frequency of CBT techniques for the treatment of mild-to-moderate anxiety, depression, and/or health anxiety/somatization by psychotherapists (which is known as “adoption level” in implementation science and allows the exploration of specific techniques that are considered more useful or necessary to add by clinicians)¹⁸; (2) the degree of satisfaction with the content and remote modality of the intervention by users (referred to in implementation science as “acceptability”); and (3) the clinical utility of the interventions (or symptomatic improvement after the intervention according to standard measures). This last objective (and outcome measure) means that the present study can be classified as a hybrid effectiveness–implementation design.¹⁹

Methods

The sample composed of Mexican HCW-COVID-19 ≥ 18 years old with moderate anxiety, depression, and/or health anxiety/somatization without suicidal ideation, who agreed to participate in the study, completed all the study evaluations before and after the intervention, and attended at least one intervention session, between April 17 and December 15, 2020 (covering the case cluster scenario and the community transmission scenario, including the first COVID-19 peak in Mexico).

VARIABLES AND MEASURES

Questionnaire on sociodemographic, professional, and COVID-19-related variables (Q1)

Self-report questions about participants’ sex, age, marital status, education, profession, personal COVID-19 status, and COVID-19 status of friends and relatives.

State–Trait Anxiety Inventory

State–Trait Anxiety Inventory (STAI) consisting of two independent self-assessment scales of the anxiety-personality trait (STAI-T) and state anxiety (STAI-S) was used.²⁰ The instrument was graded and interpreted based on the indications for manual grading of large samples²¹ to obtain T normalized scores (0–100). The STAI has demonstrated adequate psychometric properties in different contexts and various languages, including the Spanish version for Mexico.²¹

Beck’s Depression Inventory

Beck’s Depression Inventory (BDI) comprises 21 self-report items to assess the severity of depressive symptoms.²² The minimum score is 0 and the maximum score is 63, with higher scores indicating greater symptom severity. The instrument has been shown to have acceptable validity and reliability in clinical and research practice, including the Spanish version for Mexico used in the present study.²³

Current Status Assessment Questionnaire

Current Status Assessment Questionnaire (CSAQ) is a 9-item self-applicable measure of the severity of health anxiety/somatization symptoms using a 10-point scale, which is based on a CBT model of hypochondria²⁴ and has proven to be a sensitive measure of clinical change after psychological interventions for patients with health anxiety/somatization in Mexico.²⁵ For the present study, the last item in the instrument was eliminated since it evaluated avoiding leaving home, which would have artificially inflated the score given that the data were collected during the lockdown stage of the pandemic.

Questionnaire on the acceptability of the intervention

An ad hoc list of questions on the level of satisfaction with the contents and intervention modality (remote), and the degree of complexity of the intervention, answered on a 5-point Likert scale (ranging from 0 = not at all satisfied/complex to 4 = fully satisfied/complex); and a dichotomous question (yes/no) on whether respondents would recommend the intervention to other HCW dealing with COVID-19.

PROCEDURES

The institutional review board of the Ramón de la Fuente Muñiz National Institute of Psychiatry, Mexico, approved the study procedures and materials (reference number: CEI/C/010/2020).

IMPLEMENTATION STRATEGIES

In present study, community engagement was primarily built on the collaboration in a research protocol between a researcher on intervention models, a credible, well-positioned, and influential clinician (PhD in Psychology with extensive experience in CBT implementation and training), who served as a clinical coordinator, and the volunteer mental health professionals (with at least a specialty in psychiatry or clinical psychology, and specialization or master’s degree in CBT) that the two of them invited to participate as therapists (through electronic messages by email or WhatsApp to postgraduate students in Clinical and Health Psychology at the National Autonomous University of Mexico also working at several health institutions).

All therapists received a 4-h online training session on: (1) using the intervention manuals, (2) the process for referring patients with suicidal risk and other psychiatric emergencies to psychiatric immediate attention and/or patients with other needs to different virtual clinics (to treat addictions or occupational trauma syndromes, and for grief counseling or treatment) and services (e.g., instances for legal and psychological advise on violence), and (3) the administration of the instruments and recording the data for the study (including the additional techniques they considered necessary).

