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  JMH Theme Issue 2020: COVID-19 and...

  Sep 25, 2020

  Prevalence of Perceived Stress, Anxiety, Depression, and Obsessive-Compulsive Symptoms in Health Care Workers and Other Workers in Alberta During the...

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  Authors List:

  • Kelly Mrklas  
  • Reham Shalaby  
  • Marianne Hrabok  
  • April Gusnowski  
  • Wesley Vuong  
  • Shireen Surood  
  • Liana Urichuk  
  • Daniel Li  
  • Xin-Min Li  
  • Andrew James Greenshaw  
  • Vincent Israel Opoku Agyapong  

  Abstract:

  Background: During pandemics, effective containment and mitigation measures may also negatively influence psychological stability. As knowledge about COVID-19 rapidly evolves, global implementation of containment and mitigation measures has varied greatly, with impacts to mental wellness. Assessing the impact of COVID-19 on the mental health needs of health care workers and other workers may help mitigate mental health impacts and secure sustained delivery of health care and other essential goods and services. Objective: This study assessed the self-reported prevalence of stress, anxiety, depression, and obsessive-compulsive symptoms in health care workers and other workers seeking support through Text4Hope, an evidence-based SMS text messaging service supporting the mental health of residents of Alberta, Canada, during the COVID-19 pandemic. Methods: An online cross-sectional survey gathered demographic (age, gender, ethnicity, education, relationship, housing and employment status, employment type, and isolation status) and clinical characteristics using validated tools (self-reported stress, anxiety, depression, and contamination/hand hygiene obsessive-compulsive symptoms). Descriptive statistics and chi-square analysis were used to compare the clinical characteristics of health care workers and other workers. Post hoc analysis was conducted on variables with >3 response categories using adjusted residuals. Logistic regression determined associations between worker type and likelihood of self-reported symptoms of moderate or high stress, generalized anxiety disorder, and major depressive disorder, while controlling for other variables. Results: Overall, 8267 surveys were submitted by 44,992 Text4Hope subscribers (19.39%). Of these, 5990 respondents were employed (72.5%), 958 (11.6%) were unemployed, 454 (5.5%) were students, 559 (6.8%) were retired, 234 (2.8%) selected “other,” and 72 (0.9%) did not indicate their employment status. Most employed survey respondents were female (n=4621, 86.2%). In the general sample, the 6-week prevalence rates for moderate or high stress, anxiety, and depression symptoms were 85.6%, 47.0%, and 44.0%, respectively. Self-reported symptoms of moderate or high stress, anxiety, and depression were all statistically significantly higher in other workers than in health care workers (P<.001). Other workers reported higher obsessive-compulsive symptoms (worry about contamination and compulsive handwashing behavior) after the onset of the pandemic (P<.001), while health care worker symptoms were statistically significantly higher before and during the COVID-19 pandemic (P<.001). This finding should be interpreted with caution, as it is unclear the extent to which the adaptive behavior of health care workers or the other workers might be misclassified by validated tools during a pandemic. Conclusions: Assessing symptoms of prevalent stress, anxiety, depression, and obsessive-compulsive behavior in health care workers and other workers may enhance our understanding of COVID-19 mental health needs. Research is needed to understand more fully the relationship between worker type, outbreak phase, and mental health changes over time, as well as the utility of validated tools in health care workers and other workers during pandemics. Our findings underscore the importance of anticipating and mitigating the mental health effects of pandemics using integrated implementation strategies. Finally, we demonstrate the ease of safely and rapidly assessing mental health needs using an SMS text messaging platform during a pandemic.

  • JMIR Ment Health 2020;7(9):e22408

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  Homelessness

  Sep 24, 2020

  Virtual Reality Meditation Among Youth Experiencing Homelessness: Pilot Randomized Controlled Trial of Feasibility

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  Authors List:

  • Laura Johnson Chavez  
  • Kelly Kelleher  
  • Natasha Slesnick  
  • Eugene Holowacz  
  • Ellison Luthy  
  • Laura Moore  
  • Jodi Ford  

  Abstract:

  Background: Homelessness among youth is devastating, with high rates of substance use disorders and mental health comorbidity. Mindfulness-based interventions that include meditation and mindfulness skills training reduce stress and symptoms of anxiety or depression. However, engaging high-risk youth in interventions is challenging. Virtual reality is a more flexible platform for delivering meditation and may be appealing to youth. Objective: The study objectives were to evaluate the feasibility of delivering virtual reality meditation and of collecting outcome measures, including anxiety and physiologic stress. Methods: A sample of 30 youth experiencing homelessness was enrolled in the study. Youth were randomized to receive 10 minutes of one of three interventions: (1) virtual reality meditation, (2) audio meditation (through a web-based platform), or (3) virtual reality imagery of historical pictures and text. Subjects who consented to the study attended two research visits. The first visit collected survey measures of demographics, mental health, and substance use, and oriented subjects to the intervention platforms. The second visit (1-3 days later) delivered the intervention and collected pre and post outcome measures of anxiety and physiologic stress (salivary cortisol). Changes in anxiety and cortisol at the second visit were compared across groups using a linear regression model in which the primary analysis compared virtual reality meditation to audio meditation and secondary analyses compared virtual reality meditation to virtual reality imagery. Results: Anxiety scores decreased in all groups, with a larger reduction among the virtual reality meditation group (difference=10.8) compared to the web-based meditation or virtual reality images groups (difference=5.8 and 5.0, respectively). After controlling for baseline values, there were no significant group differences in changes in anxiety scores or cortisol levels. In comparing virtual reality meditation and audio meditation, the effect size for anxiety was moderate (Cohen d=0.58) while the effect size for cortisol was small (Cohen d=0.08). Conclusions: Preliminary results suggest that virtual reality meditation has a moderate benefit for anxiety but not physiologic stress. Future research is needed to confirm these results in a larger sample and to investigate whether the effects are sustained or increase with repeated use of virtual reality mediation. Virtual reality meditation appears feasible to deliver among homeless youth and merits further study. Trial Registration: ClinicalTrials.gov NCT04004520; https://clinicaltrials.gov/ct2/show/NCT04004520

  • JMIR Ment Health 2020;7(9):e18244

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  Bipolar Disorders

  Sep 22, 2020

  A Smartphone App to Monitor Mood Symptoms in Bipolar Disorder: Development and Usability Study

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  Authors List:

  • Kelly Ann Ryan  
  • Pallavi Babu  
  • Rebecca Easter  
  • Erika Saunders  
  • Andy Jinseok Lee  
  • Predrag Klasnja  
  • Lilia Verchinina  
  • Valerie Micol  
  • Brent Doil  
  • Melvin G McInnis  
  • Amy M Kilbourne  

  Abstract:

  Background: There is considerable scientific interest in finding new and innovative ways to capture rapid fluctuations in functioning within individuals with bipolar disorder (BD), a severe, recurrent mental disorder associated with frequent shifts in symptoms and functioning. The use of smartphones can provide valid and real-world tools for use in measurement-based care and could be used to inform more personalized treatment options for this group, which can improve standard of care. Objective: We examined the feasibility and usability of a smartphone to capture daily fluctuations in mood within BD and to relate daily self-rated mood to smartphone use behaviors indicative of psychomotor activity or symptoms of the illness. Methods: Participants were 26 individuals with BD and 12 healthy control individuals who were recruited from the Prechter Longitudinal Study of BD. All were given a smartphone with a custom-built app and prompted twice a day to complete questions of mood for 28 days. The app automatically and unobtrusively collected phone usage data. A poststudy satisfaction survey was also completed. Results: Our sample showed a very high adherence rate to the daily momentary assessments (91% of the 58 prompts completed). Multivariate mixed effect models showed that an increase in rapid thoughts over time was associated with a decrease in outgoing text messages (β=–.02; P=.04), and an increase in impulsivity self-ratings was related to a decrease in total call duration (β=–.29; P=.02). Participants generally reported positive experiences using the smartphone and completing daily prompts. Conclusions: Use of mobile technology shows promise as a way to collect important clinical information that can be used to inform treatment decision making and monitor outcomes in a manner that is not overly burdensome to the patient or providers, highlighting its potential use in measurement-based care.

  • JMIR Ment Health 2020;7(9):e19476

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  Telepsychiatry

  Sep 18, 2020

  Pediatric Telebehavioral Health: A Transformational Shift in Care Delivery in the Era of COVID-19

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  Authors List:

  • Ujjwal Ramtekkar  
  • Jeffrey A Bridge  
  • Glenn Thomas  
  • Eric Butter  
  • Jennifer Reese  
  • Erica Logan  
  • Simon Lin  
  • David Axelson  

  Abstract:

  The use of telebehavioral health has been expanding in the past decade to improve access to psychiatric care and address critical shortages in the psychiatric workforce. The coronavirus (COVID-19) pandemic forced a sudden shift from traditional in-person visits to alternative modalities. There are key factors associated with successful transitional and large-scale implementation of telehealth with existing resources. We describe the experience of a large health care system using telehealth technology, and we identify strategies and discuss considerations for long-term sustainability after the pandemic.

