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Telepsychiatry – mobility through technology


In an average year, between one in six and one in five people in the adult population will develop a mental illness. Half of these people will have more than one illness at the same time. About one in three people with depression get their diagnosis from primary care and only one in seven get help in secondary care. We know that despite the high prevalence and potentially disabling consequences of mental disorders, mental health services are often deficient, leading to the “mental health gap”. Further, services are often located in urban areas, worsening the divide between rural and urban areas.

Society as well as the health care system as we knew it changed overnight for most of us in March 2020 and with this, “telepsychiatry” gained new wind. Social distancing and isolation very rapidly became household words and the concept of “TISK” (testing, isolation, contact tracing, quarantine) has had a direct impact on the morbidity and mortality of our population. Novel methods for providing care were introduced in most places to provide support and active help. One of these, telepsychiatry is the process of providing health care from a distance, through technology, often using applied videoconferencing. The concept encompasses a variety of services, ranging from psychiatry assessments, therapy (individual therapy, group therapy, family therapy) to patient education and medication management.

Videoconferencing was first introduced during the 1950s, and by the 2000s, it was seen as effective, though different to in-person care. It is considered equivalent to in-person care in terms of diagnostic accuracy, treatment effectiveness and patient satisfaction and it is recognized that it often saves time, money and other resources. In some settings, such as for children or adolescents on the autistic spectrum or for adults with disabling anxiety, telepsychiatry may even be preferable to in-person contact.

Several guidelines exist and have been published by RCPsych, CDC, Australia and New Zealand as well as Canada, among others. Guidelines all recommend that remote consultations should be encouraged where safe and appropriate, taking care to consider suitability. Though many patients may be unperturbed by the possibility of a video consultation, care should be taken in order to gain the patient’s own view on technology, and adapted if needed. Explicit consent should always be sought and the patient should retain the option to withdraw from the process at any time. Another issue is confidentiality. One should think twice before engaging in individual therapy with a person in an internet café, though if thoroughly evaluated and deemed safe, this could still be considered suitable. The same would be the case for mental capacity, in which specific attention must be given concerning whether the patient is able to give informed consent.

Bringing focus down to hardware and practicalities is also important. When utilising telepsychiatry, or any form of telemedicine, one should always have a backup plan. Many patients struggle with self-harm, suicidality or domestic violence and all patients should be assessed in terms of risk and whether the use of video consultation is appropriate and safe. Who can you contact if the line goes dead or the patient does or says something unexpected that you cannot control through the screen? Do you have an alternate method of contact if the patient hangs up or the connection fails? Moreover, even when the consultation itself is going according to plan, it is essential to have equipment that works reliably and that provides a service, which complies with security features such as encryption, passphrases or two-factor authentication.

Numerous studies report high willingness to use this model of care as well as high ratings of patient satisfaction. Despite this, some may remain sceptical concerning efficacy and quality. Negative perceptions and expectations should not be ignored, as they may predict actual use and satisfaction. The most frequent barrier reported is a view that telepsychiatry is less personal. Decreased ability to detect non-verbal cues across a screen or difficulties in picking up nuances and emotions as well as gestures such as handing tissues to a tearful patient or moving a chair closer in support may carry important emotional significance. Guidelines advise particular awareness in some areas when talking to a computer screen; such as using clear language, a slower pace of talking, more articulation, as well as a focus on the use non-verbal cues. This goes for both the therapist, and the patient. Lighting is important, as is focusing on the camera, and not the patient’s eyes. Interestingly, clinicians appear to rate patients’ comfort and satisfaction less highly than do patients, and they rate patients’ levels of comfort as lower than their own.

Video consultations are not the sole way for communicating with patients or other health care workers remotely. There are a number of apps and other digital technologies that can be beneficial for health. A tip here is to consider whether the app is appropriate. For instance, some apps may not comply with data security standards and these should only be recommended with caution. The American Psychiatric Association (APA) app evaluation framework suggests that users (patients and clinicians) evaluate safety and privacy, evidence, ease of use and interoperability prior to using health apps.

Just as with regular consultations, there are a number of things that require consideration and planning when using telepsychiatry. This said, the potential benefits for use in rural areas, through catastrophic events or during pandemics, are large. In addition, telepsychiatry provides new opportunities for rapid communication both between health care workers, and between health care workers and patients. Finally, telepsychiatry presents a unique opportunity to explore the possibility for more tailored care. □


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