Telepsychiatry: How did we get here and where do we go now?
A lot has been changed by the COVID-19 pandemic in the last 6 months.
For those of us familiar with the inside of clinic rooms, one of the starkest changes may be the sudden reliance upon providing health care electronically.
As a medical student, I spend a lot of time shadowing doctors in the clinic, and since returning to medical school for Year 5, my peers and I have increasingly noticed that consultations are taking place over the phone or on a video call. Over the past 5 weeks, I have been on my paediatrics placement, and because of COVID-19, a large proportion of the clinics have been conducted via telephone consultation. Where this was once a futuristic rarity, it has very rapidly become commonplace in all specialties within medicine, psychiatry included.
Over the summer, and throughout the last year, I have been working at the University of Edinburgh as part of their Learning Technology team. Our reliance as a society upon video-conferencing and other technologies to teach, learn and have meetings has increased a thousandfold since the beginning of the pandemic, and my job means that I have been working at the forefront of this.
The university has adapted so many teaching exercises to enable online learning, and here at Edinburgh Medical School, we are now having practical exams teleconferencing, fully online, with mock patients. I personally have my first set of these exams in November (wish me luck) and am looking forward to learning more about the techniques and best practices for conducting consultations online.
My interest and experience in the learning technology sector, alongside my long-standing fascination with psychiatry, prompted me to think about the possibilities that exist when combining these. I have always been particularly interested in psychiatry because of its position as a very patient-centred and holistic speciality. It involves being observant and listening well in order to build a strong therapeutic relationship with each individual patient.
I began to wonder — how does one establish such a rapport and display empathy like that online?
Therefore, now more than ever, I felt it is crucial to discuss developments in telepsychiatry and what its future holds.
Technically defined as ‘a subspecialty of telemedicine which includes psychiatric assessments or follow-up interviews conducted using telephone calls, audio and video digital platforms’, telepsychiatry can be taken to mean the use of technology in delivering psychiatric care. Though the COVID-19 pandemic may have accelerated the adoption of telepsychiatric techniques, the first use of videoconferencing in psychiatry was reported as far back as the 1950s, when the Nebraska Psychiatric Institute first used video-calling for group therapy, liaison psychiatry and teaching at the state hospital.
In Europe, telepsychiatry was used in 1998 to bring specialist psychiatric services to the population of the 3 Aran Islands off the west coast of Ireland. Interestingly, at the time, the authors of the case study recounted that “each link-up costs nine times the price of an ordinary telephone call for an equivalent length of time”. Just over 20 years later, the practice of telepsychiatry is probably almost nine times cheaper than an in-person session, when the costs of transport and consultation room hire are taken into account.
Yet, we must remain mindful that not everyone has the technology and quiet space available in order to engage with telepsychiatric methods.
There is also the wider question of whether seeing patients online can ever enable the same insight as a physical consultation. One can think of many reasons why this can cause issues for the delivery of mental health care specifically.
The nature of psychiatry means that it relies upon a therapeutic relationship and an understanding between the patient and their psychiatrist.
We all know how hard it is to make friends over Zoom (think about all the awkward conference icebreaker sessions you’ve been to over the last few months), let alone to establish and develop an effective therapeutic relationship with a patient.
Not being able to see someone face-to-face may cause difficulties in interpreting body language. Especially now everyone is online more often, we have the added obstacle of unstable WiFi signals causing glitches and delays. This can mean that personal and intimate discussions (as are often required in psychiatry) are much more challenging and less productive.
These potential weaknesses of telepsychiatric care are perhaps more obvious, but we should consider that still there is promise in the concept, at least in some contexts.
For example, there is data to show that being able to consult with your psychiatrist from the comfort of your own home improves the likelihood of a patient attending an appointment. The American Psychiatric Association has conducted some preliminary work into the use of telepsychiatry methods during the COVID-19 pandemic, and the percentage of psychiatrists who reported that all their patients kept their appointments increased from 9% before, to 32% since the pandemic was declared an emergency.
This is particularly important in psychiatry, where many patients have complex health and social circumstances acting as a barrier to them accessing regular healthcare (due to the cost of commuting to the hospital, for example). For these patients, telepsychiatry can alleviate a significant burden.
In fact, there are some patient groups for which telepsychiatry may actually be preferable to face-to-face consultations.
The Oxford Precision Psychiatry Lab suggest that, for children and adolescents on the autistic spectrum, or for adults with severe social anxiety, telepsychiatry may be preferred (and can be well-coupled with emailing as an option too). It is easy to see how this might help these specific patient groups, who often struggle in physical social situations.
One of the additional clinical benefits of telepsychiatry might be that mental health professionals can get a valuable glimpse inside a patient’s home. In the same way that home visits in general practice can give GPs insight into how a patient is coping (or not), videoconference appointments may afford psychiatrists the same insight. Although in psychiatry some outpatients do get home visits, the vast majority of patients are seen in clinic. Perhaps we should consider the value of the extra information gained by seeing the patient’s home environment via telepsychiatric methods.
