Telepsychiatry in the Setting of COVID-19 and Beyond

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COVID-19 has become a global pandemic affecting the lives of millions worldwide.^1-3 Widespread outbreaks like COVID-19 have been found to be closely associated with symptoms of mental illness such as anxiousness, increased stress, feelings of hopelessness, and depressed mood.^1,3-5

In the elderly population, living under quarantine during previous disease outbreaks has led to increased incidences of depression, irritability, insomnia, and suicidal behavior.⁶ Adverse psychological sequelae of social isolation, which will be discussed in greater detail, have been shown to be correlated with female gender, toddler- and adolescent-aged children, higher-educational status, student status, and having symptoms resembling a COVID-19 infection.⁷ In elderly individuals, additional risk factors include having a negative perception of aging, health care-related occupations, abundant exposure to COVID-19-related information, knowing someone infected with COVID-19, and having a history of medical concerns.⁶

Any given population under quarantine is more likely to experience heightened anxiety. Unwavering and occasionally sensationalized media coverage, sometimes perpetuating misinformation, may precipitate mass hysteria, stockpiling of supplies, xenophobia, and social unrest.⁷ Families unable to see loved ones in the hospital before their deaths are vulnerable to anger, resentment, and trauma.⁷ Rates of domestic violence have risen as more time is spent with those living in the same home.⁷

Individuals who are predisposed to anxious tendencies may find that their anxiety manifests in the form of obsessive behaviors, such as increased temperature checks and more frequent sterilization.⁷ Patients previously treated for underlying psychiatric illness(es) may discontinue therapy and/or medications due to strict policies placed on health care access.⁷ In infected individuals, posttraumatic symptoms have been noted to develop during isolation, the severity of which correlated with the length of quarantine.⁷ It appears that virtually no demographic can escape the psychological pressure that quarantine imposes, resulting in various expressions of mental illness among the population as a whole.

In the setting of this public health crisis and subsequent mass psychological distress, society relies on health care professionals to support mental health. Abruptly increased patient volume can present new challenges for clinicians regarding their ability to meet these demands in a timely and effective manner. Because of the pandemic, telemedicine is being utilized more frequently to help provide better access to care.⁸ New technological advances have made it possible to provide a virtual platform for medical care that minimizes physical exposure.

To illustrate the challenges and opportunities for improvement in access to COVID-19-related mental health care, we present a case of a 58-year-old female who tested positive for COVID-19. Shortly thereafter, the patient developed symptoms of psychological and emotional distress, which necessitated mental health services.

Case Report

History (Obtained During the Initial Psychiatry Assessment)

“Ms Harris” is a 58-year-old, single, Black-American woman with no significant psychiatric history. Ms Harris had been employed fulltime as a primary caregiver. She was referred to psychiatry for anxiety and concerns for possible depression. Ms Harris reported limited social support and no close relationships with family members.

Prior to her first appointment with psychiatry, the patient self-isolated at home for 3 weeks after testing positive for COVID-19. The patient agreed to a telephone visit, given the circumstances of an ongoing outbreak. During her initial psychiatric consult, Ms Harris endorsed feeling extremely “down and depressed,” noticing changes in her mood and behavior after learning of her positive test result. She said that she received no follow-up care from any health care provider since being in quarantine and isolation, and she described feeling as though she has been “abandoned and left alone.” Ms Harris speculated that “Maybe there is nothing they can do for me,” and disclosed severe feelings of anxiety regarding her health. Due to in-house quarantine measures, Ms Harris had not been working and was worried about being able to support herself financially. She stated that she had been living in fear, unsure if or when she would recover.

Ms Harris was diagnosed with adjustment disorder with anxiety and depression after a clinical psychiatric telephone interview. The patient was counseled regarding coping strategies and skills and provided with both online and telephone resources related to COVID-19. Ms Harris was scheduled for a follow-up telephone appointment with psychiatry 3 weeks after her initial consult, at which time she reported that her mood had improved and that she was less anxious about her health. Given her improvement, no medications were prescribed. Afterward, Ms Harris attended 2 subsequent appointments in which she demonstrated gradual improvement in her mental health. Ms Harris missed her fourth appointment and did not return the clinic’s calls thereafter.

Discussion

In order to limit the spread of disease, quarantine and isolation procedures have been implemented during the COVID-19 pandemic. Quarantine was recently implemented during the 2003 SARS epidemic and the 2009 H1N1 epidemic.^9,10 Studies of psychological symptoms during those periods found that being quarantined may be associated with a wide range of negative responses, including symptoms such as depressed mood, increased stress, irritability, insomnia, anger, fear, and emotional exhaustion.^9,11-15 Other studies concerned with the long-term psychological sequelae of quarantine demonstrate that quarantined individuals may be at higher risk of posttraumatic stress disorder (PTSD) and depressive symptoms up to 3 years later.^16-18 Literature on the current and prior quarantines have uncovered a plethora of risk factors for developing or exacerbating depression and anxiety, of which Ms Harris had several: female gender, advanced age, Black-American race, unemployment, recent health care occupation, single status, and lack of offspring.

Black Americans have been found to have higher rates of infections, unemployment, death, and anxiety related to the financial recession during the pandemic.19 Despite these experiences, in the same study, it was found that Black Americans had lower rates of anxiety and depression overall compared to non-Black Americans.¹⁹ Conversely, another study found that Black Americans experienced higher rates of anxiety and depression.²⁰ Given the discrepancy between these 2 studies, it may be worthwhile to further investigate the psychological effect of the COVID-19 pandemic on Black Americans.

