Telepsychiatry, Hospitals, and the COVID-19 Pandemic

Calls for social distancing and concerns about the mental health effects of the COVID-19 pandemic have drawn considerable attention to telepsychiatry. Reports during the early stages of the pandemic in China suggested that online mental health services, including surveys, education programs, and counseling options, facilitated public health monitoring and access to care (1). In turn, U.S. agencies revised regulations to support telepsychiatry use, including expanding Medicare payments for telehealth outpatient visits (2), allowing initiation of buprenorphine treatment without in-person evaluation (3), and deferring blood monitoring requirements for clozapine treatment, if indicated (4). A recent editorial argued that this pandemic “may be the defining moment for digital mental health” (5).

Much of the attention to telepsychiatry during this pandemic has focused on outpatient settings, including medication management visits, psychotherapy, and mobile mental health applications. In contrast, this column examines ways in which dissemination of telepsychiatry during the COVID-19 pandemic might shape hospital-based psychiatric care and proposes a research agenda for studying and optimizing these services.

Staffing

A 2018 report estimated that 54% of U.S. counties did not have any psychiatrists (6), and a 2019 national survey reported that just 28% of psychiatrists worked in hospitals (7). The COVID-19 pandemic may exacerbate shortages of mental health professionals in hospitals because of staff illness, travel restrictions, and absenteeism due to concerns of contracting or spreading COVID-19. Telepsychiatry could mitigate these shortages by enabling clinicians to provide remote care to hospitalized patients and expanding access to specialists, such as child, addiction, or geriatric psychiatrists (8). As long as staff can establish secure systems, such as portable video communication devices, mental health professionals can offer psychiatric care in most hospital environments. Research suggests telepsychiatry can be effective for delivering mental health services in many settings (5, 8); however, a 2015 systematic review concluded that the literature on telepsychiatry in acute settings is “remarkably limited” and “almost entirely based on surveys or opinions” (9). Small studies of telepsychiatry for inpatient psychiatry units, inpatient medical and surgical services, and emergency departments have shown promising results regarding patient and clinician experiences (9). By allowing clinicians to work remotely, telepsychiatry may not only help existing hospital-based staff provide care during the COVID-19 pandemic but may also attract new cohorts of mental health professionals who might otherwise not consider working in these settings.

Safety

Given the risks of COVID-19 transmission, hospital leadership may support telepsychiatry to limit nonessential in-person interactions between patients and staff. Rapid adoption of hospital-based telepsychiatry could bring new possibilities for promoting patient and staff safety. If shown to be effective, video-based telepsychiatry could become the rule, rather than the exception, for providing psychiatric care to patients on infectious disease precautions. If hospitals replace one-to-one sitters with virtual monitoring for patients on suicide precautions during this pandemic (10), these practices might become more standard moving forward. Because telepsychiatry may be difficult to coordinate when patients are disorganized or violent, hospitals could develop systems, such as protected screens embedded in walls, that allow clinicians to interact with these patients while minimizing safety risks; however, these situations also highlight how hospital-based telepsychiatry could raise unique informed-consent dilemmas.

Social Connection

As hospitals restrict visitors and physical interactions during this pandemic, hospitalized patients may encounter difficulties maintaining social connections. Visitors to hospitals often face obstacles related to travel, parking, and navigating visitor policies. Patients on psychiatric units may face even more restrictive visitor policies, such as policies that bar children from locked units or require screening visitors for contraband. Setting up secure hospital videoconferencing devices for patients to communicate with loved ones may help bridge these divides. These technologies might offer alternatives to in-person meetings, such as group therapy or family meetings, that can play a key role during inpatient psychiatric treatment. Routinely integrating these technologies into hospitals might help families and friends connect with psychiatric patients or participate in meetings by video. If patients cannot attend group therapy in person (e.g., because of pain or immobility), video-based alternatives could offer new ways for patients to participate.

Real-Time Responsiveness

Researchers are exploring the utility of digital technologies for improving real-time psychiatric care, such as tracking mood and substance use through mobile applications. However, rapid adoption of hospital-based telepsychiatry during the COVID-19 pandemic may offer ways to improve real-time responsiveness in psychiatric care. Mental health professionals cannot be in multiple places simultaneously when urgent situations arise with inpatients, and dissemination of video-based technologies in hospitals may enable clinicians to bridge these limitations more easily. If video-based terminals become more widely available in hospital rooms, an on-call trainee who receives an urgent page from the other side of the hospital might videoconference with staff at a patient’s bedside in order to provide initial recommendations while in transit. By comparison, if a trainee is unsure about a clinical scenario overnight, a supervising clinician could join the encounter remotely to gather direct clinical data and to provide guidance rather than simply describing suggestions over the phone.

Research Agenda

Hospital-based telepsychiatry faces many challenges that are similar to those of outpatient telepsychiatry, including ensuring that clinicians are licensed to practice remotely, creating training programs to develop clinicians’ skills, obtaining patient consent for participation, and using secure platforms that adhere to privacy regulations. Still, clinicians need more information not only to better understand the unique risks and benefits of hospital-based telepsychiatry but also to design systems that are secure, ethical, and cost-effective. Therefore, we propose the following research agenda to further explore hospital-based telepsychiatry.

