Education for mental healthcare is an important topic as there is a high incidence of mental illness worldwide, and it is projected to be an increasing cause of burden of disease in the future [67, 68]. Research and technology is constantly improving, as such the understanding of mental illness is also improving, creating new treatment and education methods for clinicians and healthcare students . SBE has been viewed as an educational method with the potential to improve the care of individuals with mental illness . The use of simulation has been implemented in medical and nursing education for decades with evidence suggesting its benefits, to both learners and patients .
This current scoping review was conducted in order to determine the existing evidence regarding the use of simulation and its effect in improving mental health patient outcomes. However, the scoping review did not uncover any literature reporting on patient mental health outcomes related to SBE. As a consequence of the broad literature search strategy, current information was also gathered on other outcomes of SBE within mental health such as learner reactions to SBE (Kirkpatrick model, level 1), knowledge and educational outcomes (Kirkpatrick model, level 2) and application of this education (Kirkpatrick model, level 3). In an environment where no patient outcomes have been reported, knowledge, skill enhancement and skill application are important outcomes which may inform future studies of SBE in relation to patient mental health outcomes.
The seven simulation types identified by the scoping review were SPs (n = 17), virtual reality (n = 9), role play (n = 6), manikins as patients (n = 4), computer simulation (n = 4), OCSE (n = 4) and voice simulation (n = 4). These results suggest that although SBE is being used, it has received very little empirical examination in the mental health sector. The following discussion will focus on the skill enhancement and efficacy of various forms of simulation used in mental health education, and potential links to mental health patient outcomes.
Simulated standardised patients (SPs)
The use of individuals to portray patients has been suggested as the most effective way to educate healthcare professionals in communication and other clinical skills . Communication skills are vital for any healthcare workers with the need for developing effective inter-personal techniques a central component in all patient/client interactions, especially within mental healthcare . SPs are a valuable modality when there is a high degree of emotion and/or communication required, as they can provide non-verbal as well as verbal information and responses .
SPs: skill enhancement
Hall  noted that the use of actors to portray psychiatric patients was effective in enhancing the assessment and therapeutic communication skills of nursing students. Of the 112 students that were a part of the pilot study, 80% agreed that the SP accurately portrayed depression and 100% of the cohort reflected improved communication .
A mixed methods study by Lewy  reported that paediatric residents (n = 34) working with SPs attained an increased confidence in patient treatment, with 69% stating the intervention was “extremely helpful”. Shahabudin  trained medical students to act as patients presenting with various mental illnesses in order to assess the knowledge and diagnostic abilities of 42 general practitioners (GPs). The findings were grouped into three categories based on the performance of the doctors: group A—where 11.9% of the GPs informed the SPs of their anxiety diagnosis, group B—28.6% of the GPs prescribed medication for anxiety but did not inform the SP of their diagnosis and group C—where 59.5% of GPs did not diagnose nor treat the SP . This study highlighted the lack of consistent training, assessment and treatment in the GP management of mental health and highlights an opportunity for future research and investigation.
SPs: simulation efficacy
Fussell’s study in  suggested that actors portraying people with substance abuse provided a reliable and effective learning modality in the education and assessment of substance abuse counsellors. Role play was suggested by Roberts’  randomised controlled trial to be neither effective nor ineffective in improving the assessment skills and views of undergraduate medical students regarding people living with a mental illness.
Virtual reality (VR)
Virtual reality is a computer-generated scenario or environment with which an individual can actively interact . The concept is becoming increasingly common in healthcare education with the concomitant decrease in risk to patient safety . VR technologies can include the computer-generated scenarios of virtual environments, voice simulation and virtual patients. Seventeen articles included the use of virtual reality technologies with occupations incorporating a mix of nursing, medical and psychiatric students and practitioners. The general consensus between the main findings of the studies is that these methods are effective in mental health education [6, 41, 56].
VR: simulation efficacy
Guise  found that virtual patients can be very effective in teaching clinical decision-making skills to nursing students, especially those parts of distance learning groups. The reduced risk of negative consequences for incorrect diagnosis and treatment-assisted students in learning mental health clinical skills. Lambert  found that the use of a simulated virtual patient, or avatar, portraying a person living with a mental illness was effective in educating nursing students on appropriate communication methods. The study investigated 85 mental health nursing students who followed the in-hospital journey of the fictional avatar for a 2-week period. Although the study did not focus on any form of assessment, it found that the students became more understanding and ethical practitioners at the completion of the fortnight and urged other organisations to follow suit in their training methods .
Voice simulation is effective in portraying the experience of schizophrenia, and as Weiland’s  qualitative study suggested, it is a valuable tool in increasing patience and empathy in nursing students. Seventy-four students listened to audio recordings of common voices heard in schizophrenia while attempting to complete certain tasks such as a job application. Based on the reflective evaluations completed by the students post-intervention, common themes emerged included feelings of “frustration” and “feeling overwhelmed”. However, the experience had positive outcomes, with reporting of increased levels of patience and empathy towards schizophrenic patients .
