Introduction

The COVID-19 pandemic has had a profound impact on the adoption of telepsychiatry and digital mental health. The rapid shift toward remote mental health services was facilitated by several factors. First, there was an increased recognition of the importance of mental health during the pandemic, as the crisis led to heightened levels of stress, anxiety, depression, and other mental health challenges (Holmes et al., 2020; Kinoshita et al., 2020; Mucic et al., 2021). This increased demand for mental health care services necessitated a more flexible and accessible approach to care delivery. Second, the pandemic catalyzed changes in regulations and reimbursement policies for telehealth services in many countries, including the USA, where the Centers for Medicare and Medicaid Services temporarily expanded coverage for telehealth services (Centers for Medicare and Medicaid Services, 2020). This facilitated the broader adoption of telepsychiatry and digital mental health tools among clinicians and patients. Third, the availability of various technologies, such as videoconferencing platforms, mobile applications, and remote monitoring devices, enabled mental health professionals to deliver care remotely, while also allowing patients to access care from the safety of their homes (Torous & Wykes, 2020).

The pandemic highlighted the potential benefits associated with telepsychiatry and digital mental health. Telepsychiatry has demonstrated its potential to increase access to care for individuals in remote areas, reduce wait times, improve treatment adherence, and minimize the stigma associated with seeking mental health care (Kavoor, 2020). Telepsychiatry cultural adaptations emphasize the crucial role of community involvement and quality service delivery (Ruiz-Cosignani et al., 2022). If workflow, infrastructure, and economic barriers can be addressed, access and multi-organizational collaborations are possible. Increased use of telepsychiatry was driven by advances in technology and the need for more efficient and cost-effective mental health care (Hilty et al., 2023). A standard framework for telepsychiatric economic cost analysis could help programs with planning, implementation, and evaluation: a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost–benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); and a broad perspective (e.g., societal perspective) rather than a program in isolation (Hilty et al., 2023).

On the other hand, telepsychiatry concerns include digital privacy, security, and technology facility, such that the digital divide persists, particularly in low- and middle-income countries. Furthermore,

while patients and clinicians are largely satisfied with telepsychiatry, concerns exist about establishing rapport, and in some countries, reimbursement/financial, legal/regulatory and licensure/credentialing are not facile across states (Gentry et al., 2019)—unless pandemic adjustments are continued. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Therefore, it remains important to set goals toward quality outcomes, be efficient, and employ user-centered technology. By grasping how systems are designed and tailored to collect data, clinicians can use technology to inform decisions and facilitate outcomes—based on input from all care participants about priorities, as well as user competencies or skills for the patient, clinician, and organization (Hilty et al., 2021). This emphasizes the need for ongoing research and innovation to address these challenges (Torous et al., 2020).

To address these challenges, various guidelines and standards have been developed within the last decade to ensure the safe and effective use of telepsychiatry. One of the most widely recognized sets of guidelines is the American Telemedicine Association (ATA)–American Psychiatric Association (APA) Practice Guidelines for Telemental Health, which provide a comprehensive framework for the use of telepsychiatry (Shore et al., 2018). A revision in progress provides an update on video and other technologies and suggests maintaining pandemic-based changes. Guidelines for telepsychiatry/telehealth have been developed in a few countries, e.g.. India (Ministry of Health & Family Welfare, Government of India, 2020); Australia (Pirkis et al., 2020; Royal Australian and New Zealand College of Psychiatrists, 2021); Canada (Practice Guidelines for Video-based Telehealth Services, 2014); Denmark (Helverskov et al., 2021; Nielsen et al., 2020); Poland (Krzystanek et al., 2021); and the UK Private and Independent Practice Specialist Interest Group for Psychiatrists (PIPSIG) (2013). The Canadian Agency for Drugs and Technologies in Health (2015) focused on clinical effectiveness and safety to facilitate decision to leverage telehealth/telemedicine in emergency and non-emergency psychiatric situations.

