Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions' approaches to an evolving healthcare landscape

A mixed methods analysis of existing assessment and evaluation tools (AETs) for mental health applications

Introduction

Mental health Applications (MH Apps) can potentially improve access to high-quality mental health care. However, the recent rapid expansion of MH Apps has created growing concern regarding their safety and effectiveness, leading to the development of AETs (Assessment and Evaluation Tools) to help guide users. This article provides a critical, mixed methods analysis of existing AETs for MH Apps by reviewing the criteria used to evaluate MH Apps and assessing their effectiveness as evaluation tools.

Methods

To identify relevant AETs, gray and scholarly literature were located through stakeholder consultation, Internet searching via Google and a literature search of bibliographic databases Medline, APA PsycInfo, and LISTA. Materials in English that provided a tool or method to evaluate MH Apps and were published from January 1, 2000, to January 26, 2021 were considered for inclusion.

Results

Thirteen relevant AETs targeted for MH Apps met the inclusion criteria. The qualitative analysis of AETs and their evaluation criteria revealed that despite purporting to focus on MH Apps, the included AETs did not contain criteria that made them more specific to MH Apps than general health applications. There appeared to be very little agreed-upon terminology in this field, and the focus of selection criteria in AETs is often IT-related, with a lesser focus on clinical issues, equity, and scientific evidence. The quality of AETs was quantitatively assessed using the AGREE II, a standardized tool for evaluating assessment guidelines. Three out of 13 AETs were deemed 'recommended' using the AGREE II.

Discussion

There is a need for further improvements to existing AETs. To realize the full potential of MH Apps and reduce stakeholders' concerns, AETs must be developed within the current laws and governmental health policies, be specific to mental health, be feasible to implement and be supported by rigorous research methodology, medical education, and public awareness.

Innovation in the Delivery of Behavioral Health Services

Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.

Live two-way video versus face-to-face treatment for depression, anxiety, and obsessive-compulsive disorder: A 24-week randomized controlled trial

AIM

Live two-way video, easily accessible from home via smartphones and other devices, is becoming a new way of providing psychiatric treatment. However, lack of evidence for real-world clinical setting effectiveness hampers its approval by medical insurance in some countries. Here, we conducted the first large-scale pragmatic, randomized controlled trial to determine the effectiveness of long-term treatment for multiple psychiatric disorders via two-way video using smartphones and other devices, which are currently the primary means of telecommunication.

METHODS

This randomized controlled trial compared two-way video versus face-to-face treatment for depressive disorder, anxiety disorder, and obsessive-compulsive disorder in the subacute/maintenance phase during a 24-week period. Adult patients with the above-mentioned disorders were allocated to either a two-way video group (≥50% video sessions) or a face-to-face group (100% in-person sessions) and received standard treatment covered by public medical insurance. The primary outcome was the 36-Item Short-Form Health Survey Mental Component Summary (SF-36 MCS) score. Secondary outcomes included all-cause discontinuation, working alliance, adverse events, and the severity rating scales for each disorder.

RESULTS

A total of 199 patients participated in this study. After 24 weeks of treatment, two-way video treatment was found to be noninferior to face-to-face treatment regarding SF-36 MCS score (48.50 vs 46.68, respectively; p < 0.001). There were no significant differences between the groups regarding most secondary end points, including all-cause discontinuation, treatment efficacy, and satisfaction.

CONCLUSION

Two-way video treatment using smartphones and other devices, was noninferior to face-to-face treatment in real-world clinical settings. Modern telemedicine, easily accessible from home, can be used as a form of health care.

Telepsychiatry in Australia: A Scoping Review

Telepsychiatry formed part of the Australian mental health response to COVID-19, but relevant reviews pre- and post-pandemic are sparse. This scoping review aimed to map the literature on telepsychiatry in Australia and identify key research priorities. We searched databases (Medline, PubMed, PsycINFO, Scopus, Web of Science, EBSCO Psychology & Behavioral Sciences Collection, Proquest databases, and Cochrane Central Register of Controlled Trials) and reference lists from January 1990 to December 2022. Keywords included telepsychiatry, videoconferencing, telephone consultation, psychiatry, mental health, and Australia. Two reviewers independently screened titles, abstracts, and full texts. We identified 96 publications, one-third of which appeared since 2020. Extracted data included article types, service types, usage levels, outcome measures, perceptions, and research gaps. Most publications were quantitative studies (n = 43) and narrative reports of services (n = 17). Seventy-six papers reported mostly publicly established services. Videoconferencing alone was the most common mode of telepsychiatry. There was increased use over time, with the emergence of metropolitan telepsychiatry during the pandemic. Few papers used validated outcome measures (n = 5) or conducted economic evaluations (n = 4). Content analysis of the papers identified perceptions of patient (and caregiver) benefits, clinical care, service sustainability, and technology capability/capacity. Benefits such as convenience and cost-saving, clinical care issues, and implementation challenges were mentioned. Research gaps in patient perspectives, outcomes, clinical practice, health economics, usage patterns, and technological issues were identified. There is consistent interest in, and growth of, telepsychiatry in Australia. The identified perception themes might serve as a framework for future research on user perspectives and service integration. Other research areas include usage trends, outcome measures, and economic evaluation.

Stakeholders' views and opinions on existing guidelines on "How to Choose Mental Health Apps"

Background

Mental health Applications (Mhealth Apps) can change how healthcare is delivered. However, very little is known about the efficacy of Mhealth Apps. Currently, only minimum guidance is available in Assessment and Evaluation Tools (AETs). Therefore, this project aims to understand AET developers' perspectives and end users' experiences and opinions on "how to choose a Mhealth App".

Objective

The primary objectives were: (1) obtaining stakeholder's opinions and experiences of development and use of AETs for Mhealth Apps, their weaknesses and strengths, and barriers in their implementation of Mhealth Apps; (2) the experiences of App users, their analyzation and, obstacles in the use of apps; and (3) to quantify themes related to choosing a Mhealth App.

Methods

This qualitative study, used a sampling method to recruit six stakeholders (one App developer, two AET developers, an individual with lived experience of mental health illness, and two physicians) who were interviewed using a topic guide. These were examined by researchers (CT, WK, & FN) using thematic content analysis. Additionally, an anonymous online survey of 107 individuals was conducted.

Findings

Our analyses revealed six main themes: (a) needs and opportunities; (b) views on Mhealth apps; (c) views & opinions on AETs; (d) implementation barriers; (e) system of evaluation and; (f) future directions. The first key concept was, all stakeholders agreed that Apps could significantly impact mental health and that end-users were unaware of mental health AETs and Apps. Secondly, due to commercial interests, end-users reliability of App evaluations requires clear conflict-free guidelines. Thirdly, AETs should be evaluated and developed through a rigorous methodology. Finally, stakeholders shared insights into future developments for AETs and Mhealth Apps. Additionally, online survey respondents chose a "health professional" as their preferred source of guidance in selecting a Mhealth app (84%) and best suited to develop guidelines (70%).

Conclusion

The interviews and survey highlight the need for Mhealth Apps to be regulated and the importance of health professionals' engagement in the implementation process. Similarly, without well-defined roles for App evaluations within the health care system, it is unlikely that AETs will have wider spread use and impact without risk.

Enabling Expedited Disposition of Emergencies Using Telepsychiatry in Israel: Protocol for a Hybrid Implementation Study

BACKGROUND

Telepsychiatry is the use of virtual communication, such as a video link, to deliver mental health assessment, treatment, and follow-up. Previous studies have shown telepsychiatry to be feasible, accurate compared with in-person practice, and satisfying for psychiatrists and patients. Telepsychiatry has also been associated with reduced waiting times for evaluation and, in some studies, lower admission rates. However, most previous studies focused on using telepsychiatry in community settings and not on involuntary admission.