  • JMIR Ment Health 2020;7(9):e20157

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  Theory and Frameworks in Mental Health

  Sep 18, 2020

  The VOICES Typology of Curatorial Decisions in Narrative Collections of the Lived Experiences of Mental Health Service Use, Recovery, or Madness: Qualitative...

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  Authors List:

  • Caroline Yeo  
  • Laurie Hare-Duke  
  • Stefan Rennick-Egglestone  
  • Simon Bradstreet  
  • Felicity Callard  
  • Ada Hui  
  • Joy Llewellyn-Beardsley  
  • Eleanor Longden  
  • Tracy McDonough  
  • Rose McGranahan  
  • Fiona Ng  
  • Kristian Pollock  
  • James Roe  
  • Mike Slade  

  Abstract:

  Background: Collections of lived experience narratives are increasingly used in health research and medical practice. However, there is limited research with respect to the decision-making processes involved in curating narrative collections and the work that curators do as they build and publish collections. Objective: This study aims to develop a typology of curatorial decisions involved in curating narrative collections presenting lived experiences of mental health service use, recovery, or madness and to document approaches selected by curators in relation to identified curatorial decisions. Methods: A preliminary typology was developed by synthesizing the results of a systematic review with insights gained through an iterative consultation with an experienced curator of multiple recovery narrative collections. The preliminary typology informed the topic guide for semistructured interviews with a maximum variation sample of 30 curators from 7 different countries. All participants had the experience of curating narrative collections of the lived experiences of mental health service use, recovery, or madness. A multidisciplinary team conducted thematic analysis through constant comparison. Results: The final typology identified 6 themes, collectively referred to as VOICES, which stands for values and motivations, organization, inclusion and exclusion, control and collaboration, ethics and legal, and safety and well-being. A total of 26 subthemes related to curation decisions were identified. Conclusions: The VOICES typology identifies the key decisions to consider when curating narrative collections about the lived experiences of mental health service use, recovery, or madness. It might be used as a theoretical basis for a good practice resource to support curators in their efforts to balance the challenges and sometimes conflicting imperatives involved in collecting, organizing, and sharing narratives. Future research might seek to document the use of such a tool by curators and hence examine how best to use VOICES to support decision making.

  • JMIR Ment Health 2020;7(9):e16290

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  Users' and Patients' Needs for Mental...

  Sep 16, 2020

  Mental Health Professional Consultations and the Prevalence of Mood and Anxiety Disorders Among Immigrants: Multilevel Analysis of the Canadian Community...

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  Authors List:

  • Chinenye Nmanma Nwoke  
  • Udoka Okpalauwaekwe  
  • Hauwa Bwala  

  Abstract:

  Background: There is a significant body of evidence on the link between migration and mental health stressors. However, there has been very little research on the use of mental health services by immigrants in Canada. The prevalence of mental health professional consultations among immigrants, as well as its correlations, are not well understood and remain largely unknown. Objective: This study aims to examine how specialist mental health visits (to a psychiatrist) differ from general mental health visits (to a family doctor or general practitioner) from immigrants, when compared to visits from those born in Canada, in a nationally representative sample of Canadian adults. This study also examines which group—immigrant or Canadian-born—suffers more from depression or anxiety, 2 of the more common mental health conditions. Methods: We used data from the Canadian Community Health Survey (CCHS) between the years 2015 and 2016. The outcome variables included consultation with any mental health professional, consultation with a specialist (psychiatrist), and the prevalence of mood and anxiety disorders. The independent variable was immigrant status. Other variables of interest were adjusted for in the analyses. Multilevel regression models were developed, and all analyses were performed with Stata IC statistical software (version 13.0, StataCorp). Results: The prevalence of mood and anxiety disorders was significantly lower among immigrants compared with individuals born in Canada; the prevalence of mood disorders was 5.24% (389,164/7,422,773) for immigrants vs. 9.15% (2,001,829/21,885,625) for individuals born in Canada, and the prevalence of anxiety disorders was 4.47% (330,937/7,410,437) for immigrants vs. 9.51% (2,083,155/21,898,839) for individuals born in Canada. It is expected that individuals with a lower prevalence of mood or anxiety disorders would use mental health services less frequently. However, results show that immigrants, while less likely to consult with any mental health professional (OR=0.80, 95% CI 0.72-0.88, P<.001), were more likely to consult with a psychiatrist (OR=1.24, 95% CI 1.04-1.48, P=.02) for their mental health visits when compared to individuals born in Canada. Conclusions: The results of this study reveal an unusual discord between the likelihood of mental health professional consultations with any mental health professional and mental health visits with psychiatrists among immigrants compared to nonimmigrants in Canada. Mental health initiatives need to be cognizant of the differences in the associated characteristics of consultations for immigrants to better tailor mental health services to be responsive to the unique needs of immigrant populations in Canada.

