Published on 28.08.20 in Vol 7, No 8 (2020): August
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/21108, first published Jun 05, 2020.
COVID-19 and Telepsychiatry: Development of Evidence-Based Guidance for Clinicians
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
The coronavirus disease (COVID-19) and the measures taken to limit its spread present unique challenges in all aspects of our everyday life. It is a rapidly progressing disease, evolving from its first description in December 2019 to a global pandemic with consequences worldwide . In the absence of a new and effective vaccine, social distancing, isolation, and quarantine are the most effective interventions used across many countries to slow the spread of transmission [ ].
These interventions have provided significant challenges for mental health care systems who (as part of wider health care) have been forced to reappraise ways of working in a rapid time frame, to change to telepsychiatry where possible and to provide adequate information technology systems for mental health care staff to provide remote care. This has happened in a time frame that in many countries, including the United Kingdom, would have been considered impossible only a few months ago . In addition, the need for mental health support is likely to increase. Although COVID-19 is primarily a respiratory disease, data from the long-term neuropsychiatric sequelae of other severe coronavirus infections such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), and preliminary data for COVID-19 suggest not only significant rates of delirium in the acute stage but also depression, anxiety, fatigue, posttraumatic stress disorder (PTSD), and rarer neuropsychiatric syndromes in the longer term [ ]. These longer-term mental health symptoms combined with the stresses of quarantine and self-isolation [ ] are likely to increase demand for assessment and support from mental health services.
Despite evidence that e-therapy is equivalent to face-to-face therapy in terms of therapeutic alliance , there remains a concern from clinicians that telepsychiatry, in general, may not be as effective as “in-person” mental health care. In addition, clinicians are concerned that telepsychiatry cannot replace the team assessment and multidisciplinary approach that are at the center of modern mental health care provision [ ]. It is also often assumed that patients may be reluctant or unable to engage with the technology involved. Mental health care provision, especially in the United Kingdom, has previously reflected this view [ ], and although telepsychiatry has been introduced in the United Kingdom in some more remote areas [ ], this has been, to at least some extent, out of necessity rather than preference.
In fact, the evidence, especially from the United States  shows the opposite. Telemedicine and telepsychiatry are well-established fields and are preferable in many areas such as for patients on the autistic spectrum and those with anxiety symptoms [ ]. It can add value, for example, in bringing together subspecialty expertise in an easier and quicker way than in-person assessment, and in completing home and nursing home assessments more rapidly and efficiently. There is strong evidence of effectiveness and acceptability across different settings and many disciplines of psychiatry including older adult, child, and adolescent psychiatry, and across different cultures [ ].
COVID-19 and its associated restrictions have prompted both clinicians and patients to reconsider telepsychiatry as a viable and valuable option. However, with change comes uncertainty and many clinicians in mental health feel unprepared for the new ways of working . Areas of uncertainty such as issues of information governance, consent and confidentiality, accuracy of diagnosis, and modifications to any physical examination that may be appropriate are frequent questions in implementing digital technologies in the era of COVID-19 [ ].
To integrate telepsychiatry successfully into the post–COVID-19 plan for clinical practice in psychiatry, clinicians, patients, and health care organizations need access to reliable and pragmatic clinical guidance and evidence . In this rapidly evolving situation, with daily updates from specialties, countries, and world organizations, the amount of information available for the busy clinician can be overwhelming. We aim to meet this need by providing focused, evidence-based guidance on the use of digital technologies and telepsychiatry.