OBJECTIVE

The aim of this study is to examine the effectiveness and implementation process of patient assessment for involuntary admissions in the psychiatric emergency department (ED) using a video link.

METHODS

This type 1 hybrid implementation study will examine telepsychiatry effectiveness and the implementation process, by comparing telepsychiatry (n=240) with historical controls who had a face-to-face evaluation (n=240) during the previous, usual care period in 5 psychiatric EDs in Israel. A temporary waiver of the standing policy requiring in-person evaluations only, for the purpose of research, was obtained from the Israeli Ministry of Health. During the telepsychiatry phase, clinical staff and patients will join a video call from the ED, while the attending physician will log in elsewhere. The Promoting Action on Research Implementation in Health Services (PARIHS) framework will guide the evaluation of the telepsychiatry implementation process in the ED. PARIHS has the following 3 constructs: (1) evidence: staff's opinions regarding the innovation's viability and practicality, their satisfaction levels with its use, and patients' perceptions of the change; (2) context: level of approval of new strategies in the ED, decision-making processes, and the manner in which clinical teams converse and work together; (3) facilitation: adequacy of the facilitation efforts using champions reports. Primary clinical outcomes include ED length of stay and violent incidents obtained from medical records.

RESULTS

This study received Helsinki approval from the Ethics Committee of Abarbanel Mental Health Center (174; March 13, 2023), Jerusalem Mental Health Center (22-21; November 6, 2022), Lev-Hasharon Mental Health Medical Center (LH12023; February 12, 2023), Tel-Aviv Medical Center (TLV-22-0656; January 3, 2023), and Sha'ar Menashe (1-4-23; April 18, 2023). Data collection began in July 2023 in 2 study sites and will begin soon at the others.

CONCLUSIONS

Telepsychiatry could have significant benefits for patients in the psychiatric ED. Examining telepsychiatry effectiveness in the ED, in addition to identifying the facilitators and barriers of implementing it in different emergency settings, will facilitate better policy decisions regarding its implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05771545; https://clinicaltrials.gov/study/NCT05771545.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49405.

Patient Experience of Digitalized Follow-up of Antidepressant Treatment in Psychiatric Outpatient Care: Qualitative Analysis

BACKGROUND

Nonadherence to pharmaceutical antidepressant treatment is common among patients with depression. Digitalized follow-up (ie, self-monitoring systems through mobile apps) has been suggested as an effective adjunct to conventional antidepressant treatment to increase medical adherence, improve symptoms of depression, and reduce health care resource use.

OBJECTIVE

The aim of this study was to determine patients' experience of digitalized follow-up using a mobile app as an adjunct to treatment concurrent with a new prescription, a change of antidepressant, or a dose increase.

METHODS

This was a qualitative, descriptive study. Patients at 2 psychiatric outpatient clinics were recruited at the time of changing antidepressant medication. After using a mobile app (either a commercial app or a public app) for 4-6 weeks with daily registrations of active data, such as medical intake and questions concerning general mental health status, individual semistructured interviews were conducted. Recorded data were transcribed and then analyzed using content analysis.

RESULTS

In total, 13 patients completed the study. The mean age was 35 (range 20-67) years, 8 (61.5%) were female, and all reported high digital literacy. Overall, the emerging themes indicated that the patients found the digital app to be a valuable adjunct to antidepressant treatment but with potential for improvement. Both user adherence and medical adherence were positively affected by a daily reminder and the app's ease of use. User adherence was negatively affected by the severity of depression. The positive experience of visually presented data as graphs was a key finding, which was beneficial for self-awareness, the patient-physician relationship, and user adherence. Finally, the patients had mixed reactions to the app's content and requested tailored content.

CONCLUSIONS

The patients identified several factors addressing both medical adherence and user adherence to a digital app when using it for digitalized follow-up concurrent with the critical time related to changes in antidepressant medication. The findings highlight the need for rigorous evidence-based empirical studies to generate sustainable research results.

Telepsychiatry versus face-to-face treatment: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The COVID-19 pandemic has transformed healthcare significantly and telepsychiatry is now the primary means of treatment in some countries.

AIMS

To compare the efficacy of telepsychiatry and face-to-face treatment.

METHOD

A comprehensive meta-analysis comparing telepsychiatry with face-to-face treatment for psychiatric disorders. The primary outcome was the mean change in the standard symptom scale scores used for each psychiatric disorder. Secondary outcomes included all meta-analysable outcomes, such as all-cause discontinuation and safety/tolerability.

RESULTS

We identified 32 studies (n = 3592 participants) across 11 mental illnesses. Disease-specific analyses showed that telepsychiatry was superior to face-to-face treatment regarding symptom improvement for depressive disorders (k = 6 studies, n = 561; standardised mean difference s.m.d. = -0.325, 95% CI -0.640 to -0.011, P = 0.043), whereas face-to-face treatment was superior to telepsychiatry for eating disorder (k = 1, n = 128; s.m.d. = 0.368, 95% CI 0.018-0.717, P = 0.039). No significant difference was seen between telepsychiatry and face-to-face treatment when all the studies/diagnoses were combined (k = 26, n = 2290; P = 0.248). Telepsychiatry had significantly fewer all-cause discontinuations than face-to-face treatment for mild cognitive impairment (k = 1, n = 61; risk ratio RR = 0.552, 95% CI 0.312-0.975, P = 0.040), whereas the opposite was seen for substance misuse (k = 1, n = 85; RR = 37.41, 95% CI 2.356-594.1, P = 0.010). No significant difference regarding all-cause discontinuation was seen between telepsychiatry and face-to-face treatment when all the studies/diagnoses were combined (k = 27, n = 3341; P = 0.564).

CONCLUSIONS

Telepsychiatry achieved a symptom improvement effect for various psychiatric disorders similar to that of face-to-face treatment. However, some superiorities/inferiorities were seen across a few specific psychiatric disorders, suggesting that its efficacy may vary according to disease type.

Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US

OBJECTIVE

To identify potential barriers to care, this study examined the general psychiatry outpatient new appointment availability in the US, including in-person and telepsychiatry appointments, comparing results between insurance types (Medicaid vs. private insurance), states, and urbanization levels.

METHOD

This mystery shopper study investigated 5 US states selected according to Mental Health America Adult Ranking and geography to represent the US mental health care system. Clinics across five selected states were stratified sampled by county urbanization levels. Calls were made during 05/2022-07/2022. Collected data included contact information accuracy, appointment availability, wait time (days), and related information.

RESULTS

Altogether, 948 psychiatrists were sampled in New York, California, North Dakota, Virginia, and Wyoming. Overall contact information accuracy averaged 85.3%. Altogether, 18.5% of psychiatrists were available to see new patients with a significantly longer wait time for in-person than telepsychiatry appointments (median = 67.0 days vs median = 43.0 days, p < 0.01). The most frequent reason for unavailability was provider not taking new patients (53.9%). Mental health resources were unevenly distributed, favoring urban areas.

CONCLUSION

Psychiatric care has been severely restricted in the US with low accessibility and long wait times. Transitioning to telepsychiatry represents a potential solution for rural disparities in access.