In addition, telepsychiatry guidelines have also been developed for specific populations or settings/clinical applications, largely in the USA, including the following:

  • •use in rural areas (Substance Abuse and Mental Health Services Administration, 2017);

  • •child and adolescent psychiatry per the American Academy of Child and Adolescent Psychiatry (2017) and the ATA Child and Adolescent Telemental Health Guideline (2017);

  • •ethical use of telemedicine and telehealth (Maheu et al. 2019);

  • •telemedicine, including telepsychiatry (American Medical Association, 2016);

  • •use in disaster response and recovery, emphasizing the need for cultural competence and sensitivity to trauma and stress (Maheu et al., 2019);

  • •assessment of patients at risk for suicide in-person or via technology (Department of Veterans Affairs and Department of Defense, 2019).

  • •interventions in the treatment of psychotic disorders (Gaebel et al., 2016; European Psychiatric Association);

  • •posttraumatic stress disorder (PTSD) (Gaebel et al., 2017; European Psychiatric Association).

California, one of the largest states in the USA, has developed their own guidelines and regulations related to telepsychiatry related to reimbursement, informed consent, privacy and security, and documentation (California Department of Health Care Services, 2023).

Other national or international behavioral health professions have contributed best practices, position statements, and guidelines on video and asynchronous technologies (Hilty et al., 2021). Those include psychology (Goss et al., 2001; British Association for Counselling and Psychotherapy, 2019; Canadian Psychological Association, 2006; Australian Psychological Society, 2011; American Psychological Association (USA 2013); National Association of Social Workers (USA 2017); American Counseling Association (2014) and Canadian Counselling and Psychotherapy Association (2019); American Association for Marriage and Family Therapy (2015); and Association of Marriage and Family Therapy Regulatory Boards (2016)). The majority of the work is related to video, with work generalized to all populations and some specifications for age, culture, and other factors. Psychology organizations around the world (i.e., Australia, Britain, Canada, USA) have discussed in-depth patient assessment/treatment, health knowledge, systems-based practice, and professionalism; practice-based learning; and interpersonal and communication skills.

The World Psychiatric Association (WPA) Telepsychiatry Global Guidelines (TGG)

Despite the progress with technology and the innovation during the pandemic, a set of guidelines is needed at a global level to unify key themes and address challenges related to clinical considerations, ethical and legal considerations, and technological requirements (Barnett, 2019). To address these challenges, the World Psychiatric Association (WPA) has developed Telepsychiatry Global Guidelines (TGG), first published in February, 2021 (World Psychiatric Association, 2021). The TGG were developed by an international task force of experts in telepsychiatry and mental health care providing a thorough framework for the development, implementation, and evaluation of telepsychiatry services while offering valuable information for mental health professionals looking to incorporate telepsychiatry into their practice. The TGG focus on the ethical, technical, and clinical aspects of telepsychiatry, emphasizing the importance of providing patient-centered care, ensuring the confidentiality and security of patient information, and engaging in ongoing evaluation and quality improvement. These guidelines focus on the use of live interactive videoconferencing often referred to as telepsychiatry but also a number of other terms maybe used including telemental health, telebehavioral health, and digital mental health. Their purpose is to assist providers and organizations in providing high-quality telepsychiatric care. However, following these guidelines, unless implemented and evaluated, does not guarantee successful outcomes nor are they intended to establish a legal standard of care.

The WPA Global Telepsychiatry Guidelines cover a wide range of essential elements, such as clinical practice, ethical considerations, technological challenges, education and training, research, and specific populations and settings, with an emphasis on international and cross-cultural dimensions. Finally, the appendix of the guidelines provides a collection of additional resources and information, enabling professionals to enhance their telepsychiatry services and deliver high-quality care.

Clinical Considerations

The WPA guidelines provide recommendations for the use of telepsychiatry in various clinical settings, including assessment, diagnosis, treatment, and follow-up care. The guidelines emphasize the importance of ensuring that telepsychiatry is appropriate for the specific clinical situation and that patients are provided with adequate information and support to participate in telepsychiatry sessions. The guidelines also recognize that telepsychiatry may not be appropriate for all patients or conditions and that in-person care may be necessary in some cases.

