Telephone-based telepsychiatry consultations: a qualitative exploration of psychiatrists’ experiences in Oman

Abstract

Objectives

The utilisation of tele-mental health services has the potential to address challenges in mental health services within the Eastern Mediterranean Region. However, the adoption of tele-mental health in Oman remains limited. Therefore, this study aimed to explore the experiences of psychiatrists with telephone consultations, offering valuable insights to advance the field of telepsychiatry.

Design

This is a qualitative exploratory study. The analysis of the data involved the application of manifest content analysis.

Setting

The semi-structured interviews were conducted with the psychiatrists at Al Masarra Hospital.

Participants

A total of 10 semi-structured interviews were conducted.

Results

The study reveals that psychiatrists encounter communication challenges in telephone consultations, such as the absence of visual cues, confirming patient identity, conducting comprehensive assessments and effectively communicating with younger patients who may lack developed social skills or patients with specific health conditions. Infrastructure limitations, such as outdated medical records, lack of electronic prescriptions and limited availability of child/adolescent psychiatric medications, further restrict the effectiveness of telepsychiatry consultations. In contrast, telephone appointments offer convenience and flexibility for psychiatrists, allowing them to manage non-clinical responsibilities and provide focused consultations tailored to individual needs. In addition, it benefits patients by improving appointment adherence, diminishing stigma and financial savings compared with in-person consultations.

Conclusions

Tele-mental health has emerged as a promising avenue for enhancing mental healthcare services in Oman. Addressing psychiatrists’ challenges is crucial to further developing and strengthening these services.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The outsider perspective of the first author helped reduce bias and encouraged psychiatrists to share their experiences openly and comfortably.

• The interviewer’s prior experience with telephone consultations enhanced the familiarity with the mental health system and enriched data analysis.

• Including psychiatrists of various genders and experience levels in both general adult and child and adolescent psychiatry enhanced the study’s academic credibility.

• The study only examines psychiatrists’ perspectives, recommending future research to involve patients to better understand their perspectives on telephone-based psychiatric consultations.

• The use of purposive sampling may introduce selection bias, potentially compromising the generalisability of the study’s findings.

Introduction

The COVID-19 pandemic has brought about numerous challenges across various sectors, including the healthcare system. Among the affected fields, the provision of healthcare services has been significantly burdened, necessitating the implementation of tools to ensure continuity and deliver high-quality care to patients despite limitations.¹ One area greatly impacted is outpatient services, which have experienced a substantial reduction in face-to-face appointments due to physical distancing measures implemented to curb the spread of the pandemic.¹ The interruption of these services can lead to severe consequences, such as worsening illnesses and increased disease-related anxiety, ultimately affecting patients’ quality of life.¹ To address this reduction, telehealth emerged as a vital tool, encompassing the delivery of healthcare services through digital communication to enhance patient care.² Telehealth encompasses various methods, including telephone calls, video conferencing, text messaging, and email newsletters, providing flexibility and convenience for both patients and healthcare providers.² While telehealth existed before the pandemic, its utilisation dramatically increased during the global health crisis.^{1 3} For instance, a study conducted in 2017 found that only 0.1% of medical enrolees were using telehealth, whereas, in 2020, 83% of orthopaedic departments in the USA implemented telehealth services.¹

Literature has demonstrated the influential role of telehealth, including telepsychiatry, during the COVID-19 pandemic in reducing the spread of infection while providing care to patients.^{1 3–5} In the realm of urology outpatient care at Sultan Qaboos University Hospital in Oman, telehealth, specifically messaging services, telephone consultations and email communication, played an effective role in managing patients during the pandemic.⁴ These technologies helped overcome the challenges and ensured continuous care provision.⁴ However, telehealth also comes with limitations, such as difficulties in examining patients, the absence of visual cues, concerns about the quality of health information provided, and the need to ensure patient privacy.^{3 5} A qualitative study conducted in Muscat shed light on physicians’ experiences with telephone consultations in healthcare centres during the pandemic, highlighting challenges related to limited staff training, inadequate technical and financial support, and difficulties in maintaining patient privacy and confidentiality.⁵ Additionally, certain communication barriers, such as unfamiliarity with technology among elderly patients and language barriers with non-Arabic or non-English speaking patients, posed challenges and occasionally required conversion to face-to-face sessions.⁵

Telepsychiatry, a subset of telehealth, involves providing psychiatric care remotely through various communication channels, such as telephone calls, videoconferencing, text messaging, emails or fax.^{3 6} The demand for telepsychiatry services surged during the pandemic due to the negative impact on mental health, increasing rates of depression, anxiety and other psychological disorders.^{6 7} Consequently, the implementation of telepsychiatry became crucial in providing psychiatric services while maintaining physical distancing to curb the spread of infection.^6–8 In Oman, telepsychiatry services were initially limited to non-governmental clinics using telephone calls and messaging services, but during the pandemic, governmental hospitals and non-governmental clinics adopted videoconferencing and email communication.^6–8 Recent studies in Oman explored the effectiveness of telepsychiatry, with one qualitative study highlighting positive experiences among psychotherapists and patients conducting therapy sessions via videoconferencing, along with recommendations for improvement.⁸ Another study conducted a randomised controlled trial comparing different telepsychiatry modalities in patients with anxiety and depression, finding that video-conferencing with online therapist-guided therapy had a more significant impact compared with self-help emails.⁷