An umbrella review of candidate predictors of response, remission, recovery, and relapse across mental disorders

We aimed to identify diagnosis-specific/transdiagnostic/transoutcome multivariable candidate predictors (MCPs) of key outcomes in mental disorders. We conducted an umbrella review (protocol  link ), searching MEDLINE/Embase (19/07/2022), including systematic reviews of studies reporting on MCPs of response, remission, recovery, or relapse, in DSM/ICD-defined mental disorders. From published predictors, we filtered MCPs, validating MCP criteria. AMSTAR2/PROBAST measured quality/risk of bias of systematic reviews/individual studies. We included 117 systematic reviews, 403 studies, 299,888 individuals with mental disorders, testing 796 prediction models. Only 4.3%/1.2% of the systematic reviews/individual studies were at low risk of bias. The most frequently targeted outcome was remission (36.9%), the least frequent was recovery (2.5%). Studies mainly focused on depressive (39.4%), substance-use (17.9%), and schizophrenia-spectrum (11.9%) disorders. We identified numerous MCPs within disorders for response, remission and relapse, but none for recovery. Transdiagnostic MCPs of remission included lower disease-specific symptoms (disorders = 5), female sex/higher education (disorders = 3), and quality of life/functioning (disorders = 2). Transdiagnostic MCPs of relapse included higher disease-specific symptoms (disorders = 5), higher depressive symptoms (disorders = 3), and younger age/higher anxiety symptoms/global illness severity/ number of previous episodes/negative life events (disorders = 2). Finally, positive trans-outcome MCPs for depression included less negative life events/depressive symptoms (response, remission, less relapse), female sex (response, remission) and better functioning (response, less relapse); for schizophrenia, less positive symptoms/higher depressive symptoms (remission, less relapse); for substance use disorder, marital status/higher education (remission, less relapse). Male sex, younger age, more clinical symptoms and comorbid mental/physical symptoms/disorders were poor prognostic factors, while positive factors included social contacts and employment, absent negative life events, higher education, early access/intervention, lower disease-specific and comorbid mental and physical symptoms/conditions, across mental disorders. Current data limitations include high risk of bias of studies and extraction of single predictors from multivariable models. Identified MCPs can inform future development, validation or refinement of prediction models of key outcomes in mental disorders.

Internet use and psychological wellbeing among older adults in England: a difference-in-differences analysis over the COVID-19 pandemic

BACKGROUND

Longitudinal evidence on how Internet use affects the psychological wellbeing of older adults has been mixed. As policymakers invest in efforts to reduce the digital divide, it is important to have robust evidence on whether encouraging Internet use among older adults is beneficial, or potentially detrimental, to their wellbeing.

METHODS

We observe depressive symptoms and loneliness of adults aged 50 + in the nationally representative English Longitudinal Study of Ageing, from before (2018/19) to during the coronavirus disease 2019 (COVID-19) pandemic (June/July and November/December 2020). Our quasi-experimental difference-in-differences strategy compares within-individual wellbeing changes between older adults who desired to use the Internet more but experienced barriers including lack of skills, access, and equipment, with regular Internet users who did not desire to use the Internet more. To reduce selection bias, we match both groups on demographic and socioeconomic characteristics that are predictive of Internet use. We assume that in the absence of COVID-19 - a period of increased reliance on the Internet - the wellbeing trajectories of both groups would have followed a common trend.

RESULTS

Compared with matched controls (N = 2983), participants reporting barriers to Internet use (N = 802) experienced a greater increase in the likelihood of depressive symptoms from before to during the pandemic, but not worse loneliness levels. This effect was stronger for women, those aged above 65 years, and those from lower-income households.

CONCLUSIONS

Besides enabling access to digital services, efforts to ensure older adults continue to be engaged members of an increasingly digital society could deliver returns in terms of a buffer against psychological distress.

Mobile health in the specific management of first-episode psychosis: a systematic literature review

Purpose

The purpose of this systematic literature review is to assess the therapeutic efficacy of mobile health methods in the management of patients with first-episode psychosis (FEP).

Method

The participants are patients with FEP. The interventions are smartphone applications. The studies assess the preliminary efficacy of various types of application.

Results

One study found that monitoring symptoms minimized relapses, visits to A&E and hospital admissions, while one study showed a decrease in positive psychotic symptoms. One study found an improvement in anxiety symptoms and two studies noted an improvement in psychotic symptoms. One study demonstrated its efficacy in helping participants return to studying and employment and one study reported improved motivation.

Conclusion

The studies suggest that mobile applications have potential value in the management of young patients with FEP through the use of various assessment and intervention tools. This systematic review has several limitations due to the lack of randomized controlled studies available in the literature.

Mental Health Professionals' Attitudes Toward Digital Mental Health Apps and Implications for Adoption in Portugal: Mixed Methods Study

BACKGROUND

Digital health apps are among the most visible facets of the ongoing digital transition in health care, with mental health-focused apps as one of the main therapeutic areas. However, concerns regarding their scientific robustness drove regulators to establish evaluation procedures, with Germany's Digitale Gesundheitsanwendungen program pioneering in app prescription with costs covered by statutory health insurance. Portugal gathers a set of conditions and requirements that position it as an excellent test bed for digital health apps. Its daunting mental health landscape reinforces the potential interest in new interventions. To understand if they would be acceptable, we need to understand the supply side's attitudes and perceptions toward them, that is, those of psychiatrists and psychologists.

OBJECTIVE

This study aims to understand the attitudes and expectations of psychiatrists and psychologists toward digital mental health apps (DMHAs) in the Portuguese context, as well as perceived benefits, barriers, and actions to support their adoption.

METHODS

We conducted a 2-stage sequential mixed methods study. Stage 1 consisted of a cross-sectional web survey adapted to the Portuguese context that was delivered to mental health professionals and psychologists. Stage 2 complemented the insights of the web survey results with a key opinion leader analysis.

RESULTS

A total of 160 complete survey responses were recorded, most of which were from psychologists. This is the most extensive study on mental health professionals' attitudes and perceptions of DMHAs in Portugal. A total of 87.2% (136/156) of the respondents supported the opportunity to prescribe DMHAs. Increased health literacy (139/160, 86.9%), wider adherence to treatment (137/160, 85.6%), and proper disease management (127/160, 79.4%) were the most frequently agreed upon benefits of DMHAs. However, only less than half (68/156, 43.6%) of the respondents planned to prescribe or recommend DMHAs, with psychologists being more favorable than psychiatrists. Professionals faced substantial barriers, such as a lack of information on DMHAs (154/160, 96.3%), the level of initial training effort (115/160, 71.9%), and the need for adjustments of clinical processes and records (113/160, 70.6%). Professionals reported that having more information on the available apps and their suitability for health objectives (151/160, 94.4%), more scientific evidence of the validity of the apps as a health intervention (147/160, 91.9%), and established recommendations of apps by specific clinical guidelines or professional societies (145/160, 90.6%) would be essential to foster adoption.

CONCLUSIONS

More information about DMHAs regarding their clinical validity and how they work is necessary so that such an intervention can be adopted in Portugal. Recommendations from professional and scientific societies, as well as from governmental bodies, are strongly encouraged. Although the benefits of and the barriers to using these apps are consensual, more evidence, along with further promotion of mental health professionals' digital literacy, is needed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/41040.

Modification of the therapist's facial expressions using virtual reality technology during the treatment of social anxiety disorder: a case series

Exposure therapy is a mainstream of treatment for social anxiety disorder (SAD). However, effort and time are required to recreate interpersonal situations that produce moderate anxiety. On the other hand, virtual reality exposure therapy can easily control anxiety-inducing conditions and allow for graduated exposure. However, artificial intelligence and animations that speak as naturally as actual humans are not yet practical, adding to the limitations of these treatments. The authors propose the use of a virtual reality technology that can transform facial expressions into smiling or sad faces in real time and display them on a monitor, potentially solving the above-mentioned problems associated with virtual reality animations. This feasibility study was conducted to determine whether this system can be safely applied to the treatment of SAD patients. A total of four SAD patients received 16 exposure therapy sessions led by an experienced therapist over a monitor; throughout the sessions, the facial expressions of the therapist were modified using software to display expressions ranging from smiling to sad on the monitor that was being viewed by the patient. Client satisfaction, treatment alliance, and symptom assessments were then conducted. Although one patient dropped out of the study, treatment satisfaction and treatment alliance were scored high in all the cases. In two of the four cases, the improvement in symptoms was sustained over time. Exposure therapy in which the interviewer's facial expressions are modified to induce appropriate levels of anxiety in the patient can be safely used for the treatment of SAD patients and may be effective for some patients.

