This is an Accepted Manuscript for Irish Journal of Psychological Medicine as part of the Cambridge

Coronavirus Collection. Subject to change during the editing and production process. DOI:
10.1017/ipm.2020.54

The Use of Telepsychiatry During COVID-19 and Beyond

M. O’Brien1,*, F. McNicholas1,2,3
1
CHI at Crumlin, Crumlin, Dublin 12
2
Lucena Clinic, Rathgar, Dublin 6
3
Dept. of Child and Adolescent Psychiatry, SMMS, UCD

*Address for correspondence: M. O’Brien, CHI at Crumlin, Crumlin, Dublin 12

The COVID-19 pandemic has disrupted the traditional practice of psychiatric assessment and

treatment via face to face interaction. Telepsychiatry, the delivery of psychiatric care remotely

through telecommunications technology, is an existing and under-utilised tool that may help to

minimise disruption to patient care. Technological advancement is at a stage where it can facilitate

widespread use of this practice; however concerns that limited its expansion previously were not

unfounded. This article discusses the use of telepsychiatry in the context of the COVID-19

pandemic.

Key words: COVID-19, Coronavirus, Telemedicine, Telepsychiatry, Mental Health, Psychiatry,

Pandemic, Technology
Introduction

The COVID-19 pandemic has presented the medical community with a sweeping collection of

challenges. Given the nature and scale of the problem and the speed of its spread across the globe,

no healthcare system has the necessary infrastructural resources to adequately cope with the

evolving impact of this novel coronavirus. Moreover, the effects of this pandemic will likely be

present for some considerable time and hence management initiatives that seek to overcome barriers

to medical care caused by physical distancing measures must be sustainable over a protracted

period. National healthcare systems are radically restructuring and reorganising their services with

the intention of expeditiously diagnosing and treating those affected by the disease. Meanwhile,

every effort is being made to retain and preserve existing service provision as non COVID-19

related medical need persists. It is a source of concern that patients may become increasingly

reluctant to present with other serious health problems due to fear of contracting the virus in a

healthcare setting (Fagan, 2020). As well as the difficulties the pandemic is causing for patients,

negative effects on the physical and mental well-being of healthcare staff can compromise the

collective response. Reduced staffing numbers due to necessary self-isolation in confirmed,

suspected or potential positive cases not only limits the capacity for the delivery of medical care but

also places a greater strain on the remaining staff members. Resultant stress and burnout can

insidiously erode productivity and ultimately impede patient care. Examination of the psychological

impact on healthcare employees during the 2003 SARS outbreak found that approximately 10% of

respondents experienced high levels of post-traumatic stress symptoms (Wu et al. 2009). There are

already high rates of burnout among Irish hospital doctors across all specialties (Hayes et al. 2017)

and within psychiatry in the child and adolescent mental health service (McNicholas et al. 2020).

This, coupled with concerns that rates of job stress in Ireland may be higher than other European

countries (Russell et al. 2018), increases the vulnerability of the workforce to widespread

psychological sequelae resulting from this pandemic. The rapid and evolving changes to procedures
and protocols in healthcare settings is a further burden on staff. Typically, healthcare systems

introduce change in a slow and purposeful manner and only following extensive planning, training

and pilot testing. The enforced response demanded by COVID-19 is radically different, as abrupt

widespread changes to practice have had to be incorporated in a short period of time. These have

impacted on every facet of healthcare activity, both in hospital and community settings.

In the context of growing healthcare demand, an overburdened healthcare system, a need to

physically distance and a population who may view healthcare settings and personnel as potential

sources of avoidable infection, clearly a different approach to healthcare engagement is required.

Hence, due consideration should be given to a tool that simultaneously enables us to connect and to

distance at the same time – telemedicine.

Telemedicine

Telemedicine refers to the use of telecommunication technology for the remote assessment and

treatment of patients. Though the term is often used interchangeably with ‘telehealth’, the latter

typically denotes a broader scope of healthcare services involving not only clinical assessment and

treatment, but also non-clinical activities such as patient education, provider training and

administrative meetings. The use of telemedicine is not a new concept. It has evolved over time in

parallel with developing technologies. An instance of its use was described in The Lancet in 1879,

when an anonymous writer reported a case where a doctor successfully diagnosed a child over the

telephone in the middle of the night (Bashshur & Shannon, 2009). One of the first instances of the

use of television images for medical treatment occurred in the late 1950s when the Nebraska

Psychiatric Institute established a closed-circuit television link with Norfolk State Hospital,

allowing for consultations (Von Hafften, 2018). The beginning of manned space flight saw an

acceleration in the development of telemedicine as the American National Aeronautics and Space

Administration (NASA) sought to manage the health of astronauts remotely (Bashshur & Shannon,
2009). Indeed, the advent of personal computers and the internet in the 1990s and 2000s has led to

ever-increasing opportunities in the field. However, despite sufficient technological advancement,

the widespread use of telemedicine has been slow to evolve (Smith & Gray, 2009; Barnett et al.