Telephone consultations have been a widely used form of telehealth worldwide, particularly in primary care in the UK and internal medicine in the USA.⁹ Therefore, it is crucial to explore the satisfaction of physicians and patients regarding telephone consultations to assess their benefits, drawbacks and identify recommendations for improvement. Telephone consultations have shown potential benefits, including improved access to healthcare services, counselling purposes such as smoking cessation, increased flexibility, reduced waiting times and minimised travel to healthcare institutes.^{3 9} These consultations have also aided physicians in managing their workload effectively, easily accessing patients and making efficient decisions.¹⁰ However, physicians have expressed concerns about the safety of such consultations due to the absence of visual cues, limitations in conducting physical examinations and potential gaps in comprehensively assessing patients, as the focus primarily revolves around their presenting complaints.⁹ Evidence has indicated a link between low confidence levels among primary healthcare physicians and telephone consultations, attributed to insufficient training in telephone consulting competencies.⁹ Furthermore, studies have revealed lower patient satisfaction with telephone consultations compared with face-to-face interactions with healthcare providers.¹¹

In Oman’s governmental sectors, telephone psychiatric consultations have emerged as the most prevalent form of telepsychiatry. However, there is a dearth of literature examining the effectiveness of psychiatric telephone consultations and psychiatrists’ satisfaction with this specific form of telepsychiatry. Thus, this qualitative study aims to explore psychiatrists’ experiences with telephone consultations in Oman’s largest tertiary mental health institution. The majority of current literature extensively explores videoconferencing in psychiatric consultations. In contrast, our study uniquely focuses on the examination of telephone-based psychiatry consultations, presenting a distinctive contribution to existing research. By elucidating psychiatrist perspectives, our research aims to provide valuable insights into telepsychiatry, guiding future improvements in service delivery.

Methods

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Study design

Due to the paucity of literature that focuses on the use of telephone consultations as a tool in mental health in the Middle East we conducted a qualitative explorative study based on semi-structured face-to-face individual interviews at the psychiatrist’s workplace.

Study setting

All interviews took place at Al Masarra Hospital (AMH). The interviews were conducted in different private rooms and at different times depending on what was most convenient for the participants.

Sampling of informants

The study’s objectives and the advantages and disadvantages of participation were discussed with the psychiatrists in person, with confidentiality assured to be maintained throughout the data collection process. An electronic consent form, the meeting date, and the location were sent by email to the participants who agreed to participate.

Inclusion and exclusion criteria of study participants

All practicing doctors conducting telephone consultation clinics at AMH who submitted electronic informed consent were deemed eligible to participate in the study.

Data collection

Purposive sampling was used in this study and during January and February 2023. Psychiatrists were approached during the two consecutive days following the handover morning meeting, and all doctors who attended accepted the invitations. 15 practicing psychiatrists were approached, and 15 agreed to take part in the study with a response rate of 100%. Electronic consent was obtained from each participant. After the eighth interview, data saturation was reached, and the researcher then added two more interviews. A total of 10 semi-structured interviews were completed. Saturation is defined as the point at which new additional data is no longer acquired from the interviews. Moreover, the objectives of the study were attained.¹² As a result, the interview process was terminated. All of the interviews were conducted by a single researcher, the first author (TA-M) to ensure the absence of any potential interviewer bias. The researcher is a female psychiatry resident in her third year (PGY3) at the Oman Medical Specialty Board. She had prior experience in telephone-based psychiatry consultations before conducting the study. She has a specific interest in telepsychiatry, with prior research experience in this field. The researcher communicated the study objectives to the participants, emphasising that the goal was to enhance the quality of healthcare provided. No pre-existing relationship was established before the commencement of the study between the interviewer and the study participants.

An interview guide was designed in advance and contained core questions related to telephone-based psychiatry consultations (box 1). The interviews were conducted in English. The interviews were audio-recorded in an attempt to capture the interview data efficiently. The average duration of each interview was 30 min.

Box 1. Semi-structured face-to-face interview guide questions.

1. What encouraged you to start delivering telephone-based-psychiatry consultations?

2. How was your experience listening to the patient’s problem over the phone?

3. What encouraged you to continue using telephone-based-psychiatry consultations?

4. What discouraged you from continuing to use telephone-based-psychiatry consultations?

5. What were the challenges and difficulties associated with conducting telephone-based-psychiatry consultations?

6. What factors affected your ability to communicate effectively with the patients during the telephone-based-psychiatry consultations?

7. When the telephone-based-psychiatry consultations were conducted with the caregivers what were the challenges associated with receiving patients’ mental health conditions from their caregivers?

8. How do you feel regarding the quality of the information provided by a family member over the phone? (Prop: Have you ever thought that the information provided is insufficient?)

9. How confident are you in making decisions regarding diagnosing or managing the patient based on the information provided by their relatives over the phone?