Protecting the public interest while regulating health professionals providing virtual care: A scoping review

Technology is transforming service delivery in many health professions, particularly with the rapid shift to virtual care during the COVID-19 pandemic. Health profession regulators must navigate legal and ethical complexities to facilitate virtual care while upholding their mandate to protect the public interest. The objectives of this scoping review were to examine how the public interest is protected when regulating health professionals who provide virtual care, discuss policy and practice implications of virtual care, and make recommendations for future research. We searched six multidisciplinary databases for academic literature published in English between January 2015 and May 2021. We also searched specific databases and websites for relevant grey literature. After screening, 59 academic articles and 18 grey literature sources were included for analysis. We identified five key findings: the public interest when regulating health professionals providing virtual care was only implicitly considered in most of the literature; when the public interest was discussed, the dimension of access was emphasized; criticism in the literature focused on social ideologies driving regulation that may inhibit more widespread use of virtual care; subnational licensure was viewed as a barrier; and the demand for virtual care during COVID-19 catalyzed licensure and scope of practice changes. Overall, virtual care introduces new areas of risk, potential harm, and inequity that health profession regulators need to address as technology continues to evolve. Regulators have an essential role in providing clear standards and guidelines around virtual care, including what is required for competent practice. There are indications that the public interest concept is evolving in relation to virtual care as regulators continue to balance public safety, equitable access to services, and economic competitiveness.

Telemedicine during the COVID-19 pandemic in Germany: Results from three nationally representative surveys on use, attitudes and barriers among adults affected by depression

Introduction

The COVID-19 pandemic has necessitated a reduction in face-to-face consultations, resulting in significant limitations in healthcare for individuals with depression. To ensure safe and adequate care, e-health services, such as telemedicine, gained a more prominent role. Governments have eased restrictions on the use of telemedicine, enabling healthcare professionals to increasingly offer video and telephone consultations.

Objective

This study examines, 1) possible changes over the course of the pandemic in reported use of video and telephone consultations and intended future use of video consultations with healthcare professionals among adults with diagnosed depression; 2) their attitudes towards video and telephone consultations and perceived barriers towards using e-health after prolonged time of the pandemic; and 3) differences in results between subgroups based on sociodemographic and clinical characteristics.

Methods

Three population-representative online surveys were conducted in Germany at different timepoints (t) during the COVID-19 pandemic. Respondents aged 18-69 years with a professionally diagnosed depression were included in the present analyses (t1: June/July 2020 with n = 1094; t2: February 2021 with n = 1038; t3: September 2021 with n = 1255).

Results

The overall proportion of adults with depression who used video or telephone consultations did not change significantly in the time surveyed (t1: 16.51 %, n = 179; t2: 20.23 %, n = 210; t3: 18.47 %, n = 230). However, among users, reported use of video consultations with a psychotherapist increased significantly from t1 (34.83 %, n = 62) to t3 (44.98 %, n = 102, p = .023). Intended future use of VC for healthcare varied depending on the purpose of the consultation. Significant differences over time were only found for the purpose of using VC to discuss clinical findings, laboratory results and diagnostic analyses with a doctor, with higher intentions reported at t2 during lockdown in Germany. At t3, the majority of adults with depression felt that video and telephone consultations were too impersonal and considered them more as a helpful support rather than an alternative to face-to-face psychotherapy. Key barriers to using e-health were found within the societal context and the lacking support from significant others for using e-health, while knowledge and skills represented facilitators for using e-health.

Conclusion

Despite ambivalent attitudes towards video and telephone consultations among adults with depression, reported use of video consultations with a psychotherapist increased during the COVID-19 pandemic.

[Maintaining a comprehensive provision of inpatient child and adolescent mental health services in the years to come-a German perspective]

BACKGROUND

A considerable number of child and adolescent psychiatry inpatient units in Germany suffer from a significant shortage of doctors, which endangers the current system of nation-wide availability of high-quality child and adolescent inpatient services.

METHODS

Drawing on recent data, this article pictures the status quo of child and adolescent psychiatry inpatient services in Germany. The authors then discuss the pros and cons of different suggestions of how to cope with the doctor shortage crisis in child and adolescent psychiatry.

RESULTS

The following options for action are suggested: reduction of service provision across the board, shift from personnel-intensive inpatient towards home-based treatment, trans-sectoral cooperation by means of tele-psychiatry, delegation of clinical responsibilities to psychologists, limiting ward physicians' tasks to mere medical care of patients, improvement of working conditions in inpatient units, recruitment of doctors from abroad, and increased recruiting efforts at medical school level. From the authors' viewpoint, the latter option offers the best chance of lasting success; however, this requires a long-term, nationwide approach and considerable efforts of all departments involved.

Japan Geriatrics Society "Statement for the use of telemedicine in geriatric care: Telemedicine as a complement to in-person medical practice": Geriatric Medical Practice Committee consensus statement

Telemedicine has changed from a way to treat patients with limited access to hospitals to a necessary method of treatment for non-urgent conditions during the coronavirus disease 2019 pandemic. There are two styles of telemedicine, namely "hybrid medical care" and "gateway medical care," which take advantage of the characteristics of online medical care and might become important in the near future. During hybrid medical care, a patient and their primary care physician have face-to-face medical care while simultaneously being examined by a specialist physician through telemedicine, leading to an overall improvement in the level of local medical care and expansion in the number of treatable diseases. Gateway medical practice is a form of telemedicine used for patients who would otherwise refuse or not receive in-person medical care to engage in consultation with a physician. Telemedicine allows physicians to determine disease severity and triage patients, while reducing unnecessary home visits, emergency hospitalizations and the spread of infection. Telemedicine is less intense than in-person medical care, and allows for easier collaboration with other healthcare providers. However, telemedicine is not optimal for conditions requiring a definitive diagnosis and a comprehensive understanding of the patient's medical history. It is limited by the patient's ability to use telemedicine devices, and the risk of accidental treatments and fraud. The use of telemedicine might result in the development of new, online comprehensive geriatric assessment tools and technologies. Geriatr Gerontol Int 2022; 22: 913-916.

Implementation of telemedicine consultations for people with mental health conditions in the community: a protocol for a systematic review

Background: The COVID-19 pandemic response has led to an exponential increase in the use and spread of telemedicine internationally. In community mental health care settings, telemedicine services were implemented within a few weeks, with little time for rigorous planning. Despite the reported acceptability of telemedicine by patients and clinicians, barriers to its implementation have come to light. There is now a need to investigate these barriers, and facilitators, as telemedicine begins to show potential promise beyond the pandemic. We propose a review that aims to identify the factors affecting the implementation of telemedicine consultations for patients with mental health conditions in the community.

Methods: A systematic review will be conducted and reported according to the PRISMA guidelines. Five electronic databases will be searched using a pre-defined search strategy from 2016 to 2021. Only studies of synchronous, interactive telemedicine consultations conducted via video, phone or live messaging between patients and providers will be included. Quantitative, qualitative and mixed methods studies will be eligible for inclusion. Only studies published in the English language will be included. Titles and abstracts will be screened by two reviewers. Full text articles will be screened by two reviewers. The methodological quality of studies will be assessed using the Mixed Method Appraisal Tool (MMAT) by two reviewers. Data will be extracted and tabulated to address the aims of the review. A narrative synthesis will be conducted and reported factors will be mapped to the domains of the Consolidated Framework for Implementation Research (CFIR).

