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|Year : 2020
: 62 | Issue : 9 | Page
|“Telepsychiatry” in the time of COVID-19: Overcoming the challenges
Sayuri R Perera1, Harischandra Gambheera2, Shehan S Williams3
1 Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Sri Lanka
2 National Institute of Mental Health, Ministry of Health, Sri Lanka
3 Department of Psychiatry, Faculty of Medicine, University of Kelaniya, Sri Lanka
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|Date of Submission||10-Jul-2020|
|Date of Decision||22-Jul-2020|
|Date of Acceptance||31-Aug-2020|
|Date of Web Publication||28-Sep-2020|
| Abstract|| |
Telepsychiatry, the application of telemedicine in the field of psychiatry is defined as the use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance. COVID 19 and its implications related to physical distancing for patients and service providers has made tele- psychiatry and e-consultations an attractive option. Psychiatry, more than any other field in medicine stands to benefit through tele-psychiatry as a physical examination may not be always necessary to arrive at a diagnosis. Some have gone on to suggest that tele psychiatry is likely to replace in person psychiatric assessments pertaining to certain clinical situations. The article reviews the existing evidence for tele-psychiatry and addresses the challenges and pitfalls in the South Asian context.
Keywords: COVID-19, e-psychiatry, telemedicine, telepsychiatry
|How to cite this article:|
Perera SR, Gambheera H, Williams SS. “Telepsychiatry” in the time of COVID-19: Overcoming the challenges. Indian J Psychiatry 2020;62, Suppl S3:391-4
| Introduction|| |
Seven months into the epidemic, with more than eight million infected persons and 450,000 deaths, the COVID-19 is unrelenting. In the absence of a vaccine, the World Health Organization and the Centre for Disease Control have considered social distancing as the most effective strategy of curbing this devastating pandemic.
| The Concept of Telepsychiatry|| |
In response to COVID-19, a fresh impetus has been infused in telemedicine. Many countries are improving their telemedicine facilities and are encouraging patients to utilize this service more. It appears sensible to limit face-to-face consultations with doctors at least for the time being.
Telepsychiatry, the application of telemedicine in the field of psychiatry, is defined as the use of electronic communication and information technologies to provide or support clinical psychiatric care from a distance. This definition includes many communication modalities such as phone, fax, e-mail, the Internet, still imaging, and live interactive two-way audio-video communication. However, what is implied by the word telepsychiatry is usually the latter. While it is relatively new to South Asia and Sri Lanka, it has been in practice in several other countries for many years.
Telemedicine in its budding stages, in the 1940s, was used to convey radiology images between two towns through telephone lines. During the 1960s, the USA Health and Human Services department invested time and money to develop telemedicine. It has since grown in leaps and bounds, and many clinicians today are confidently using it.
| The Evidence for Telepsychiatry|| |
There is a growing body of evidence showing its success in a range of psychological problems. Some psychiatrists argue that there is no difference in accuracy or satisfaction between assessments carried out in-person versus through telepsychiatry. Others have even gone on to say that telepsychiatry is likely to replace in-person psychiatric assessments in certain clinical situations.
Research has shown that telepsychiatry could be successfully utilized in a clinic setting where there is no in-site psychiatrist, and that regular online consultations could be effective in preventing relapse and increasing medication adherence, particularly for depression. There is evidence that both clinicians and patients have a positive outlook toward telepsychiatry. For instance, its use appears to reduce the need for inpatient hospital admissions; the quality of doctor–patient interactions is the same as an in-person interview, while it also is seemingly cost-effective. A meta-analysis of 14 studies showed telepsychiatry to be similar to face-to-face care based on objective assessment instruments or satisfaction scales with no difference in accuracy or satisfaction between the two modalities.