RECRUITMENT AND EVALUATION OF HCW-COVID-19 IN NEED OF PSYCHOLOGICAL CARE

Mexican HCW-COVID-19 were invited through official media to participate in the national online system to identify and treat MHP. Regardless of the results of the self-administered scales comprising the identification tool, all HCW-COVID-19 received free access links to online courses and training videos covering HCW-COVID-19s educational needs, including the most widely used evidence-based techniques for self-care promotion,^26–28 stress management,²⁸ handling uncooperative patients,²⁹ and the acquisition of new skills³⁰ (described and evaluated elsewhere).³¹

Cases with moderate anxiety, depression, and/or health anxiety/somatization without suicidal ideation—according to the 5-item Anxiety Scale for ICD-11 Primary Health Care field studies,³² the Patient Health Questionnaire-2 (PHQ-2),³³ and the first eight items in the CSAQ,²⁴ respectively—were referred to a free, confidential, brief, remote psychological intervention available on request through an email or telephone call to the coordinator of the service, at a time that suited the HCW, including weekends.

Those who contacted the coordinator received a brief explanation of the nature and procedures of the intervention and study and the corresponding consent form. Those who agreed to participate in this study completed Q1, STAI, BDI, and CSAQ through Google Forms. Those who reported suicide risk were immediately referred to a psychiatrist with experience in handling psychiatric emergencies through a free 24/7 hotline. At the end of the intervention, HCW-COVID-19 once again completed the clinical measures, and the questionnaire on the acceptability of the intervention, through Google Forms.

REMOTE INTERVENTION: RECOMMENDED AND ADDED TECHNIQUES REGISTRATION

The intervention involved the adaptation and manualization of (1) standard CBT for anxiety and depression,³⁴ based on a manual for Mexican patients³⁵; (2) standard CBT for somatic symptoms,²⁴ based on a manual for Mexican patients²⁵; and (3) contextual techniques³⁶ for coping with HCW-COVID-19-specific stressors. Techniques are listed in Table 3. Therapists were allowed to use the techniques they considered pertinent for each case, regardless of whether they formed part of the intervention manual. However, to determine the adoption level of the manual and the need to incorporate new techniques, they were asked to record the techniques used and the reasons for their use in every session and case in a form specially designed for the study.

DATA ANALYSIS

Data analyses were conducted with SPSS-X V21.0, prefixing an alpha of 95%. The main analyses included (1) chi-square tests to compare sociodemographic, professional, and COVID-19-related variables among HCW-COVID-19 who decided not to take the treatment, those who started but dropped out, and those who completed it; and a one-factor analysis or variance with a Bonferroni post hoc test to compare age (since the variable showed normal distribution according to Levene’s test); (2) independent sample Student’s t tests for comparisons between the baseline scores of clinical instruments of those who dropped out of treatment and those who completed it; (3) repeated-measures Student’s t tests for comparisons between the total scores of the clinical instruments before and after the intervention of those who finished the intervention and completed both evaluations (given that all variables showed normal distribution according to the Kolmogorov–Smirnov test); (4) Cohen’s d formula³⁷ to calculate the magnitude of the change, with results being interpreted as 0–0.3 = small, 0.5 = medium, 0.8 = large, and 1.20 = very large magnitude of change³⁸; and (5) a content analysis was conducted by categorizing the meanings³⁹ of the reasons for the use of the additional techniques.

Results

A total of 253 HCW were referred for treatment by 1 of the 47 therapists available; only 22.2% (n = 56) of whom began treatment. Of these, 25 (44.6%) dropped out, and 31 (55.4%) completed the intervention—although 5 (16.1%) failed to complete the postintervention assessment (Fig. 1).

**Fig. 1. Study flowchart. HCW, health care worker.**

Table 1 shows the comparison of demographic, professional, and COVID-19-related variables between those who failed to start treatment, those who dropped out, and those who completed it (regardless of whether they answered the subsequent evaluation). It was found that men and those with higher educational attainment were more likely to complete treatment.