Conclusion: By identifying the factors that influence the implementation of telemedicine consultations for patients with mental conditions in the community, consideration can be given to both barriers and facilitators that could be addressed in future mental health services planning.

PROSPERO registration:CRD42021273422 (04/10/2021)

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Mental health professionals views and the impact of COVID-19 pandemic on implementing digital mental health in China: A nationwide survey study

BACKGROUND

Using digital health technologies (DHTs) to deliver and augment healthcare is an innovative way to solve common challenges that the mental healthcare setting faces. Despite China's rapid development of DHT, a comprehensive understanding of staff views of DHTs is lacking, which limited the evidence to support implementation strategies. In the current study, we aim to: (i) investigate staff attitudes towards digital technology for mental health problems in China; (ii) explore staff's views on the facilitators and barriers regarding uptake and adoption of digital technology in mental health services in China; and (iii) understand how the COVID-19 pandemic has changed staff views on digital mental health.

METHODS

An online survey was conducted to explore staff attitudes towards implementing DHTs in China. Descriptive statistics were conducted to summarise quantitative data. Free-text data were analysed using qualitative content analysis.

RESULTS

1270 mental health professionals completed the survey. Respondents reported low levels of knowledge of DHTs and moderate levels of accessibility of DHTs in their hospitals. Respondents expressed positive attitudes towards DHTs and demonstrated moderate levels of perceived feasibility and acceptability of implementing DHTs in clinical services. As expected, respondents reported that the COVID-19 pandemic caused significant impacts on their clinical services, and almost all respondents deemed DHTs useful for services provision during the pandemic and were willing to apply such technologies in clinical services after the pandemic.

CONCLUSIONS

Despite the Chinese mental health staff expressed positive attitudes towards implementing DHTs in clinical practice, most of the staff lacked sufficient knowledge to provide such services. These findings highlight the need to develop implementation strategies such as training programmes and dissemination of research evidence to support the translation of research.

Identifying neurocognitive disorder using vector representation of free conversation

In recent years, studies on the use of natural language processing (NLP) approaches to identify dementia have been reported. Most of these studies used picture description tasks or other similar tasks to encourage spontaneous speech, but the use of free conversation without requiring a task might be easier to perform in a clinical setting. Moreover, free conversation is unlikely to induce a learning effect. Therefore, the purpose of this study was to develop a machine learning model to discriminate subjects with and without dementia by extracting features from unstructured free conversation data using NLP. We recruited patients who visited a specialized outpatient clinic for dementia and healthy volunteers. Participants’ conversation was transcribed and the text data was decomposed from natural sentences into morphemes by performing a morphological analysis using NLP, and then converted into real-valued vectors that were used as features for machine learning. A total of 432 datasets were used, and the resulting machine learning model classified the data for dementia and non-dementia subjects with an accuracy of 0.900, sensitivity of 0.881, and a specificity of 0.916. Using sentence vector information, it was possible to develop a machine-learning algorithm capable of discriminating dementia from non-dementia subjects with a high accuracy based on free conversation.

Suicidality in clinically stable bipolar disorder and schizophrenia patients during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has a disproportionate impact on vulnerable subpopulations, including those with severe mental illness (SMI). This study examined the one-year prevalence of suicidal ideation (SI), suicide plans (SP), and suicide attempts (SA) in bipolar disorder (BD) and schizophrenia (SCZ) patients during the pandemic. Prevalence rates were compared between the two disorders and associated factors were examined. A survey was conducted in six tertiary psychiatric hospitals and psychiatric units. People with a diagnosis of BD or SCZ were invited to participate. SI, SP, and SA (suicidality for short) were assessed and associated factors were examined using binary logistical regression. The 1-year prevalence of SI, SP and SA in BD patients were 58.3%, (95% CI: 54.1-62.6%), 38.4% (95% CI: 34.3-42.6%) and 38.6% (95% CI: 34.5-42.8%), respectively, which were higher than the corresponding figures in SCZ patients (SI: 33.2%, 95% CI: 28.6-37.8%; SP: 16.8%, 95% CI: 13.2-20.5%; SA: 19.4%, 95% CI: 15.5-23.3%). Patients with younger age, experience of cyberbullying, a history of SA among family or friends, a higher fatigue and physical pain score, inpatient status, and severe depressive symptoms were more likely to have suicidality. The COVID-19 pandemic was associated with increased risk of suicidality, particularly in BD patients. It is of importance to regularly screen suicidality in BD and SCZ patients during the pandemic even if they are clinically stable.

Influence of the COVID-19 pandemic on regular clinic visits and medication prescriptions among people with diabetes: Retrospective cohort analysis of health care claims

The aim of this study was to investigate the effect of the COVID-19 pandemic on regular clinic visits among people with diabetes and to elucidate the factors related to visit patterns among these patients during the pandemic. This was a longitudinal study using anonymized insurance claims data from the Joint Health Insurance Society in Tokyo from October 2017 to September 2020. First, we identified patients with diabetes who were fully enrolled in the health plan from fiscal year 2017 until September 2020 and who were regularly receiving glucose-lowering medications (every 1-3 months) from October 2017 to September 2018. We divided follow-up into the pre-pandemic period (October 2018 to March 2020) and the pandemic period (April 2020 to September 2020). A multilevel logistic regression model was used to determine the risks of delayed clinic visits/medication prescriptions (i.e., >3 months after a previous visit/prescription) during the pandemic period. We identified 1118 study participants. The number of delayed clinic visits/medication prescriptions during the pre-pandemic and pandemic periods was 188/3354 (5.6%) and 125/1118 (11.2%), respectively. There was a significant increase in delayed clinic visits during the pandemic (adjusted odds ratio 3.68 (95% confidence interval 2.24 to 6.04, P < .001), even after controlling for confounding factors. We also found a significant interaction between sex and delayed visits; women had significantly fewer clinic visits during the COVID-19 pandemic than men. We clarified the relationship of the COVID-19 pandemic with delays in regular clinic visits and medication prescriptions among people with diabetes. The response to the COVID-19 pandemic differed between men and women.

Mental health of patients with mental illness during the COVID-19 pandemic lockdown: a questionnaire-based survey weighted for attrition

BACKGROUND

Individuals with pre-existing mental illness may be particularly vulnerable to the negative impact that the coronavirus disease 2019 (COVID-19) pandemic seems to have on mental health. Accordingly, the objective of the present study was to assess whether patients with mental illness experienced deterioration in mental health during the COVID-19 lockdown of Denmark in the Spring of 2020.

METHODS

We conducted a cross-sectional, questionnaire-based survey coupled with sociodemographic and clinical data from the medical records of all invitees. The latter enabled analysis of attrition and weighting of results. The online questionnaire included the 18-item Brief Symptom Inventory (BSI-18), the five-item World Health Organization Well-Being Index (WHO-5), and 14 questions evaluating worsening or improvement in symptoms during lockdown using the pre-pandemic period as reference.

RESULTS

A total of 992 randomly drawn patients with mental illness from the psychiatric services of the Central Denmark Region responded to the questionnaire (response rate = 21.6%). The weighted mean WHO-5 and BSI-18 scores were 38 and 28, respectively. A total of 52% of the respondents reported that their mental health had deteriorated during the lockdown, while 33% reported no change, and 16% reported improvement. The most commonly reported reasons for deterioration were loneliness, disruption of routines, concerns regarding the coronavirus, less contact with family/friends, boredom, and reduced access to psychiatric care.

CONCLUSION

More than half of the patients reported worsening of their mental health during the pandemic lockdown. There should be an increased emphasis on ensuring both social and clinical support for individuals with mental illness during pandemics.

