COVID-19 and the Future with Digital Mental Health: Need for Attention to Complexities

Following the recent announcement of COVID-19 funding for virtual care in mental health, Gratzer et al. ¹ have identified an opportunity to advance greater use of digital technology in delivering mental health services during and beyond the period of the pandemic. While advocating for greater utilization of digital technology, they have suggested need for caution and made 5 specific recommendations for future.

In this commentary, while supporting the intent of the editorial, we offer further exploration in the context of the complexity of mental health and related service delivery relevant to the use of digital technology:

• 1. The vast majority of individuals receive their mental health care in the community for the entire range and severity of mental disorders through hospital-based or community clinics, private offices or through home visits to individuals living alone, with family or in group homes. Many would be recovering from a recent episode of illness, while others may be relatively stable primarily through being provided care in the community, including crisis intervention. With the current disruption of services, many providers have shifted delivery of some services to distance communication (telephone, e-mail or interactive videoconferencing); however, these changes have been made without adequate preparation, organization, or attention to possible increase in severity ² and assume patients’ access to such technical resources.

The use of Internet-based therapies and apps facilitating access and follow-up, although not tested enough in patient populations, have seen greater use during the pandemic circumstances simply to maintain some semblance of service. ³ Of the 3 modes discussed in the editorial, telepsychiatry has the greatest potential to be scaled up immediately given a relatively robust evidence base for feasibility, acceptance, and effectiveness for assessment, pharmacotherapy, and counselling in a variety of psychiatric disorders. ⁴ Greater utilization of this mode of service delivery can be facilitated by current circumstances, while continuing to close gaps in knowledge such as impact on clinical process and therapeutic relationship, effectiveness in crisis and emergency interventions, effective use in specific forms of psychotherapy, ⁴ and for wider use in serious mental disorders such as psychoses. ⁵

Future success in therapeutic use of digital technology will require considerable redesign, guidance in using new methods of service delivery, attention to consent and ethics as well as additional staff required to closely monitor more vulnerable patients who are accustomed to in-person contact with their service providers. Digital interventions (e.g., MOST and MOST+) may indeed be more effective than routine care when combined with routine care and when a therapist involvement and monitoring is a key component of the e-intervention. ⁶ E-interventions, designed for specific patient populations and adapted to different geographic and cultural contexts, may also be effective for severe mental disorders such as major depression and psychosis. ^5,7 Virtual methods of delivery of care could become an important component of future delivery of community mental health care but will not be sufficient if applied alone.

• 2. The high risk of onset of all psychiatric and addiction disorders among youth (12 to 25 years old) is further increased by the pandemic, ⁸ while access to mental health services is reduced. At even more heightened risk are youth who are indigenous, under state protection, homeless, immigrants, and/or have addiction problems, family history of mental illness, and adverse social and personal circumstances exacerbated by the pandemic. Interestingly, open access “youth spaces” are a key aspect of the newly transformed youth mental health services ⁹ and will need to be reconfigured through combining virtual as well as face-to-face places of care, while also developing e-mental health strategies to aid early case finding and rapid access to assessment and treatment. These could be ideal for expansion of scope, rapid innovation, and implementation. This age group may be particularly open to using technology as part of the service response to their presenting problems, provided they have access to such technology.

• 3. Given the present circumstances there are “new risk” groups such as health care workers involved in caring for individuals receiving hospital care for COVID-19 virus infection. ¹⁰ Their risk comes from anxieties associated with contracting the disease or bringing it to their families, trauma associated with repeated exposure to life and death situations, exhaustion from working long hours, and guilt associated with not being able to do enough. They will need significant support and guidance for self-help for their mental well-being as well as access to quick identification of and attention to any emerging psychiatric symptoms. In addition, families who have experienced loss of its members, without being able to grieve properly, form an additional “new risk” group as do families trying to deal with a combination of challenges associated with caring for children at home, while struggling economically. These new risk populations may be ideal targets for digital technology-driven interventions, likely to be limited in time, supported by more traditional face to face services, if and when required.

• 4. The current pandemic circumstances, likely to be prolonged, pose special challenges to providing in-hospital care. Although necessary for only a minority of psychiatric patients, such care poses the unique challenge of protecting patients from both the health consequences of the virus and from social isolation required to combat the spread. Unlike medical care, in-patient psychiatric care is provided in open spaces where social interaction is part of the recovery process. Special resources are needed to maintain this unique balance of physical safety and recovery from mental illness. These will include more selective use of hospital beds through better management of patients in community settings, especially those in crisis, and higher staff/space: patient ratio along with readily accessible expert guidance regarding social interaction in the context of social distancing. Digital technology could be utilized for better preparation of patients for discharge and follow-up through improved distant communication with staff, especially during periods of crisis.

• 5. Just like the need for face-to-face contact in our own lives, it is equally important for mental health professionals to value such contact with our patients. In psychiatry, we have been trained to carefully read the semiotics of such encounters, starting with the handshake, observations of variations in posture, and the way the patient leaves the office. The possibility of exclusive e-mental health may tempt equally patients and clinicians to meet virtually, while in the comfort of their respective personal physical spaces. This needs to be considered as possibly a negative consequence.

• 6. Apart from Internet-related security issues, there might be an equally important problem of physical security for vulnerable patients (children, adolescents, abusive home environment, prisons, etc.) that will be hard to monitor through virtual care. These risks may be difficult to detect, but clinicians will need guidance on how to assess and mitigate such risk.

• 7. A major shift toward digital care will also affect mental health providers. Indeed, practice of psychiatry is fundamentally a product of “human technology,” nourished by formal and informal case discussions and consultation with colleagues across disciplines. While the field is rapidly adapting its professional education using various communication platforms, how the formal and informal personal exchanges will be affected by a heavy emphasis on e-mental health is unclear. A reasonable balance between face-to-face and e-platform connectedness between professionals may be essential for a healthy integration of e-mental health in clinical practice.

An announcement of large injection of funds for a new initiative needs to have a transparent and effective process for deployment of the new resources. In Canada, we have a well-developed scientific community in mental health care capable of guiding implementation of existing evidence-based innovations (e.g., tele-psychiatry) and creating new ones to address needs of specific populations. It would be prudent for the Government to use its own scientific infrastructure (e.g., Canadian Institutes of Health Research) and organizations (e.g., Mental Health Commission of Canada) to rapidly assemble a community of service innovators. The latter should pursue a participatory design for such innovation and implementation through meaningful involvement of a variation of service users, health care scientists, service providers, and decision makers and be tasked to guide effective ways of rapidly addressing the diverse needs discussed above. Using third-party contractors and brokers of service with no in-house expertise would be both unnecessary and unproductive given the gravity and urgency of the problems to be addressed.

We are at a new beginning for e-mental health delivery and need to embrace this change and adapt to its foreseen and unforeseen consequences. The technology-focused interventions, even used exclusively, could benefit promotion of mental wellness and prevention, while assessment, treatment, and follow-up of mental illness will require a mixture of evidence-based interventions designed specifically for delivery through technology but supported by experienced treatment providers and face-to-face service delivery. Our observations based on short-term response to a crisis will require scientifically rigorous research to assure a long-term future for digital mental health. This will require collaboration between service, academic, and government sectors, with active involvement of current and future recipients of care, to address the moral imperative of caring adequately for people with mental health problems.