10. What psychiatric conditions make telephone-based psychiatry consultations an inappropriate treatment model?

11. What ethical considerations might be different in telephone-based-psychiatry consultation versus in-person consultations?

12. What is your view on making a first psychiatric assessment and management recommendation via telephone consultation without physically seeing the patient?

13. How could the telephone-based-psychiatry consultation be improved?

14. Would you choose to use the telephone-based-psychiatry consultation tool to deliver consultations again in the future?

15. Is there anything else you’d like to say or share?

Data analysis

Data were analysed manually using qualitative manifest content analysis.¹³ Manifest content analysis was based on close statements of the psychiatrist’s words without extensions to the underlying meanings. The first author transcribed the audio recording into written text. The data analysis was started after the first interviews, and the transcriptions were read through several times by three researchers (TA-M, KA-A and FA-S) to ensure familiarisation with the data. A text dealing with experiences related to telephone-based consultations and the implications of these experiences (outcomes) were identified as meaning units, which were condensed, interpreted and labelled with codes. The identified experiences with similar content were developed further into categories and subcategories, and the implications of the experiences were listed as groups for each subcategory. Finally, the categories were further grouped into one of two contexts. No software was used for data management/analysis.

Results

Ten participants who provided telephone-based psychiatry consultations were interviewed. These participants are from two subspecialties: general adult psychiatry and child and adolescent psychiatry. These are the only two subspecialties that offer telephone-based consultation services at AMH. The summary of participants’ characteristics is presented in table 1.

Table 1.

Participants’ characteristics

Psychiatrist	Gender	Age range (years)	Employment position	Subspecialty	Experience in the specialty (years)	Experience with telephone consultations
1	Female	25–35	Medical officer	General adult psychiatry	2	6 months
2	Male	35–45	Sr specialist	Child and adolescent psychiatry	13	3
3	Female	35–45	Sr specialist	General adult psychiatry	9	2
4	Male	35–45	Specialist	General adult psychiatry	10	1 year and 4 months
5	Female	35–45	Specialist	Child and adolescent psychiatry	10	1
6	Male	35–45	Sr specialist	General adult psychiatry	17	1 year and 6 months
7	Female	35–45	Specialist	Child and adolescent psychiatry	8	2
8	Female	25–35	Specialist	General adult psychiatry	7	1
9	Female	35–45	Consultant	General adult psychiatry	18	3
10	Male	35–45	Specialist	Child and adolescent psychiatry	10	3

The analysis of the interviews with physicians captured their experiences while providing telepsychiatry care and was categorised into two contexts: context A: psychiatrist and context B: patients (context B reflects the psychiatrist’s perception of patient experiences). The experiences discussed by the physicians are summarised in table 2.

Table 2.

Exploration of psychiatrists’ experiences towards telephone-based psychiatry consultations

Context	Categories	Subcategories	Experiences (outcomes)
Psychiatrists	Limitations of telephone consultations	Patients’ first visit	Difficult to confirm the patients’ identity Difficult to do the primary assessment Difficult to do the mental state examination Limited clinical examination Limited access to laboratory investigation and imaging Difficult to confirm the diagnosis Difficult to formulate the management plan
		Child/adolescent patients	Undeveloped children’s social skills Children might be at school The hesitancy of parents receiving consultations
		Patients with multiple health problems	Patients with hearing impairment Patients with mutism Patients with intellectual disabilities Patients with acute psychiatric emergency conditions Drug naive patients
		Patient–provider communication difficulties	Difficulties with the absence of visual cues Difficulties with the absence of facial expressions Difficulties with the absence of body language Difficulties in building patient–pprovider relationships High satisfaction Good opportunity for practicing active listening
	Efficiency	Timing	Convenient Flexible appointments
		Consultation	Short Focused Flexible duration
	Infrastructure for eHealth	Tools/technical support	Limited external phone lines Outdated patients’ medical records Absence of communication channels between different levels of care Absence of video aided consultations
		Pharmaceutical support	Absence of electronic prescriptions Absence of child and adolescent medications in some areas
Patients	Availability	Timing	Suitable for scheduling early appointments Reduced appointment waiting time Reduced unnecessary travel time
		Commitment	Reduced stigma Improved adherence to the appointments Improved with staying at home patients
		Financial benefits	No consultation fees No transportation fees
	Environment	Space/place	Difficulties in finding a suitable place while at work Difficulties with shared rooms while at work
		Privacy	Compromised Breach of confidentiality
		Safety	Difficulties in reporting patients at risk Difficulties in involving anyone to support
	Family support	Patient caregiver	Difficulties in confirming their identity Exaggerating the patient’s symptoms over the phone Unavailable during the consultation

(A) Psychiatrists

(1) Capabilities (knowledge, skills and abilities)

(a) Patients’ first visit

After discussing with the psychiatrists, several limitations were revealed regarding conducting the first visit in the form of telephone-based psychiatry consultation. One main challenge is confirming the patient’s identity, which could be difficult over the phone. Additionally, conducting a thorough primary assessment and mental state examination can be challenging without being able to observe the patient in person, including their appearance, behaviour and distress. Another limitation mentioned is the restricted ability to conduct clinical examinations, such as physical and neurological examinations, as well as limited access to lab investigations and imaging. These factors could make the diagnosis challenging and eventually impossible to develop a comprehensive management plan.