Table 1. Description and Comparison of Demographic, Professional, and COVID-19-Related Variables Between Those Who Were Referred, Dropped Out, or Completed Treatment

VARIABLE N REFERRALS WHO FAILED TO CONTACT SERVICES DROPOUTS COMPLETED TREATMENT (WITH OR WITHOUT POST-TEST)

Sex, n (%)^a 253

Women 174 (88.3) 21 (84.0) 22 (71.0)

Men 23 (11.7) 4 (16.0) 9 (29.0)

Age, mean ± SD (range) 245 39.3 ± 10.4 (18–68) 37.1 ± 8.9 (18–56) 36.9 ± 10.7 (22–57)

Marital status, n (%) 241

Partnered 81 (43.8) 12 (48.0) 12 (38.7)

Unpartnered 104 (56.2) 13 (52.0) 19 (61.3)

Educational attainment, n (%)^b 253

Undergraduate 59 (29.9) 6 (24.0) 2 (6.5)

Bachelor’s degree 88 (44.7) 17 (68.0) 21 (67.7)

Graduate degree 50 (25.4) 2 (8.0) 8 (25.8)

Professional profile, n (%) 240

Medicine^c 89 (48.1) 9 (37.5) 22 (71.0)

Nursing 45 (24.3) 6 (25.0) 3 (9.7)

Paramedics 19 (10.3) 3 (12.5) 3 (9.7)

Other^d 32 (17.2) 6 (25.0) 3 (1.3)

COVID-19 status, n (%) 253

No symptoms 135 (68.5) 17 (68.0) 176 (69.6)

Personal COVID-19 32 (16.2) 4 (16.0) 40 (15.8)

Relative with COVID-19 30 (15.2) 3 (12.0) 36 (14.2)

Table 2 shows the results of the comparison of baseline clinical scores between those who dropped out and those who completed treatment. Those who completed treatment had greater baseline severity of anxiety and depressive symptoms than those who dropped out.

Table 2. Description and Comparison of Baseline Scores for Anxiety, Depression, and Somatization Between Dropouts and Those Who Completed Treatment

VARIABLE DROPOUTS (N = 16) COMPLETED TREATMENT (N = 31) TEST–TEST VALUES (DEGREES OF FREEDOM)

Anxiety-trait, mean ± SD 41.6 ± 12.5 49.5 ± 12.2 −2.08 (45), p = 0.043

Anxiety-state, mean ± SD 46.3 ± 12.3 54.9 ± 10.1 −2.62 (45), p = 0.012

Depressive symptoms, mean ± SD 10.6 ± 9.8 17.4 ± 8.8 −2.38 (45), p = 0.022

Health anxiety/somatization, mean ± SD 45.5 ± 17.4 49.5 ± 20.7 −0.67 (45), p = 0.504

ADOPTION AND ADDITION OF PSYCHOLOGICAL TECHNIQUES

The number of sessions and techniques used for 20 of the 26 participants was reported. In this subsample, the average number of intervention sessions was 4.6 ± 2.43 (range = 2–11). Table 3 presents the frequency of use of intervention techniques. Reasons for the use of these additional techniques were classified into two main themes: (1) Special needs, with four subthemes: workplace problems, insomnia, COVID-19 status, and family bereavement; and (2) Enhancement of techniques, with two subthemes: general and anxiety. Table 3 also offers examples of quotes classified in each theme and subtheme according to the content analysis.

Table 3. Type, Frequency of Intervention Techniques, and Reasons for Use of Additional Techniques (n = 20)

MANUAL TECHNIQUES ADDITIONAL TECHNIQUES

n (%) n (%) REASONS

THEMES/SUBTHEMES RESPONSES (EXAMPLES)

Cognitive modification 14 (70) Assertive training 10 (50) Special needs/workplace problems “For managing limits at work and excessive workload”

Psychoeducation 12 (60) Self-instructions 10 (50) Strengthening of techniques/anxiety “It was included to increase the use of the emotional self-regulation (anxiety) techniques learned in the session”

Deep breathing 12 (60) Behavior reinforcement 4 (20) Strengthening of techniques/general “Reinforcement of adaptive behaviors” “to reinforce the use of technique” “for the recognition of progress”

Jacobson’s muscle relaxation 10 (50) Problem-solving 4 (20) Special needs/workplace problems “To resolve the delay in training as an internal medicine specialist due to only caring for COVID-19 patients”

