COVID-19 and the Future with Digital Mental Health: Need for Attention to Complexities

1. The vast majority of individuals receive their mental health care in the community for the entire range and severity of mental disorders through hospital-based or community clinics, private offices or through home visits to individuals living alone, with family or in group homes. Many would be recovering from a recent episode of illness, while others may be relatively stable primarily through being provided care in the community, including crisis intervention. With the current disruption of services, many providers have shifted delivery of some services to distance communication (telephone, e-mail or interactive videoconferencing); however, these changes have been made without adequate preparation, organization, or attention to possible increase in severity ² and assume patients’ access to such technical resources.

2. The high risk of onset of all psychiatric and addiction disorders among youth (12 to 25 years old) is further increased by the pandemic, ⁸ while access to mental health services is reduced. At even more heightened risk are youth who are indigenous, under state protection, homeless, immigrants, and/or have addiction problems, family history of mental illness, and adverse social and personal circumstances exacerbated by the pandemic. Interestingly, open access “youth spaces” are a key aspect of the newly transformed youth mental health services ⁹ and will need to be reconfigured through combining virtual as well as face-to-face places of care, while also developing e-mental health strategies to aid early case finding and rapid access to assessment and treatment. These could be ideal for expansion of scope, rapid innovation, and implementation. This age group may be particularly open to using technology as part of the service response to their presenting problems, provided they have access to such technology.

3. Given the present circumstances there are “new risk” groups such as health care workers involved in caring for individuals receiving hospital care for COVID-19 virus infection. ¹⁰ Their risk comes from anxieties associated with contracting the disease or bringing it to their families, trauma associated with repeated exposure to life and death situations, exhaustion from working long hours, and guilt associated with not being able to do enough. They will need significant support and guidance for self-help for their mental well-being as well as access to quick identification of and attention to any emerging psychiatric symptoms. In addition, families who have experienced loss of its members, without being able to grieve properly, form an additional “new risk” group as do families trying to deal with a combination of challenges associated with caring for children at home, while struggling economically. These new risk populations may be ideal targets for digital technology-driven interventions, likely to be limited in time, supported by more traditional face to face services, if and when required.

4. The current pandemic circumstances, likely to be prolonged, pose special challenges to providing in-hospital care. Although necessary for only a minority of psychiatric patients, such care poses the unique challenge of protecting patients from both the health consequences of the virus and from social isolation required to combat the spread. Unlike medical care, in-patient psychiatric care is provided in open spaces where social interaction is part of the recovery process. Special resources are needed to maintain this unique balance of physical safety and recovery from mental illness. These will include more selective use of hospital beds through better management of patients in community settings, especially those in crisis, and higher staff/space: patient ratio along with readily accessible expert guidance regarding social interaction in the context of social distancing. Digital technology could be utilized for better preparation of patients for discharge and follow-up through improved distant communication with staff, especially during periods of crisis.

5. Just like the need for face-to-face contact in our own lives, it is equally important for mental health professionals to value such contact with our patients. In psychiatry, we have been trained to carefully read the semiotics of such encounters, starting with the handshake, observations of variations in posture, and the way the patient leaves the office. The possibility of exclusive e-mental health may tempt equally patients and clinicians to meet virtually, while in the comfort of their respective personal physical spaces. This needs to be considered as possibly a negative consequence.

6. Apart from Internet-related security issues, there might be an equally important problem of physical security for vulnerable patients (children, adolescents, abusive home environment, prisons, etc.) that will be hard to monitor through virtual care. These risks may be difficult to detect, but clinicians will need guidance on how to assess and mitigate such risk.

7. A major shift toward digital care will also affect mental health providers. Indeed, practice of psychiatry is fundamentally a product of “human technology,” nourished by formal and informal case discussions and consultation with colleagues across disciplines. While the field is rapidly adapting its professional education using various communication platforms, how the formal and informal personal exchanges will be affected by a heavy emphasis on e-mental health is unclear. A reasonable balance between face-to-face and e-platform connectedness between professionals may be essential for a healthy integration of e-mental health in clinical practice.