Patterns of use.

A recent study estimated that 28.2% of U.S. inpatient mental health facilities offered telepsychiatry in 2017 (11); however, use was highly variable across the country, and this rate seems low considering that health systems, notably in Australia (12), began using hospital-based telepsychiatry decades ago. Because COVID-19 will likely lead to considerable shifts in hospital-based telepsychiatry, further studies are needed to evaluate the U.S. telepsychiatry landscape in terms of geography, hospital type, and specific functions (e.g., emergency, consultation liaison, or inpatient psychiatry). These data should include rates of combined telepsychiatry and in-person psychiatric services, which may take different forms depending on the clinical setting. Likewise, studying the ways in which telepsychiatry use may be associated with specific changes in practices (e.g., consultation rates, psychotropic prescribing, use of restraints) is key. For instance, a 2019 study described an academic telepsychiatry consultation service that was developed for involuntary patients awaiting psychiatric beds at a community hospital (13). After about 10 consultations in the first 6 months, the service became better known; the number of consultations quickly rose to nearly 50 over the second 6 months and remained high after another year of follow-up. Despite the program’s initial aims, psychiatrists began completing more general and curbside consultations, and most patients were not involuntarily detained and boarding when interviewed. These types of longitudinal studies can help identify unexpected patterns of use to improve existing services and to expand telepsychiatry to other facilities that might benefit from these services.

Stakeholder perspectives.

Evaluating how patients, clinicians, administrators, lawmakers, and other stakeholders perceive hospital-based telepsychiatry is necessary for modifying and supporting development of these services. Surveying participants about the perceived benefits and disadvantages of hospital-based telepsychiatry compared with usual care is one approach (9). For instance, despite its promise for alleviating staffing shortages, hospital-based telepsychiatry could disrupt staff relationships. Staff working on site could become frustrated by their continued exposure to the risks of in-person care (e.g., contracting COVID-19 or being assaulted) or by difficulties communicating with those working remotely. Staff working remotely might feel that they do not have the latest information about patients or that they cannot adequately contribute to on-the-ground patient care. Because effective inpatient psychiatric care often requires team-based collaboration, future studies should examine how telepsychiatry affects relationships between onsite and offsite staff, as well as opportunities for communication, such as regular team teleconferencing. Insights from these studies could inform development of inpatient-specific training modules to prepare staff for new roles related to telepsychiatry.

Studying behaviors can also clarify how attitudes related to hospital-based telepsychiatry play out in real-world settings. As an example, both clinicians and patients might have privacy concerns about hospital-based telepsychiatry. Staff may worry about patients’ abilities to subvert Internet restrictions or to share information online about others, and psychiatric units frequently limit patients’ access to devices (14). In contrast, patients who worry about digital privacy might refuse to participate in these services. Still, in a 2016 pilot study of 30 inpatient telepsychiatry consultations, just one patient would not participate, suggesting that many patients may agree to use these services despite these potential concerns (15).

Diverse models of care.

Hospital-based telepsychiatry is potentially useful for multiple types of facilities and clinical scenarios. Available studies have largely examined these services in academic medical centers and rural settings; however, these services should be examined in various settings, including rural communities, academic medical centers, state psychiatric hospitals, and Veterans Health Administration facilities. Recent reports have described telepsychiatry models, such as reviewing psychotropic regimens for nursing home residents, that could support a continuum of care around hospitalization and may be useful during and after this pandemic (13). Research is needed to clarify the effectiveness of telepsychiatry as a stand-alone service (i.e., in place of in-person care), for augmentation of in-person services, and for consultation services (e.g., providing care to remote sites). Modifications of conventional audio-video telepsychiatry, such as integration with interpreter services, will be necessary to accommodate the needs of patients with sensory impairments and language barriers. Because COVID-19 has brought about rapid changes in telemedicine reimbursement policies, research is also needed to examine how regulatory changes and novel payment models influence the use of hospital-based telepsychiatry.

Medical education.

Evaluating the effects of telepsychiatry on supervision and teaching in medical education is important. For example, if trainees use telepsychiatry to provide care at remote hospitals, studying trainee perceptions of these experiences might provide useful comparisons to in-person training rotations, including whether to expand or redesign these telepsychiatry experiences. Trainees and supervisors may benefit from guidelines specifying situations when clinicians should perform in-person evaluations as opposed to remote assessments. Similarly, research is needed to evaluate the feasibility of on-site direct supervision as opposed to off-site remote supervision of trainees providing hospital-based psychiatric care, particularly because supervisors may have concerns about the implications of telepsychiatry for teaching, medicolegal liability, and other issues (16).

Conclusions

The COVID-19 pandemic may rapidly accelerate adoption of telepsychiatry in hospital settings. Hospital-based telepsychiatry offers potential benefits compared with in-person services, but these benefits must be weighed alongside the many uncertainties and risks of these technologies. A multifaceted research portfolio can improve our understanding of best practices for hospital-based telepsychiatry and support evidence-based use of these interventions moving forward.