Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence

Psychological first aid for Ukrainian civilians: protocol and reflections on a volunteer international phone-based intervention

Informal mental healthcare groups often provide telephonic and text-based interventions to support communities affected by natural and man-made disasters. Operating outside formal regulations, these groups offer flexible and innovative care; documenting their practices is crucial for evaluating service quality. This paper presents a protocol of an international, informal Psychological First Aid (PFA) telephone-based initiative and a reflective account from a volunteering therapist. The initiative aimed to support Ukrainian civilians affected by the Russian-Ukrainian war through crisis intervention and resilience-building. Guided by PFA principles, theoretical first aid models, and evidence-based practices, the telephone interventions focused on reducing distress, providing moral support, and restoring functioning. A Russian-speaking therapist assisted 34 Ukrainian civilians, primarily addressing acute stress, anxiety, and panic attacks. Using an autoethnographic approach, this study integrates the therapist's retrospective reflections, cultural context, and professional learning to examine PFA implementation in a crisis setting. Individuals who received telephone-based PFA reported decreased distress and enhanced coping strategies, suggesting effectiveness. The initiative's three-year continuation illustrates its sustainability. The therapist's reflections highlight the importance of professional preparation, shared linguistic and cultural backgrounds, and a sense of purpose in delivering effective support. While limitations include the absence of standardized measures and potential self-selection and volunteer biases, this study demonstrates the feasibility of providing remote psychological first aid to civilians through informal international groups. Critically evaluating practices adopted by these informal organizations is essential for understanding their effectiveness, improving future implementation, and co-creating best practices for crisis intervention and support services that embrace "Care Without Address" models.

Implementation of telepsychiatry in an urban pediatric satellite emergency department

While pediatric mental health emergencies are increasing in frequency and severity, psychiatric resources remain concentrated in tertiary care facilities. Telepsychiatry has successfully mitigated these challenges in rural emergency departments (EDs), suggesting potential benefits for urban EDs that lack psychiatric resources. We implemented telepsychiatry in an urban ED to reduce ED length of stay and the need for transferring pediatric patients with mental and behavioral health complaints. We conducted a retrospective review of patients aged 0-17 presenting from July 1, 2018 to May 31, 2020 (PRE-intervention) and from June 1, 2020 to June 30, 2023 (POST-intervention) for psychiatric evaluation, suicidal ideation, homicidal ideation, behavioral issues, intentional ingestion, or altered mental status. Our outcomes of interest were ED length of stay, proportion transferred, and proportion with a repeat visit within 30 days for a mental health complaint. There were 199 patients; 74 PRE and 125 POST. Post-intervention, 91% (114 patients) were evaluated completely via telepsychiatry; thus only 11 (9%) required transfer. The median age was 14 years (range 8-17). The most common complaints were suicidal ideation, intentional ingestion, and behavioral problems. Seventy-four percent of patients (n = 84) evaluated by telepsychiatry were discharged from the satellite ED. The median length of stay decreased significantly from 473 min (95% CI: 431-733) to 275 min (95% CI: 316-462) after implementation. Repeat visits for mental health complaints within 30 days decreased from 23% to 10%. Implementing a telepsychiatry evaluation program in an urban pediatric satellite ED reduced transfers and decreased patient length of stay.

Evaluation of Telemedicine Support for Medics from the Perspective of Course Instructors

INTRODUCTION

Health services in the theater/district areas often contain difficulties. Although telemedicine has a huge potential to support medics in the area, there are challenges as well. Our aim is to evaluate the telemedicine support that can be provided to the medics from the perspective of course instructors.

MATERIALS AND METHODS

Our study was carried out in The University of Health Sciences, Türkiye. All of the instructors of a medic course were asked to fill a 13-question questionnaire and Likert-type scale, sent via e-mail. Among 79 instructors, 71 of them (55 physicians, 16 nonphysicians) responded and were included in the study. The distributions of the categorical variables in the groups were analyzed with the Pearson Chi-square.

RESULTS

Of the 71 participants, 37 (52.11%) stated that there is a need for legal and ethical regulations for telemedicine (medical liability, malpractice, obtaining consent from the casualties, civilians, cross border missions, and rank-related problems) and patients' rights, additionally, to clarify the responsibilities of the doctors giving telemedicine support and the medics in the area. It was observed that physicians' and nonphysician group's opinions about the telepsychotherapy were statistically significantly different (χ2 = 8.675, P = .013).

CONCLUSIONS

Most of the instructors believed that telemedicine could carry the knowledge and skills of specialist physicians to the field of operation. Access to high-quality health services in a short time through telemedicine support can increase the courage and commitment of the personnel. It is thought that with telemedicine, medics will not feel alone in the field, their worries about making wrong decisions will decrease, and their knowledge and skills will increase. Participants were particularly concerned about who will be held responsible for problems arising from interventions carried out using telemedicine, and strict legal and medical regulations are needed.

Using a Digital Mental Health Intervention for Crisis Support and Mental Health Care Among Children and Adolescents With Self-Injurious Thoughts and Behaviors: Retrospective Study

BACKGROUND

Self-injurious thoughts and behaviors (SITBs) are increasing dramatically among children and adolescents. Crisis support is intended to provide immediate mental health care, risk mitigation, and intervention for those experiencing SITBs and acute mental health distress. Digital mental health interventions (DMHIs) have emerged as accessible and effective alternatives to in-person care; however, most do not provide crisis support or ongoing care for children and adolescents with SITBs.

OBJECTIVE

To inform the development of digital crisis support and mental health care for children and adolescents presenting with SITBs, this study aims to (1) characterize children and adolescents with SITBs who participate in a digital crisis response service, (2) compare anxiety and depressive symptoms of children and adolescents presenting with SITBs versus those without SITBs throughout care, and (3) suggest future steps for the implementation of digital crisis support and mental health care for children and adolescents presenting with SITBs.