Sometimes I can’t confirm the identity of the person who is responding to the phone call. (Female with 1 year experience with telepsychiatry)

First assessment requires face-to-face attendance for the mental state examination, the physical examinations, and the necessary laboratory examination … that is why I prefer to have the first assessment in person because of these limitations. (Female with 2 years experience in telepsychiatry)

It is very difficult to arrive at a diagnosis over the phone, maybe you can have some provisional diagnosis … but I think no one can give a conclusive diagnosis without seeing the patient’s expressions and conducting a comprehensive psychiatric assessment, as in in-person consultation. (Male with 1 year and 4 months of experience in telepsychiatry)

I cannot diagnose and make a full plan based only on the phone call assessment. I have to do a comprehensive assessment, which includes a mental state examination, and a physical examination. I can receive collateral history over the phone but I can’t conduct the first psychiatric assessment over the phone. (Female with 1 year of experience in telepsychiatry)

(b) Child/adolescent patient

Discussions with child and adolescent psychiatrists revealed several challenges associated with telephone-based psychiatry consultations for children and adolescents. One of the challenges is that children’s social skills may not be fully developed, which could make it challenging to communicate effectively over the phone. Another challenge is that children may be attending school during the consultation, which could make it difficult to have their full assessment. Additionally, the parents are sometimes hesitant to receive consultation in the workplace and this may limit the ability to gather essential information about the child’s mental health history or current condition.

Some children & adolescents’ social skills are not yet fully developed, and they want to avoid embarrassing questions with sensitive issues so they find communication through the phone easier. (Male with 3 years of experience in telepsychiatry)

The children might be at school and you’ll be able to reach only the caregiver. Also, sometimes the caregivers themselves might be at the workplace and they might not be comfortable receiving calls from psychiatrists. Therefore, the amount and the quality of information may differ. (Male with 3 years of experience in telepsychiatry)

(c) Patients with multiple health problems

According to psychiatrists, certain patients with multiple health problems are not suitable for telephone-based psychiatry consultations, including those with hearing impairment, mutism and intellectual disabilities. Patients with these conditions require additional support and accommodations to effectively communicate and participate in the consultation and may benefit more from accessing traditional in-person mental health services. Additionally, patients with acute psychiatric emergencies, such as those experiencing a manic episode or those with suicidal or homicidal tendencies, should be evaluated in person, as telephone-based consultations may not provide sufficient access to emergency resources and interventions necessary for their immediate care. Moreover, patients who have never been exposed to medications may not be suitable for telephone-based psychiatry consultations as important assessments such as vital sign monitoring, lab investigations and ECG need to be performed in person before prescribing medications.

Telephone-based psychiatry consultations are not suitable for patients with hearing impairment, or those patients’ experiencing mutism or those with mental retardation. (Female with 6 months of experience in telepsychiatry)

All psychiatric emergency conditions such as aggressive, manic patients, and acute cases in general, most of them are not suitable for telephone consultations. Patients who cannot communicate appropriately either due to their illness or when they don’t feel safe and free to talk through the phone, I prefer to ask them for an in-person consultation. (Female with 2 years of experience in telepsychiatry)

Psychiatric emergencies, such as suicidal patients and, treatment-naive patients who need to be commenced on medications without prior exposure need to be evaluated through vital signs, baseline laboratory investigations, and recorded ECG. (Male with 1 year and 4 months of experience in telepsychiatry)

(d) Patient–provider communication difficulties

The results of the study indicated that psychiatrists faced several challenges when communicating over the phone, such as the inability to observe the patient’s visual cues, facial expressions and body language. These challenges can hinder the development of a strong patient-doctor relationship and may affect the understanding of the patient’s mental health condition. Nevertheless, the results found that the majority of the psychiatrists expressed high levels of satisfaction with telephone-based consultations and appreciated the opportunity for active listening.

We are not able to perform the patient’s mental state examination. Because, of the absence of visual clues, and facial expressions. Also, we can’t assess the patient’s body language. (Female with 6 months of experience in telepsychiatry)

When you’re communicating over the phone, you listen better because you are mainly focusing on listening. So, I am really getting attention, giving attention, and listening very well. So, it worked for me. it worked well. (Male with 3 years of experience in telepsychiatry)

(2) Efficiency

(a) Timing

According to psychiatrists, telephone-based appointments were found to be convenient and flexible, allowing them to easily rearrange their schedules to accommodate other non-clinical duties, such as administrative work, without compromising patient care.

Telephone appointments are very helpful to the psychiatrist, we get more free time for other administrative work, like writing patients’ reports. (Female with 1 year of experience with telepsychiatry)

In my in-person clinic, I am overbooked, and the nearest appointment in my in-person clinic is usually after two months. Therefore, I can book the patients for a follow-up appointment within 1–2 weeks through telephone-based-psychiatry consultations and this solves the issue of the delayed follow-up appointment. (Female with 3 years of experience with telepsychiatry)

(b) Consultation

During the discussion with the psychiatrists, it was revealed that the duration of the consultation was precise, focused and flexible. The short and focused duration of these consultations allows patients to receive the care they need efficiently and effectively, without wasting time. Additionally, the flexible duration of consultations means that the duration of the appointments is tailored to fit patients’ needs and preferences, allowing for a more personalised and patient-centred approach to care.

