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Implementation Science of Telepsychotherapy for Anxiety, Depression,
and Somatization in Health Care Workers Dealing with COVID-19
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Rebeca Robles, PhD,1 Leticia Ascencio, PhD,2 Dulce Dı́az, PhD,1
Susana Ruiz, MS,3,* Lizette Gálvez, MS,2 Magaly Sánchez, MS,4
Fátima Espinoza, MS,5 Alejandro Hernández-Posadas, MS,5
Ana Fresán, PhD,6 Hamid Vega, PhD,1
and Silvia Morales-Chainé, PhD5
1 answered a final questionnaire on the acceptability of the inter-
Global Mental Health Research Center, Ramón de la Fuente
Muñiz National Institute of Psychiatry, Mexico City, Mexico.
2
Palliative Care Unit, National Cancer Institute, Mexico City,
Mexico.
3
Globality Studies Seminar, Medicine Faculty, National
Autonomous University of Mexico, Mexico City, Mexico.
4
Psycho-Onclology and Palliative Care Unit, Morelos Children’s
Hospital, Mexico City, Mexico.
5
Coordination of Training Centers and Psychological Services,
Psychology Faculty, National Autonomous University of Mexico,
Mexico City, Mexico.
6
Subdirectorate of Clinical Research, Ramón de la Fuente Muñiz
National Institute of Psychiatry, Mexico City, Mexico.
*Correction added on September 30, 2022 after first online pub-
lication of September 20, 2022: one of the co-author’s name was
corrected from Susan Ruiz to Susana Ruiz.
Abstract
Introduction: Cognitive behavioral therapy (CBT) has proven to
be effective in treating affective and somatic symptoms, which
are among the leading mental health problems of health care
workers (HCWs) dealing with COVID-19 (HCW-COVID-19).
However, efforts to develop and evaluate the strategies required
to promote its implementation in clinical practice are still
scarce, particularly in low- and middle-income countries.
Objective: To describe and evaluate the implementation process
and clinical impact of a brief, remote, manualized CBT-based
intervention for moderate anxiety, depressive, and somatic
symptoms among Mexican HCW-COVID-19 ‡18 years old.
DOI: 10.1089/tmj.2022.0155 ª M A R Y A N N L IE B E R T , IN C .  VOL. 29
and other resources online.
Methods: The implementation process comprises community
engagement, intervention systematization and education, lead-
ership engagement, and team-based coaching as main strategies.
A total of 26 participants completed self-report measures of
symptoms before and after treatment, and a subsample of 21
vention. Therapists registered the techniques used in each case,
regardless of whether they were part of the intervention manual.
Results: The number of sessions was 4.6 (2.43). The most
frequently employed techniques were those included in the
intervention manual, especially identifying and modifying
maladaptive thoughts, used to treat 70% of HCW-COVID-19.
Supplementary techniques were implemented to enhance
treatment or meet HCW-COVID-19s special needs (such as
workplace issues, insomnia, COVID-19 status, and bereave-
ment). The intervention had a significant effect (delta Cohen’s
coefficients ‡1), and the majority of HCW-COVID-19 were
‘‘totally satisfied’’ with its contents and considered it ‘‘not
complex’’ (95.2% and 76.1%, respectively).
Conclusions: Telepsychotherapy for anxiety, depression, and
somatization in HCW coping with health emergencies in
middle-income countries is a feasible, clinically valuable, and
acceptable form of treatment.
Keywords: telepsychotherapy, common mental disorders,
health care workers, mental health services, evidence-based
practices, implementation science, telemedicine
Introduction
W
orldwide, 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 Gi-
ven the need to minimize face-to-face interventions to reduce the
NO. 5  MAY 2023 TELEMEDICINE and e-HEALTH 751
 ROBLES ET AL.
spread of COVID-19 and taking advantage of technological de-
velopments, 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 tele-
psychotherapy, 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
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the emerging field of implementation science of evidence-based
practices (EBPs)—as opposed to the sciences for their develop-
ment 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 popu-
lations 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 ex-
amples 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 adapta-
tions 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 partici-
pation 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 interven-
tion 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 strate-
gies: (1) intervention systematization, which refers to the de-
752 TELEMEDICINE and e-HEALTH M A Y 2 0 2 3
velop 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 clin-
ical outcomes16 and given service providers personally in-
volved in collecting data are more willing to use scientific
evidence than their peers without such experience17; (3) edu-
cation, referring to conduct educational meetings targeted to-
ward different stakeholder groups (e.g., providers) to teach
them about the clinical innovation16; (4) leadership engage-
ment, 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 innova-
tion is delivered (or is more successfully delivered).16
The present study evaluates this implementation process