METHODS

This retrospective study was conducted using data from children and adolescents (aged 1-17 y; N=2161) involved in a pediatric collaborative care DMHI. SITB prevalence was assessed during each live session. For children and adolescents who exhibited SITBs during live sessions, a rapid crisis support team provided evidence-based crisis support services. Assessments were completed approximately once a month to measure anxiety and depressive symptom severity. Demographics, mental health symptoms, and change in the mental health symptoms of children and adolescents presenting with SITBs (group with SITBs) were compared to those of children and adolescents with no SITBs (group without SITBs).

RESULTS

Compared to the group without SITBs (1977/2161, 91.49%), the group with SITBs (184/2161, 8.51%) was mostly made up of adolescents (107/184, 58.2%) and female children and adolescents (118/184, 64.1%). At baseline, compared to the group without SITBs, the group with SITBs had more severe anxiety and depressive symptoms. From before to after mental health care with the DMHI, the 2 groups did not differ in the rate of children and adolescents with anxiety symptom improvement (group with SITBs: 54/70, 77% vs group without SITBs: 367/440, 83.4%; χ21=1.2; P=.32) as well as depressive symptom improvement (group with SITBs: 58/72, 81% vs group without SITBs: 255/313, 81.5%; χ21=0; P=.99). The 2 groups also did not differ in the amount of change in symptom severity during care with the DMHI for anxiety (t80.20=1.37; P=.28) and depressive (t83.75=-0.08; P=.99) symptoms.

CONCLUSIONS

This study demonstrates that participation in a collaborative care DMHI is associated with improved mental health outcomes in children and adolescents experiencing SITBs. These results provide preliminary insights for the use of pediatric DMHIs in crisis support and mental health care for children and adolescents presenting with SITBs, thereby addressing the public health issue of acute mental health crisis in children and adolescents.

The Use of Telepsychiatry Services in Emergency Settings: Scoping Review

BACKGROUND

Telepsychiatry (TP), a live video meeting, has been implemented in many contexts and settings. It has a distinct advantage in the psychiatric emergency department (ED) setting, as it expedites expert assessments for psychiatric patients. However, limited knowledge exits for TP's effectiveness in the ED setting, as well as the process of implementing TP in this setting.

OBJECTIVE

This scoping review aimed to review the existing evidence for the administrative and clinical outcomes for TP in the ED setting and to identify the barriers and facilitators to implementing TP in this setting.

METHODS

The scoping review was conducted according to the guidelines for the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Three electronic databases were examined: PubMed, Embase, and Web of Science. The databases were searched from January 2013 to April 2023 for papers and their bibliography. A total of 2816 potentially relevant papers were retrieved from the initial search. Studies were screened and selected independently by 2 authors.

RESULTS

A total of 11 articles were included. Ten papers reported on administrative and clinical outcomes of TP use in the ED setting and 1 on the barriers and facilitators of its implementation. TP is used in urban and rural areas and for settings with and with no on-site psychiatric services. Evidence shows that TP reduced waiting time for psychiatric evaluation, but in some studies, it was associated with prolonged total length of stay in the ED compared with in-person evaluation. Findings indicate lower admission rates in patients assessed with TP in the ED. Limited data were reported for TP costs, its use for involuntary commitment evaluations, and its use for particular subgroups of patients (eg, those with a particular diagnosis). A single paper examined TP implementation process in the ED, which explored the barriers and facilitators for implementation among patients and staff in a rural setting.

CONCLUSIONS

Based on the extant studies, TP seems to be generally feasible and acceptable to key stakeholders. However, this review detected a gap in the literature regarding TP's effectiveness and implementation process in the ED setting. Specific attention should be paid to the examination of this service for specific groups of patients, as well as its use to enable assessments for possible involuntary commitment.

Development of the Therapeutic Alliance in Alternative Settings to Psychiatric Hospitalization: An Open Comparative Study

Patient-therapist alliance in two alternative treatment settings developed similarly to that in traditional psychiatric hospitalization.

Remote crisis intervention and suicide risk management in COVID-19 frontline healthcare workers

Introduction

Despite the propagation of virtual mental health services for vulnerable groups during COVID-19 pandemic, the implementation and evaluation of remote evidence-based practices (EBP) to manage them in low- and middle-income countries remains scarce. In the current study, we describe and evaluate the implementation process and clinical impact of brief, remote, manualized EBP for crisis intervention and suicide risk management among healthcare workers attending patients with COVID-19 (COVID-19-HCWs) in Mexico.

Methods

The implementation process comprised community engagement of volunteer mental health specialists, creation of new clinical teams with different disciplines and skills, intervention systematization through manuals and education through 4-h remote training as main strategies. Mexican COVID-19-HCWs who had used a free 24-h helpline rated their pre- and post-intervention emotional distress. Therapists recorded patients' pre-intervention diagnosis, severity, and suicide risk, the techniques used in each case, and their post-treatment perception of COVID-19-HCWs' improvement at the end of the intervention.

Results

All techniques included in the intervention manual were employed at least in one case (n = 51). At the beginning of the intervention, 65.9% of the COVID-19-HCWs were considered moderately ill or worse according to Clinical Global Impression-Severity (CGI-S) scores, whereas at the end, 79.4% of them were perceived as much or very much improved according to CGI-Improvement scores (CGI-I), and their emotional distress had been significantly reduced (p < 0.001).

Discussion

This prospective study provides evidence that implementation of remote EBP is feasible and useful to reduce emotional distress and suicide risk among COVID-19-HCWs from a middle-income country. However, this study was limited by lack of a control group, improvement ratings provided by therapists and non-anonymous satisfaction ratings.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings

OBJECTIVE

The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization.

METHODS

Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care.

RESULTS

The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios.