The consultations are usually short and focused, and they don’t extend beyond 20 minutes. (Male with 1 year and 6 months experience in telepsychiatry)

(3) Infrastructure for eHealth

(a) Tools/technical support

The psychiatrists revealed several challenges associated with the tools and technical support available for telephone-based psychiatric consultations at AMH. One major challenge is the limited availability of external phone lines, which is inadequate for the number of psychiatrists conducting telepsychiatry clinics. Moreover, the psychiatrists reported feeling frustrated with outdated patient medical records that often contain incorrect phone numbers for patients or their caregivers. As a result, psychiatrists need to spend a significant amount of time trying to reach the correct phone number for their patients, which can be time-consuming and cause delays in scheduled appointments.

One of the challenges faced by the psychiatrists at AMH is the limited communication channels between the different levels of care, including primary, secondary and tertiary care. To address this issue, they propose conducting telephone appointments in collaboration with psychiatrists at primary and secondary care. This way, mental status examinations, physical and neurological examinations, imaging and lab investigations can be completed and fed electronically or by phone to the psychiatrists at AMH who can then provide more comprehensive telepsychiatry appointments. Additionally, the absence of video-aided consultations is another challenge that limits the ability of psychiatrists to conduct comprehensive assessments and provide visual cues for communication. These challenges emphasise the need for further investment and development of telepsychiatry infrastructure to better support patients and psychiatrists at AMH.

Currently, the external telephone lines are limited … we have 3–5 psychiatry consultation clinics to be conducted on the same day by 3–5 psychiatrists, and we only have 2 external telephone lines. (Female with 3 years of experience in telepsychiatry)

Sometimes we call the patients using the phone numbers registered in the electronic medical records, these are usually the numbers given by the patient or his primary caregiver who brought them to the hospital on the first visit and opened their file in the hospital. We get surprised that the person responding might be a brother or a sister who is not involved with patient care, and it’s a breach of confidentiality if they get to know that their sisters or brothers are followed up in our hospital. So, it is very important to revise the phone numbers registered in the electronic files. (Female with 3 years of experience in telepsychiatry)

Because we are providing tertiary care mental health services in Al Masarra Hospital it would be great if we could connect with the patient and the regional psychiatrist at home area. We can depend on the regional psychiatrist in performing the mental status examination, physical examination, and laboratory investigations. We can also assist the regional psychiatrist with the differential diagnosis and the management plan. (Female with 3 years of experience in telepsychiatry)

If the GP, family physicians, and the psychiatrists in primary and secondary care can cooperate with the child and adolescent psychiatrist in our tertiary care, they can perform the physical examination, mental status examination, and do necessary laboratory investigations & we can provide our opinion over the phone. (Male with 3 years experience in telepsychiatry)

I recommend adding videoconference tools to the telepsychiatry appointments, this will increase the therapeutic relationship, especially if the patient is an adolescent, he will feel his psychiatrist is interested and enjoy seeing his physician following him. (Female with 2 years experience in telepsychiatry)

(b) Pharmaceutical support

The child and adolescent psychiatrists revealed two additional limitations of the telepsychiatry services provided at AMH. First, the absence of electronic prescriptions is a significant challenge. Even when providing assessments and care over the phone, the caregiver of the child must travel all the way to the hospital to collect the child’s prescription. This causes inconvenience and additional burdens for the caregiver. Second, another challenge lies in the absence of child and adolescent psychiatric medications in primary and secondary care settings. In the Ministry of Health, these medications are only dispensed at AMH. This means that patients who require such medications must travel long distances to access them, which can be particularly challenging for families who live far from the hospital. This limitation can cause delays in treatment and can have a negative impact on the health outcomes of patients. Overall, these limitations highlight the need for further investment in the telepsychiatry infrastructure, including the implementation of electronic prescriptions and the availability of essential child/adolescent psychiatric medications in primary and secondary care settings.

Also, I hope we can issue the child/adolescent medications from the polyclinics because they are closer to the patients. Because the general adult psychiatry patients can receive their psychiatric medication from polyclinics. (Female with 1 year experience in telepsychiatry)

Some medications require prescriptions, and we don’t have an electronic prescription. So, this is a problem. Unfortunately, in most cases, the patients have to come to the hospital, our hospital, because these medications are not available in other regions. (Male with 3 years experience in telepsychiatry)

If medications can be dispensed from the primary or secondary care instead of making the caregiver travel all the distance to our hospital will be good. However, children and adolescent medications are not available in primary/secondary care. (Male with 3 years experience in telepsychiatry)

(B) Patients

(1) Availability

(a) Timing and access

According to the interviewed psychiatrists, telephone-based psychiatry consultations offer several benefits for patients. One major advantage is the flexibility and convenience of appointment timings. Patients can easily schedule early appointments without having to worry about long waiting times, this reduces the appointment waiting time. Therefore, patients no longer have to wait for long periods to get an appointment, and this can be especially beneficial for patients who require urgent and close mental healthcare. Moreover, telephone-based psychiatry consultations also reduce unnecessary travel time. Patients who live far from the hospital or have mobility issues can receive care from the comfort of their own homes. This ultimately increases patient satisfaction and improves access to mental health services.