VR: skill enhancement
Satter’s  study of 14 practicing primary care physicians (PCPs) found that they were slightly better at diagnosing major depressive disorder and post-traumatic stress disorder with the use of avatars, as compared to those who used paper-based scenarios. In another study, Heiser  found that psychiatrists had the same chance of correctly diagnosing paranoia for a computer-simulated patient or a real patient, which suggests that this method may be suitable for use in mental healthcare education. Given the technology capability in 1979, Heiser’s results may not be necessarily comparable with modern day technology but the general method of simulation used is still relevant and transferable today. VR is proving to be a more prominent method for mental health education in today’s society, particularly as technology advances. Its effectiveness is yet to be fully determined; however, the indication from the majority of studies is that VR is a positive way to educate healthcare professionals regarding mental illness.
Manikins as patients
This scoping review only located four articles that utilised manikins in the mental health setting. All of these articles focussed on nursing students, suggested a positive response and portrayed the effectiveness of the use of manikins in mental health education.
A study by Kameg  found that students who were previously at risk of failing were no longer at risk after completing training with the use of high-fidelity manikins. The quasi-experimental study used a cohort of 35 nursing students to complete a 30-item Health Education Systems Incorporated (HESI™) custom exam pre- and post-simulation . There was a statistically significant improvement in the student risk profile post-simulation, with 10 of the 13 “at risk” students improving their category to the “non-risk” level .
In an earlier study, Kameg  noted that the use of manikins was an effective approach in teaching communication skills to nursing students. Similarly, Grant’s  review paper noted that high-fidelity manikins, when in combination with OSCE’s, were a viable training source to improve therapeutic communication skills. Unsworth’s study in  utilised the SimMan (a medium-fidelity manikin) and found that the use of manikins demonstrated to students where their areas of weaknesses were and what needed to be improved for their prospective healthcare careers. The qualitative measures of the study revealed the students thought of the intervention as “bridging the gap” between developing vital skills that are rarely seen in practice but are necessary to understand .
Mental health patient outcomes
Although much evidence exists to support the use of SBE in medical and nursing education, both in terms of educational and patient outcomes, there is far less evidence regarding its use in the healthcare category of mental health. Moreover, to the best knowledge of the authors, no studies have been published that report on patient mental health outcomes in relation to SBE. Many of the attitudes, skills and competencies necessary for effective mental healthcare are well-suited to SBE, and there appears to be abundant opportunities for the development and evaluation of this teaching methodology within mental health . However, the mental health educational outcomes reported in this paper including knowledge, skill enhancement and skill application have relevance and may be used to inform future studies in the area, including those concerned with patient outcomes. The measurable patient outcomes in mental health interventions may be less tangible compared with that of physical disorders. This may present one of the challenges in taking the evaluation of simulation in mental healthcare beyond educational outcomes.
Articles not in English were excluded from this review; this is an important limitation and publication-bias as significant data may have been missed due to the inability to appropriately categorise the articles. The search of grey literature sites yielded only peer-reviewed articles; this suggests the depth of included articles does not incorporate non-peer-reviewed literature which could have brought strength to the findings. Also, with only three articles reporting on impacts in non-westernised countries [30, 32, 42], care must be taken when generalising results to the wider population.
Recommendations for future research
The most significant gap in the current research base is the lack of evidence that mental health SBE directly impacts patient outcomes. This scoping review has found several gaps in the current literature that may provide researchers, policymakers and educators with a “roadmap” of future research opportunities. These include interdisciplinary research, patient outcomes, different methods of simulation (such as pre-recorded DVDs which may use simulated patients portraying various clinical situations), prehospital care and SPs.
Although there are a number of articles in the literature reporting on simulation in mental healthcare education, there is a lack of patient outcome measures linked to SBE. This was supported in the evaluation using Kirkpatrick’s model as nil level 4 studies were located in any of the 48 articles. Further research needs to be conducted into how simulation in mental healthcare relates to patients’ outcomes in terms of successful or unsuccessful treatment, including the quality of life of the patient and their family. It is the authors’ view that further research is also needed for professions other than medicine and nursing. As a large portion of the existing research focussed on these professions, the findings may not be generalisable to other disciplines. In addition, more focus needs to be given to out-of-hospital care, including emergency paramedic clinicians and GPs working with people experiencing acute mental health issues. A significant gap in the mental health literature relates to indigenous populations including Aboriginal Australians. Similarly, there is a dearth of literature on the use of SBE in the mental healthcare of paediatric patients, young adults and the elderly population.
The evidence suggests that robust evaluation of simulation programs needs to be undertaken to provide evidence of the impact of simulation in mental healthcare education beyond educational outcomes. SBE holds many opportunities for curricula improvement and development. Ideally, evaluation plans would be incorporated at the design phase of new programs and introduced into programs which already exist. That is, planning backwards and teaching forward, that consider Kirkpatrick’s model. Further research should consider and focus on designs that are both qualitative and quantitative to obtain both narrative and objective data. Consideration should also be given to improve reporting where SP and role play approaches are involved .