  • JMIR Ment Health 2020;7(9):e19168

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  Depression and Mood Disorders;...

  Sep 11, 2020

  Suicidal Thoughts and Behaviors and Their Associations With Transitional Life Events in Men and Women: Findings From an International Web-Based Sample

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  Authors List:

  • Alyssa Clare Milton  
  • Tracey A Davenport  
  • Frank Iorfino  
  • Anna Flego  
  • Jane M Burns  
  • Ian B Hickie  

  Abstract:

  Background: Although numerous studies have demonstrated sex differences in the prevalence of suicidal thoughts and behaviors (STB), there is a clear lack of research examining the similarities and differences between men and women in terms of the relationship between STB, transitional life events, and the coping strategies employed after experiencing such events when they are perceived as stressful. Objective: This study aims to examine the differences between men’s and women’s experiences of STB, sociodemographic predictors of STB, and how coping responses after experiencing a stressful transitional life event predict STB. Methods: A web-based self-report survey was used to assess the health and well-being of a voluntary community-based sample of men and women aged 16 years and older, living in Australia, Canada, New Zealand, the United Kingdom, and the United States, who were recruited using web-based social media promotion and snowballing. Results: In total, 10,765 eligible web-based respondents participated. Compared with men, a significantly greater proportion of women reported STB (P<.001) and endorsed experiencing a transitional life event as stressful (P<.001). However, there were no gender differences in reporting that the transitional life event or events was stressful for those who also reported STB. Significant sociodemographic adjusted risk factors of STB included younger age; identifying as a sexual minority; lower subjective social connectedness; lower subjective intimate bonds; experiencing a stressful transitional life event in the past 12 months; living alone (women only); not being in employment, education, or training (women only); suddenly or unexpectedly losing a job (men only); and experiencing a relationship breakdown (men only). Protective factors included starting a new job, retiring, having a language background other than English, and becoming a parent for the first time (men only). The results relating to coping after experiencing a self-reported stressful transitional life event in the past 12 months found that regardless of sex, respondents who reported STB compared with those who did not were less likely to engage in activities that promote social connections, such as talking about their feelings (P<.001). Coping strategies significantly explained 19.0% of the STB variance for men (F_16,1027=14.64; P<.001) and 22.0% for women (F_16,1977=36.45; P<.001). Conclusions: This research highlights multiple risk factors for STB, one of which includes experiencing at least one stressful transitional life event in the past 12 months. When individuals are experiencing such events, support from services and the community alike should consider using sex-specific or targeted strategies, as this research indicates that compared with women, more men do nothing when experiencing stress after a transitional life event and may be waiting until they experience STB to engage with their social networks for support.

  • JMIR Ment Health 2020;7(9):e18383

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  Methods and New Tools in Mental...

  Sep 10, 2020

  Detection of Behavioral Anomalies in Medication Adherence Patterns Among Patients With Serious Mental Illness Engaged With a Digital Medicine System

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  Authors List:

  • Jonathan Knights  
  • Zahra Heidary  
  • Jeffrey M Cochran  

  Abstract:

  Background: Adherence to medication is often represented in the form of a success percentage over a period of time. Although noticeable changes to aggregate adherence levels may be indicative of unstable medication behavior, a lack of noticeable changes in aggregate levels over time does not necessarily indicate stability. The ability to detect developing changes in medication-taking behavior under such conditions in real time would allow patients and care teams to make more timely and informed decisions. Objective: This study aims to develop a method capable of identifying shifts in behavioral (medication) patterns at the individual level and subsequently assess the presence of such shifts in retrospective clinical trial data from patients with serious mental illness. Methods: We defined the term adherence volatility as “the degree to which medication ingestion behavior fits expected behavior based on historically observed data” and defined a contextual anomaly system around this concept, leveraging the empirical entropy rate of a stochastic process as the basis for formulating anomaly detection. For the presented methodology, each patient’s evolving behavior is used to dynamically construct the expectation bounds for each future interval, eliminating the need to rely on model training or a static reference sequence. Results: Simulations demonstrated that the presented methodology identifies anomalous behavior patterns even when aggregate adherence levels remain constant and highlight the temporal dependence inherent in these anomalies. Although a given sequence of events may present as anomalous during one period, that sequence should subsequently contribute to future expectations and may not be considered anomalous at a later period—this feature was demonstrated in retrospective clinical trial data. In the same clinical trial data, anomalous behavioral shifts were identified at both high- and low-adherence levels and were spread across the whole treatment regimen, with 77.1% (81/105) of the population demonstrating at least one behavioral anomaly at some point in their treatment. Conclusions: Digital medicine systems offer new opportunities to inform treatment decisions and provide complementary information about medication adherence. This paper introduces the concept of adherence volatility and develops a new type of contextual anomaly detection, which does not require an a priori definition of normal and allows expectations to evolve with shifting behavior, removing the need to rely on training data or static reference sequences. Retrospective analysis from clinical trial data highlights that such an approach could provide new opportunities to meaningfully engage patients about potential shifts in their ingestion behavior; however, this framework is not intended to replace clinical judgment, rather to highlight elements of data that warrant attention. The evidence provided here identifies new areas for research and seems to justify additional explorations in this area.

  • JMIR Ment Health 2020;7(9):e21378

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  Interventions and Support for...

  Sep 3, 2020

  The Use of Mumsnet by Parents of Young People With Mental Health Needs: Qualitative Investigation

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  Authors List:

  • Lauren Croucher  
  • Elif Mertan  
  • Roz Shafran  
  • Sophie D Bennett  

  Abstract:

  Background: There are high rates of mental health needs in children in the United Kingdom, and parents are increasingly seeking help for their children's needs. However, there is not enough access to child and adolescent mental health services and parents are seeking alternative forms of support and information, often from web-based sources. Mumsnet is the largest web-based parenting forum in the United Kingdom, which includes user-created discussions regarding child mental health. Objective: This qualitative investigation aimed to explore the emergent themes within the narratives of posts regarding child mental health on Mumsnet and to extrapolate these themes to understand the purpose of Mumsnet for parents of children and young people with mental health needs. Methods: A total of 50 threads from Mumsnet Talk Child Mental Health were extracted. Following the application of inclusion and exclusion criteria, 41 threads were analyzed thematically using the framework approach, a form of qualitative thematic analysis. Results: In total, 28 themes were extracted and organized into 3 domains. These domains were emotional support, emotional expression, and advice and information. The results suggested that parents of children with mental health needs predominantly use Mumsnet to offer and receive emotional support and to suggest general advice, techniques, and resources that could be applied outside of help from professional services. Conclusions: This paper discusses the future of health information seeking. Future research is required to establish initiatives in which web-based peer-to-peer support and information can supplement professional services to provide optimum support for parents of children with mental health needs.

  • JMIR Ment Health 2020;7(9):e18271

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  Depression and Mood Disorders;...

  Sep 3, 2020

  Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study

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  Authors List:

  • Katarzyna Stawarz  
  • Chris Preist  
  • Debbie Tallon  
  • Nicola Wiles  
  • David Kessler  
  • Katrina Turner  
  • Roz Shafran  
  • David Coyle  

  Abstract:

  Background: Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists’ workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. Objective: The research aimed to explore patients’ and therapists’ views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. Methods: We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. Results: Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists’ workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. Conclusions: To meet clients’ and therapists’ needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists’ workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context.

  • JMIR Ment Health 2020;7(9):e15972

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  Diagnostic Tools in Mental Health

  Sep 1, 2020

  Utilizing Machine Learning on Internet Search Activity to Support the Diagnostic Process and Relapse Detection in Young Individuals With Early Psychosis:...