It decreases the long list of in-person appointments and helps with giving close phone call appointments. Also, it helps patients with transportation difficulties … because many don’t live nearby, they have to travel at least 2–3 hours. (Female with 1 year of experience with telepsychiatry)

(b) Commitment

The psychiatrists revealed that telephone-based consultations have improved adherence to appointments, as patients can avoid the logistical challenges associated with travelling to the hospital. Additionally, the psychiatrists stated that employed patients have exhibited a particular preference for telephone-based appointments, especially those who face time constraints and inflexible work schedules that make in-person consultations difficult for them. Similarly, patients who are homemakers or housewives can benefit from the flexibility that telephone-based consultations offer, allowing them to more easily attend appointments around their busy duties and schedules. In addition, phone consultations can reduce the stigma associated with seeking mental health treatment, as patients do not need to physically attend AMH. This may make it easier for some patients to seek and engage with treatment, particularly those who may be hesitant to attend in-person appointments due to concerns about being seen by others or feeling embarrassed.

I think another benefit of telephone appointments is that it increases the patient’s adherence to follow-up appointments and adherence to their prescribed medications. (Male with 1 year and 6 months of experience with telepsychiatry)

Telephone appointments reduce stigma because patients don’t need to come to a mental health facility. (Female with 1 year of experience with telepsychiatry)

Sometimes it’s difficult for housewives to find another caregiver for their children at home, telephone consultations for them could be conducted without affecting their duties at home. (Female with 3 years of experience with telepsychiatry)

(c) Financial benefits

The psychiatrists have observed that patients who receive telephone calls for their appointments experience financial benefits compared with those who attend in-person appointments. This is because telephone appointments do not incur consultation fees that are typically required for face-to-face appointments. Additionally, patients who attend physical appointments often have to pay for transportation, which can be particularly costly for those who live far away from the hospital. As AMH is the only tertiary psychiatric care facility affiliated with the Ministry of Health, patients from all over the country have to travel long distances to receive care. Therefore, telephone appointments offer a more accessible and cost-effective way for patients to receive psychiatric care, particularly for those who face financial difficulties.

It is time-convenient for the patient and his family to avoid the time spent traveling & the travel costs. (Female with 1 year experience with telepsychiatry)

Actually, some patients are asking for telephone follow-up appointments, because of the long driving distance (some may drive up to 4 hours),travel expenses are also an issue (that can cost up to 20–30 OMR, especially for those who need to hire a taxi), waiting time, work absenteeism, and sometimes difficulty with finding another caregiver for their other children at home. Therefore, with telephone calls, they won’t need to pay the visiting fees. It’s a very economical choice for many patients from low socio-economic classes. (Female with 3 years experience with telepsychiatry)

(2) Environment

(a) Space/place

Psychiatrists have pointed out that patients attending telephone consultations may face difficulties with the space in which they have the call. For instance, some employed patients may struggle to find a suitable place while they are at work, which could lead to distractions and interruptions during the call. Similarly, patients may encounter problems if they are in a shared room, as they may not have the necessary privacy or quiet environment needed for the call. These issues can have a negative impact on the effectiveness of the consultation and the patient’s overall experience. Therefore, it’s crucial for patients to have access to a suitable and private space during telephone reviews to ensure the best possible outcome.

Sometimes telephone appointments are a big deal for the patient stigma because they are being called in their workplace. So, they re-schedule the call until another 30 minutes so that they can leave their workspace, so they are not overheard by their colleagues at work. (Male with 1 year and 6 months experience in telepsychiatry).

(b) Privacy

Another potential drawback is that the consultation may be impaired if the patient takes the call while at work. For instance, the patient may not have the opportunity to discuss sensitive or private information during the call because they are concerned about being overheard by coworkers or superiors. This can significantly limit the effectiveness of the appointment and the patient’s ability to receive the necessary care. However, if patients leave the workplace temporarily to access more privacy for the call, they can potentially overcome this drawback and have a more successful appointment.

When spouses answer telephone consultations, psychiatrists navigate a delicate balance between maintaining confidentiality and ensuring accurate information exchange. Non-disclosure becomes a crucial aspect of the consultation, as psychiatrists must refrain from divulging sensitive information to unauthorised individuals. Simultaneously, efforts to confirm the caller’s identity are undertaken to safeguard privacy.

