Telepsychiatry, Hospitals, and the COVID-19 Pandemic

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.

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).

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.

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).