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New Global Telepsychiatry Guidelines Released

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead authors Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, Denmark, told meeting attendees.

“Now is the time to build a user-friendly digital healthcare system that can better meet the inevitable future challenges,” Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.

Breaking Down Barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.

A New Paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry…that are capable of changing the whole delivery of mental healthcare,” Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual healthcare professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers,” he added.

A Blended Future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, the Netherlands, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

These included that the technology was not available or could be used by all patients, especially the elderly, and that unstable internet connections have posed a problem. Moreover, video conferencing is considered a “poor substitute” for face-to-face interactions by many patients.

In the subsequent discussion, Möller told Medscape Medical News he believes guidelines in this area are important, especially to differentiate among various offerings on the internet, some of which are “not very good,” and to help patients identify those that are “very well established.”

Riper agreed, saying that several initiatives to introduce guidelines at the European level are now underway.

The biggest challenge from a technologic standpoint is to offer flexibility to patients while still applying “therapeutic principles,” she noted.

“There is a need for guidelines, but those guidelines need to be open to a certain amount of flexibility if you really want to upscale technology into routine care,” Riper said.

Cautious Optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, Vienna, Austria, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase both in terms of diagnostics and treatment,” she said.

Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Riper said.

The presenters have disclosed no relevant financial relationships.

European Psychiatric Association (EPA) 2021 Congress: Abstract O159 and debate. Presented April 11, 2021.

World Psychiatric Association. Telepsychiatry Global Guidelines 2021. Full text

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