CONCLUSIONS

A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

Qualitative study on the use of emergency services by people with serious mental disorder in Spain

BACKGROUND

The population with severe mental disorders (SMD) is a frequent user of emergency services. Situations of psychiatric decompensation can have devastating consequence and can cause problems in getting urgent medical care. The objective was to study the experiences and needs of these patients and their caregivers regarding the demand for emergency care in Spain.

METHODS

Qualitative methodology involving patients with SMD and their informal caregivers. Purposive sampling by key informants in urban and rural areas. Paired interviews were carried out until data saturation. A discourse analysis was conducted, obtaining a codification in categories by means of triangulation.

RESULTS

Forty-two participants in twenty-one paired interviews (19 ± 7.2 min as mean duration). Three categories were identified. 1º Reasons for urgent care: poor self-care and lack of social support, as well as difficulties in accessibility and continuity of care in other healthcare settings. 2º Urgent care provision: trust in the healthcare professional and the information patients receive from the healthcare system is crucial, telephone assistance can be a very useful resource. 3º Satisfaction with the urgent care received: they request priority care without delays and in areas separated from the other patients, as well as the genuine interest of the professional who attends them.

CONCLUSIONS

The request for urgent care in patients with SMD depends on different psychosocial determinants and not only on the severity of the symptoms. There is a demand for care that is differentiated from the other patients in the emergency department. The increase in social networks and alternative systems of care would avoid overuse of the emergency departments.

Impact of COVID-19 on mental health and social service provision in Singapore: Learnings from a descriptive mixed-methods study for future resource planning

Introduction

COVID-19 restrictions and lockdown measures have led to impact on the mental health and social service delivery, including the rapid adoption of digital solutions to mental healthcare delivery in Singapore. This study aims to rapidly document the quantitative and qualitative impact of the pandemic restrictions on mental health and social services.

Method

This descriptive mixed-methods study consisted of a survey arm and a qualitative arm. Providers and clients from eligible mental health organisations and social service agencies were recruited. The respondents completed a survey on changes to their service delivery and the extent of impact of the pandemic on their clients. In-depth interviews were also conducted with representatives of the organisations and clients.

Results

There were 31 organisation representatives to the survey, while 16 providers and 3 clients participated in the in-depth interviews. In the survey arm, all representatives reported pivoting to remote means of delivering care during the lockdown. An increase in new client referrals and more domestic violence were reported from primary and community health partners respondents who made up 55.5% of health partners respondents. Three distinct response themes were recorded in the in-depth interviews: impact on clients, impact on service provision and impact on mental health landscape.

Conclusion

Two key findings are distilled: (1) mental health and social services have been challenged to meet the evolving demands brought about by the pandemic; (2) more societal attention is needed on mental health and social services. The findings indicate a necessary need for extensive studies on COVID-19 that can inform policies to build a more pandemic-resilient nation.

Comparable reliability and acceptability of telepsychiatry and face-to-face psychiatric assessments in the emergency room setting

OBJECTIVE

This study aims to compare the reliability and acceptability of psychiatric interviews using telepsychiatry and face-to-face modalities in the emergency room setting.

METHODS

In this prospective observational feasibility study, psychiatric patients (n = 38) who presented in emergency rooms between April and June 2020, went through face-to-face and videoconference telepsychiatry interviews in a non-randomised varying order. Interviewers and a senior psychiatry resident who observed both interviews determined diagnosis, recommended disposition and indication for involuntary admission. Patients and psychiatrists completed acceptability post-assessment surveys.

RESULTS

Agreement between raters on recommended disposition and indication for involuntary admission as measured by Cohen's kappa was 'strong' to 'almost perfect' (0.84/0.81, 0.95/0.87 and 0.89/0.94 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively). Partial agreement between the raters on diagnosis was 'strong' (Cohen's kappa of 0.81, 0.85 and 0.85 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively).Psychiatrists' and patients' satisfaction rates, and psychiatrists' perceived certainty rates, were comparably high in both face-to-face and telepsychiatry groups.

CONCLUSIONS

Telepsychiatry is a reliable and acceptable alternative to face-to-face psychiatric assessments in the emergency room setting. Implementing telepsychiatry may improve the quality and accessibility of mental health services.Key pointsTelepsychiatry and face-to-face psychiatric assessments in the emergency room setting have comparable reliability.Patients and providers report a comparable high level of satisfaction with telepsychiatry and face-to-face modalities in the emergency room setting.Providers report a comparable level of perceived certainty in their clinical decisions based on telepsychiatry and face-to-face psychiatric assessments in the emergency room setting.

Exploring Trauma and Resilience among NYS COVID-19 Pandemic Survivors

The New York State (NYS) Office of Mental Health created the NYS COVID-19 Emotional Support Helpline and enlisted graduate students to provide phone-based emotional support initially to the NYS community. This NYS-funded initiative transformed into providing psychosocial support for callers across the United States. Four NYS doctoral students acted as the helpline agents and received 251 individual calls from May–August 2020. The agents documented the calls with clinical notes which cannot be traced back to specific callers. The purpose of this retrospective qualitative study was to explore the themes that emerged from the calls to give voice to the trauma that callers were reporting during the early phases of the pandemic, and the resilience they demonstrated as they engaged with the Helpline. The agents’ clinical transcripts were converted into codes using a critical-constructivist grounded theory approach (Levitt, 2021) with the NVIVO qualitative data analysis software. A second research team audited the initial codes for construct clarity. Emergent themes detailed the unique traumas that helpline callers divulged, how the agents provided support, and the callers’ capacities for resilience. Recommendations are suggested to inform clinicians working with pandemic survivors, to offer guidance on providing distance or virtual interventions as well as to enhance policymakers’ understanding of addressing mental health needs across populations served via the NYS COVID-19 Emotional Support Helpline.