A team of researchers with multidisciplinary backgrounds (including mental health clinicians, researchers, methodologists, and a pharmacist) from the Oxford Precision Psychiatry Lab  systematically searched English language websites from the United Kingdom, the United States, Australia, New Zealand, Canada, and Singapore for guidelines on telepsychiatry and telemedicine relevant to mental health and applicable in the context of the current COVID-19 pandemic and afterwards. We decided to focus on English language guidelines in the initial search both to meet the rapid time scale for focused guidance requested by our local clinicians and to include non-UK sites to ensure the synthesis of guidelines is relevant across other countries [ ]. Two researchers (KS and EO) searched independently across the following sources in English, without age limits: Public Health England, Royal College of Psychiatrists, Royal College of Nursing, The National Association of Intensive Care and Low Secure Units, Royal College of Physicians, Healthcare Improvement Scotland, South London and Maudsley National Health Service (NHS) Trust, the National Institute for Health and Care Excellence, NHS Wales, General Medical Council, NHSX, Nursing and Midwifery Council (NMC), Centers for Disease Control and Prevention (CDC), US Department of Labor, American Psychiatric Association, Massachusetts General Hospital Department of Psychiatry, Federation of State Medical Boards (FSMB), Centers for Medicare and Medicaid Services (CMS), World Health Organization, Inter Agency Standing Committee, the United Nations International Children's Emergency Fund, World Psychiatric Association, Singapore Ministry of Health, Singapore Psychiatric Association, Singapore Medical Association, Health Canada, Canadian Psychiatric Association, Australian Government Department of Health, and the Royal Australian and New Zealand College of Psychiatrists. References to other sources from each website were also searched. Our search focused on guidelines for telepsychiatry in the context of COVID-19 up to and including May 2020. However, we decided to use a broad approach to the search to include both pre–COVID-19 guidelines where appropriate and guidelines for relevant digital technologies such as digital platforms for monitoring symptoms and the use of apps. A search on Google was also completed using keywords relevant to COVID-19 (eg, COVID-19, coronavirus, SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2]), digital mental health (eg, digital mental health, telepsychiatry, digital psychiatry), and guidelines (eg, guideline, guidance, recommendation). Queries or disagreements were resolved by team discussion, and the team collaborated with an expert in the field to keep the guidance global, focused, and comprehensive.
The final synthesis of guidelines on telepsychiatry (including other relevant digital technologies) is presented here and is also available in an open-access webpage  in three different formats: (1) a webpage with embedded hyperlinks for online viewing, (2) a downloadable PDF for saving or printing, and (3) a detailed Word (Microsoft Corporation) document with sources and all information. Feedback and corrections from readers of the webpage are actively invited. Questions and answers are grouped together for ease of use. The sources are searched on a regular basis, and the tables on the webpage are updated accordingly.
We synthesized the guidelines and produced both a short practical checklist () for clinicians to consider before, during, and after the consultation, and detailed textboxes ( - ) with a full summary of all the guidelines. Different guidelines use different terms (for example, telemedicine, telepsychiatry, videoconferencing, and telephone consultation). In our textboxes we have used the original terms from each guideline, and a glossary of definitions is included at the beginning of . - cover general guidance (for all ages) with specific-labelled sections for children and adolescents, and older adults. The most up to date and detailed versions of the textboxes are available online [ ].
We used a synthesis of the guidelines to answer specific questions generated by clinicians on telepsychiatry and related digital technologies using the following sources: American Psychiatric Association (APA), CDC, CMS, FSMB, General Medical Council (GMC), Massachusetts General Hospital Department of Psychiatry, NHS Wales, NHSX (a joint team from the Department of Health and Social Care and NHS England and NHS Improvement), the National Institute for Health and Care Excellence (NICE), NMC, Public Health England, Royal College of Psychiatrists, and Singapore Psychiatric Association.
The full list of the sources searched, specific sources used, and further detail with webpage links on each point are contained in.
In this paper we have summarized the available evidence base for guidelines in telepsychiatry across a wide variety of treatment modalities and populations. Telepsychiatric treatment has not previously been implemented on the scale and speed demanded by the current COVID-19 crisis. This is, at least in part, because mental health clinicians feel a lack of detailed knowledge and experience in telepsychiatry, and often express concerns about establishing rapport and therapeutic alliance , and key areas such as assessing risk and safeguarding [ ]. Developing skills in telepsychiatry, including competence in creating a so-called “webside manner” [ ] requires knowledge, training, and experience. Building confidence and knowledge is the first important step and requires easy access to a reliable source of existing information, such as that summarized in our synthesis of guidance.
Training clinicians is the next key area, both in the practical use of remote consultations and in the use of digital interventions, treatments, and mobile apps. Frameworks for training exist [, ] but have not been widely implemented in practice. However, teaching experience such as with psychiatry residents has been positive, and there are already many successful examples of teaching telemedicine [ ]. Training takes time, so it does not offer an immediate solution to the current crisis, but it will build capacity for increased access to care for the mental health sequelae of the current crisis and help to prepare for the next.