Emotional validation 10 (50) Sleep hygiene 3 (15) Special needs/insomnia “For having trouble falling asleep due to distressing thoughts and bad sleeping habits”

Behavioral activation 6 (30) Use of metaphors 2 (10) Special needs/COVID-19 status “To determine what is and is not under control in relation to having COVID-19 according to the FACE COVID protocol”

Mindfulness 4 (20) Relaxation by imagery 2 (10) Special needs/COVID-19 status “As she was infected, she had pleurisy, intense fatigue and difficulty breathing, so deep breathing hurt. In addition, the session was by phone and lying face down, so she could not do the progressive muscle relaxation exercises”

Self-reinforcing 2 (10) Enhancement of techniques/anxiety “Because it is a good complement to deep breathing to achieve a deeper level of relaxation”

Reattribution of symptoms 2 (10) Crisis intervention 1 (5) Special needs/family bereavement “Patient called at an unscheduled time because she was extremely distressed due to the sudden death of her niece”

Thought stopping 1 (5) Emotional writing 1 (5) Special needs/family bereavement “Patient needed to process the death of her husband, which had occurred some months earlier”

ACCEPTABILITY OF THE INTERVENTION

Of the 26 HCW-COVID-19 who completed the intervention, a subsample of 21 reported their satisfaction level and perception of the complexity of the intervention: 95.2% (n = 20) were “totally satisfied” and the remaining 4.7% (n = 1) “very satisfied” with the contents of the intervention. The majority (n = 16, 76.1% of the subsample) considered the intervention “not complex,” and all of them would recommend it to their colleagues. More than 40% were “very satisfied” (n = 3, 14.3%) or “totally satisfied” (n = 6, 28.6% of the subsample) with the remote modality.

UTILITY OF THE INTERVENTION

The final sample of 26 HCW-COVID-19 who completed the intervention, and the baseline and final measurements included 18 women (69.2%) and 8 men (30.8%), with a mean age of 37.7 ± 11.0 (range = 22–57) years. Most of them (n = 19, 73.1%) had a medical background (seven general practitioners, six medical specialty residents, three interns, two undergraduate medical students, and one specialist doctor), together with three paramedics (11.5%), two nurses (7.7%), and two psychologists (7.7%). The majority were single (n = 16, 61.5% vs. n = 10, 38.5% partnered) and held bachelor’s degrees (n = 19, 73.1% vs. n = 7, 26.9% with graduate degrees).

Four of them (15.4%) had a suspected or confirmed diagnosis of COVID-19 (personal COVID-19 status), whereas three (11.5%) reported a suspected or confirmed diagnosis of a family member. Table 4 presents the comparisons between anxiety scores, depression symptoms, and health anxiety/somatization before and after the intervention, and the magnitude of change achieved after the intervention. As can be seen, significant differences between pre- and post-measures of anxious, depressive, and somatic symptoms were found, and the diminutions of mean scores were all of great magnitude.

Table 4. Anxiety, Depression, and Somatization Symptoms Before and After Intervention (n = 26)

VARIABLE BEFORE TREATMENT AFTER TREATMENT TEST–TEST VALUES (DEGREES OF FREEDOM) MAGNITUDE OF CHANGE

Anxiety-trait, mean ± SD 51.0 ± 12.7 37.6 ± 9.5 6.82 (24), p ≤ 0.0001 d = −1.1

Anxiety-state, mean ± SD 55.8 ± 11.1 37.2 ± 8.2 −8.03 (24), p ≤ 0.0001 d = −1.7

Depressive symptoms, mean ± SD 18.9 ± 8.8 6.0 ± 5.6 6.68 (23), p ≤ 0.0001 d = −1.5

Health anxiety/somatization, mean ± SD 50.4 ± 21.8 27.5 ± 17.6 5.60 (24), p ≤ 0.0001 d = −1.1

Discussion

To evaluate the impact of the implementation process of a brief, remote, manualized, evidence-based psychological intervention for anxiety, depressive, and health anxiety/somatic symptoms among HCW-COVID-19 in a middle-income country, the specific aims of present study were to determine clinicians’ rates of use of CBT techniques (as indicator of the level of providers’ adoption of the EBPs), patients’ satisfaction (referred in implementation science as acceptability), and clinical improvement (as a measure of intervention’s effectiveness).