Telepsychiatry services across an emergency department network: A mixed methods study of the implementation process

BACKGROUND

Due to limited community resources for mental health and long travel distances, emergency departments (EDs) serve as the safety net for many rural residents facing crisis mental health care. In 2019, The Leona M. and Harry B. Helmsley Charitable Trust funded a project to establish and implement an ED-based telepsychiatry service for patients with mental health issues in underserved areas. The purpose of this study was to evaluate the implementation of this novel ED-based telepsychiatry service.

METHODS

This was a mixed-methods study evaluating the new ED-based telepsychiatry consult service implemented in five EDs across three rural states that participated within a mature hub-and-spoke telemedicine network between June 2019 and December 2020. Quantitative evaluation in this study included characteristics of the telehealth encounters and the patient population for whom this service was used. For qualitative assessments, we identified key themes from interviews with key informants at the ED spokes to assess overall facilitators, barriers, and impact. Integrating the quantitative and qualitative findings, we explored emergent phenomena and identified insights to provide a comprehensive perspective of the implementation process.

RESULTS

There were 4130 encounters for 3932 patients from the EDs during the evaluation period. Approximately 54% of encounters involved female patients. The majority of patients seen were white (51%) or Native American (44%) reflecting the population of the communities where the EDs were located. Among the indications for the telepsychiatry consult, the most frequently identified were depression (28%), suicide/self-harm (17%), and schizophrenia (12%). Across sites, 99% of clinician-to-clinician consults were by phone, and 99% of clinical assessments/evaluations were by video. The distribution of encounters varied by the day of the week and the time of day. Facilitators for the service included increasing need, a supportive infrastructure, a straightforward process, familiarity with telemedicine, and a collaborative relationship. Barriers identified by respondents at the sites included the lack of clarity of process and technical limitations. The themes emerging from the impact of the telepsychiatry consultation in the ED included workforce improvement, care improvement, patient satisfaction, cost-benefit, facilitating COVID care, and access improvement.

CONCLUSIONS

Implementation of a telepsychiatry service in ED settings may be beneficial to the patient, local ED, and the underserved community. In this study, we found that implementing this service alleviated the burden of care during the COVID-19 pandemic, enhanced local site capability, and improved local ability to provide quality and effective care.

In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments

OBJECTIVES

The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality.

METHODS

This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality.

RESULTS

The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons.

CONCLUSIONS

We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

The Impact of NC Statewide Telepsychiatry Program (NC-STeP) on Cost Savings by Reducing Unnecessary Psychiatric Hospitalizations During a 6½ Year Period

OBJECTIVE

To study the impact of the North Carolina Statewide Telepsychiatry Program in reducing unnecessary psychiatric hospitalizations and cost savings during a 6½ year period.

METHODS

Patient encounter data was extracted from the NC-STeP database that captured records of 19,383 patients who received services over a 6½ -years' period. We analyzed the data to calculate the total number of patient encounters, the number of encounters with an IVC, and the number of encounters with an IVC that was overturned. For encounters with an overturned IVC, we also determined the patient discharge disposition. We estimated the cost of a typical mental health hospitalization to measure the savings generated by the overturned IVCs in the NC-STeP program.

RESULTS

Over the 6½ year period there were 19,383 NC-STeP patient encounters at partner hospital emergency departments. There were 13,537 encounters where the patient had an IVC in place during the ED stay, and 4,627 where the IVC was overturned (34 %). For patients where there was an IVC that was overturned, 85.9 % of those patients were ultimately discharged home. Using the "three-way bed" cost estimate of $ 4,500 for each overturned IVC, the cost savings generated by the NC-STeP program from November 2013 to June 2020 were $ 20,821,500.

CONCLUSIONS

Telepsychiatry consultation services in the emergency departments can decrease unnecessary psychiatric hospitalizations and contribute to significant cost savings to the healthcare system and society and improve the outcomes for patients and families by decreasing financial burden and stress associated with a hospital stay.

Implementation Evaluation of HUGS/Abrazos During the COVID-19 Pandemic: A Program to Foster Resiliency in Pregnancy and Early Childhood

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020-8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Digital NHS Wales: a coding reliability analysis based on the voices of 22 978 patients and clinicians on the benefits, challenges and sustainability of video consulting

INTRODUCTION

The use of video consulting (VC) in Wales UK has expanded rapidly. Previous VC evidence has been the subject of small-scale projects and evaluations. Technology Enabled Care Cymru is an all-Wales digital service and rolls out digital interventions and evaluates on large scales, thus capturing representative data sets across Wales, and therefore a wide range of National Health Service (NHS) specialties.

OBJECTIVE

To extract and analyse narrative feedback from patients and clinicians using the NHS Wales VC Service for 6 months (September 2020 to March 2021).

DESIGN

A coding reliability approach of a cross-sectional study was conducted.

SETTING

From all health boards across Wales.

PARTICIPANTS

NHS patients and clinicians across primary, secondary and community care settings in Wales.

RESULTS

Data were captured on benefits, challenges and sustainability of VC. A coding reliability analysis was used with six domain summaries materialising to include: 'The Ease of VC'; 'The Personal Touches'; 'The Benefits of VC'; 'The Challenges of VC'; 'Technical Quality'; and 'Recommendations & Future Use'. An additional 17 subdomains are included. Direct quotations from patients and clinicians are provided for context.

CONCLUSIONS

A total of 22 978 participants were included. These data help demonstrate that NHS remote service delivery, via the method of VC, can be highly satisfactory, well accepted and clinically suitable yielding many benefits. Despite this, the data are not without its challenges surrounding engagement and suitability for VC. The NHS Wales VC Service rolled out and evaluated at scale and demonstrates that VC has potential for long-term sustainability. For the future, use a 'blended approach' for NHS appointments that are clinically judged and centred on patient choice.

