Emerging Needs and Viability of Telepsychiatry During and Post COVID-19 Era: A Literature Review

The coronavirus disease 2019 (COVID-19) pandemic has resulted in nationwide stay-at-home orders in an effort to slow the spread severely impacting the healthcare sector. Telepsychiatry provides a platform bridging the gap through advanced technologies connecting mental health providers and patients who need their services, overcoming previous barriers of great distances, lack of transportation, and even time constraints. The most obvious benefit is increased accessibility to mental healthcare, especially in underserved and remote areas where there is no easy access for in-person care. It is important to note that benefits are not limited to patients, but also allow clinicians greater flexibility in scheduling and reduced practice overhead costs, both of which aid with physician burnout and burden. Telepsychiatry during COVID-19 provides its own unique advantages over in-person visits. The risk of exposure to healthcare workers and patients receiving care is reduced, allowing immunocompromised patients to receive much-needed psychiatric care. Without the need to meet in person, self-isolating psychiatrists can still provide care, decreasing strain on their co-workers. Although telepsychiatry is relatively new, it has already exhibited considerable success in its effectiveness at treating psychiatric conditions and widespread corollary benefits. Telepsychiatric consults may be carried out synchronously and asynchronously, each having benefits and setbacks. Different mobile application interventions have been explored, which are available for the purpose of both monitoring/assessing patients and/or providing treatment. The scope of conditions these applications address is broad, from anxiety disorders to schizophrenia to depression. As promising and beneficial telepsychiatry may seem, it is necessary to recognize that building the program can be challenging. It involves adapting to new methods in medicine. We highlighted barriers to general telepsychiatry, the most prominent being technological literacy of both physician and patient, and possible negative effects of eliminating the in-person patient-doctor interaction.


Introduction And Background
The recent coronavirus disease 2019 (COVID- 19) pandemic has resulted in nationwide stay-at-home orders in an effort to slow the spread of the disease severely impacting many industries, including the healthcare sector [1]. As hospitals and healthcare providers pause non-emergency services and elective procedures, many patients are unable to receive care. In fact, 45% of U.S. adults reported they or someone in their household had deferred medical care due to the coronavirus pandemic [2]. Although the lack of these services may seem insignificant given their non-emergent status, they can still prove detrimental to an individual's well-being, especially when it comes to mental health. With patients being unable to see their psychiatrists for in-person sessions, it is imperative that alternative methods be explored in an attempt to bypass this obstacle.
As the prevalence of mental health disorders continues to increase among young adults, there is an imminent need for new and innovative ways to meet the populations' demands of effective delivery of psychiatric care [3]. In addition to the challenges introduced by COVID-19, there is an existing disparity regarding access to healthcare; 3.6 million Americans are unable to receive medical care due to a lack of transportation [4]. Telepsychiatry offers a prospective solution to all the aforementioned problems, promising a delivery method that is not only much easier to access but can adapt to match the demand whilst abiding by social distancing policies in place [5].
Telepsychiatry provides a virtual platform for the matching and communication between mental health providers and the patients who need their services, overcoming previous barriers of great distances, lack of transportation, and even time constraints. Many mental health conditions require outpatient follow-up and medical management. Given that, telepsychiatry has the potential to increase access to care while improving waiting times and reducing costs and the need for hospitalization [6].
This review examines the methods and limitations of telepsychiatry that are currently available and provides valuable insight into the outcomes of populations that are currently being implemented in telepsychiatry. It is important to note that telepsychiatry is not a cure-all solution. Despite the encouraging benefits, there are many questions to be considered, such as: Will the patient feel as connected with the provider as in-person visits? Can the same trust and emotional bond be forged over a virtual session? Psychiatry is different from other medical specialities where treatment is often a prescription or a one-time procedure. Ninety percent of the diagnosis and fifty percent of treatment involve direct communication between patient and psychiatrist, so it is imperative to address how telepsychiatry may modify or change the physician-patient relationship.

