We Need to Find Right Balance Between Telehealth, In-Person Care

Many community-based mental health practitioners have welcomed the focus on telehealth in response to the COVID-19 pandemic by governments around the world, yet there has been little or no focus on enhancing face-to-face and home-visiting services when needed, with appropriate safety precautions.

In a recent article in Psychiatric News, James Shore, M.D., and Peter Yellowlees, M.D., correctly noted that the much wider psychiatric use of telehealth in response to the COVID-19 pandemic has been transformative (Psychiatric News). We need to ensure, however, that this transformation doesn’t also overextend to replacing in-person care almost completely with telepsychiatry for mental health assessments; reviews; and crisis and disaster interventions, especially in community, regional, rural, remote, indigenous, and forensic settings, as detailed in an international review published in the July 20, 2020, Current Opinion in Psychiatry by me and my colleagues, Luis Salvador-Carulla and Gill Neeraj.

The needs of people with moderate to severe mental illness were often poorly served prior to the pandemic. This represents a pre-existing crisis as the mental health systems in many countries were already broken, depleted, or under extreme strain. In addition, many people living with mental illness and psychosocial disabilities were already existing on the margins of society, and so they have been extremely vulnerable to the pandemic and its associated economic recessions and high levels of unemployment. Many are isolated, homeless, and at risk for suicide, and others may be living at close quarters with families who are critically in need of support themselves.

In the shock of the initial phases of the pandemic, public, private, and many non-governmental organizations (NGOs ) that provide mental health services saw a sharp drop in face-to-face care and a withdrawal from home-based and assertive outreach modes of providing such care, just when it was greatly needed for a wider range of people who were more isolated than ever. In part, this was related to justifiable concerns about patient and staff safety, often including deficiencies of personal protective equipment, explicit procedures and training for safe home visiting, and community transport of patients and their caretakers.

While many clinicians have put their own health at risk to care for their patients, others have shown poor leadership. Some senior clinicians, even those not in designated vulnerable health or age categories, have withdrawn to work only digitally from their homes and offices. Severe losses of in-person crisis backup by mental health clinicians has been experienced by NGO community support workers. In addition, telehealth is still too expensive and inaccessible for many vulnerable or marginalized people, and many still lack the connection costs, skills, hardware, or privacy to use digital devices to benefit from telehealth services.

We can no longer put off prioritizing care for people with moderate to severe, persistent, and complex mental illnesses and suicidality, whose numbers will only continue to swell as further climate-related domino adversities unfold. We need to find an optimal balance between digital and face-to-face and outreach services for these patients. A call to action to this effect was directed to the Australian federal government in mid-2020, co-signed by many leading psychiatrists, other clinicians, and academics, including practitioners who provide both in-person and telehealth services.

There are increasing numbers of published studies on telehealth systems used in recent disasters, but they are predominantly descriptive. They tacitly or explicitly encourage public mental health teams to “pivot” (in contemporary management jargon) almost completely to telehealth provided by hospitals and clinics, without providing rigorously controlled evidence of telehealth’s comparative or equivalent effectiveness. Telehealth suits some clientele but not others, and some expert U.S. “hybrid” (combined telehealth and in-person care) clinicians suspect that such “pivoting” solely to telehealth consultations can often be much more safe, convenient, and lucrative for practitioners than it is effective for many of the individuals and families who need to be served.

One key solution is to deploy more evidence-based assertive mobile community-based mental health teams integrated with and augmented by telepsychiatry services. However, we need an optimal and adjustable “hybrid” mix of both face-to-face and digital services and to encourage the use of digitally enhanced in-person and home outreach services in all regions.

The legacy of lessons from previous disasters and the likely exponentially increasing demand for mental health services due to climate change crises suggest that we need to develop and stabilize this balance for the future, making these arrangements more equitable and ongoing. Government responses to addressing the continuing mental health impacts of trauma and prolonged economic consequences of environmental disasters need to be sustained on an ongoing basis, not for just a few months at a time. These problems may ultimately affect not only those with the greatest disabilities and socioeconomic disadvantages, but ultimately all of us.

Ample subsidies for adequate digital equipment, network access, and training to use digitally enhanced services must be made available to patients and their families who need them. Service managements must ensure the availability of personal protective and other safety equipment and procedures and pastoral support for patients, health care personnel, and support workers.

Both during and beyond this pandemic, we must call on all governments and mental health service systems to ensure that an optimal range and balance of telehealth, person-to-person, and mobile outreach community services, including inpatient care and residential alternatives to hospitals, are accessible to all populations in need. ■