Association Between Telepsychiatry Capability and Treatment of Patients With Mental Illness in the Emergency Department

OBJECTIVE

Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions.

METHODS

ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined.

RESULTS

There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01).

CONCLUSIONS

Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.

The Impact of COVID-19 Lockdown on Daily Activities, Cognitions, and Stress in a Lonely and Distressed Population: Temporal Dynamic Network Analysis

Background

The COVID-19 pandemic and its associated lockdown measures impacted mental health worldwide. However, the temporal dynamics of causal factors that modulate mental health during lockdown are not well understood.

Objective

We aimed to understand how a COVID-19 lockdown changes the temporal dynamics of loneliness and other factors affecting mental health. This is the first study that compares network characteristics between lockdown stages to prioritize mental health intervention targets.

Methods

We combined ecological momentary assessments with wrist-worn motion tracking to investigate the mechanism and changes in network centrality of symptoms and behaviors before and during lockdown. A total of 258 participants who reported at least mild loneliness and distress were assessed 8 times a day for 7 consecutive days over a 213-day period from August 8, 2020, through March 9, 2021, in Germany, covering a “no-lockdown” and a “lockdown” stage. COVID-19–related worry, information-seeking, perceived restriction, and loneliness were assessed by digital visual analog scales ranging from 0 to 100. Social activity was assessed on a 7-point Likert scale, while physical activity was recorded from wrist-worn actigraphy devices.

Results

We built a multilevel vector autoregressive model to estimate dynamic networks. To compare network characteristics between a no-lockdown stage and a lockdown stage, we performed permutation tests. During lockdown, loneliness had the highest impact within the network, as indicated by its centrality index (ie, an index to identify variables that have a strong influence on the other variables). Moreover, during lockdown, the centrality of loneliness significantly increased. Physical activity contributed to a decrease in loneliness amid the lockdown stage.

Conclusions

The COVID-19 lockdown increased the central role of loneliness in triggering stress-related behaviors and cognition. Our study indicates that loneliness should be prioritized in mental health interventions during lockdown. Moreover, physical activity can serve as a buffer for loneliness amid social restrictions.

Video and social rehabilitation of persons with mental illness helps to structure everyday life: a qualitative study

BACKGROUND

Living with a mental disorder has a significant impact on everyday life. In 2018, one out of every six adults, equivalent to 17.3% of the adult population of the European Union, had symptoms of mental disorders. This paper focus on social rehabilitation of patients with mental illness who have been discharged from hospital and who use video communication technologies in their rehabilitation in collaboration with their social worker. The aim of this study has been to explore the experiences of persons with mental illnesses who participated in a long-term video-based tele-social rehabilitation program, the Video Assist.

METHODS

The overall research strategy is the case study method. Data collection techniques are based on triangulation. Document analysis has been performed. Participant observation in homes of persons with mental using video with social workers (168 hours). Semi structured qualitative interviews with persons with mental illness (n=13) has been conducted lasting between 30 and 60 minutes. Data were analyzed using NVivo 10.0.

RESULTS

Experiences of persons with mental illness participating in the tele-social rehabilitation program are in themes: user friendly video technology, video created a new means of communication between citizen and social worker, feeling of surveillance by having the technology in the home, development of new coping strategies in everyday life and need for psychosocial support and training via the video technology.

CONCLUSIONS

Persons with mental illness who are in a recovery process find that participating in a tele-social-rehabilitation program gives them a sense of mobility, security, surveillance but the ability to develop new coping strategies in their everyday lives. Future research is needed on long-term effects of tele-social rehabilitation for persons with mental illness.

Lessons for psychiatrists from the COVID pandemic: the need for expanded roles and additional competencies

The disaster of the COVID-19 pandemic has fundamentally changed the norms of psychiatric practice: from its methods of care delivery to its methods of practice. Traditional methods of care delivery using in-person visits became impractical or unsafe. Meanwhile, the pandemic has resulted in an increased demand for services. The resulting pivot to telepsychiatry required a skillset that was not a part of traditional psychiatry training. To meet the demand for services, many providers needed to join collaborative models of care to help scale their expertise. Although many innovative collaborative models of care exist, providers remain in their traditional consultative roles within many of those models. In a disaster, when there is an expanding mental health care need in the population, psychiatrists need to adapt their practice to meet expanded roles that naturally build on their usual ones. We explore the expanded roles that psychiatrists will need to fill based on what is known about the field of disaster mental health and principles from Psychological First Aid (PFA). In preparation for a new normal, in what George Everly describes as a 'disaster of uncertainty,' we propose evolutions in the way psychiatrists are trained. Specific training on telepsychiatry best practices will prepare psychiatrists to use this method most effectively and appropriately. Additional training should focus on the core competencies of disaster psychiatry: effective crisis leadership and strategic planning, disaster surveillance, knowledge of benign vs. concerning symptoms, psychological triage, implementation of crisis interventions, resource facilitation, crisis communication, and self and peer care. Developing and integrating these competencies into psychiatry training programs will best prepare psychiatrists for the expanding mental health care needs of the community in this ongoing disaster and future ones.

Lessons Learned or Forgotten? Impacts of COVID-19 on the Future Direction of Global (e-)Mental Health Care

PURPOSE OF REVIEW

The COVID-19 pandemic has impacted lives globally, posing unique challenges to mental health services exposing vulnerability and limitations within these systems. During the course of the pandemic, telecommunications technologies (e-mental health care) have served a critical role in psychiatric care. It is important to understand current lessons learned in e-mental health care and implications for global mental health systems for both emerging from the pandemic and after the pandemic has ended.

RECENT FINDINGS

There are significant regulatory, policy, and evaluation challenges for global e-mental health impacting patients, clinicians, health systems, and decision-makers. These include complex regulatory issues, difficulties of providing care across boundaries, and keeping pace with the implementation of new technologies in behavioral health. The collaborative development of global standards along with policies, appropriate regulations, and developing new models of research and development opens the possibility of improved access to care across national boundaries.