Review
With the COVID-19 pandemic came a dramatic shift of the U.S. healthcare system as traditional medicine transitioned from in-person visits to telemedicine instead. Without a vaccine or standardized effective treatment options, social distancing procedures and stay-at-home orders have become the primary forms of intervention. Given that, clinicians, healthcare workers, and insurers alike have been forced to adapt rapidly in order to provide an alternative to in-person care, turning to telemedicine. This surge in telemedicine has largely been focused on triage screening patients, much of which has been related to physical symptoms pertaining to COVID-19 [7,8]. What has been neglected amidst this pandemic, though, is the delivery and availability of mental healthcare. Whether it be the detrimental effects of social isolating, the panic that comes from losing one's job in a period of economic instability, or simply the stress that comes from living during such uncertain times, it is clear that mental health is more important than ever. During this viral outbreak, there has been a huge surge in symptoms of depression, anxiety, insomnia, and acute stress, whether it be healthcare providers or the general public [9][10][11]. As the prevalence of mental health disorders continues to increase at a startling rate, it is pertinent to turn to telepsychiatry as a means of increasing access to mental healthcare.
Before diving into the benefits, limitations, and methods of implementation of telepsychiatry, it is important to gain a thorough understanding and definition of telepsychiatry (Table 1). Specifically, what makes it different from telemedicine? Telemedicine is described as the remote assessment, diagnosis, and treatment of patients through the use of telecommunication audiovisual technology. This includes, but is not limited to, consultations over the phone, video calls or text messaging, digital transmission of medical imaging, and remote diagnoses. Telepsychiatry is a specific application of telemedicine within the speciality of psychiatry and involves making psychiatric diagnoses and administering psychiatric treatment or therapy through technological means. The history of telemedicine is long and extensive, with the first use of telemedicine being described in The Lancet in 1879 as the transmission of medical knowledge and conducting medical appointments through the telephone [12]. However, telepsychiatry was not documented until nearly a century later, in the 1950s, when the Nebraska Psychiatric Institute utilized videoconferencing for consultations, educational endeavours, and training for patients [13].

Telemedicine Telepsychiatry
Remote assessment, diagnosis, and treatment of patients through the use of telecommunication audiovisual technology. Application of telemedicine within the specialty of psychiatry.
Use of telemedicine was first described in The Lancet in 1879. Related terms are telemental health and telepsychology.
Administration of psychiatric treatment or therapy via technological communication.
First use of videoconferencing in psychiatry was in the 1950s at the Nebraska Psychiatric Institute.

TABLE 1: Comparison of traditional telemedicine with telepsychiatry
Although telepsychiatry is a newer branch of telemedicine, the potential benefits of implementation are extensive and far-reaching ( Table 2). The increased accessibility to mental healthcare especially for those in underserved and remote areas seems to benefit maximally; additionally, transportation times and expenses are reduced along with base patient costs. These benefits result in lower attrition rates of patients, along with increased patient satisfaction with care [14][15][16]. It is important to note that benefits are not limited to patients, but also allow clinicians greater flexibility of scheduling and reduces practice overhead costs, both of which can aid with physician burnout and burden. Telepsychiatry during COVID-19 provides its own unique advantages over in-person visits. The risk of exposure to both healthcare workers and patients receiving care is greatly reduced, allowing immunocompromised patients to receive much-needed psychiatric care. Without the need to meet in person, self-isolating psychiatrists can still provide care, decreasing strain on their co-workers. Patients who have tested positive for coronavirus will still be able to meet with their psychiatrists.

Barriers Benefits
Adapting to novel practice model and technology  Within the branch of telepsychiatry, one can dissociate between synchronous and asynchronous telepsychiatry, each having its own benefits and setbacks. Synchronous telepsychiatry requires the presence of both the patient and the psychiatrist at the same time, engaging in real-time communication.
Asynchronous telepsychiatry, on the other hand, can be thought of as the store-and-forward transmission of medical data, as well as clinical diagnosis, treatment, and recommendations [17,18]. For an extensive comparison of the relative benefits and setbacks, refer to Table 3. Given the varying advantages, we recommend that the use of either method be situational; it is a decision that should be made largely depending on the patient-provider relationship and what would optimize individual patient care.
Consists of pre-recorded videos of psychiatrist that are then sent to the patient to be viewed on their own time.
Allows for real-time live interaction and assessment.
Involves acquiring medical data and transmitting it to the psychiatrist at a convenient time for assessment offline.
Can gain additional details essential for care during the session, which is more efficient in making a clinical decision and providing advice during the interaction.
Patients can get timely care without needing to travel beyond the location of their primary care providers.
Real-time telepsychiatry provides timely care, especially in emergencies or urgent situations, and maintains the concept of the doctor-patient relationship by enabling a face-to-face analysis and treatment.
Wait times for specialty care are lessened, especially in areas with shortages of psychiatrists.
The doctor can see the patient and engage in conversation, much as they would in an office visit.
The store-and-forward process can overcome language and cultural barriers.
Patients who are traveling or live in a different timezone can receive care without inconvenience.
The turnaround time to receive answers to patient concerns/questions may be longer than synchronous telepsychiatry.