Training for clinicians is only one part of the story. It is also important to ensure that all patients have access to telepsychiatry. Many people may be prevented from accessing digital health, either because of a lack of skill or competence, or because of a lack of suitable access to reliable internet connections, smartphones, or similar platforms . These reasons affect particularly the most vulnerable in society; issues such as age, language, cultural background, and homelessness can all contribute. Training programs for patients [ ] have been effective in increasing patients’ confidence and competence, but practical access to relevant technology is a wider societal issue. Clinicians also need to be aware that telepsychiatry is a tool for consultation, which needs to be adapted flexibly and creatively to each patient’s needs, preferences, and circumstances. As the guidelines in section 2a of outline, a pragmatic approach needs to be taken, particularly during the constraints of the COVID-19 pandemic; for example, telephone consultations may be used to facilitate engagement with those who lack access to digital technology or the skills or confidence to use video platforms. Alternatively, a hybrid or blended approach (as discussed later) may be the best option for some patients after weighing the potential risks and benefits for an individual, even during the COVID-19–related constraints imposed on in-person contact. Careful preparation in advance, as outlined in section 3a of , can also help to ensure that time spent during the consultation is as comfortable and effective for the patient as possible. Part of this preparation should also be to remind patients that their usual rights (for example, for a second opinion, to make a complaint, or decline a treatment) are the same whether the meeting is in person or delivered remotely.
As well as clinicians and patients, organizations providing services in mental health care also need to implement changes to reflect the acceptance of telepsychiatry as a valid and beneficial treatment option. In the short-term response to the crisis, there have been examples of organizational changes such as the lifting of state and federal regulation in the United States that had previously been barriers . Longer term, it is unclear whether these changes will return to pre–COVID-19 rules or not. To ensure that these changes continue, clinicians and organizations need to campaign proactively for long-term change [ ]. Central to this will be widespread dissemination of evidence-based guidance to clinicians who can then gain the confidence and competence needed to implement telepsychiatry and to extend its use beyond the short-term crisis. Research on the implementation of telepsychiatry will also need to assess outcomes and their cost-effectiveness, to support long-term change to systems of payment and insurance [ ].
One route to demonstrating the clinical efficacy and cost-effectiveness of telepsychiatry, particularly as a longer-term strategy, will be to assess its use not only as a replacement for face-to-face care but also as a possibility for an enhanced level of care. It offers options for patients to personalize their treatment in choosing how they want to see their psychiatrist. In the aftermath of COVID-19, many patients may choose to continue with remote consultation because of its advantages such as privacy (reducing stigma) and convenience. For a small minority, particularly those with psychosis or persecutory beliefs, remote psychiatry may seem less trustworthy than in-person care. Post–COVID-19, patients will be able to individualize their care, balancing the pros and cons for their own treatment, with many opting for a hybrid model across different remote and in-person settings. Clinicians will need to balance the strengths, limitations, and adjustments needed for each approach and feel competent in using all media .
Telepsychiatry also offers options for easily combining with other digital technologies. These include platforms for monitoring symptoms such as mood monitoring systems  or combining care with apps [ ]. Smartphone apps offer advantages in accessibility, insights into physical and cognitive behavior, and a range of resources designed to aid health. However, there are challenges to be addressed; clinicians and patients need to assess these digital resources for efficacy, safety, and security so that only high quality and clinically effective apps are offered to patients [ ]. Although there are app comparison sites (for example, [ ]), the volume of work in appraising apps is ever increasing, so sites often show a lack of concordance between ratings of the same app, may use qualitative measures, and are quickly out of date. For example, the initial version of the NHS Apps Library [ ] was withdrawn after criticism of a lack of consistency in evidence of effectiveness, privacy, and confidentiality. The library was relaunched but now offers advice rather than regulation. The APA app evaluation framework [ ] suggests that users (patients and clinicians) ask questions across the areas of safety and privacy, evidence, ease of use, and interoperability, supplemented if possible with a self-certification checklist completed by developers or volunteers on a frequent basis. Ideally, this would mean that a patient could filter categories for app choices that meet their requirements across the areas assessed. Apps are twice as effective when used with a clinician [ ], so their combination with telepsychiatry presents exciting opportunities. Similarly, the addition of apps to provide lifestyle interventions [ ] is particularly relevant during the current restrictions and will be an important opportunity both during the acute crisis of COVID-19 and afterwards.