Our data suggest that community engagement guarantees the availability of sufficient professional resources (n = 47) to attend HCW-COVID-19 needing specialized interventions, who implemented manualized EBPs and followed all study procedures in the time and manner established by the group leaders. This, in turn, was reflected in positive implementation outcomes, including significant levels of patient satisfaction and the reduction of moderate-to-severe anxious, depressive, and/or somatic symptoms at the beginning of the treatment to mild-minimal symptoms at the end of it.

The most frequently used techniques were those included in the intervention manual, particularly cognitive modification, adopted by clinicians to treat 70% of HCW-COVID-19. The higher frequency of using techniques to treat anxiety symptoms than those primarily designed to decrease depressive or health anxiety/somatization symptoms may reflect the differential frequency of these symptoms in the sample. Additional techniques were consistently the most frequently used to achieve the management of anxiety, or to allow its management in a particular case diagnosed with COVID-19 (who was unable to use those suggested in the manual due to her condition during the therapeutic session) (Table 3). The remaining additional techniques highlighted the particular stressors of HCW-COVID-19 and the availability of psychological interventions to help cope with them or decrease their frequency, including workplace and training problems, insomnia, and family bereavement.

Taken as a whole, the levels of adoption of this set of CBT and contextual techniques are in keeping with the findings of Buselli et al.⁴⁰ In their study, the use of CBT techniques for the psychological care of HCW-COVID-19 was perceived as appropriate by 67% of the sample. Moreover, the addition of techniques to those included in the manuals should be seen as an appropriate choice by psychotherapists, who enhanced these materials for their future use in similar populations and circumstances. According to Chen et al.,⁴¹ various unplanned adaptations of psychological interventions are expected to occur to address patients’ novel and specific needs, which are more common in extraordinary stressful circumstances.

Moreover, considering Cohen³⁷ and Sawilosky’s³⁸ suggestions for the interpretation of delta coefficients, both the recommended and added techniques resulted in an intervention with a significant effect on anxiety, depressive, and health anxiety/somatic symptoms. This type of interventions not only produces a significant decrease in immediate perceived stress levels and related symptoms but also prevents the development of severe psychiatric disorders, such as post-traumatic stress disorder and major depression.⁴²

However, our results also reveal significant problems that must be solved to increase the impact of psychological EBPs among HCW-COVID-19, including the extremely low proportion of those who use them. Less than a quarter of those identified as having moderate anxious, depressive, and/or health anxiety/somatic symptoms through screening measures began treatment. Just more than 10% (12.3%) completed the intervention, and even they reported experiencing difficulty in attending the treatment sessions due to their increased workload. Compared with the 6% of the Mexican general population that receive adequate treatment for a depressive disorder under normal circumstances (before COVID-19),⁴³ at least twice this percentage of HCW-COVID-19 received evidence-based treatment for their MHP, suggesting that free and/or remote intervention available at work and outside working hours could increase the use of mental health services.

Nevertheless, the evaluation and elimination of other barriers to mental health care among HCW is still needed to increase the degree to which they seek, maintain, and complete specialized treatment when required. Seeking and receiving mental health care must be reconceptualized as institutional and individual imperatives and professional competencies⁴⁴ to eradicate discriminatory attitudes so feared by HCWs in the face of an eventual detriment to their professional development (e.g., expulsion from medical residency due to the idea that a HCW which has been diagnosed and treated for depression does not have the emotional capacity to be an effective clinician) and minimize the potential impact of health care work under special moments of stress on HCWs’ mental health, clinical competence, and professional functioning; just as is suggested for mental health professionals (e.g., Standard 2.06 about professional competencies for psychotherapeutic practice).⁴⁵

LIMITATIONS AND SUGGESTIONS

Limitations include those inherent to this type of hybrid effectiveness–implementation studies.¹⁹ First, regarding its implementation component, this study is merely a process evaluation, in that it simply describes the characteristics of the use of an EBP during an implementation strategy.¹³ Future studies should evaluate specific implementation strategies in controlled trials to confirm their relationship with the implementation and clinical outcomes reported and determine the relative importance of each strategy in producing these impacts to prioritize the use of each one in the future. Second, concerning the effectiveness component, it is important to recognize that, in contrast with clinical trials with high internal validity, evaluation of clinical utility in this research was conducted under naturalistic conditions. Our results should therefore be generalized with caution.

