July 2020Telehealth

Using the digital tools of telepsychiatry to forge emotional bonds

Comfort of home helps clients open up to their therapists

Compared to many other branches of medicine, psychiatry might appear to be a dubious candidate for telehealth, where bonds are forged with screens and keyboards, rather than in the privacy and intimacy of the doctor’s office.

And yet, long-distance counselling has taken root and flourished at the JGH—and more widely throughout CIUSSS West-Central Montreal—since the lockdown came into effect in March for the coronavirus (COVID‑19) pandemic.

“I’ve noticed that the quality of the sessions and, in some ways, the nature of the therapeutic relationship improves when it happens virtually,” says Dr. Marc Miresco, a psychiatrist and Director of Adult Psychiatric External Services in the Institute of Community and Family Psychiatry at the JGH.

“This may sound counter-intuitive, but it’s true. The fact is, many patients initially feel somewhat shy or reserved about opening up to a mental health professional, even though we try to be as receptive as possible and encourage them to speak freely.

“For these patients, there’s something about using their own computer in their own environment at home that makes it easier and more comfortable for them to say what’s really on their mind.”

“Many patients—especially if they’re new to therapy—may also feel nervous about possibly being stigmatized,” adds Tung Tran, Director of the CIUSSS’s Mental Health and Addiction Program.

“The benefit of telehealth is that they don’t need to go to the hospital and be treated in a psychiatric setting, so they feel more comfortable and less self-conscious. If they feel secure at home, they’re more inclined to express their thoughts and emotions, and more open to talking about what’s happening in their lives.

“Of course, this means that as a professional, you have to make some adjustments and learn what to do when you’re in front of a screen. For example, eye contact is extremely important, so you have look into the camera and really talk directly to the patient. It’s not something we do instinctively, but if it’s done properly, it can be very effective.”

A natural step

“Psychiatry and mental health are actually the low-hanging fruit and the most obvious candidates for telehealth,” adds Dr. Miresco. “We’re one of the only—if not the only—medical specialties where we don’t need to place our hands on our patients to examine them. We don’t ask them to undress and we don’t have to closely observe any parts of their bodies.

“Since Psychiatric and mental health assessments are conducted solely through interviews with a patient, it’s a natural step to proceed via video-conference or even by phone.”

“Since assessments are conducted through interviews , it’s natural for us to proceed via video-conference or by phone.”

Before COVID-19 struck, says Mr. Tran, telehealth was not an option for Quebec psychiatrists, because the Ministry of Health rarely remunerated doctors for work that was done remotely with a digital connection. By contrast, telepsychiatry had already been introduced in some other parts of Canada and the United States.

However, as the threat of a pandemic loomed in February, the government changed its policy and allowed payment to be made to physicians who practice with telehealth. In addition, safeguards were put in place to ensure the security and confidentiality of the online tools.

By that point, Mr. Tran had already begun preparing his entire CIUSSS team for the impending digital transformation. For staff working from home, this included access to electronic medical records and ensuring that everyone was comfortable with Zoom and other types of software.

A quick transition

What was encouraging to staff, says Dr. Miresco, was evidence-based research from elsewhere in the world, which “showed that assessments by telepsychiatry are equally as safe and effective as those done in person.

“That made a difference in the transition, which was very quick. In ideal circumstances, you would take many months or a year to change the work habits of 30-odd psychiatrists and nearly 100 other mental health professionals. We had to do all of that in two weeks or less.

“And it wasn’t easy for those members of our department who are older and less familiar with this type of technology. If you’ve been practicing face to face with your patients for 30 or 40 years, and then all of a sudden you switch to a screen, it feels very different. So there was a period when the clinicians had to learn a new way of practicing and engaging with their patients.”

In the process, four noteworthy projects were developed:

  • Therapeutic webinars, moderated by professionals, have been “broadcast” four times a week since April to an audience of about 60 people. This has enabled clients to stay connected to the department, see some familiar faces among the therapists, and receive valuable advice on fighting stress in difficult times.
  • With support from Bell Canada and the JGH Foundation, iPads have been lent to vulnerable clients who are at home and don’t have a computer, tablet or cell phone. The iPads allow them to connect remotely to their treating teams and to make use of resources like the therapeutic webinars.
  • Because of the pandemic, special measures were needed to protect the health of psychiatrists in their 70s and 80s, who wanted to maintain contact with their patients, despite the vulnerability of these doctors to COVID-19. This has been accomplished by giving tablets to certain patients when they are admitted or are in the Emergency Department.
  • The Youth Drop-In Clinic has switched from in-person sessions to Zoom. Aimed at clients between the ages of 14 and 25, it’s held on Tuesdays and Thursdays from 3:00 to 5:00 p.m. The informal discussions are chaired by professionals, who can refer a participant to a treatment team, if necessary.

Telehealth Intervention Program for Isolated Older Adults

On a related note, the Telehealth Intervention Program for Isolated Older Adults has also been introduced to provide support via telehealth to vulnerable older individuals, for whom the isolation of the pandemic meant a potential increase in stress and depression.

Dr. Blanca Vacaflor

Dr. Blanca Vacaflor

“We know that older adults are disproportionately affected by this crisis, because they are at the highest risk of mortality from COVID-19,” says Dr. Blanca Vacaflor, a resident in geriatric psychiatry at the JGH. “For this reason, we initiated a unique clinical trial to help alleviate their stress.”

The program is directed by Dr. Syeda Bukhari, a Postdoctoral Fellow, and by Dr. Soham Rej, a Geriatric Psychiatrist at the JGH and researcher at the Lady Davis Institute. CIUSSS West-Central Montreal is considered an ideal venue for this data-driven assessment of new way of delivering services, because the CIUSSS is home to the provinces’ largest number of seniors.

“Before the pandemic, vulnerable older adults could at least get out to exercise, shop and participate in community events,” says Dr. Vacaflor. “But during the crisis, they were self-isolated and cut off from caregivers and loved ones. So what became of their mental health? This is where we believed our volunteer outreach could be of service.”

Outlook for the future

But will telepsychiatry be able to maintain its high degree of usefulness once the immediate threat of the pandemic subsides? Mr. Tran says he’s sure it will, since the move to this form of treatment was inevitable; what the crisis did was simply accelerate its implementation.

“One of our broader goals is to increase access to our services, and that’s just what telehealth is now doing and will continue to do,” he explains.

“One of our broader goals is to increase access to services, and that’s just what telehealth will continue to do.”

“Telehealth is also helping us to improve the way the service performs. If the service is available wherever the patient or client happens to be, there’s a better chance of having more people show up for their appointment. Fewer no-shows means you can see more patients and not have to contend with lost hours of service.”

Dr. Miresco agrees, adding that one of psychiatry’s major challenges is making sure that patients stick with their treatment and don’t drop out. “Telehealth makes it easier to stay engaged, because it’s a much more convenient way of connecting.

“I think the classic style of face-to-face psychiatry will always be there, and many patients and clinicians will prefer it. But telehealth and telepsychiatry are finally being accepted as mainstream options that are becoming part of the permanent landscape.”

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