Ethical and Legal Considerations

The WPA guidelines emphasize the importance of ethical and legal considerations in the use of telepsychiatry. The guidelines emphasize the need for informed consent, privacy and confidentiality, and the use of evidence-based practices. The guidelines highlight the importance of complying with local and national laws and regulations related to telepsychiatry.

Technological Requirements

The WPA guidelines provide recommendations for the technological requirements for telepsychiatry, including hardware, software, and network infrastructure. It is recommend that telepsychiatry technology complies with international standards for interoperability and inter-compatibility to ensure that patients and providers can easily communicate with one another, regardless of the technology they are using or the country they are located in. This is especially important in cases where patients may receive care from multiple providers or institutions, requiring the seamless transfer of information between systems. This will ensure that the technology is not only effective but also safe and secure, protecting patient privacy and data security. The guidelines also recognize that the technological requirements for telepsychiatry may vary depending on the clinical setting and the needs of patients.

Education and Training

The guidelines recommend that mental health professionals receive education and/or training. Adult competency sets for video, mobile health, wearable sensors, and other asynchronous care; these have included suggestions for training, faculty development, and institutional change (Hilty et al., 2019, 2021). While in-person care and synchronous care are similar in many ways, the clinician’s approach to asynchronous care has many differences. The core skills are in the following areas:

  1. 1.

    Technical skills: Mental health professionals must be proficient in using telepsychiatry technology, including videoconferencing, secure messaging, and other remote communication tools.

  2. 2.

    Clinical skills: Mental health professionals must be able to conduct a comprehensive clinical assessment and provide evidence-based interventions through telepsychiatry.

  3. 3.

    Cultural competence: Mental health professionals must be sensitive to the diverse needs of patients from various cultural backgrounds, including those with limited English proficiency.

  4. 4.

    Ethics: Mental health professionals must adhere to ethical principles when providing telepsychiatry services, including informed consent, confidentiality, privacy, and security of patient data.

Research

The guidelines emphasize the following key points related to research in telepsychiatry:

  1. 1.

    Efficacy and effectiveness: Research should aim to determine the efficacy and effectiveness of telepsychiatry interventions, including their impact on patient outcomes, quality of care, and cost-effectiveness.

  2. 2.

    Safety: Research should also examine the safety of telepsychiatry, including the potential risks associated with technology and the impact of telepsychiatry on patient safety.

  3. 3.

    Ethical implications: Research should address the ethical implications of telepsychiatry, including informed consent, privacy, confidentiality, and the security of patient data.

  4. 4.

    Cultural competence: Research should examine the cultural competence of telepsychiatry, including its impact on diverse populations and ways to ensure cultural sensitivity and competence in telepsychiatry practice.

International and Cross-Cultural Perspectives in Telepsychiatry

International telepsychiatry enables the exchange of knowledge, expertise, and best practices across borders (Mucic, 2016). However, considerations related to licensure and national laws and regulations must be taken into account when practicing telepsychiatry across international borders. Telepsychiatry allows mental health professionals to collaborate and share their expertise beyond geographical boundaries, leading to the development of new treatment approaches, better understanding of cultural differences, and improved mental health care quality (Hilty et al., 2018; Mucic, 2010). Within the framework of the WPA Telepsychiatry Global Guidelines, studies on cross-cultural telepsychiatry emphasize the promising potential of utilizing telepsychiatry to mitigate disparities in mental health care access and deliver culturally attuned care to a variety of populations (Mucic, 2008, 2010).

Appendix

The WPA Telepsychiatry Global Guidelines appendix offers a comprehensive collection of tools, templates, and resources for mental health professionals seeking to implement telepsychiatry in their practice. This includes guidelines for remote consultation clinical practice and professional behavior, which outline the ethical, technical, and clinical standards that mental health professionals must maintain when providing telepsychiatry services. These standards are designed to ensure that patients receive high-quality care and are kept safe in a remote healthcare setting.

