Abstract
The COVID-19 pandemic has shown that research meetings and clinical consultations can be conducted reasonably safely and efficiently using video-conferencing approaches. Herein, we use the term telepsychiatry to denote provision of mental health care from a distance through use of technology, often videoconferencing such as Zoom, Skype and Microsoft Teams. Although such approaches have undoubtedly allowed for real-time communication between patients and clinicians where they might not have otherwise been possible or safe, they still carry many challenges. Two immediate concerns are to do with privacy and confidentiality. Privacy concerns relate to challenges for patients, and at times healthcare professionals, in finding a quiet setting where no one else is present. Confidentiality relates to privacy as well as data storage and remote recording of sessions.
Further challenges with telepsychiatry include digital exclusion and technical competence. Challenges related to privacy, digital exclusion and technical competence overlap with socio-economic factors such as poverty, overcrowding and unstable housing. In a mental health context, this is particularly relevant given the social causation and social drift hypotheses associated with those who suffer with mental health conditions. Further, there may also be demographic determinants such as age. Such factors mean that this is a clear gap and variation in access within and between countries.
Even where available, unreliable or low bandwidth internet connectivity makes real-time communication challenging with intermittent connections and poor audio-visual quality. One way of managing this is the use of asynchronous tele-psychiatry where pre-recorded patient information by the patient themselves or by the referring agent and sending the video to an expert psychiatrist. In some cases, such interviews may be carried out by a primary care health professional often using a semi-structured protocol (Yellowlees et al., 2010). The specialist can then review patient’s video, with an accurate translation if needed, along with other relevant materials, third-party information and offer a formal clinical opinion. Asynchronous telepsychiatry can therefore eliminate the need for a real time interpreter, rendering the service more cost effective and avoids the potentially unreliable connectivity based interactions between the patient and the clinician (Butler & Yellowlees, 2012).
Due to a number of factors even before the pandemic, telepsychiatry had started to become popular and the United Kingdom has also seen a huge acceleration in the uptake of videoconferencing during the pandemic (Venkataramakrishnan, 2020). Similar trends have been noted in other countries owing to regulatory changes and widening of health insurance reimbursements related to such tele-care provision. These approaches have become much more acceptable and convenient over the past few years for a number of reasons supported by advancing technologies such as smartphones. Limited number of professionals and geographical distances as services are often concentrated in urban areas have further accelerated the increased adaptation of tele-psychiatry in many countries.
A number of randomized controlled trials and reviews have shown telepsychiatry to be of equal standing compared to traditional face-to-face interviews. Drago et al. (2016) in their meta-analysis from 26 randomized controlled trials with more than 2,200 patients, reported that telepsychiatry was not inferior to traditional face-to-face consultations in terms of psychiatric assessment and efficacy. However, they also acknowledged that their analysis did not include studies with psychotherapy, or assessment of the quality of the therapeutic alliance, or the compliance to the management. Hilty et al. (2015) noted that some studies reported no significant issues regarding patients’ satisfaction, and working alliance between patient and clinician were related to the quality technology bandwidth. Greene et al. (2010) demonstrated in a study on a small group of patients receiving anger-management group therapy that the therapeutic alliance and attrition rates were not significantly different except a lower alliance with the tele-group leader.
Hubley et al. (2016) analysed different aspects of tele-psychiatry looking at patient’s and provider’s satisfaction, reliability, treatment outcomes, implementation outcomes and cost effectiveness. They also found that telepsychiatry is comparable to the regular setting in terms of the reliability of treatment outcomes and assessment. In addition, not surprisingly, such approaches have been shown to be cost-effective in many countries (Hilty et al., 2013) and can also reduce the number of admissions (Salmoiraghi & Hussain, 2015). It has been shown that even purely telephone-based approach (rather than video-conferencing) may be effective, especially improving patient’s medication adherence resulting in better quality of health and decrease of costs (Bashshur et al., 2016). Some patients owing to cultural background and personal preferences may find tele-psychiatry as an easier approach to treatments, seen as less stigmatizing and more personalized.
Telepsychiatry also provides a potential solution to the workforce difficulties and staffing problems, improving access to care and offering flexibility in terms of location of service delivery. If used well, it can also help increase efficiency through a greater collaboration between primary care physicians and psychiatrists, not only in the management of patients, but also further educational opportunities and integrated care approaches.
There is little doubt that the COVID-19 global pandemic is likely to be a catalyst and tipping point in the global adoption of telepsychiatry, but a note of caution is needed. Prolonged social isolation as a result of the national ‘lockdowns’ that took place in many countries, along with the fear and panic in the community, is likely to lead to serious psychological consequences which may require interventions. Zhou et al. (2020) predict that healthcare workers themselves may well experience high levels of burnout, stress, anxiety and depression as they strive to provide services, undertake assessments and determine clinical risk during the crisis from a distance. Tele-psychiatry may provide relief or support but may also add to the stress and burnout for mental health professionals delivering care.
However, some key questions remain about the use of tele-psychiatry for psychotherapies. Cowan et al. (2019) point out that after the initial mistrust, patients can work with technology although, not surprisingly, this seems to vary with age. Equally importantly, some patients would still prefer face-to-face contact as they may feel uncomfortable for a number of reasons.
We are particularly interested in psychodynamic psychotherapy and challenges that come with it. As Fishkin et al. (2011) highlight, there are psychodynamic considerations related to treatment, training and supervision when using interest-based video conferencing technologies. Asen, Stern, Yakeley and van Velsen, who are all eminent psychotherapists in different fields, offer their personal perspectives in the following pages that need to be discussed further. Issues related to transference and counter-transference raise specific challenges in tele-psychiatry and further careful debate is urgently needed.