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  Authors List:

  • Michael Leo Birnbaum  
  • Prathamesh "Param" Kulkarni  
  • Anna Van Meter  
  • Victor Chen  
  • Asra F Rizvi  
  • Elizabeth Arenare  
  • Munmun De Choudhury  
  • John M Kane  

  Abstract:

  Background: Psychiatry is nearly entirely reliant on patient self-reporting, and there are few objective and reliable tests or sources of collateral information available to help diagnostic and assessment procedures. Technology offers opportunities to collect objective digital data to complement patient experience and facilitate more informed treatment decisions. Objective: We aimed to develop computational algorithms based on internet search activity designed to support diagnostic procedures and relapse identification in individuals with schizophrenia spectrum disorders. Methods: We extracted 32,733 time-stamped search queries across 42 participants with schizophrenia spectrum disorders and 74 healthy volunteers between the ages of 15 and 35 (mean 24.4 years, 44.0% male), and built machine-learning diagnostic and relapse classifiers utilizing the timing, frequency, and content of online search activity. Results: Classifiers predicted a diagnosis of schizophrenia spectrum disorders with an area under the curve value of 0.74 and predicted a psychotic relapse in individuals with schizophrenia spectrum disorders with an area under the curve of 0.71. Compared with healthy participants, those with schizophrenia spectrum disorders made fewer searches and their searches consisted of fewer words. Prior to a relapse hospitalization, participants with schizophrenia spectrum disorders were more likely to use words related to hearing, perception, and anger, and were less likely to use words related to health. Conclusions: Online search activity holds promise for gathering objective and easily accessed indicators of psychiatric symptoms. Utilizing search activity as collateral behavioral health information would represent a major advancement in efforts to capitalize on objective digital data to improve mental health monitoring.

  • JMIR Ment Health 2020;7(9):e19348

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  Telepsychiatry

  Aug 28, 2020

  COVID-19 and Telepsychiatry: Development of Evidence-Based Guidance for Clinicians

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  Authors List:

  • Katharine Smith  
  • Edoardo Ostinelli  
  • Orla Macdonald  
  • Andrea Cipriani  

  Abstract:

  Background: The coronavirus disease (COVID-19) presents unique challenges in health care, including mental health care provision. Telepsychiatry can provide an alternative to face-to-face assessment and can also be used creatively with other technologies to enhance care, but clinicians and patients may feel underconfident about embracing this new way of working. Objective: The aim of this paper is to produce an open-access, easy-to-consult, and reliable source of information and guidance about telepsychiatry and COVID-19 using an evidence-based approach. Methods: We systematically searched existing English language guidelines and websites for information on telepsychiatry in the context of COVID-19 up to and including May 2020. We used broad search criteria and included pre–COVID-19 guidelines and other digital mental health topics where relevant. We summarized the data we extracted as answers to specific clinical questions. Results: Findings from this study are presented as both a short practical checklist for clinicians and detailed textboxes with a full summary of all the guidelines. The summary textboxes are also available on an open-access webpage, which is regularly updated. These findings reflected the strong evidence base for the use of telepsychiatry and included guidelines for many of the common concerns expressed by clinicians about practical implementation, technology, information governance, and safety. Guidelines across countries differ significantly, with UK guidelines more conservative and focused on practical implementation and US guidelines more expansive and detailed. Guidelines on possible combinations with other digital technologies such as apps (eg, from the US Food and Drug Administration, the National Health Service Apps Library, and the National Institute for Health and Care Excellence) are less detailed. Several key areas were not represented. Although some special populations such as child and adolescent, and older adult, and cultural issues are specifically included, important populations such as learning disabilities, psychosis, personality disorder, and eating disorders, which may present particular challenges for telepsychiatry, are not. In addition, the initial consultation and follow-up sessions are not clearly distinguished. Finally, a hybrid model of care (combining telepsychiatry with other technologies and in-person care) is not explicitly covered by the existing guidelines. Conclusions: We produced a comprehensive synthesis of guidance answering a wide range of clinical questions in telepsychiatry. This meets the urgent need for practical information for both clinicians and health care organizations who are rapidly adapting to the pandemic and implementing remote consultation. It reflects variations across countries and can be used as a basis for organizational change in the short- and long-term. Providing easily accessible guidance is a first step but will need cultural change to implement as clinicians start to view telepsychiatry not just as a replacement but as a parallel and complementary form of delivering therapy with its own advantages and benefits as well as restrictions. A combination or hybrid approach can be the most successful approach in the new world of mental health post–COVID-19, and guidance will need to expand to encompass the use of telepsychiatry in conjunction with other in-person and digital technologies, and its use across all psychiatric disorders, not just those who are the first to access and engage with remote treatment.

  • JMIR Ment Health 2020;7(8):e21108

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