Benefits

The benefits of the WPA Telepsychiatry Global Guidelines include the following:

  1. 1.

    Standardization: The guidelines provide a standardized framework for the practice of telepsychiatry, ensuring that mental health professionals around the world are operating under a common set of guidelines and best practices.

  2. 2.

    Quality improvement: The guidelines aim to improve the quality of care provided through telepsychiatry by emphasizing the importance of clinical, ethical, and technical standards that must be upheld.

  3. 3.

    Patient safety: The guidelines prioritize patient safety by addressing the potential risks associated with telepsychiatry and outlining the measures that must be taken to ensure patient privacy, confidentiality, and data security.

  4. 4.

    Accessibility: The guidelines promote the use of telepsychiatry to increase access to mental healthcare, particularly for underserved populations who may have limited access to in-person care.

  5. 5.

    Education and training: The guidelines emphasize the importance of education and training for mental health professionals to ensure they have the necessary skills and knowledge to practice telepsychiatry effectively and safely.

  6. 6.

    Research: The guidelines highlight the importance of ongoing research to evaluate the effectiveness, safety, and ethical implications of telepsychiatry, ultimately aiming to improve patient care and outcomes in a remote healthcare setting.

Limitations

The limitations of the WPA Telepsychiatry Global Guidelines include the following:

  1. 1.

    Adherence: The guidelines are not legally binding and rely on mental health professionals voluntarily adhering to the recommended standards, which may not be universally followed.

  2. 2.

    Cultural differences: The guidelines may not be suitable for all cultural contexts and may need to be adapted to meet the specific needs of different populations and regions.

  3. 3.

    Technology limitations: The guidelines are dependent on the availability and reliability of technology, and in regions with limited resources or infrastructure, the implementation of telepsychiatry may be challenging.

  4. 4.

    Legal and regulatory differences: The guidelines do not account for differences in legal and regulatory frameworks across countries and regions, which may impact the practice of telepsychiatry.

  5. 5.

    Lack of specificity: The guidelines are general, broad, and may not provide specific guidance for certain aspects of telepsychiatry practice, such as the use of certain technologies or specific clinical populations.

  6. 6.

    Inadequate evaluation: The guidelines may not be regularly evaluated or updated to reflect new research and emerging best practices in telepsychiatry.

  7. 7.

    More specific recommendations with “should” versus “shall” stratification.

Discussion

The WPA Telepsychiatry Global Guidelines remain relevant and applicable, but it is important for practitioners and researchers to stay informed about ongoing developments in the field. More studies are required to determine the efficacy of telepsychiatry in diverse clinical settings and patient populations. Moreover, there is a need for further investigation to identify the most effective approaches for implementing and assessing telepsychiatry programs, emphasizing the importance of continuous innovation and adaptation (Shore, 2013). Ensuring that all patients have access to high-quality mental health care will require the development of culturally sensitive and contextually appropriate telepsychiatry programs. Furthermore, the guidelines will need to be updated periodically as telepsychiatry evolves, and they can be further developed with specific, weighted recommendations.

However, they may need to be adapted to meet the specific needs of different countries and regions. It is why the development of country-specific guidelines highlights the importance of tailoring best practices and ethical standards to meet the unique needs and cultural contexts of different regions.

Moreover, a survey on the use of WPA telepsychiatry global guidelines can provide important insights into how the guidelines are being implemented and their impact on telepsychiatry programs. This information can be used to improve the guidelines and promote the adoption of evidence-based practices in telepsychiatry.

It is important to recognize that telepsychiatry is a versatile field that incorporates a range of technologies to enhance access to mental health care and overcome barriers such as distance, limited resources, and stigma. Providing telepsychiatry without prior training and/or education can have several downsides, including the following:

  1. 1.