Remote mental health services: a mixed-methods survey and interview study on the use, value, benefits and challenges of a national video consulting service in NHS Wales, UK

Social distancing laws during the first year of the pandemic, and its unprecedented changes to the National Health Service (NHS) forced a large majority of services, especially mental health teams to deliver patient care remotely. For many, this approach was adopted out of necessity, rather than choice, thus presenting a true 'testing ground' for remote healthcare and a robust evaluation on a national and representative level.

OBJECTIVE

To extract and analyse mental health specific data from a national dataset for 1 year (March 2020-March 2021).

DESIGN

A mixed-methods study using surveys and interviews.

SETTING

In NHS mental health services in Wales, UK.

PARTICIPANTS

With NHS patients and clinicians across child and adolescent, adult and older adult mental health services.

OUTCOME MEASURES

Mixed methods data captured measures on use, value, benefits and challenges of video consulting (VC).

RESULTS

A total of 3561 participants provided mental health specific data. These data and its findings demonstrate that remote mental health service delivery, via the method of VC is highly satisfactory, well-accepted and clinically suitable for many patients, and provides a range of benefits to NHS patients and clinicians. Interestingly, clinicians working from 'home' rated VC more positively compared with those at their 'clinical base'.

CONCLUSIONS

Post 1-year adoption, remote mental health services in Wales UK have demonstrated that VC is possible from both a technical and behavioural standpoint. Moving forward, we suggest clinical leaders and government support to sustain this approach 'by default' as an option for NHS appointments.

Limits of remote working: the ethical challenges in conducting Mental Health Act assessments during COVID-19

COVID-19 has created additional challenges in mental health services, including the impact of social distancing measures on care and treatment. For situations where a detention under mental health legislation is required to keep an individual safe, psychiatrists may consider whether to conduct an assessment in person or using video technology. The Mental Health (Care and Treatment) (Scotland) Act 2003 does not stipulate that an assessment has to be conducted in person. Yet, the Code of Practice envisions that detention assessments would be conducted face to face in all circumstances. During the pandemic, the Mental Welfare Commission for Scotland, a statutory body with a duty to promote best practice of the Act, has been asked whether it may be acceptable and indeed preferable for some assessments to be conducted via video technology. Where an assessment is needed to determine if a patient needs to be detained, and where there is a need for social distancing or the need for 'shielding', remote assessments may in some circumstances be preferable. In this article, we outline the modification of the Mental Welfare Commission's previous outright rejection of virtual assessments as the pandemic progressed and discuss the ethical and legal issues the possibility of remote assessments has exposed. We also discuss the limits and when a virtual assessment is not considered ethical. As the pandemic moves from a state of emergency into a 'new normal' in psychiatric services during second, or subsequent, waves, the use and place (if any) of remote assessments for detention needs to be considered.

A qualitative study on patients' and their support persons' preferences for receiving one longer consultation or two shorter consultations when being informed about allogeneic hematopoietic stem cell transplantation

Background

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only potentially curative treatment option for many patients with hematological disorders but it includes a significant risk of mortality and long-term morbidity. Many patients and their support persons feel overwhelmed when being informed about alloHSCT and may benefit from improvements in consultation style and timing.

Aims

To explore, qualitatively, in a sample of hematological cancer patients and their support persons, their preferences for receiving one longer consultation or two shorter consultations when being informed about alloHSCT. Participants’ perceptions of when and how different consultation styles should be offered were also examined.

Methods

Semi-structured face-to-face and phone interviews were conducted. A purposeful sampling frame was used. Data were analysed using framework analysis.

Results

Twenty patients and 13 support persons were recruited (consent rate: 96%, response rate: 91%). Most patients (60%) and support persons (62%) preferred two shorter consultations over one longer consultation. This helped them digest and recall the information provided, remember questions they had, involve significant others and search for additional information. Patients would have liked to be offered paper and pen to take notes, take a break after 30 min and have their understanding checked at the end of the first consultation, e.g. using question prompt lists. Some patients and support persons preferred both consultations to happen on the same day to reduce waiting times as well as travel times and costs. Others preferred having a few days in-between both consultations to better help them prepare the second consultation. Participants reported varying preferences for different consultation styles depending on personal and disease-related characteristics, such as age, health literacy level and previous treatment.

Conclusion

To our knowledge, this is the first qualitative study to explore patients’ and their support persons’ preferences for having one longer consultation or two shorter consultations when being informed about alloHSCT. Receiving two shorter consultations may help patients process and recall the information provided and more actively involve their support persons. Clinicians should consider offering patients and their support persons to take a break after 30 min, provide paper and pen as well as question prompt lists.

[Digital forms of service delivery for personalized crisis resolution and home treatment]

Hintergrund

Die stationsäquivalente psychiatrische Behandlung (StäB) wurde 2018 als Krankenhausleistung für Menschen eingeführt, die die Kriterien einer stationären Behandlung erfüllen. Die rasanten Fortschritte im Bereich der Informations- und Kommunikationstechnologie bieten neue Chancen für innovative digitale Versorgungsangebote wie telemedizinische, eHealth- oder mHealth-Verfahren.

Ziel der Arbeit

Diese Übersichtsarbeit soll einen umfassenden Überblick über neue digitale Versorgungsformen geben, die zur Personalisierung der StäB bei schweren psychischen Erkrankungen beitragen und somit klinische und soziale Outcomes verbessern sowie direkte und indirekte Kosten reduzieren könnten.

Methode

Diese Arbeit basiert auf einer selektiven Literaturrecherche (Narratives Review).