Sometimes the husband or the wife are curious to know about the patient’s condition, so they reply to the phone call. I think this is also a breach of confidentiality. Unless the spouse is the caregiver responsible for him/her. Otherwise, we need permission from the patient to disclose the patient’s information. (Male with 1 year and 6 months experience with telepsychiatry)

I can’t ensure confidentiality and privacy as I might call the husband and the wife answers or vice versa. And they might ask me health-related questions that the patient may not want to share and disclose. And, sometimes I can’t confirm the identity of the person who is responding to the phone call. (Female with 1 year experience with telepsychiatry)

Maintaining privacy is difficult with telephone consultations because other relatives attending the call can overhear the conversation. But, in face-to-face consultations, I can assure more privacy by asking the relatives to give us some time alone in the consultation room. (Female with 1 year of experience with telepsychiatry)

(c) Safety

The psychiatrist encountered challenges due to the absence of robust emergency preparedness protocols for telephone consultations, emphasising the necessity for clear reporting guidelines and coordination with law enforcement. The discussed challenges include the limited safety provision for patients experiencing psychiatric emergencies in the telepsychiatry setting, where immediate access to the emergency room and inpatient care may be constrained compared with traditional in-person appointments.

In addition, psychiatrists may experience difficulties in reporting any risky concerns, such as suicidal/homicidal ideation or self-harm behaviours, to the public relations officer and law enforcement. This can be especially concerning as the psychiatrists may not be able to ensure full safety levels, which may lead to possible harmful outcomes.

Furthermore, psychiatrists also experience difficulties in convincing patients with suicidal ideas to attend the emergency room, moreover, they reported difficulty in involving social support for the patients during telephone consultations, such as family members or caregivers. This can limit the patient’s ability to receive the necessary emotional and physical support they need during the appointment, which can be detrimental to their overall well-being.

if the patients report suicidal ideas or even plans during the in-person consultations I can easily admit the patient. But, with phone consultations, it is difficult to convince the patient to attend to the ER. (Female with 1 year of experience with telepsychiatry)

If a patient experiences active suicidal thoughts during the phone call consultation, this becomes a huge responsibility compared to an in-person consultation. For example, what if you couldn’t reach his family? What if you couldn’t reach the patient? What if I couldn’t convince him to attend the emergency room? What should I do? I should also report the public relations officer and the police. (Male with 1 year and 6 months of experience with telepsychiatry)

(3) Family support

(a) Patient caregiver

Psychiatrists conducting telephone appointments encounter a range of challenges associated with the involvement of family members and caregivers in their patients’ care. According to interviews, the level of family support can vary widely, with some caregivers providing high levels of involvement and support, while others are unresponsive or unavailable during consultations. Moreover, some caregivers may exaggerate the patient’s symptoms over the phone for secondary gains such as admission to a hospital. This can make it difficult for psychiatrists to accurately assess the patient’s condition and provide appropriate treatment over the phone. Psychiatrists overcome this challenge by requesting in-person assessments in the outpatient clinic prior to deciding on admission. Another challenge is the difficulty in confirming the identity of the caregiver, which can be problematic in cases where there are concerns about legal authority or decision-making power.

Sometimes when I call the father, he would just direct me to the mother and the mother will direct me to the brother. This is one of the problems and this happens because some family members are not aware of the patient’s condition. And, I will have to call several family members to gain a better insight into his symptoms. Which is time-consuming. (Female with 3 years of experience with telepsychiatry)

Some caregivers feel burned out from the patient’s care and they exaggerate the patient’s symptoms for them to get admitted, and they can get relieved from the care. But we perform the pre-admission assessment, and we can find that the patient is quite stable. So, we understand and relate to the family. (Female with 6 months experience with telepsychiatry)

Discussion

The present study delves into the experiences of psychiatrists using telephone-based psychiatry consultations at AMH. The discussion section will now explore the perspectives of psychiatrists and their perspectives of their patient’s experiences, highlighting the benefits and limitations observed.

Psychiatrists perspective

One of the primary challenges reported by psychiatrists in using telephone-based consultations was the absence of visual cues. This limitation directly impacted communication strategies and decision-making processes, particularly during initial visits, when interacting with children, adolescents and patients with poor communication skills or specific psychiatric conditions like intellectual disabilities. Similar concerns were raised in a study conducted in Oman, which examined physicians’ experiences with telephone-based consultations in primary healthcare centres, highlighting that communication via phone can pose a significant barrier between patients and physicians, especially when dealing with elderly patients.⁵ The psychiatrists interviewed in this study overcame this barrier by assessing the patients with in-person consultations. In an Irish survey, 100% of participants reported difficulties in assessing patients with cognitive impairments during telephone consultations compared with in-person appointments, and 92% of psychiatrists expressed reduced confidence in making diagnoses through phone calls due to the absence of visual cues.³ Additionally, conducting physical examinations, measurements and lab investigations is impossible in telephone-based consultations.¹⁴ Gharbal et al suggested that incorporating a visual component, such as video calls, instead of telephone-based consultations may enhance the quality of care provided and achieve comparable efficiency to in-person visits.¹⁴ Similar views were expressed by the psychiatrists in our study. By using video calls, care providers can conduct thorough assessments and identify patients with low, intermediate or high risk.^{5 8} Moreover, the utilisation of wearable devices that capture body measurements, such as blood pressure and heart rate, and transmit the data to physicians, can enhance the effectiveness of virtual clinics.¹⁴