2018). Patient reticence, lack of regulatory framework and inherent limitations, such as the inability

to physically examine, have all likely contributed to the low adoption rates.

Telepsychiatry

Telepsychiatry is the term given to the application of telemedicine within the specialty of

psychiatry. Telemental health and telepsychology are associated terms referring to the

administration of psychological treatment or therapy via technological means. Compared to a more

procedural based specialty, psychiatry is relatively well suited to remote engagement and so is in a

good position to transition to a telemedicine approach. The largely talk-based practicalities of

psychiatry lend itself to the practice. Functionally, telepsychiatry typically involves an interaction

between a psychiatrist and a patient via either telephone or videoconference. Research has indicated

that telepsychiatry is comparable to face-to-face services in terms of reliability of clinical

assessments and treatment outcome (Seritan et al. 2019). It has also been shown that it delivers high

patient satisfaction among those suffering with movement disorders such as Parkinson’s disease

(Wicklund, 2017). There have even been suggestions that it may be preferable to in-person

interaction in a subset of patients, including those with severe anxiety disorders (American

Psychiatric Association, 2018). As always, caution must be exercised when interpreting such

reports with due regard to patient population under review and particularly with regard to other

factors such as socioeconomic status, computer literacy and age profiles. The use of telepsychiatry

can also be expanded to facilitate group therapy. A systematic review of the evidence for telehealth

group-based treatment found video teleconference groups to be feasible and to result in similar

treatment outcomes to in-person groups (Gentry et al. 2019). However, the potential for small

decreases in therapeutic alliances was noted. It was also suggested that additional research is needed
to identify optimal methods of video teleconference group delivery to maximise clinical benefit and

treatment outcomes.

Despite the promise shown, concerns that have limited the expansion of the more widespread

application of telepsychiatry are not unfounded. Barriers to its use which have been identified

include considerations about rapport, privacy, safety and technological limitations (Cowan et al.

2019).

Prior Use in Disaster Scenarios

Though the use of telepsychiatry, and indeed telemedicine more broadly, has been limited to date,

their benefit in prior widespread emergencies has been documented. Telemedicine has previously

been effectively used in simulated and real disaster scenarios (Simmons et al. 2008; Doarn et al.

2018; Uscher-Pines et al. 2018). It was utilised effectively in the aftermath of hurricane Ike which

struck Texas in 2009, killing 82 people (Hubley et al. 2016). Physicians from the Center for

Telehealth Research and Policy at the University of Texas Medical Branch (UTMB) in Galveston

noted that, “Although there were significant disruptions to a majority of UTMB’s physical and

operational infrastructures, its telemedicine services were able to resume near normal activities

within the first week of the post-Ike recovery period, an unimaginable feat in the face of such

remarkable devastation.” They also credited the “plasticity” of the telemedicine program.

Telepsychiatry specifically has also been utilised in prior natural emergencies (Qadir et al. 2016)

and is notably applicable in the context of the inevitable psychological sequelae that result.

However, its use has previously only been considered when dealing with a relatively localised

disaster, with help being administered remotely from other locations. The widespread nature of the

current emergency is unique.

The patient-related advantages of the use of telemedicine prior to the outbreak of COVID-19

largely centred around convenience and efficiency. The service allows patients to dispense with

travel to the hospital or clinic and also allows for more flexibility with securing appointments. Since

the outbreak, the primary consideration has been one of safety and adherence to mandated physical

distancing measures. Telemedicine provides a means to bring doctors and patients together without

risking contamination. With regards to suspected cases of COVID-19, it allows for triage without

healthcare worker exposure to the virus. Suspected cases can initially be assessed remotely, and

investigation and treatment plans developed accordingly. In primary care settings, it allows for

continued patient monitoring and assessment, as well as prescription of medications. It also

facilitates the continuation of outpatient services across all medical specialties, though the

limitations of reduced capacity to physically examine disproportionately affect some specialities

more than others. With specific regard to psychiatry, the utilisation of a telemedicine approach

facilitates the potential for the preservation of a large proportion of doctor-patient interactions. It

allows for ongoing therapeutic work, especially when there is an established relationship between

clinician and patient. However, there are some considerations which need to be taken into account.