Ergebnisse

Es wurden vier primäre digitale Versorgungsformen identifiziert, die in der StäB gewinnbringend genutzt werden könnten: (1) Kommunikation, Behandlungskontinuität und -flexibilität durch Online-Chat und Videotelefonie, (2) Monitoring von Symptomen und Verhaltensweisen in Echtzeit durch Anwendung des ambulatorischen Assessments („ecological momentary assessment“ [EMA]), (3) Nutzung multimodaler EMA-Daten für die Generierung von personalisiertem Feedback über subjektives Erleben und Verhaltensmuster sowie (4) auf Person, Moment und Kontext zugeschnittene, adaptive ambulatorische Interventionen („ecological momentary interventions“ [EMIs]).

Diskussion

Digitale Versorgungsformen haben erhebliches Potenzial die Effektivität und Kosteneffektivität der StäB zu steigern. Ein wichtiger nächster Schritt besteht darin, die Anwendung dieser Versorgungsformen im Bereich der StäB zu modellieren und deren Qualität aus Sicht der Patient*innen, Sicherheit und initiale Prozess- und Ergebnisqualität sowie Implementierungsbedingungen sorgfältig zu untersuchen.

Beam Me Out: Review of Emergency Department Telepsychiatry and Lessons Learned During COVID-19

PURPOSE OF REVIEW

The aim of this review is to critically evaluate recent literature on the use of telepsychiatry in emergency departments (EDTP) and synthesize the evidence on telepsychiatry during public health emergencies. We also report on experiences and success stories from a state-wide EDTP program in South Carolina during the COVID-19 pandemic.

RECENT FINDINGS

We identified 12 peer-reviewed articles published between January 2019 and February 2021 that evaluated EDTP interventions and their impact on patient outcomes. The recent evidence on EDTP shows a significant association between EDTP implementation or use and decreased patients' wait time in emergency department (ED), shorter length of stay in certain settings, reduced ED revisit rates, improved ED patient disposition (e.g., more discharge to home, less observational stays, and decreased inpatient admissions), and reduced follow-up encounters involving self-harm diagnosis. The EDTP virtual delivery model can help healthcare systems reduce burden of public health emergencies on providers, staff, and patients alike. While a disruption of magnitude seen by COVID-19 may be infrequent, strategies used during the pandemic may be implemented to enhance care in rural settings, and/or enhance preparedness of communities and healthcare systems during more commonly occurring natural disasters.

Rapid Systemwide Implementation of Outpatient Telehealth in Response to the COVID-19 Pandemic

The COVID-19 pandemic, with its resultant social distancing, has disrupted the delivery of healthcare for both patients and providers. Fortunately, changes to legislation and regulation in response to the pandemic allowed Emory Healthcare to rapidly implement telehealth care. Beginning in early March 2020 and continuing through the initial 2-month implementation period (when data collection stopped), clinicians received telehealth training and certification. Standard workflows created by means of a hub-and-spoke operational model enabled rapid sharing and deployment of best practices throughout the system’s physician group practice. Lean process huddles facilitated successful implementation. In total, 2,374 healthcare professionals, including 986 attending physicians, 416 residents and fellows, and 555 advanced practice providers, were trained and certified for telehealth; 53,751 new- and established-patient audio–video telehealth visits and 10,539 established-patient telephone visits were performed in 8 weeks for a total of 64,290 virtual visits. This initiative included a new COVID-19 virtual patient clinic that saw 705 patients in a 6-week period. A total of $14,662,967 was charged during this time; collection rates were similar to in-person visits. Initial patient satisfaction scores were equivalent to in-person visits. We conclude that rapid deployment of virtual visits can be accomplished through a structured, organized approach including training, certification, and Lean principles. A hub-and-spoke model enables bidirectional feedback and timely improvements, thus facilitating swifter implementation and a quick rise in patient volume. Financial sustainability is achievable, but to sustain that, telehealth requires the support of continued deregulation by legislative and regulatory bodies.

Implementation of a Centralized Telepsychiatry Consult Service in a Multi-Hospital Metropolitan Health Care System: Challenges and Opportunities

BACKGROUND

Providing adequate psychiatry consultation capacity on a 24/7 basis is an intrinsic challenge throughout many multihospital health care systems. At present, implementation research has not adequately defined the effectiveness and feasibility of a centralized telepsychiatry consultation service within a multihospital health care system.

OBJECTIVE

To demonstrate feasibility of a hub and spoke model for provision of inpatient consult telepsychiatry service from an academic medical center to 2 affiliated regional hospital sites, to reduce patient wait time, and to develop best practice guidelines for telepsychiatry consultations to the acutely medically ill.

METHODS

The implementation, interprofessional workflow, process of triage, and provider satisfaction were described from the first 13 months of the service.

RESULTS

This pilot study resulted in 557 completed telepsychiatry consults over the course of 13 months from 2018 to 2019. A range of psychiatric conditions commonly encountered by consultation-liaison services were diagnosed and treated through the teleconferencing modality. The most common barriers to successful use of telepsychiatry were defined for the 20% of consult requests that were retriaged to face-to-face evaluation. The average patient wait time from consult request to initial consultation was reduced from >24 hours to 92 minutes.

CONCLUSIONS

This study demonstrated the feasibility of a centralized telepsychiatry hub to improve delivery of psychiatry consultation within a multihospital system with an overall reduction in patient wait time. This work may serve as a model for further design innovation across many health care settings and new patient subpopulations.

Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service

Introduction

Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP.

Methods

We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017–January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population.

Results

A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13–0.17]).

Conclusion

The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.

Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

Patient Perspectives on Telepsychiatry on the Inpatient Psychiatric Unit During the COVID-19 Pandemic

Hospitals have eliminated many in-person interactions and established new protocols to stem the spread of COVID-19. Inpatient psychiatric units face unique challenges, as patients cannot be isolated in their rooms and are at times unable to practice social distancing measures. Many institutions have experimented with providing some psychiatric services remotely to reduce the number of people physically present on the wards and decrease the risk of disease transmission. This case report presents 2 patient perspectives on receiving psychiatric care via videoconferencing while on the inpatient unit of a large academic tertiary care hospital. One patient identified some benefits to virtual treatment while the second found the experience impersonal; both were satisfied with the overall quality of care they received and were stable 2 weeks after discharge. These cases demonstrate that effective care can be provided remotely even to severely ill psychiatric patients who require hospitalization.

COVID-19: сonsequences for mental health and the use of e-Mental health options

The current COVID-19 pandemic is associated with fear, insecurity, and perceived social isolation worldwide. In this editorial, we discuss the influence of the COVID-19 pandemic on mental health among the general population and among particularly vulnerable groups (e.g., people with pre-existing mental illness). Additionally, we explore the role of e-mental health options in times of social distancing. Preliminary empirical evidence indicates that a wide range of people have experienced mental health difficulties due to the COVID-19 pandemic and corresponding infection-control measures. E-mental health options are a feasible means of addressing psychological distress and mental illness during the pandemic. Thus, these options should be made available in a timely fashion. Future multidisciplinary research is needed to develop e-mental health strategies that specifically focus on the consequences of social isolation, economic hardship and fear of infection.

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

BACKGROUND

The coronavirus disease (COVID-19) presents unique challenges in health care, including mental health care provision. Telepsychiatry can provide an alternative to face-to-face assessment and can also be used creatively with other technologies to enhance care, but clinicians and patients may feel underconfident about embracing this new way of working.

OBJECTIVE

The aim of this paper is to produce an open-access, easy-to-consult, and reliable source of information and guidance about telepsychiatry and COVID-19 using an evidence-based approach.

METHODS

We systematically searched existing English language guidelines and websites for information on telepsychiatry in the context of COVID-19 up to and including May 2020. We used broad search criteria and included pre-COVID-19 guidelines and other digital mental health topics where relevant. We summarized the data we extracted as answers to specific clinical questions.

RESULTS

Findings from this study are presented as both a short practical checklist for clinicians and detailed textboxes with a full summary of all the guidelines. The summary textboxes are also available on an open-access webpage, which is regularly updated. These findings reflected the strong evidence base for the use of telepsychiatry and included guidelines for many of the common concerns expressed by clinicians about practical implementation, technology, information governance, and safety. Guidelines across countries differ significantly, with UK guidelines more conservative and focused on practical implementation and US guidelines more expansive and detailed. Guidelines on possible combinations with other digital technologies such as apps (eg, from the US Food and Drug Administration, the National Health Service Apps Library, and the National Institute for Health and Care Excellence) are less detailed. Several key areas were not represented. Although some special populations such as child and adolescent, and older adult, and cultural issues are specifically included, important populations such as learning disabilities, psychosis, personality disorder, and eating disorders, which may present particular challenges for telepsychiatry, are not. In addition, the initial consultation and follow-up sessions are not clearly distinguished. Finally, a hybrid model of care (combining telepsychiatry with other technologies and in-person care) is not explicitly covered by the existing guidelines.

CONCLUSIONS

We produced a comprehensive synthesis of guidance answering a wide range of clinical questions in telepsychiatry. This meets the urgent need for practical information for both clinicians and health care organizations who are rapidly adapting to the pandemic and implementing remote consultation. It reflects variations across countries and can be used as a basis for organizational change in the short- and long-term. Providing easily accessible guidance is a first step but will need cultural change to implement as clinicians start to view telepsychiatry not just as a replacement but as a parallel and complementary form of delivering therapy with its own advantages and benefits as well as restrictions. A combination or hybrid approach can be the most successful approach in the new world of mental health post-COVID-19, and guidance will need to expand to encompass the use of telepsychiatry in conjunction with other in-person and digital technologies, and its use across all psychiatric disorders, not just those who are the first to access and engage with remote treatment.

Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction

BACKGROUND

The purpose of this study was to identify factors associated with a high risk of involuntary psychiatric in-patient hospitalization both on the individual level and on the level of mental health services and the socioeconomic environment that patients live in.

METHODS

The present study expands on a previous analysis of the health records of 5764 cases admitted as in-patients in the four psychiatric hospitals of the Metropolitan City of Cologne, Germany, in the year 2011 (1773 cases treated under the Mental Health Act and 3991 cases treated voluntarily). Our previous analysis had included medical, sociodemographic and socioeconomic data of every case and used a machine learning-based prediction model employing chi-squared automatic interaction detection (CHAID). Our current analysis attempts to improve the previous one through (1) optimizing the machine learning procedures (use of a different type of decision-tree prediction model (Classification and Regression Trees (CART) and application of hyperparameter tuning (HT)), and (2) the addition of patients' environmental socioeconomic data (ESED) to the data set.

RESULTS

Compared to our previous analysis, model fit was improved. Main diagnoses of an organic mental or a psychotic disorder (ICD-10 groups F0 and F2), suicidal behavior upon admission, admission outside of regular service hours and absence of outpatient treatment prior to admission were confirmed as powerful predictors of detention. Particularly high risks were shown for (1) patients with an organic mental disorder, specifically if they were retired, admitted outside of regular service hours and lived in assisted housing, (2) patients with suicidal tendencies upon admission who did not suffer from an affective disorder, specifically if it was unclear whether there had been previous suicide attempts, or if the affected person lived in areas with high unemployment rates, and (3) patients with psychosis, specifically those who lived in densely built areas with a large proportion of small or one-person households.

CONCLUSIONS

Certain psychiatric diagnoses and suicidal tendencies are major risk factors for involuntary psychiatric hospitalization. In addition, service-related and environmental socioeconomic factors contribute to the risk for detention. Identifying modifiable risk factors and particularly vulnerable risk groups should help to develop suitable preventive measures.