Technical and pharmaceutical challenges also pose significant barriers for psychiatrists conducting telephone-based consultations. These challenges include a lack of technical support, insufficient external phone lines, inadequate communication channels between different levels of healthcare facilities, and the absence of electronic prescription use within the Omani health system. Numerous studies have demonstrated that a lack of technical support can impact the usability of telemedicine and reduce its efficiency in telephone or video-based consultations.¹⁴ A study conducted in Malaysia reported that 62% of participating physicians using different telemedicine modalities identified technical difficulties as a common barrier.¹⁴ Providing care providers with a quiet room and fixed phone lines are crucial resources for delivering the best possible care to patients using telephone consultations.⁹ Furthermore, the lack of communication channels between primary, secondary, and tertiary healthcare levels, as well as the absence of implementation of electronic prescriptions, can cause inconvenience for both psychiatrists and patients, potentially leading to delays in the patient’s management plan. The implementation of electronic prescriptions should be integrated into a secure electronic system, adhering to specific regulations to mitigate health-related risks and misuse.¹⁵ An Irish study investigating the use of electronic prescriptions during the COVID-19 pandemic reported incidents of medication safety issues and near misses among participating general practitioners, primarily attributed to the lack of integration within the existing electronic system and its impact on current workflow practices.¹⁶ Countries that had implemented electronic prescriptions in their healthcare systems before the pandemic have benefited from improved medication management processes.¹⁶ Thus, the establishment of an eHealth system that facilitates communication between different healthcare levels and includes pharmacies with electronic prescription capabilities can enhance the efficacy of telemedicine across the country. Barriers to implementing digital mental health and health interventions often stem from the insufficient availability of necessary resources, and a lack of capable leadership. Conversely, facilitators commonly revolve around support for organisational change.¹⁷ The close association between assistance for organisational change and capable leadership is noteworthy, explaining why capable leadership ranks high among the barriers. It is unsurprising, as effective implementation relies on well-trained and educated managers who can provide crucial support. Addressing this issue necessitates the development of an implementation strategy that focuses on enhancing managerial knowledge and skills.¹⁷

Psychiatrists generally expressed a favourable opinion about telephone consultations due to their convenience and time efficiency. However, Gharbal et al reported contrasting views among physicians, citing various difficulties such as technical issues or challenges in communicating with patients, which can prolong call duration and reduce the efficiency of telephone-based consultations.¹⁴ Nevertheless, other studies have reported that most physicians find telephone consultations satisfactory in terms of time management and their impact on patients, particularly when dealing with straightforward diagnoses.^{5 11}

Patient experiences from the psychiatrist’s perspective

According to the psychiatrist’s perspective, the patients derive several benefits from telephone consultations, including flexibility and convenience. The ability to receive care without the need to travel to the hospital ensures continuity of care and improvement in their condition.¹⁴ Telephone consultations are also considered cost-effective compared with in-person appointments.⁶ In a qualitative study exploring clients’ experiences with tele-mental health, clients expressed satisfaction with virtual mental health consultations, considering them safe, convenient and flexible.⁸ Telephone consultations reduce their absence from work or college and help minimise the stigma associated with seeking mental healthcare services.⁸ However, ensuring privacy for patients during telephone-based consultations remains a barrier in various Middle Eastern countries.¹⁴ Studies have shown that privacy is a significant concern for patients using telemedicine services.⁶ Gharbal et al reported that 70% of participants believed that the lack of legal protection in delivering care through telemedicine could negatively influence physicians’ perception of the safety of telemedicine services.¹⁴ Similar concerns have been raised by physicians in Saudi Arabia and Turkey.¹⁴

Methodological considerations and limitations

The data for this study were collected by the first author, an Omani psychiatry resident physician unaffiliated with the hospital where the interviewed psychiatrists work. The interviewer had previous experience with telephone consultations, providing an advantage in terms of familiarity with the mental health system and a nuanced understanding of psychiatrists’ experiences, which enriched the data analysis. The first author’s outsider perspective further contributed to mitigating bias in portraying physicians’ experiences with telephone-based consultations as they felt more open and comfortable in sharing their experience. The study included psychiatrists of various genders with different years of experience in both general adult and child and adolescent psychiatry, adding to its academic weight. However, the participants in this study were only psychiatrists; therefore, it is important to have similar studies interviewing the patients directly, which could offer crucial insights into patients’ perspectives of telephone-based consultations’ effectiveness in the field of psychiatry. Moreover, the use of purposive sampling is a limitation in the study as it may introduce selection bias, potentially compromising the generalisability of the study’s findings to the broader population.

Conclusion

Telepsychiatry is a valuable tool for providing efficient and convenient mental healthcare, especially through telephone-based consultations during and beyond the COVID-19 pandemic. To optimise this service and minimise health risks, it is crucial to address challenges faced by both physicians and patients. While telepsychiatry offers significant benefits, its universal suitability, especially for groups like children and individuals with complex health needs, should be carefully considered. Investigating patients’ perspectives and assessing the usability of diverse implementation strategies is vital for a comprehensive understanding of telepsychiatry’s applicability, emphasising the need for further research.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and the Medical Research Ethics Committee approved the study at the Ministry of Health (MoH/CSR/22/263889). The audio recordings and transcriptions were kept on a password-protected computer with the participants’ identities concealed. All of the participants were chosen based on their willingness to participate. The right to withdraw from the research study at any time was explained to all participants.