Conclusions

Remote brief CBT interventions for anxiety, depression, and health anxiety/somatic symptoms among HCW-COVID-19 can be effectively implemented in middle-income countries such as Mexico through specific implementation strategies that could be reproduced in the future (including voluntary, collaborative, and multidisciplinary work by various local mental health institutions, organized around EBPs by a national leader in the field through training in manuals adapted to target populations). The high degree of clinician’s adoption of the techniques proposed in the manuals and training reflects their perception of EBPs’ relevance for these purposes and population, whereas the large proportion of HCW satisfied with the contents of the intervention echoes their positive view of their effectiveness. Moreover, standard clinical measures of anxiety, depressive, and health anxiety/somatic symptoms decreased after treatment.

Authors’ Contributions

R.R.: Conceptualization (lead), methodology (lead), formal analysis (lead), supervision (lead), and writing—original draft (lead). L.A. and D.D.: Project administration (equal), investigation (equal), data curation (equal), and writing—review and editing (supporting). S.R., L.G., M.S., F.E., and A.H.-P.: Investigation (equal) and writing—review and editing (supporting). A.F.: Formal analysis (supporting), validation (equal), and writing—review and editing (supporting). H.V.: Investigation (supporting), validation (equal), and writing—review and editing (supporting). S.M.-C.: Investigation (supporting), resources (supporting), and software (supporting).

Acknowledgments

We are grateful to Beatriz Ramírez, Dení Salazar, Edith Rojas, Alinka Granados, Claudia Pineda, Aline Suárez, Mayra Mora, Zamira Amezcua, Liliana Rivera Fong, Lucía Torres, Omar Hernández, Virginia Montes de Oca, Jaqueline Olea, Elizabeth Peña, Erika Pineda, Fernando Manzanilla, Cinthia Cervantes, Elizabeth Bautista, Elizabeth Calzada, and the rest of the psychotherapists at the Anxiety, Depression, and Somatization Clinic for Health Personnel Dealing with COVID-19 in Mexico. We would also like to thank the National Autonomous University of Mexico for its support in implementing the national screening tool to identify MHP among HCWs referred for treatment to the remote services evaluated in this study (Reference number: DGAPA-PAPIIT IV300121).

Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

No funding was received for this article.

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**Table 1. Description and Comparison of Demographic, Professional, and COVID-19-Related Variables Between Those Who Were Referred, Dropped Out, or Completed Treatment**
VARIABLE	N	REFERRALS WHO FAILED TO CONTACT SERVICES	DROPOUTS	COMPLETED TREATMENT (WITH OR WITHOUT POST-TEST)
Sex, n (%)^a	253
Women		174 (88.3)	21 (84.0)	22 (71.0)
Men		23 (11.7)	4 (16.0)	9 (29.0)
Age, mean ± SD (range)	245	39.3 ± 10.4 (18–68)	37.1 ± 8.9 (18–56)	36.9 ± 10.7 (22–57)
Marital status, n (%)	241
Partnered		81 (43.8)	12 (48.0)	12 (38.7)
Unpartnered		104 (56.2)	13 (52.0)	19 (61.3)
Educational attainment, n (%)^b	253
Undergraduate		59 (29.9)	6 (24.0)	2 (6.5)
Bachelor’s degree		88 (44.7)	17 (68.0)	21 (67.7)
Graduate degree		50 (25.4)	2 (8.0)	8 (25.8)
Professional profile, n (%)	240
Medicine^c		89 (48.1)	9 (37.5)	22 (71.0)
Nursing		45 (24.3)	6 (25.0)	3 (9.7)
Paramedics		19 (10.3)	3 (12.5)	3 (9.7)
Other^d		32 (17.2)	6 (25.0)	3 (1.3)
COVID-19 status, n (%)	253
No symptoms		135 (68.5)	17 (68.0)	176 (69.6)
Personal COVID-19		32 (16.2)	4 (16.0)	40 (15.8)
Relative with COVID-19		30 (15.2)	3 (12.0)	36 (14.2)