Some psychiatrists find telepsychiatry sessions to be more focused and concise than real-time interviews, as there is less need for social obligations at the opening and conclusion of an interview. A randomized trial assessed the reliability of the structured clinical interview for diagnostic and statistical manual disorders (SCID) by comparing in-person assessments versus assessments done through the video-conferencing portal. Each subject had a SCID assessment in both formats, and there were no statistical differences in outcome between the two formats. Telepsychiatry may serve an important role in treatment as well. It has proved to be effective in delivering psychotherapy for anxiety disorders, particularly generalized anxiety disorder, posttraumatic stress disorder, and depression.
Within the current context, China has already made headway using telemedicine facilities to assess rates of depression and anxiety disorders among health-care workers, patients, and the general population. They have also used it to deliver online psychological therapies such as cognitive behavioral therapy for depression, anxiety, and insomnia, although it is unclear whether it was used to assess and review outpatients with psychological disorders. Nonetheless, China has reported a significant acceleration in the use of their online platforms after COVID-19.
| Patient Factors in Telepsychiatry|| |
While there is little information about the interpersonal dynamics associated with telepsychiatry, anecdotal reports have suggested that from a patient's perspective, getting accessed by their clinician from the comfort of their home can be satisfying. Time taken to travel the clinic or hospital is also saved. Some have mentioned that telemedicine makes them feel “as if I were in the same room as the doctor,” and there is evidence that through positioning the equipment appropriately between the patient and the clinician, the former feels that they are on an equal footing as opposed to the power differential which can sometimes occur in a face-to-face setting. Telepsychiatry may also enable patients with social phobia or Aspergers disorder to feel more at ease than during an in-person one.
| Misgivings and Challenges in Telepsychiatry|| |
Despite the encouraging research findings, many remain skeptical about its pragmatic aspects. They argue that the positive findings in research related to telepsychiatry are attributable to the Hawthorne effect, where the observation per se contributes to the effect which may not be sustained in a real-world scenario. The halo effect of positivity and novelty associated with anything digital too could be influencing research participants in these studies.
While some think psychiatry is most suited for telemedicine as a physical examination may not be mandatory, others disagree. Psychiatry is a discipline where up to 65% of interpersonal communication is relayed through nonverbal communication. Many of these are unconscious, and empathy is core to the understanding of psychopathology, unlike in any other medical specialty. Furthermore, many psychiatrists question their ability to establish a sound therapeutic alliance with their patients while communicating with them on the telepsychiatry portal. It is established that the therapeutic alliance plays a central role in predicting a positive patient outcome. Even in a face-to-face meeting, developing a positive therapeutic alliance needs skill on the part of the psychiatrist. In order to establish a similar therapeutic alliance through the digital media, the psychiatrist would be required to inculcate a new set of interview skills and styles. Moreover, the patient's ease of communicating their emotions as well as expressing themselves verbally and nonverbally relies heavily on how well the clinician recognizes and responds to these emotions and behaviors. Will the patient, particularly someone presenting for the first time to a psychiatric service feel at ease expressing themselves when speaking “into a screen” rather than meeting the doctor in person?
The phenomena of transference, which plays a central role in assessing and managing certain patients, may be significantly undermined when the client finds himself/herself not within close proximity of his/her clinician. In the South Asian context, patients often present with dissociative and trance and possession states which too can be a challenge to identify, interpret, and manage through a digital interface. Distant communication may not pick up contextual clues, which may easily be detected during an in-person interview. Assessing a patient with substance withdrawal or with agitation, retardation, or stupor too can be challenging. Nevertheless, several documents giving tips on how to build an online rapport in telehealth are being released.
| Telepsychiatry and the Family|| |
In the South Asian context, the family plays a significant role in the care of the person needing psychiatric help. In a telepsychiatric consultation, one or more members will be involved in setting up the tele-interview. In such a situation, it may be difficult for the patient to have the interview in confidentiality. Further challenges will be in relation to collateral information gathering, family involvement in decision-making, and psychoeducation through the e-portal. Striking the right balance in the telepsychiatry time allocated to the family while ensuring the rights of the patient in the management is another sensitive issue that needs attention.