In some ways, psychiatry may be one of the specialties best suited to use of video technology, as many of the therapeutic modalities used in psychiatry are talking-based, e.g. cognitive behavioural therapy, or rely on medication rather than clinical devices or surgical techniques.
Furthermore, in other aspects of mental health care, technological solutions are being heralded as an exciting development. Mood-tracking algorithms coupled with features like messaging an online therapist are just some of the ways in which apps like BetterHelp are beginning to make their mark. Just a few months ago, InSPIre the Mind published a blog about these apps, which I would highly recommend for a more in-depth discussion of these tools.
There is vast potential for these two related but distinct technologies to work together to enhance psychiatric care, and I look forward to watching this unfold in my future career.
It is impressive that since telepsychiatry has become a necessity due to the pandemic, many toolkits have been created or rapidly repurposed to allow clinicians to adapt to the change.
In March, shortly after the COVID-19 restrictions came into place, a webinar was held suggesting ways to glean key information through an online neurological examination, and many of the common cognitive examinations now have online video versions, like the Montreal Cognitive Assessment.
As a community, psychiatry has responded well to the challenge COVID-19 has presented, and there have been innovative solutions aiding the transition across to online services. For example, a visual step-by-step guide for clinicians to use video consultations in mental health services was published rapidly in May, detailing the ethical and logistical considerations required to deliver safe, effective care.
Additionally, it is exciting to see the Royal College of Psychiatrists starting to explore technological tools too — they are organising a conference discussing novel but meaningful ways of practicing psychiatry online.
Now that there are so many tools that exist to allow clinicians to practice telepsychiatry, how effective is it? Numerous studies have been done each looking at very specific patient groups, e.g., adult transplant recipients with depression; children with depression; elderly patients with mild cognitive impairment, to name just a few.
Using all of these studies, in widely different settings and patient demographic groups, a strong evidence base has been built supporting the view that telepsychiatric consultations are equally as effective as face-to-face consultations, if not more. This means that patients had the same diagnostic outcomes as from an in-person consultation and that the patients found the consultations to be just as helpful.
For example, one study in the USA looked at the reliability of diagnosis via telepsychiatry by comparing psychiatrists’ evaluations of patients presenting to the emergency department. Patients were evaluated by a psychiatrist using videoconferencing, and another psychiatrist, who was physically present in the room, also completed an assessment of the patient. It was found that there was no significant difference in the psychiatrists’ evaluation of the patient’s mental state, or in their treatment recommendations.
Additionally, another study compared patient satisfaction levels between face-to-face and video consultations using a validated tool called a Client Satisfaction Questionnaire. They found that patients found the two modalities of consultation to be equally satisfactory.
Additionally, when looking at providing long-term treatment over videoconferencing, there is good evidence that this is also equally effective compared to face-to-face treatment.
A study in Australia compared whether Cognitive Behavioural Therapy (a type of talking therapy used for mood and anxiety disorders) administered via videoconference produces comparable clinical outcomes to in-person treatment, ultimately finding that they the two methods are equally effective.
Some research has even gone a step further and trialled asynchronous telepsychiatric care — i.e., the patient and psychiatrist are not having a live online conversation, but rather a video of a consultation with a primary care provider (such as a general practitioner), along with email correspondence between the patient and the primary care provider are sent to a psychiatrist who then consults all the sources of information at a different time. They are then able to report back to the primary care provider who can implement their recommendations in the community.
Though the study is still ongoing and the full results of this work are unpublished, in theory, this model could improve access to psychiatric care, especially for patients who may have otherwise had to travel far or wait a long period of time for a direct consultation with a psychiatrist. It was also calculated to be more cost-effective than both synchronous (i.e. real-time) telepsychiatry, and in-person psychiatric consultations.
In summary, though prompted by such global devastation, the recent advances in telepsychiatry show promise in a multitude of ways.
Patients may get access to services quicker. Psychiatrists can get an illuminating glimpse into a patient’s home life. The cost and barriers to attending appointments may lower. Most importantly, they are proving to be of equal effectiveness to face-to-face consultations.
However, we must keep being mindful that, as with all things in psychiatry, this is a nuanced discussion — ultimately, psychiatric care should be delivered in whatever manner is most effective and beneficial for the patient, something which may vary significantly between individuals and their circumstances.
Personally, I look forward to seeing the evidence base for telepsychiatry develop in a range of settings and demographics as it has the potential to greatly improve access to services and remove many of the barriers patients face when seeking treatment.
Special note from the editors: This is the eighth blog of our series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.
If you enjoyed today’s blog by Anushka, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, male mental health, and neuropsychiatry.