and its clinical impact on HCW-COVID-19s anxiety, de-
pressive, 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 pa-
tient 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 im-
plementation 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 im-
provement after the intervention according to standard
measures). This last objective (and outcome measure) means
that the present study can be classified as a hybrid effective-
ness–implementation design.19
Methods
The sample composed of Mexican HCW-COVID-19 ‡ 18
years old with moderate anxiety, depression, and/or health
ª MARY ANN LIEBERT, INC.
 TELEPSYCHOTHERAPY FOR HEALTH CARE WORKERS DEALING WITH COVID-19
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’
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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 inter-
preted 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 ver-
sion 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 re-
liability in clinical and research practice, including the Spanish
version for Mexico used in the present study.23
Current Status Assessment Questionnaire. Current Status As-
sessment 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 elimi-
nated 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 com-
plexity of the intervention, answered on a 5-point Likert scale
(ranging from 0 = not at all satisfied/complex to 4 = fully
ª M A R Y A N N L I E B E R T , I N C .  VOL. 29
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 influ-
ential clinician (PhD in Psychology with extensive experi-
ence in CBT implementation and training), who served as a
clinical coordinator, and the volunteer mental health pro-
fessionals (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 work-
ing 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 occu-
pational trauma syndromes, and for grief counseling or
treatment) and services (e.g., instances for legal and psycho-
logical 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 tech-
niques 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
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 ROBLES ET AL.
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 interven-
tion 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 ex-
planation 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
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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 manualiza-
tion 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 pa-
tients25; 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 deter-
mine the adoption level of the manual and the need to in-
corporate 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, prefix-
ing 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 com-
pare age (since the variable showed normal distribution ac-
cording 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 instru-
ments before and after the intervention of those who finished
754 TELEMEDICINE and e-HEALTH M A Y 2 0 2 3
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 cal-
culate the magnitude of the change, with results being inter-
preted 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).
Table 1 shows the comparison of demographic, profes-
sional, 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 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.
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 tech-
niques. 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.
ACCEPTABILITY OF THE INTERVENTION
Of the 26 HCW-COVID-19 who completed the intervention,
a subsample of 21 reported their satisfaction level and per-
ception 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
ª MARY ANN LIEBERT, INC.
 TELEPSYCHOTHERAPY FOR HEALTH CARE WORKERS DEALING WITH COVID-19
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Fig. 1. Study flowchart. HCW, health care worker.
‘‘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
ª M A R Y A N N L I E B E R T , I N C .  VOL. 29
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%) re-
ported a suspected or confirmed diagnosis of a
family member. Table 4 presents the compari-
sons between anxiety scores, depression symp-
toms, 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 so-
matic symptoms were found, and the diminu-
tions of mean scores were all of great magnitude.
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 tech-
niques (as indicator of the level of providers’
adoption of the EBPs), patients’ satisfaction (re-
ferred in implementation science as acceptability),
and clinical improvement (as a measure of inter-
vention’s effectiveness).
Our data suggest that community engagement
guarantees the availability of sufficient profes-
sional resources (n = 47) to attend HCW-COVID-19
needing specialized interventions, who im-
plemented manualized EBPs and followed all study proce-
dures in the time and manner established by the group leaders.
This, in turn, was reflected in positive implementation out-
comes, 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 symp-
toms than those primarily designed to decrease depressive or
health anxiety/somatization symptoms may reflect the
NO. 5  MAY 2023 TELEMEDICINE and e-HEALTH 755
 ROBLES ET AL.