Clinical Considerations

The initial consideration relates to the patient’s level of familiarity with the applicable technology,

and their ability to utilise it effectively and with ease. This method of engagement may be less

suitable for certain cohorts of patients, such as those who have diminished cognitive capacity or are

less technologically literate, for example. Equally, those with hearing difficulties, visual impairment

or poor manual dexterity may struggle with the practicalities of its use. These limitations inherently

disproportionately affect elderly patients and unless they can be adequately supported in its use, the

embrace of telepsychiatry should be tempered with cognisance of the potential for an imbalance in
patients’ access to care. A similar imbalance may also be caused by the digital divide - the uneven

distribution of access to required technology such as smartphones or high-speed internet. This

divide is often affected by geographical or socioeconomic realities. It is prudent that clinicians take

these factors into account and strive to ensure equitable access to care for all of their patients. This

may involve reverting to face-to-face engagements where clinically indicated.

Beyond such logistical concerns, the important aspect of rapport needs to be considered, as some

patients may find remote engagement to be a barrier to establishing a bond with their clinician. It

might be more acceptable to some if they already have an established, trusting therapeutic

relationship with their healthcare provider. In such circumstances, the telepsychiatry assessment is

intended to supplement but not replace the more traditional face-to-face encounter.

In terms of securing the patient’s informed consent, the nature and purpose of the interaction must

be fully explained in advance, together with the known limitations such as an inability to perform a

physical examination or to identify other cues that might be relevant to making a diagnosis. The

Irish Medical Council states in its ‘Guide to Professional Conduct and Ethics for Registered

Medical Practitioners’ that an explanation should be made to patients that there are aspects of

telemedicine that are different to traditional medical practice, including the inability to perform a

physical examination (Medical Council Ireland, 2019). Though psychiatry may be less reliant on

physical examination than other specialties, it is nevertheless a key component of a comprehensive

assessment. Separate to the act of performing a structured physical examination, huge amounts of

information are garnered from being in the physical presence of a patient. An odour of alcohol,

loose-fitting clothes indicating weight loss and gait abnormalities are all examples of integral pieces

of information that are lost with the use of telepsychiatry. Ultimately this consideration needs to be

factored into the overall clinical picture, and arrangement for physical examination and

investigation made at the earliest convenience.

remote standpoint (Seritan et al. 2019). However, there are no published reports of instances of

same related to telepsychiatry. In a circumstance where there is a likelihood of imminent harm to

the patient or others, immediate contact should be made with An Garda Síochána, who may perform

a welfare check and intervene in accordance with Section 12 of the Mental Health Act 2001, if

applicable (Government of Ireland, 2001). Clinicians in secondary care often deal with complex

clinical scenarios, and the introduction of telemedicine may require new strategies for managing

certain clinical scenarios which could arise with this new method of assessment.

Matters of privacy and confidentiality are essential elements in all doctor-patient relationships.

When conducting a remote interview, the interviewer cannot be certain that the person is in a secure

and private setting. Other parties may be surreptitiously present but not within the range of the

camera. The potential to influence the patient in terms of how he / she reports symptom burden and

experiences may be influenced in such circumstances. It is important therefore that the interviewer

seeks to establish precisely who is present when conducting a telemedicine interview. Depending

on an individual’s social circumstances and housing situation, it may or may not be possible to

secure a private location.

Another key aspect of comprehensive clinical care is involvement from various members of the

multidisciplinary team. The nature of a one-on-one remote assessment by telepsychiatry may

impact negatively on the conduct of a holistic multi-faceted review. It is important that the integral

role of the full MDT is not overlooked due to a change in the modality of assessment and treatment.

Record-Keeping and Indemnity Considerations

Comprehensive and contemporary medical note-taking is a crucial component of the doctor-patient

interaction. Medical records safeguard patients by allowing for continuity of care and offer medico-
legal protection to doctors by accurately reflecting information present to them at the time of

decision-making. Medical record practices for telepsychiatry are the same as for face-to-face

contact. Before an assessment, access to the patient’s existing medical notes should be available and

reviewed. After the engagement prompt recording of appropriate medical notes should be made.

There are however some additional points of information that should be documented in a

telepsychiatry interaction. It should be clearly noted that the assessment was not conducted face-to-

face and that the patient gave informed consent to proceed, cognisant of the strengths and

limitations of this engagement. A record of the location of both the doctor and patient should be

recorded. One particular indemnity consideration that has become pertinent with telepsychiatry is

the circumstance of a patient seeking remote medical assessment and treatment when they are

outside Ireland. In this case, the initial course of action should involve talking to the patient and

assessing the situation (Hendry, 2020). A recommendation should then be made to the patient about

the most appropriate alternative route for assistance, which may involve seeking local medical care.

Another consideration for clinicians is the capacity for patients to record telepsychiatry interactions.