**Table 2. Description and Comparison of Baseline Scores for Anxiety, Depression, and Somatization Between Dropouts and Those Who Completed Treatment**
VARIABLE	DROPOUTS (N = 16)	COMPLETED TREATMENT (N = 31)	TEST–TEST VALUES (DEGREES OF FREEDOM)
Anxiety-trait, mean ± SD	41.6 ± 12.5	49.5 ± 12.2	−2.08 (45), p = 0.043
Anxiety-state, mean ± SD	46.3 ± 12.3	54.9 ± 10.1	−2.62 (45), p = 0.012
Depressive symptoms, mean ± SD	10.6 ± 9.8	17.4 ± 8.8	−2.38 (45), p = 0.022
Health anxiety/somatization, mean ± SD	45.5 ± 17.4	49.5 ± 20.7	−0.67 (45), p = 0.504

**Table 3. Type, Frequency of Intervention Techniques, and Reasons for Use of Additional Techniques (n = 20)**
MANUAL TECHNIQUES	ADDITIONAL TECHNIQUES
Cognitive modification	14 (70)		Assertive training		10 (50)	Special needs/workplace problems	“For managing limits at work and excessive workload”
Psychoeducation	12 (60)		Self-instructions		10 (50)	Strengthening of techniques/anxiety	“It was included to increase the use of the emotional self-regulation (anxiety) techniques learned in the session”
Deep breathing	12 (60)		Behavior reinforcement		4 (20)	Strengthening of techniques/general	“Reinforcement of adaptive behaviors” “to reinforce the use of technique” “for the recognition of progress”
Jacobson’s muscle relaxation	10 (50)		Problem-solving		4 (20)	Special needs/workplace problems	“To resolve the delay in training as an internal medicine specialist due to only caring for COVID-19 patients”
Emotional validation	10 (50)		Sleep hygiene		3 (15)	Special needs/insomnia	“For having trouble falling asleep due to distressing thoughts and bad sleeping habits”
Behavioral activation	6 (30)		Use of metaphors		2 (10)	Special needs/COVID-19 status	“To determine what is and is not under control in relation to having COVID-19 according to the FACE COVID protocol”
Mindfulness	4 (20)		Relaxation by imagery		2 (10)	Special needs/COVID-19 status	“As she was infected, she had pleurisy, intense fatigue and difficulty breathing, so deep breathing hurt. In addition, the session was by phone and lying face down, so she could not do the progressive muscle relaxation exercises”
Self-reinforcing	2 (10)					Enhancement of techniques/anxiety	“Because it is a good complement to deep breathing to achieve a deeper level of relaxation”
Reattribution of symptoms	2 (10)		Crisis intervention		1 (5)	Special needs/family bereavement	“Patient called at an unscheduled time because she was extremely distressed due to the sudden death of her niece”
Thought stopping	1 (5)	Emotional writing		1 (5)	Special needs/family bereavement	“Patient needed to process the death of her husband, which had occurred some months earlier”

**Table 4. Anxiety, Depression, and Somatization Symptoms Before and After Intervention (n = 26)**
VARIABLE	BEFORE TREATMENT	AFTER TREATMENT	TEST–TEST VALUES (DEGREES OF FREEDOM)	MAGNITUDE OF CHANGE
Anxiety-trait, mean ± SD	51.0 ± 12.7	37.6 ± 9.5	6.82 (24), p ≤ 0.0001	d = −1.1
Anxiety-state, mean ± SD	55.8 ± 11.1	37.2 ± 8.2	−8.03 (24), p ≤ 0.0001	d = −1.7
Depressive symptoms, mean ± SD	18.9 ± 8.8	6.0 ± 5.6	6.68 (23), p ≤ 0.0001	d = −1.5
Health anxiety/somatization, mean ± SD	50.4 ± 21.8	27.5 ± 17.6	5.60 (24), p ≤ 0.0001	d = −1.1

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