Table 1. Description and Comparison of Demographic, Professional, and COVID-19-Related Variables Between Those Who
Were Referred, Dropped Out, or Completed Treatment
REFERRALS WHO FAILED COMPLETED TREATMENT
VARIABLE N TO CONTACT SERVICES DROPOUTS (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)

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

b
Educational attainment, n (%) 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

c
Medicine 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)

d
Other 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)

a
Pearson’s chi-square = 6.68, degrees of freedom = 2, p = 0.035.
b
Pearson’s chi-square = 13.24, degrees of freedom = 4, p = 0.010.
c
Includes undergraduate physicians, general practitioners, interns, medical specialty residents, and specialist physicians.
d
Categories with <10% of the total sample: psychologists, social workers, laboratory, and administrative staff.
SD, standard deviation.

Table 2. Description and Comparison of Baseline Scores for Anxiety, Depression, and Somatization Between Dropouts
and Those Who Completed Treatment
COMPLETED TREATMENT TEST–TEST VALUES
VARIABLE DROPOUTS (N = 16) (N = 31) (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

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 TELEPSYCHOTHERAPY FOR HEALTH CARE WORKERS DEALING WITH COVID-19

Table 3. Type, Frequency of Intervention Techniques, and Reasons for Use of Additional Techniques (n = 20)
MANUAL TECHNIQUES ADDITIONAL TECHNIQUES
REASONS
n (%) n (%) 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/ ‘‘It was included to increase the use of the
anxiety emotional self-regulation (anxiety)
techniques learned in the session’’

Deep breathing 12 (60) Behavior reinforcement 4 (20) Strengthening of techniques/ ‘‘Reinforcement of adaptive behaviors’’ ‘‘to
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general 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)
BEFORE AFTER TEST–TEST VALUES
VARIABLE TREATMENT TREATMENT (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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 ROBLES ET AL.
differential frequency of these symptoms in the sample. Ad-
ditional 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 psycho-
logical interventions to help cope with them or decrease their
frequency, including workplace and training problems, in-
somnia, and family bereavement.
Taken as a whole, the levels of adoption of this set of CBT
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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 un-
planned 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 sugges-
tions for the interpretation of delta coefficients, both the re-
commended 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 de-
velopment 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 propor-
tion of those who use them. Less than a quarter of those iden-
tified as having moderate anxious, depressive, and/or health
anxiety/somatic symptoms through screening measures began
treatment. Just more than 10% (12.3%) completed the inter-
vention, and even they reported experiencing difficulty in at-
tending 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 treat-
ment for their MHP, suggesting that free and/or remote inter-
vention available at work and outside working hours could
increase the use of mental health services.
758 TELEMEDICINE and e-HEALTH M A Y 2 0 2 3
Nevertheless, the evaluation and elimination of other bar-
riers to mental health care among HCW is still needed to in-
crease 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 develop-
ment (e.g., expulsion from medical residency due to the idea
that a HCW which has been diagnosed and treated for de-
pression does not have the emotional capacity to be an ef-
fective 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 psycho-
therapeutic 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 im-
plementation 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 in-
ternal 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 na-
tional 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 re-
flects 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
ª MARY ANN LIEBERT, INC.
 TELEPSYCHOTHERAPY FOR HEALTH CARE WORKERS DEALING WITH COVID-19
view of their effectiveness. Moreover, standard clinical mea-
sures 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), investi-
gation (equal), data curation (equal), and writing—review and
editing (supporting). S.R., L.G., M.S., F.E., and A.H.-P.: In-
vestigation (equal) and writing—review and editing (sup-
porting). A.F.: Formal analysis (supporting), validation
Downloaded by Sistemas Biblioinforma S.a De C.v. from www.liebertpub.com at 08/02/23. For personal use only.
(equal), and writing—review and editing (supporting). H.V.:
Investigation (supporting), validation (equal), and writing—
review and editing (supporting). S.M.-C.: Investigation (sup-
porting), resources (supporting), and software (supporting).
Acknowledgments
We are grateful to Beatriz Ramı́rez, Denı́ Salazar, Edith Rojas,
Alinka Granados, Claudia Pineda, Aline Suárez, Mayra Mora,
Zamira Amezcua, Liliana Rivera Fong, Lucı́a Torres, Omar Her-
nández, Virginia Chávez Montes de Oca*, Jaqueline Olea, Eliza-
beth Peña, Erika Pineda, Fernando Manzanilla, Cinthia Cervantes,
Elizabeth Bautista, Elizabeth Calzada, and the rest of the psy-
chotherapists 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).
*Correction added on September 30, 2022 after first online
publication of September 20, 2022: one of the author’s name
was corrected from Virgina Montes de Oca to Virginia
Chávez Montes de Oca
Disclosure Statement
The authors declare no conflicts of interest.
Funding Information
No funding was received for this article.
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