| Maintaining Boundaries in Telepsychiatry|| |
The potential for violation of the therapeutic boundaries between the doctor and the patient is another area of concern. A set of guidelines for formalizing the consultation is necessary. This should include a dress code for the doctor and the patient and an appropriate private space for both parties to conduct the tele-interview. A formal log and monitoring process should be developed including guidelines for fees if appropriate. Clinicians need to be aware of the online disinhibition effect and must take the necessary precautions. On occasions, the clinician may be exposed to verbal outbursts or other embarrassing behaviors which may be difficult to contain over the Internet.
| Ease of Access and Use of Technology|| |
Despite a growing trend in technology platforms, most of them have not been widely adopted in the South Asian countries compared to the high-income countries. The lack of infrastructure across digital payments, banking, mobility, and health, especially in vast rural areas inhabited by a large population, showcase the lack of technical maturity in the ecosystem.
Even though the technology was introduced to improve efficiency and break barriers among different classes of populations, the same technology ends up causing a rift due to the lack of sophisticated infrastructure and Internet connectivity impeding access to telepsychiatric care for vast rural neighborhoods.
If telepsychiatry is to develop in our region, the need also arises to ensure patients are comfortable using the technology. Patients from varying cultural and socioeconomic backgrounds may find it difficult to get accustomed to the technology. These so-called “digital immigrants,” indicating persons who did not grow up with digital technology and only started using it as adults, contrast significantly with “digital natives,” who grew up in digital technology incorporated environments. It is assumed that digital natives will be more comfortable and flexible using telepsychiatry methods than their digital immigrant counterparts. In a country like Sri Lanka where digital technology is only approximately two decades old, it would be fair to state that most adults are computer illiterate digital immigrants. One could assume that this holds true for most of the South Asian population as well where the cost, accessibility, and the ease of use are obstacles to telepsychiatry. Before the onset of COVID-19, most Asian governments were in a debate about the costs and benefits of establishing telemedicine in the Asian region on a national scale. However, once the pandemic struck, the benefits were obvious, and many governments including South Korea, Japan, and Indonesia have made online medical platforms available to the general public in an effort to contain the virus while providing a continuation of care for those who required it.
| Ethical Issues|| |
Telepsychiatry opens up gateways to other problems relating to technology, particularly in terms of security, data privacy, and safety. Ethical issues around data, storage, and its use have taken center stage over the years with the change of regulations.
The general data protection and regulations act was enacted by the European Union to help empower owners of data to keep it in safe hands and to always have access to “data portability” or the ability to move sensitive information away from data processes such as Facebook, Google, and Amazon. The same issues are surfacing in modern health care, as records are digitized and moved into virtual clouds. Ensuring that user information is stored securely without it being accessed by third parties is critical. In todays world, people are extra cautious about privacy and ownership of data, as there numerous instances where privacy has been violated.
Even though it is our responsibility to be informed, literate, and cautious while accessing the digital platforms and sensitive information, it is unfortunate that it is practiced a lot less than it is preached, and this could be a challenge to telepsychiatry where even sessions can be recorded covertly leading to a breach of doctor–patient confidentiality.
| Conclusions|| |
Telepsychiatry is expected to stay in the new world of social distancing and COVID-19. Although it may not be a substitute for the traditional old fashioned face-to-face clinical observation, eliciting of symptoms and signs and interaction, nevertheless, it is an imperative that offers certain advantages in particular contexts and situations. Mental health practitioners will have to develop their skills while interacting digitally, conducting assessments, and therapy. However, more researches regarding good telepsychiatric practice are needed that would be evidence-based, more informed, and would fit the purpose in terms of the cultural and social South Asian milieu.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Sayuri R Perera
Faculty of Medicine, University of Peradeniya, Kandy
Source of Support: None, Conflict of Interest: None
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