    Increased risk of errors: Mental health professionals who are not trained in telepsychiatry may make errors or overlook important considerations, such as ensuring the confidentiality and security of patient information. We continue to observe instances, even today but especially under the pandemic, where telepsychiatry is being conducted through platforms (such as Skype or WhatsApp) that may not comply with privacy and security regulations in certain countries.

  2. 2.

    Lower quality of care: Without prior training, mental health professionals may not have the necessary skills and knowledge to provide high-quality telepsychiatry services. This could result in lower patient satisfaction and outcomes.

  3. 3.

    Legal and ethical implications: Providing telepsychiatry without proper training and education could raise legal and ethical concerns, such as violating patient confidentiality or failing to provide adequate informed consent.

  4. 4.

    Stigma toward telepsychiatry: Poor quality telepsychiatry services could contribute to negative attitudes and stigma toward the use of technology in mental healthcare.

Overall, providing telepsychiatry without prior training and education can have significant negative impacts on both mental health professionals and patients. It is therefore essential that mental health professionals receive adequate education and training in telepsychiatry to ensure safe and effective delivery of services.

In connection to the promotion of the guidelines, WPA has launched its first online continuing medical education (CME) course in telepsychiatry in February, 2021. Holding such a course at the regional WPA conference as well as the world conferences can help to increase awareness and knowledge of telepsychiatry among mental health professionals. Firstly, it can help mental health professionals and educators to stay up to date with the latest developments and best practices in telepsychiatry, including advancements in technology and changes in regulations. This can improve the quality of care provided to patients and ensure that mental health professionals are practicing in a safe and effective manner. Secondly, CME in telepsychiatry can help to address the potential knowledge gaps and skills deficits that mental health professionals may have when it comes to telepsychiatry. This can lead to increased confidence and competence in providing telepsychiatry services, which can improve patient outcomes and satisfaction. Finally, offering CME in telepsychiatry can signal to mental health professionals and the broader healthcare community that telepsychiatry is a legitimate and important mode of delivering mental health care. This can help to increase awareness and acceptance of telepsychiatry, which can ultimately lead to greater access to mental health care for patients.

Overall, the launch of CME in telepsychiatry by the WPA is a positive development that can help to improve the quality and accessibility of mental health care for patients, while also supporting the ongoing education and professional development of mental health professionals. Unfortunately, the vast majority of psychiatry training curricula globally do not currently include education and training in telepsychiatry, which has lagged behind its use. To increase the familiarity of professionals with TP and its use in daily clinical work, TP practice could benefit from standardized training. Training in best practices appears to be essential to the development of a sustainable and well-functioning telepsychiatry network (Moeller et al., 2022) for safe and effective practice. A certification in telepsychiatry, as a measure to ensure that the introduction of telepsychiatry services was carried out in a safe and effective manner, has been proposed (Baird et al., 2018) and is supported by the authors of this article.

However, there are also arguments against making education/training in telepsychiatry mandatory. For instance, mandating could potentially contribute to an increase in stigma toward the use of technology in mental healthcare. Additionally, it may impose additional demands on mental health professionals who are already facing time and resource constraints. Encouraging and incentivizing mental health professionals to participate in CME in telepsychiatry could be another effective approach. National and international psychiatric associations, including the WPA, can play a crucial role in promoting and providing education and training in core competencies in telepsychiatry. This includes disseminating guidelines, providing training and support, and advocating for policies that support the integration of telepsychiatry into mental healthcare delivery. By taking a leadership role in this area, psychiatric associations can help to ensure that mental health professionals have the knowledge and skills necessary to provide safe, effective, and culturally responsive telepsychiatry services to patients.

Conclusion

Telepsychiatry has emerged as a promising approach to improve access to mental health care, particularly in underserved populations. The COVID-19 pandemic has been a pivotal factor in the widespread adoption of telepsychiatry, highlighting both the opportunities and challenges in this rapidly evolving field. The insights acquired during the pandemic have the potential to guide the creation of more robust, accessible, and efficient mental health care systems in the future. The WPA Telepsychiatry Global Guidelines can play a significant role in facilitating this transformation.