The effect of the COVID-19 lockdown on mental health care use in South Africa: an interrupted time-series analysis

AIMS

The coronavirus disease 2019 (COVID-19) pandemic and ensuing restrictions have negatively affected the mental health and well-being of the general population, and there is increasing evidence suggesting that lockdowns have led to a disruption of health services. In March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on mental health care utilisation rates in private-sector care in South Africa.

METHODS

We conducted an interrupted time-series analysis using insurance claims from 1 January 2017 to 1 June 2020 of beneficiaries 18 years or older from a large private sector medical insurance scheme. We calculated weekly outpatient consultation and hospital admission rates for organic mental disorders, substance use disorders, serious mental disorders, depression, anxiety, other mental disorders, any mental disorder and alcohol withdrawal syndrome. We calculated adjusted odds ratios (OR) for the effect of the lockdown on weekly outpatient consultation and hospital admission rates and the weekly change in rates during the lockdown until 1 June 2020.

RESULTS

710 367 persons were followed up for a median of 153 weeks. Hospital admission rates (OR 0.38; 95% confidence interval (CI) 0.33-0.44) and outpatient consultation rates (OR 0.74; 95% CI 0.63-0.87) for any mental disorder decreased substantially after the introduction of the lockdown and did not recover to pre-lockdown levels by 1 June 2020. Health care utilisation rates for alcohol withdrawal syndrome doubled after the introduction of the lockdown, but the statistical uncertainty around the estimates was large (OR 2.24; 95% CI 0.69-7.24).

CONCLUSIONS

Mental health care utilisation rates for inpatient and outpatient services decreased substantially after the introduction of the lockdown. Hospital admissions and outpatient consultations for alcohol withdrawal syndrome increased after the introduction of the lockdown, but statistical uncertainty precludes strong conclusions about a potential unintended effect of the alcohol sales ban. Governments should integrate strategies for ensuring access and continuity of essential mental health services during lockdowns in pandemic preparedness planning.

Implementation of telemedicine consultations for people with mental health conditions in the community: a protocol for a systematic review

Background: The COVID-19 pandemic response has led to an exponential increase in the use and spread of telemedicine internationally. In community mental health care settings, telemedicine services were implemented within a few weeks, with little time for rigorous planning. Despite the reported acceptability of telemedicine by patients and clinicians, barriers to its implementation have come to light. There is now a need to investigate these barriers, and facilitators, as telemedicine begins to show potential promise beyond the pandemic. We propose a review that aims to identify the factors affecting the implementation of telemedicine consultations for patients with mental health conditions in the community. Methods: A systematic review will be conducted and reported according to the PRISMA guidelines. Five electronic databases will be searched using a pre-defined search strategy from 2016 to 2021. Only studies of synchronous, interactive telemedicine consultations conducted via video, phone or live messaging between patients and providers will be included. Quantitative, qualitative and mixed methods studies will be eligible for inclusion. Only studies published in the English language will be included. Titles and abstracts will be screened by two reviewers. Full text articles will be screened by two reviewers. The methodological quality of studies will be assessed using the Mixed Method Appraisal Tool (MMAT) by two reviewers. Data will be extracted and tabulated to address the aims of the review. A narrative synthesis will be conducted and reported factors will be mapped to the domains of the Consolidated Framework for Implementation Research (CFIR). Conclusion: By identifying the factors that influence the implementation of telemedicine consultations for patients with mental conditions in the community, consideration can be given to both barriers and facilitators that could be addressed in future mental health services planning. PROSPERO registration: CRD42021273422 (04/10/2021)

Internet Use among Patients with Schizophrenia and Depression

Background: The high and increasing prevalence of internet use in the general population and the significant burden of depression and schizophrenia urge us to investigate the patterns of internet use among patients with these illnesses. The aim of this study is to assess internet use and mental health-related internet use among patients suffering from schizophrenia and depression. Methods: A total of 104 patients with psychosis and 105 patients with depression were surveyed to assess their internet use and mental health-related internet use. Results: The majority of participants were internet users (87.6%), with 66.7% of internet users with psychosis and 71.4% of internet users with depression using it as a source of information on mental health. Participants with psychosis significantly more attributed the internet and mental health internet forums as helpful in coping with their mental illness and were more interested in the utilization of online mental health services than participants with depression. Conclusions: General internet use in patients with schizophrenia and depression corresponds with the internet use of the general population; however, they use it more often as a source of health information than the general population. Mental health service providers should offer more online interventions and treatment programs to patients with psychosis and depression, as our study suggests there is an unmet need for online mental health services for such patients.

Patient and provider experiences of telemental health during the COVID-19 pandemic in a New York City academic medical center

OBJECTIVE

We aimed to evaluate patient and provider experiences with telemental health (TMH) at an academic outpatient psychiatry department in New York City during the first wave of the COVID-19 pandemic.

METHODS

Patients and providers completed online surveys evaluating their experience with TMH during the first wave of the COVID-19 pandemic. Surveys were distributed to 1,178 patients and 287 providers from July 2020 through October 2020.

RESULTS

42.5% of providers and 21% of patients responded to the survey. The majority of patient and provider respondents rated the quality of phone and video visits as "equally good" or "somewhat worse" than in-person visits, while the majority of respondents were "somewhat satisfied" or "very satisfied" with video visits. Patients and providers preferred a hybrid model for future care. Common barriers to TMH included privacy, technical difficulties, and wi-fi access.

CONCLUSIONS

Patients and providers appeared willing to exchange some degree of quality for satisfaction with TMH. This study did not demonstrate with statistical significance any specific patient populations that would benefit more or less from TMH, suggesting that TMH may be a successful model for diverse patient populations. Our results suggest that providers, payors, and regulators should facilitate hybrid care delivery models that incorporate TMH beyond the pandemic.

Telepsychiatry and face-to-face psychiatric consultations during the first year of the COVID-19 pandemic in Australia: patients being heard and seen

OBJECTIVE

The Australian federal government introduced additional Medicare Benefits Schedule (MBS) telehealth-items to facilitate care by private psychiatrists during the COVID-19 pandemic.

METHOD

We analysed private psychiatrists' uptake of video and telephone-telehealth, as well as total (telehealth and face-to-face) consultations for April 2020-April 2021. We compare these to face-to-face consultations for April 2018-April 2019. MBS-Item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with face-to-face consultations for the whole of Australia.

RESULTS

Psychiatric consultation numbers (telehealth and face-to-face) were 13% higher during the first year of the pandemic compared with 2018-2019, with telehealth accounting for 40% of this total. Face-to-face consultations were 65% of the comparative number of 2018-2019 consultations. There was substantial usage of telehealth consultations during 2020-2021. The majority of telehealth involved short telephone consultations of ⩽15-30 min, while video was used more, in longer consultations.

CONCLUSIONS

Private psychiatrists and patients continued using the new telehealth-items during 2020-2021. This compensated for decreases in face-to-face consultations and resulted in an overall increase in the total patient contacts compared to 2018-2019.

Telepsychiatry: learning from the pandemic

This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.

Physical and mental health impact of COVID-19 on children, adolescents, and their families: The Collaborative Outcomes study on Health and Functioning during Infection Times - Children and Adolescents (COH-FIT-C&A)

BACKGROUND

The COVID-19 pandemic has altered daily routines and family functioning, led to closing schools, and dramatically limited social interactions worldwide. Measuring its impact on mental health of vulnerable children and adolescents is crucial.

METHODS

The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT - www.coh-fit.com) is an on-line anonymous survey, available in 30 languages, involving >230 investigators from 49 countries supported by national/international professional associations. COH-FIT has thee waves (until the pandemic is declared over by the WHO, and 6-18 months plus 24-36 months after its end). In addition to adults, COH-FIT also includes adolescents (age 14-17 years), and children (age 6-13 years), recruited via non-probability/snowball and representative sampling and assessed via self-rating and parental rating. Non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to promote health and prevent mental and physical illness in children and adolescents will be generated by COH-FIT. Co-primary outcomes are changes in well-being (WHO-5) and a composite psychopathology P-Score. Multiple behavioral, family, coping strategy and service utilization factors are also assessed, including functioning and quality of life.

