COVID-19 telehealth challenges for patients with schizophrenia and other psychoses

To the Editor

Social distancing protocols instituted during the COVID-19 pandemic have resulted in a rapid shift to telehealth in Australia. Psychiatrists have been at the forefront of telehealth delivery, due to the relative usefulness for patients with psychiatric disorders (Looi and Pring, 2020). However, there are considerable challenges in implementing telehealth for patients with schizophrenia and suspected psychosis.

When invited to consider video telehealth, patients with schizophrenia and other psychoses have expressed responses ranging from acceptance or mild reluctance through to outright dread, agitation and suspicion, often associated with persecutory delusions regarding electronic communication, technology and the Internet. As contemporary events and culture influence the themes of delusional beliefs, case reports involving Internet delusions have been published almost every year since 1997, when use of the Internet in the community became widespread (Lerner et al., 2006). In a historical context, technological delusions may be conceptualized as explanations for some of the bewildering psychotic perceptual disturbances experienced by people with schizophrenia (Tausk, 1933). Comorbid technophobia may also be present.

Challenges using telehealth for patients with schizophrenia and other psychoses are not limited to psychotic manifestations. Although emotional prosody can be partially assessed via telephone, the lack of substantive visual body language cues, even with video, where the window of view is limited, impedes assessment of mood and affect (Looi and Pring, 2020). This limitation may negatively influence the ability to discriminate between schizophreniform and affective psychosis in first-onset psychosis. Medical monitoring of psychotic medication by anthropometric measures, including weight, body mass index (BMI) and girth measurement, is compromised in the absence of face-to-face consultations. This may negatively impact on the early detection and ongoing management of metabolic syndrome. Telephone telehealth cannot be used to assess motor activity including dystonic reactions, akathisia, Parkinsonism, and tardive and other dyskinesias. This presents significant difficulties regarding medication decisions, both choice of agent and dosages. Telehealth experience has been that forming a rapport, and assessing risk issues, including safety of new patients, may be more challenging, especially if video telehealth is not available (Looi and Pring, 2020).

While telehealth is useful for psychiatric care for patients with schizophrenia and other psychoses, face-to-face consultation is necessary for new patients with suspected psychosis, risk assessment, when physical observation and examination are clinically indicated and for patients with technological delusions or phobias. Such face-to-face consultation must be accompanied by COVID-19 screening, appropriate hand hygiene and use of personal protective equipment (PPE) as indicated.