TABLE 3: Comparison of synchronous vs asynchronous telepsychiatry
Although telepsychiatry is relatively new, it has already exhibited considerable success in both its effectiveness at treating psychiatric conditions as well as widespread corollary benefits. Although there are a few cases in which no significant improvement was seen between in-person psychiatry and telepsychiatry (five out of the 16 studies listed in Table 4), peripheral consequences such as decreased cost, better patientdoctor interactions, and higher satisfaction make telepsychiatry a viable, if not preferable choice to traditional in-person medicine. This, of course, only holds true for visits and disorders that do not necessitate physical examinations, which would be much more difficult to conduct virtually. Table 4 contains a comprehensive list of studies examining the effectiveness of telepsychiatry across multiple conditions, from depression and anxiety to dementia and post-traumatic illness, among others.   Up until this point, we have discussed telepsychiatry in the context of virtual appointments and interactions that presumably take over phone or video calls, but with the advent of smartphones, mobile applications (apps) have become an area of interest. In Table 5, though, we have explored different mobile application interventions that are available for the sole purpose of both monitoring/assessing patients and/or providing treatment. The scope of conditions that these apps address is broad, ranging from anxiety disorders to schizophrenia to depression, etc. All studies reported high user satisfaction and a few even saw significant improvement in symptom reduction [44][45][46][47][48][49][50][51]. These findings, although preliminary, suggest a promising future for mobile applications that patients can use on their own time either independently or in conjunction with psychiatrist appointments and monitoring.    Unfortunately, there is very limited literature on the current implementation of telepsychiatry during the coronavirus pandemic ( Table 6). This is not a reflection of the inefficacy of telepsychiatry, though, but rather a reflection of its underutilization. This is a field of untapped potential that needs to be further explored and expanded upon, especially with the current climate of the pandemic. As promising and beneficial telepsychiatry may seem, though, it is necessary to recognize that no telemedicine program can be created overnight. There are challenges involved in adapting to this new method of medicine. Table 2 above highlights barriers to general telepsychiatry-the most prominent ones being the need for technological literacy on both the physician and patient end, as well the possible negative effects of eliminating the in-person patient-doctor interaction that is often used to build rapport.  Specific to COVID-19, structured interviews with clinicians revealed problems that they ran into when transitioning to telepsychiatry ( Table 7). These included decreased clinical data available to make an assessment or diagnosis and technological challenges (lack of reliable access to a computer, smartphone, or the internet) among other issues.  Given this, it is necessary to implement some advanced directives that will smoothly aid the shift toward telepsychiatry. We provide a few recommendations below. First and foremost, it will be crucial to evaluate telehealth competency among psychiatrists before establishing a standard for telepsychiatry training, in addition to creating frameworks for virtual psychiatric practice. This first step will provide a stable foundation for the entire psychiatric field to promote quality and regulated care.

Advance Directives
The following recommendations may be beneficial in improving telepsychiatry and telehealth services. Conducting and evaluating current telehealth competency among psychiatrists and physicians to promote quality care across practices [57]. Evaluate and improve current frameworks for technological competency and use in psychiatry [58]. Establish standardized training for psychiatrists who are currently practicing in the field extend telepsychiatry training to include undergraduate medical education for early training and introduction to telepsychiatry [59]. Provide patients with technological training to ensure that they have the digital literacy to use these virtual services and apps [60,61]. Work with social workers to ensure that patients in remote areas have consistent access to technological resources.

Conclusions
Overall, the use of telemedicine to provide medical care is not novel, but the COVID-19 pandemic has forced the US healthcare system to promptly shift to telehealth, whether or not it was ready to do so. When looking at this shift to telemedicine, some specialities have been focused on greater than others, and psychiatry is one field that has been overlooked. This current review examined the feasibility, efficacy, and likelihood of successful implementation of telepsychiatry both during the pandemic and beyond. The advantageous benefits of telepsychiatry, whether it be used in conjunction with mobile smartphone applications or synchronous/asynchronous, are widespread and many. The potential of using virtual medicine to change the way the psychiatric field is structured is unbounded, although this transition is not without barriers or difficulties. To address these issues, preemptive steps must be taken to standardize practice and thoroughly prepare healthcare providers. With careful planning and collaborative teamwork, telepsychiatry implementation can provide practical and satisfactory delivery of mental healthcare, benefitting both patients and clinicians.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.