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To the Editor:
The recent article “I’m Virtually a Psychiatrist: Problems with Telepsychiatry in Training” raises important considerations around the challenges of telepsychiatry on the provider and, in particular, the psychiatrist in training [1]. In their response to that paper, Freedman and Zaretsky outline how telepsychiatry has widened our understanding of patients, facilitating psychiatrists access to the “milieu,” which they define as “the physical and social natures of a person’s observable context” [2]. The integration of the “milieu” into the mental status exam, they argue, offers psychiatrists a strong lens into the social aspect of their patient’s lives. Unfortunately, while telepsychiatry, in comparison to in-person assessments, offers a balance of strengths and weaknesses as a tool for psychiatrists, it is not a tool for all patients. More than other clinical populations, there are unique aspects to patients with psychiatric disorders that limit the utility of telemedicine.
While COVID-19 has accelerated uptake of virtual mental health and helped improve access to care in the wake of social distancing, it has created profound barriers for vulnerable patient populations. Deficits underscore important patient factors that create barriers to digital care in knowledge, lack of access to technology, and disease-specific factors [3]. Patient knowledge deficits may often be overlooked or minimized but warrant attention and education. With growing consideration of hybrid models of care, effort should be made to consider all options and strategies to facilitate care, including bolstering digital knowledge. Incorporating a digital health care navigator, a newly developed role on mental health teams, may be an important step in helping to address this barrier for knowledge deficits in both patients meaningfully and clinicians [4].
Access to high-speed broadband and digital devices is another often forgotten barrier that should be of paramount concern for ensuring equitable care allocation. This reality is a factor for many patients with a psychiatric illness where socio-economic factors limit access to reliable Wi-Fi or digital devices. In addition, it should not be forgotten that access to high-speed broadband can also be a barrier for providers who may live in rural communities.
Finally, for patients with severe and persistent mental illness, disease-specific factors including cognition, motivation, psychosis, and organization may limit the ability to engage and trust digital interactions. At the same time, for individuals with severe and persistent mental illness, the impact of digital exclusion is particularly salient given the higher burden of comorbid addiction and physical health concerns, in addition to their psychiatric struggles [5].
While virtual care has and continues to play a vital role in psychiatric care, as the pandemic continues to evolve, psychiatrists must be vigilant and nuanced in their approach to providing proper care for the particular provider-patient context. Moreover, while supplying the appropriate care, it is also incumbent upon psychiatrists to advocate at all levels to help address inequities in access. Consequently, as the delivery of psychiatric care transforms, so does the role of psychiatrists. As the public health landscape of COVID-19 evolves, psychiatry must develop a hybrid model that works for both providers and especially patients.
References
Scott JA. I’m virtually a psychiatrist: problems with telepsychiatry in training. Acad Psychiatry. 2021;45:774–5.
Freedman DE, Zaretsky A. Comment on “I’m virtually a psychiatrist: problems with telepsychiatry in training”. Acad Psychiatry. 2021;45:778–9.
Greer B, Robotham D, Simblett S, Curtis H, Griffiths H, Wykes T. Digital exclusion among mental health service users: qualitative investigation. J Med Internet Res. 2019;21:e11696.
Wisniewski H, Gorrindo T, Rauseo-Ricupero N, Hilty D, Torous J. The role of digital navigators in promoting clinical care and technology integration into practice. Digit Biomark. 2020;4:119–35.
Spanakis P, Peckham E, Mathers A, Shiers D, Gilbody S. The digital divide: amplifying health inequalities for people with severe mental illness in the time of COVID-19. Br J Psychiatry. 2021;219:529–31.
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Dr. Danilewitz reports personal fees from Otsuka, Eisai Ltd, and Winterlight Labs outside the current work. Dr. Bahji reports research grants from the National Institutes of Health/National Institute on Drug Abuse (NIDA) [R25-DA037756, R25DA033211] through the International Collaborative Addiction Medicine Research Fellowship and the Research in Addiction Medicine Scholars Program through Boston University School of Medicine. In addition, Dr. Bahji is a recipient of the 2020 Friends of Matt Newell Endowment from the University of Calgary Cumming School of Medicine. Dr. Bahji also received financial support from a 2020 Research Grant on the Impact of COVID-19 on Psychiatry by the American Psychiatric Association and the American Psychiatric Association Foundation.
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Danilewitz, M., Bahji, A. & Gratzer, D. Comment on “I’m Virtually a Psychiatrist: Problems with Telepsychiatry in Training”. Acad Psychiatry 46, 535–536 (2022). https://doi.org/10.1007/s40596-022-01607-2
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DOI: https://doi.org/10.1007/s40596-022-01607-2