As previously discussed, health care workers are also at increased risk for adverse psychological outcomes during and after quarantine. Health care staff forced to isolate themselves at home may experience feelings of worthlessness.⁷ As a result of unrelenting exposure to acutely ill patients, those who continue as clinicians may experience apathy and withdrawal.⁷

Relationship status is another notable demographic. Isolation for married couples can lead to increased anxiety due to a perceived imbalance in support, while nonmarried couples may struggle with increased jealousy.²¹ Moreover, single individuals have been shown to experience feelings of loneliness and depression.²¹

Given the inordinate list of stressors that a population faces under quarantine, it is imperative that measures are taken to mitigate adverse mental health outcomes. Firstly, sleep difficulties are associated with suicidal behavior, so anyone with such a history should be evaluated for suicidal ideation.²² Furthermore, engagement in group activities and psychological interventions aimed at addressing maladaptive thought processes related to loneliness have demonstrated efficacy.²³ In addition, elderly individuals may ameliorate the burden of the pandemic by strengthening social connections via virtual means (eg, group chat rooms, video chats), practicing good sleep hygiene, and engaging in cognitive stimulation.

An additional hurdle that individuals face during a pandemic is seeing a health care clinician in person, which causes many patients to participate in telemedicine. Telemedicine provided access to mental health services for Ms Harris while she quarantined and involved a phone interview with 2-way, real-time communication via audio only.

However, other telemedicine modalities are now being implemented as well. We are accustomed to some of these mediums (eg, electronic medical records, mobile phones, email, SMS text messaging, videoconferencing), while others have not yet been as widely incorporated (eg, patient portals, smartphone applications, social media). Clinicians seeking to utilize these modalities must be deliberate in determining the clinical function they serve while assessing the clinical impact that the modality may have on a particular patient.

The primary consideration should be that disinhibition between the patient and clinician can occur using any of these virtual platforms, the degree of which varies with the modality.²⁴ As Jay Shore, MD, MPH, outlines in his evaluation of digital health care, virtual disinhibition may actually lead to the patient being more genuine about their experiences, although the modality itself may lead to more miscommunication.²⁴

Other constraints must be considered as well. Without video, clinicians are limited in their ability to observe nonverbal cues and perform physical exams.^25-29 A sense of mutual connectedness and understanding between the patient and clinician may also be limited, as well as between physicians and their team.^30,31 Studies have shown that phone-centered (as opposed to video-centered) telemedicine further decreases the ability to maintain positive therapeutic relationships, as facial expressions are perceived to facilitate communication.³¹ Even with video accessibility, it is a challenge to assess suicide risk, interpret body language, and provide appropriate therapy.^32,33

Some studies show that, with telemedicine, patients expect more frequent consultations, while others become less engaged.³¹ Patients often do not answer the phone when called, or they may conduct visits while they are at the grocery store, driving, at work, or otherwise distracted, which might greatly alter a psychiatric interview. During interactions, misunderstandings may arise from the use of abbreviations and emojis, or the possibility of a household member eavesdropping and/or otherwise influencing the patient’s report. The clinician should compensate for miscommunication by regularly asking if the patient’s message is being understood correctly. Ms Harris did not return for additional follow-ups after only a few telemedicine appointments, underscoring one of the major pitfalls of telemedicine: difficulty in building a therapeutic alliance.

The preferred medium for telemedicine can vary according to the age of the patient and/or clinician. In a recent study, 75% of adults over 18 years old used phone-to-phone communication while individuals under 18 used video conferencing 50% of the time.³⁴ Reductions in treatment success can occur when patients and/or clinicians use a telehealth format that they are not skilled with. However, in their study, Landes et al concluded that 48% of telemedicine challenges reported by clinicians were resolved over time after the clinicians became accustomed to the system.³⁴ Early education on how to incorporate telemedicine into patient care could mitigate these challenges before they arise.

Although we are headed in the right direction in adapting to these difficult times, there are still concerns to be addressed and further investigated. Continued research should be conducted on the disparities in mental health, specifically related to the use of telemedicine, which relies heavily on digital devices and electronic tools. The best strategy to mitigate risks associated with digital care might be to have a combination of face-to-face appointments interspersed with telemedicine visits. In their study, Tse et al determined that 83% of patients would prefer a mix of the 2 services.³⁵

One possibility could be to mandate initial consultations as face-to-face, while additional follow-up visits could be performed either virtually or in person. Alternatively, physicians could implement a system in which a patient must have a certain number of in-person visits each year. Further research needs to be performed to assess which strategies would work best for patients. Discussion of the telehealth channel should occur with the patient prior to its use and continue after as the clinician and patient adapt to its impact.

Concluding Thoughts

The psychological consequences of living through a pandemic and being in quarantine are significant and should promote a sense of urgency to find ways to support the expansion of access to mental health care. Striving for improvement in the population’s access to care will not only help during this crisis, but also cause permanent changes in future health care delivery. As we continue to make innovative advancements in medicine, physicians must strive to be informed regarding the strengths and limitations of current practices and take into consideration the population being served to provide the best patient care.

Dr Mihajlovic is a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago, Illinois. Dr Segalite is a member of the psychiatry residency faculty at Advocate Lutheran General Hospital in Park Ridge, Illinois. Mr Pagano is a fourth-year medical student at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois.

Note: The views expressed in this paper are those of the authors and do not necessarily represent the official position or policy of institutions represented by the authors.

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