RESULTS

Up to June 2021, over 13,000 children and adolescents from 59 countries have participated in the COH-FIT project, with representative samples from eleven countries.

LIMITATIONS

Cross-sectional and anonymous design.

CONCLUSIONS

Evidence generated by COH-FIT will provide an international estimate of the COVID-19 effect on children's, adolescents' and families', mental and physical health, well-being, functioning and quality of life, informing the formulation of present and future evidence-based interventions and policies to minimize adverse effects of the present and future pandemics on youth.

Changes to the practice of pediatric otolaryngology as a consequence of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology internationally due to the COVID-19 pandemic and examine potential contributors.

METHOD

An online survey was designed to assess practice demographics, patterns of COVID-19 related restrictions in communities, and changes to practice and referrals. This was disseminated via an international Covid-19 WhatsApp™ group of pediatric otolaryngologists.

RESULTS

There were 45 respondents of 177 group members (25.4%) from 15 countries. The mean estimated time spent under strictest lockdown measures was 16.2 (±10.7) weeks (range: 1-45 weeks). Operating room time was reduced for 82.9%, with an average reported reduction of 41.5%. Almost all (>75%) of respondents reported reduced referrals for five common conditions: otitis media with effusion (average reported decrease - 56.1%); acute otitis media (average decrease 62.8%); acute mastoiditis (average decrease 66.6%); recurrent pharyngotonsillitis (average decrease 51.0%); and peritonsillar abscess (average decrease 52.1%). COVID-19 cases per million population significantly influenced the acuity of referrals received (p < .05). No conditions were reported as increased in frequency and the acuity of most conditions was reported as unchanged by the majority of respondents.

CONCLUSION

The measures taken to reduce the spread of COVID-19 have resulted in many changes to pediatric otolaryngology practice and the referral patterns of common conditions. Some of these changes may have enduring sequelae.

Home direct-to-consumer telehealth solutions for children with mental health disorders and the impact of Covid-19

Delivery of mental health treatment in the home can close gaps in care. Telehealth also provides access to healthcare that has been disrupted due to the COVID-19 pandemic. In 2016, a home direct-to-consumer telehealth program was initiated. Mental health encounters made up a significant portion of all telehealth encounters and COVID-19 had a significant impact on accelerating the utilization of telehealth. Telemental health has been more successful at meeting targeted volumes than the overall health system. Of all the mental health diagnoses before and during COVID-19, attention deficit hyperactivity disorder, Autism Spectrum Disorder, and Anxiety Disorder were most common. The direct-to-consumer telehealth program saved patients a significant amount of travel miles and associated time, based on data from the period before COVID-19. Payment reimbursement for direct-to-consumer telehealth professional services was similar to reimbursement for in-person visits. This program demonstrates direct-to-consumer telehealth is a feasible and acceptable care modality for a variety of youth mental health disorders.

Editorial Perspective: Challenges of research focusing on child and adolescent mental health during the COVID-19 era: what studies are needed?

This editorial perspective focuses on the challenges of research on child and adolescent mental health during the COVID-19 pandemic. Common limitations of published/ongoing studies are (i) being conducted in one or few countries, (ii) the survey being available in one or few languages, (iii) targeting selected samples (e.g., clinical populations and health workers) rather than the general population, (iv) only recruiting/reporting on non-representative samples, (v) focusing often on a restricted set of mental health outcomes, missing the broader picture of mental and physical health, quality of life and functioning, (vi) failing to use a longitudinal design and (vii) collecting only parental ratings or self-rated questionnaires from children and adolescents, but not both. We discuss how the Collaborative Outcomes Study on Health and Functioning during Infection Times (COH-FIT) was designed to address some of these challenges, also highlighting its limitations.

Current Status and Challenges of the Dissemination of Telemedicine in Japan After the Start of the COVID-19 Pandemic

Background: The use of telemedicine is expanding worldwide in response to the COVID-19 pandemic, and deregulation is occurring even in countries with strict regulations, such as Japan. Methods: We conducted a narrative review of the activities and initiatives undertaken by the government and professional organizations to promote the use of telemedicine in Japan from January 2020, when the COVID-19 pandemic began, to September 2021. Results: In Japan, where before the pandemic the spread of telemedicine had been limited, various recommendations and deregulations have now been made, resulting in the expanded use of telemedicine. In particular, the government's overall policy direction has become a catalyst for deregulation. Conclusions: With the COVID-19 pandemic, telemedicine is now moving toward widespread use. However, further activities and initiatives, including policy changes such as reimbursement and the establishment of evidence to show the effectiveness of telemedicine in Japan, are needed to properly disseminate telemedicine.

Implementation of telemedicine consultations for people with mental health conditions in the community: a protocol for a systematic review

Background: The COVID-19 pandemic response has led to an exponential increase in the use and spread of telemedicine internationally. In community mental health care settings, telemedicine services were implemented within a few weeks, with little time for rigorous planning. Despite the reported acceptability of telemedicine by patients and clinicians, barriers to its implementation have come to light. There is now a need to investigate these barriers, and facilitators, as telemedicine begins to show potential promise beyond the pandemic. We propose a review that aims to identify the factors affecting the implementation of telemedicine consultations for patients with mental health conditions in the community. Methods: A systematic review will be conducted and reported according to the PRISMA guidelines. Five electronic databases will be searched using a pre-defined search strategy from 2016 to 2021. Only studies of synchronous, interactive telemedicine consultations conducted via video, phone or live messaging between patients and providers will be included. Quantitative, qualitative and mixed methods studies will be eligible for inclusion. Only studies published in the English language will be included. Titles and abstracts will be screened by two reviewers. Full text articles will be screened by a single reviewer, with a random 20% sample screened by a second reviewer. The methodological quality of studies will be assessed using the Mixed Method Appraisal Tool (MMAT) by two reviewers. Data will be extracted and tabulated to address the aims of the review. A narrative synthesis will be conducted and reported factors will be mapped to the domains of the Consolidated Framework for Implementation Research (CFIR). Conclusion: By identifying the factors that influence the implementation of telemedicine consultations for patients with mental conditions in the community, consideration can be given to both barriers and facilitators that could be addressed in future mental health services planning. PROSPERO registration: CRD42021273422 (04/10/2021)

Implications of the COVID-19 pandemic for people with bipolar disorders: A scoping review

INTRODUCTION

The COVID-19 (coronavirus disease 2019)-related pandemic represents a global source of societal and health burden. Yet, the impact of the pandemic on people with severe mental illness, including bipolar disorder (BD), remains unclear, warranting scoping review on the matter.

METHODS

The MEDLINE and EMBASE databases were systematically searched from inception up to April 24, 2021, adopting broad inclusion criteria to assess a variety of clinical and public health themes related to people with a primary diagnosis of BD during the COVID-19 pandemics. The present work complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) registered in the Open Science Framework (OSF) repository (https://osf.io/7evpx/).

RESULTS

Fourteen papers informed the present scoping review. Four major themes were identified: (i) impact of COVID-19-related stressors on BD; (ii) impact of COVID-19 on mental health service utilization among people with BD; (iii) impact of BD on the risk of acquiring SARS-CoV-2 infection; (iv) engagement in preventative behaviors among people with BD. Additional themes warranting further research were nonetheless detected.

LIMITATIONS

Further original studies are needed.