Some potential limitations of our work should be acknowledged. The original search was restricted to English language sources, but international collaborators are producing translations (for example, in French, Turkish, and Chinese) and adaptations for local use before dissemination. Any summary of guidance needs to reflect the global perspective, as implementation and advice on telemedicine and telepsychiatry vary. Balancing guidelines across countries is a key area of concern when producing a summary of evidence. UK guidelines on telepsychiatry (for example, those from the Royal College of Psychiatrists and GMC) are generally more cautious and emphasize possible constraints, whereas US views are more expansive, with stronger emphasis on the evidence base and the potential benefits of combining with apps and other technologies. Although valuable COVID-19 specific mental health treatment guidance is starting to be generated (for example, in the UK, COVID-19–specific guidance in how to remotely deliver the NICE recommended cognitive therapies for PTSD, social anxiety disorder, and panic disorder ), the vast majority of guidance and evidence on use of telepsychiatry is based on the pre–COVID-19 era. Although there is some preliminary data on the use of telepsychiatry in other disasters [ ], the COVID-19 crisis is different to previous pandemics. Thus, this synthesis of guidance contains a combination of pre–COVID-19 guidelines mixed with recent crisis guidelines. Although the COVID-19 guidelines are more pragmatic and perhaps more relevant, this combination does produce inconsistencies (for example, on whether consent to telepsychiatry meetings is implicit or needs to be explicit).
Most of the guidelines focus on practical implementation in general adult psychiatry (with some specific guidelines for younger and older patients). Although this is helpful, if telepsychiatry is to be integrated into routine care in the longer term, then guidance also needs to focus on those areas and patient populations who may be more difficult to engage, for example, those with learning disabilities, psychotic symptoms including persecutory beliefs, personality disorders, and eating disorders. In addition, the guidelines do not clearly differentiate between initial assessment and follow-up. Although the general principles may be the same, the focus of these different encounters may vary, and these are not clearly defined. The existing guidelines do not specifically include the concept of hybrid or blended care, which is the route most likely to be effective in the longer term. This involves the combination of telepsychiatry with not only in-person care but also other digital technologies. Frameworks for telepsychiatry alone are well established and are more preliminary for digital technologies, and there is no clear guidance on the combination of all. Hybrid care will be key in the way forward post–COVID-19 to allow clinicians and their patients to choose the individual combination of care that offers the most advantages. To do this, mental health clinicians need to become adept at managing hybrid clinician-patient relationships and have a detailed understanding of the advantages and limitations of all the tools they use to care for patients .
The acute COVID-19 pandemic and its aftermath present new challenges. Although the benefits of implementing telepsychiatry are clear, this can only be fully realized if clinicians see this as an opportunity for not only a short-term solution to a crisis but also a cultural shift and opportunity to integrate the benefits of telepsychiatry into a model of blended care in the future. The acute crisis can be an opportunity to develop and implement digital mental health in a collaborative environment between patients, carers, and clinicians. This is an important moment where mental health professionals and health care providers can embrace telepsychiatry and introduce new and innovative strategies to make long-lasting improvements in the access to and quality of mental health care provision.
KS, EO, and AC are supported by the National Institute for Health Research (NIHR) Oxford Cognitive Health Clinical Research Facility. AC is also supported by an NIHR Research Professorship (grant RP-2017-08-ST2-006), the NIHR Oxford and Thames Valley Applied Research Collaboration, and the NIHR Oxford Health Biomedical Research Centre (grant BRC-1215-20005). The views expressed are those of the authors and not necessarily those of the UK NHS, the NIHR, or the UK Department of Health.
We thank Dr John Torous for his advice and guidance with the digital mental health table. We would also like to thank our international collaborators: Peng Xie (China), Toshi Furukawa (Japan), Astrid Chevance (France), Stefan Leucht, Stephan Herres (Germany), Ayse Kurtulmus (Turkey), Armando D’Agostino (Italy), John Torous, and Scott Stroup (United States).
Conflicts of Interest
AC has received research and consultancy fees from the Italian Network for Paediatric Trials, the Cariplo Foundation, and Angelini Pharma outside the submitted work. KS, OM, and EO have nothing to declare.
Supplementary material.DOCX File , 22 KB
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|APA: American Psyciatric Association|
|CDC: Centers for Disease Control and Prevention|
|CMS: Centers for Medicare and Medicaid Services|
|COVID-19: coronavirus disease|
|FSMB: Federation of State Medical Boards|
|GMC: General Medical Council|
|NHS: National Health Service|
|NICE: National Institute of Health and Care Excellence|
|NIHR: National Institute for Health Research|
|NMC: Nursing and Midwifery Council|
|PTSD: posttraumatic stress disorder|
|SARS-CoV-2: severe acute respiratory syndrome coronavirus 2|
Edited by G Eysenbach, J Torous; submitted 05.06.20; peer-reviewed by A Knapp, S Hugh-Jones; comments to author 29.06.20; revised version received 10.07.20; accepted 10.07.20; published 28.08.20
©Katharine Smith, Edoardo Ostinelli, Orla Macdonald, Andrea Cipriani. Originally published in JMIR Mental Health (http://mental.jmir.org), 28.08.2020.
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