A prior cross-sectional survey completed in the United Kingdom found that 15% of respondents

had secretly recorded a clinic visit (Elwyn et al. 2017). The United Kingdom’s Medical Defence

Union advises that patients do not require clinician’s permission to record interactions and that such

recordings, even if taken covertly, have been admitted as evidence of wrongdoing in court (Zach,

2014). This behaviour is clearly not limited to telepsychiatry and can and does happen in face-to-

face consultations (Elwyn et al. 2015). Furthermore, it has been viewed as a positive component of

therapy, facilitating patient empowerment and enhancing their care experience, with the ability to

own, replay, share and reflect on the clinical encounter. This might raise concern for the clinician,

especially if such recordings are conducted covertly and motivated by a desire to obtain evidence of

inadequate or unsatisfactory care. Ultimately, the optimum circumstance is for openness and

transparency when patients seek to record interactions, something which doctors should strive to

facilitate.
Data Concerns / Security

All healthcare records are confidential, and every effort must be made to ensure that all personal

data is appropriately recorded and stored. All personal data must be processed and stored strictly in

conformity with the General Data Protection Regulation (GDPR) legislation which in Ireland came

in to force in May 2018. This legal framework defines and regulates the ways in which personal

data is collected and used. A detailed description of GDPR legislation is beyond the scope of this

paper but it includes several key principles encompassing lawfulness, transparency and fairness,

purpose limitation, data minimisation, accuracy, storage limitation and integrity and confidentiality

(Data Protection Commission, 2018). Personal data includes information concerning a living

individual who can be identified whether directly or indirectly. Healthcare professionals are

required to collect a high volume of personal data and are in breach of professional guidelines if

they fail to maintain proper, accurate and relevant healthcare records. Therefore, the security of the

IT platform when providing telepsychiatry services is of paramount importance. It is best practice to

use a health system approved secure network which incorporates appropriate measures to ensure an

optimal level of security. As referenced above, prior to embarking on a telemedicine interview in

which personal data is divulged, consent must be obtained and recorded as such. Consent must be

freely given, fully informed and clearly reflect the patient’s wishes. Failure to object or refuse in

itself does not constitute consent and all consent may subsequently be withdrawn in both face-to-

face and remote treatment circumstances.

Practical Considerations

For many healthcare professionals, telepsychiatry represents a novel way of engaging with patients

and families. Individual practitioners may have varying levels of comfort when using this

technology. A basic level of IT literacy is required by the clinician and access to the necessary

devices and reliable high-speed internet is of course essential. Clinicians will need to develop the
relevant skills and competencies necessary to conduct assessments using telepsychiatry, with

‘webside manner’, the telemedicine equivalent of bedside manner, being a key component of the

professional telepsychiatry interaction. Two of the key components of webside manner are

audibility and visibility. Audibility can be maintained through proximity to the microphone and

reduction of ambient noise and visibility can be enhanced by appropriate lighting and by avoiding

positioning a window in the background. Furthermore, an uncluttered and simple background

minimises the potential for distraction and every effort should be made to reduce the potential for

disturbance or interruption of the session. Establishing ‘virtual eye contact’ by looking directly into

the camera, using the person’s name often, ensuring adequate time for them to finish their

contributions and making frequent use of non-verbal encouragements may mitigate against the lack

of physical presence (McConnochie, 2019).

Beyond COVID-19

While telepsychiatry is a particularly apt solution to the problems posed by physical distancing

measures during this pandemic, its scope for benefit existed before the current crisis and will

continue long after it. The adoption of its use has been dramatically accelerated due to

unprecedented need, though the move towards technology-mediated medical intervention is long

established. In 2018, the European Commission estimated that the global telemedicine market

would reach €37 billion by 2021 (O’Brien, 2020). This is likely to be surpassed when the current

spike in use is factored. It is crucial that this current era of increased use of telemedicine be seen as

fertile ground for research, providing guidance for future direction. Increased prevalence of use,

shored up by this research, will likely add to the legitimacy of telemedicine as a component of

delivery of care. Further reassurance may be given to clinicians through appropriately developed

legal and regulatory framework. The incorporation of telemedicine-related teaching into medical

school curricula would also increase homogeneity and consistency of approach. It is prudent that

this inevitable development be coordinated with purposeful and proactive measures on both local
and organisational levels, with a view to securing functional integration long beyond this pandemic.

These measures are by their very nature disruptive as they inherently involve the restructure of

systems and therefore effective change management strategies should be employed to ensure user

adoption is sustained. Technology is no longer the limiting factor, so focus now needs to be shifted

towards financial, systematic and cultural considerations. The widespread reliance on telemedicine

during this crisis will likely emphasise its importance and aid in building trust in it as a viable

treatment tool. This in turn will ultimately lead to lasting evolution in medical and psychiatric

practice.

Financial Support

This prospective piece received no specific grant from any funding agency, commercial or not-for-

profit sectors.

Conflicts of Interest

M. O’B. and F.M. have no conflicts of interest to disclose.

Ethical Standards

The authors assert that all procedures contributing to this work comply with the ethical standards of

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