CONCLUSION

The present study confirmed the high-vulnerability hypothesis concerning people with BD versus the general population, reinforcing the need for further research related to the COVID-19 pandemic. Additional information is warranted to compare the impact of the pandemic period among BD people against pre-pandemic records, the general population, and other severe mental illnesses, namely people with schizophrenia or major depressive disorder, to inform the public health and the delivery of patient-tailored interventions.

Japanese project for telepsychiatry evaluation during COVID-19: Treatment comparison trial (J-PROTECT): Rationale, design, and methodology

Introduction

The COVID-19 pandemic has had a profound impact on the mental health of people around the world. Anxiety related to infection, stress and stigma caused by the forced changes in daily life have reportedly increased the incidence and symptoms of depression, anxiety disorder and obsessive-compulsive disorder. Under such circumstances, telepsychiatry is gaining importance and attracting a great deal of attention. However, few large pragmatic clinical trials on the use of telepsychiatry targeting multiple psychiatric disorders have been conducted to date.

Methods

The targeted study cohort will consist of adults (>18 years) who meet the DSM-5 diagnostic criteria for either (1) depressive disorders, (2) anxiety disorders, or (3) obsessive-compulsive and related disorders. Patients will be assigned in a 1:1 ratio to either a “telepsychiatry group” (at least 50% of treatments to be conducted using telemedicine, with at least one face-to-face treatment [FTF] within six months) or an “FTF group” (all treatments to be conducted FTF, with no telemedicine). Both groups will receive the usual treatment covered by public medical insurance. The study will utilize a master protocol design in that there will be primary and secondary outcomes for the entire group regardless of diagnosis, as well as the outcomes for each individual disorder group.

Discussion

This study will be a non-inferiority trial to test that the treatment effect of telepsychiatry is not inferior to that of FTF alone. This study will provide useful insights into the effect of the COVID-19 pandemic on the practice of psychiatry.

Trial Registration

jRCT1030210037, Japan Registry of Clinical Trials (jRCT).

Uses of digital technologies in the time of Covid-19: opportunities and challenges for professionals in psychiatry and mental health care

BACKGROUND

The Covid-19 pandemic has required psychiatric and mental health professionals to change their practices to reduce the risk of transmission of SARS-CoV-2, in particular by favoring remote monitoring and assessment via digital technologies.

OBJECTIVE

As part of a research project that was co-funded by the French National Research Agency (ARN) and the Centre-Val de Loire Region, we carried out a systematic literature review to investigate how such uses of digital technologies have been developing.

METHODS

The present systematic review was conducted following the PRISMA guidelines. The search was carried out in MEDLINE (PubMed) and Cairn databases, as well as in a platform specializing in mental health, Ascodocpsy. The search yielded 558 results for the year 2020. After applying inclusion and exclusion criteria, first on titles and abstracts, and then on full texts, 61 articles were included.

RESULTS

The analysis of the literature revealed a heterogeneous integration of digital technologies, not only depending on countries, contexts, and local regulations, but also depending on the modalities of care. Notwithstanding these variations, the use of videoconferencing has developed significantly, affecting working conditions and therapeutic relationships. For many psychiatric and mental health professionals, the pandemic has been an opportunity to build up an experience of remote care, and thus better identify the possibilities and limits of these digital technologies.

CONCLUSIONS

The new uses of such technologies essentially consist in a transition from the classic consultation model towards teleconsultation and makes less use of the specific potential of artificial intelligence. As professionals were not prepared for these uses, they were confronted with practical difficulties and ethical questions, such as the place of digital technology in care, confidentiality and protection of personal data, and equity in access to care. The health crisis questions how the organization of health care integrates the possibilities offered by digital technology, in particular so as to promote the autonomy and empowerment of mental health service users.

CLINICALTRIAL

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

As the COVID-19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies - such as smartphone apps, vir-tual reality, chatbots, and social media - have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for "digital phenotyping" and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self-management of psychological well-being and early intervention, along with more nascent research supporting their use in clinical management of long-term psychiatric conditions - including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders - as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real-world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.

Engagement during a Mixed In-Person and Remotely Delivered Psychological Intervention for Youth with Functional Abdominal Pain Disorders and Anxiety

Functional abdominal pain disorders (FAPD) are common disabling pain conditions frequently associated with co-occurring mental health problems such as anxiety. Psychological therapies such as cognitive behavioral therapy (CBT) have been shown to be effective. Therefore, it is important to understand participant engagement (i.e., use of intervention tools) to such approaches, and if engagement impacts treatment response. The Aim to Decrease Anxiety and Pain Treatment (ADAPT) is an effective psychological treatment approach using a blend of in-person sessions and interventionist phone support with self-paced web modules to manage pain and anxiety. The current study used a mixed-methods approach to investigate micro-level and macro-level participant engagement during the ADAPT program. In-person/phone session attendance was high (>95%) although scheduling adjustments were common (25.5%). Varied levels of engagement with web tools were observed. Thematic analysis also revealed variability in patterns of use. Additionally, while participants indicated they generally understood how to use certain skills (e.g., problem solving, detective thinking), and these skills were effective in managing symptoms during treatment, these activities were generally underutilized. Further, participant engagement did not predict response to the ADAPT intervention. These findings are important as the demand for accessible psychotherapeutic tools to manage pain and anxiety is likely to remain high.

The impact of COVID-19 lockdown on child and adolescent mental health: systematic review

COVID-19 was declared a pandemic in March 2020, resulting in many countries worldwide calling for lockdowns. This study aimed to review the existing literature on the effects of the lockdown measures established as a response to the COVID-19 pandemic on the mental health of children and adolescents. Embase, Ovid, Global Health, PsycINFO, Web of Science, and pre-print databases were searched in this PRISMA-compliant systematic review (PROSPERO: CRD42021225604). We included individual studies reporting on a wide range of mental health outcomes, including risk and protective factors, conducted in children and adolescents (aged ≤ 19 years), exposed to COVID-19 lockdown. Data extraction and quality appraisal were conducted by independent researchers, and results were synthesised by core themes. 61 articles with 54,999 children and adolescents were included (mean age = 11.3 years, 49.7% female). Anxiety symptoms and depression symptoms were common in the included studies and ranged 1.8-49.5% and 2.2-63.8%, respectively. Irritability (range = 16.7-73.2%) and anger (range = 30.0-51.3%), were also frequently reported by children and adolescents. Special needs and the presence of mental disorders before the lockdown, alongside excessive media exposure, were significant risk factors for anxiety. Parent-child communication was protective for anxiety and depression. The COVID-19 lockdown has resulted in psychological distress and highlighted vulnerable groups such as those with previous or current mental health difficulties. Supporting the mental health needs of children and adolescents at risk is key. Clinical guidelines to alleviate the negative effects of COVID-19 lockdown and public health strategies to support this population need to be developed.

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

Background

Children and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.

Objective

The objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.

Methods

We developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.

Results

During the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.

Conclusions

The telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.

Mental Health Care Providers' Attitudes Toward Telepsychiatry: A Systemwide, Multisite Survey During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic has forced a rapid transition to telepsychiatry. This study examined the experience and attitudes of mental health care providers toward telehealth.

METHODS

At 18 centers across the United States, 819 mental health care providers completed an electronic survey about telepsychiatry use and satisfaction.

RESULTS

Overall, 73% of providers using videoconferencing and 66% using the telephone rated their experience as excellent or good. Flexible scheduling or rescheduling (77%) and timely start (69%) were frequently reported advantages for both modalities. Challenges were related to patients' inability to use conferencing devices (52%), lack of sense of closeness or connection (46%), and technical problems (39%). After the pandemic resolves, 64% of respondents would want to continue using telepsychiatry in at least 25% of their caseload.

CONCLUSIONS

Telepsychiatry was very well perceived among mental health care providers, and many would like to continue using it. Access to technology and training raises concerns.