Ethical standards for telemental health must be maintained during the COVID-19 pandemic

Public health measures, including physical distancing during the COVID-19 pandemic, necessitate telemental health, such as videoconferencing, to maintain continuity in clinical care for psychiatric outpatients. The use of technology in telemental health services is not only for curative purposes but also for assessment and monitoring as part of psychological first aid for the COVID-19 pandemic (Ransing et al., 2020; Kavoor et al., 2020). Telemental health is also a strategy to close the global mental health treatment gap, especially within low-and middle-income countries (Ransing et al., 2020; Arjadi et al., 2018; Das, 2020). Despite increased interest in telemental health, the pandemic created a sudden switch from offline to online modalities challenging clinicians to rapidly adapt to meet patients’ needs. For example, more than two-thirds of psychologists in a high-income country like the US have never conducted videoconferencing to deliver their therapeutic services (Glueckauf et al., 2018). This number is higher in low and middle-income countries in Asia, for example, about 85% of clinicians in Bangladesh have never provided telemental health services to their patients (Prodhan et al., 2017). Early career clinicians in Iran provided digital support groups through chatting apps (e.g., WhatsApp and Telegram) and social media (i.e., Facebook), and some of them did not use this digital remote support previously (Ransing et al., 2020). Neophyte online clinicians might not be aware of possible ethical and privacy concerns related to technology use in their practice (DeAngelis, 2020; Elhai and Hall, 2015; Lustgarten and Elhai, 2018). Additionally, telemental health services may not be regulated yet in health law, particularly in Asian countries (Medical Council of India, 2020).

There are five key ethical concerns clinicians need to be aware of before engaging in telemental health (Liem et al., 2020). First is to ensure confidentiality due to the complexities inherent in online treatment (Lustgarten and Elhai, 2018). For example, clinicians must ensure that their online communication has end-to-end encryption, to prevent access by a third party. One of the most widely used video conference providers was recently challenged on its stated privacy policy (Iyengar and Fung, 2020). Second, clinicians must have practical competence to deliver online interventions, including assisting patients when they face logistical issues.

Third, clinicians need to update their knowledge and comply with the newest regulations related to online interventions. For instance, clinicians in the US may use smartphones (in addition to desktop computers) in delivering their telehealth services during the COVID-19 public health emergency (DeAngelis, 2020). Also, the benefits for treatment should be weighed against the possibility that either clinicians or patients may not have adequate resources for conducting online interventions (i.e., a stable and secure internet connection). Fourth, similar with in-person interventions, clinicians are obligated to seek informed consent prior to intervention, and review risks and benefits of treatment. This is even more critical for telemental health, given the privacy concerns already mentioned. Fifth, clinicians must engage in contingency planning for emergency services (i.e., suicidal intent), first determining the patient’s physical location pre-emptively beforehand, in case the application used in delivering the intervention malfunctions. A brief checklist covers these five ethical standards for telemental health is provided in Table 1 and can complement the available mental health interventions during the COVID-19 pandemic (Ransing et al., 2020; Kavoor et al., 2020; Tandon, 2020).

Table 1.

Brief overview of ethical standards for telemental health.

Confidentiality	✓Use secure internet connection and password-protections instead of public or unsecured Wi-Fi.*
	✓Use the most up to date antivirus / antimalware.*
	✓Assure nobody will record (in any form) the session without permission.* ✓Discuss confidentiality as a responsibility of both parties, including a transparent description of the limits to confidentiality.
	✓Assure that any software / program that used in the session is end-to-end encrypted to protect the data. If end-to-end encrypted software / program is not available, clinicians must explain the risks of being hacked or privacy violation to patients.
	✓Assure no one else could listen the session (unless it is a part of the intervention and being agreed prior to the session, for instance, parent or legal guardian for the minors).*
	✓Parents or legal guardians of minors should grant privacy during online sessions.
Competency	✓Adequate knowledge and competency in using the software, hardware, and network for providing online interventions, including problem solving skills on related-logistic issues that patients may experience.
	✓Consider patient’s cognitive and clinical status as well as their comfort in using technology effectively and safely.
	✓Adequate resources (appropriate device for telemental health and stable internet connection).*
	✓Minimise distractions by turning off pop-up notifications and unrelated apps on smartphone or computer.*
	✓Maintain professionalism by wearing professional attire, removing personal items in the background that may distracting patient’s focus, and conducting the session within the same duration as an in-person session. ✓Clinicians should be culturally sensitive, approaching patients with cultural humility, regardless the modality of intervention.
Compliance	✓Check and comply with regulations and policies related to reimbursement eligibility / procedure from insurance company / health care system for online interventions.*
	✓Check and comply with regulations and policies from the government (local and national level) and professional organisations related to online interventions.
Consent	✓Inform and discuss the potential risks and benefits of online interventions and how it differs from in-person sessions with the patient.
	✓If needed, discuss how the online session will be billed.
	✓Collect a signed consent from patient (or parent or legal guardian of minor). Secure electronic signing platform (i.e., DocHub) can be used if the patient cannot sign a hardcopy form.
Contingency	✓Obtain at least one emergency contact for the patient prior to the session in case the patient is in a crisis.
	✓Provide a phone number that can be reached by the patient in case any technical problems with the hardware, software, or internet connection arise.
	✓Explain the contingency plan (what clinician will do and what patient should do) if the online session is interrupted by logistic issues or other reasons.
	✓Prior to the session, find the closest health services with patient’s location in case patient needs emergency response. ✓Clinicians should discuss how the patient’s physical environment, family composition, personal privacy, and living arrangements may impact their treatment engagement. Clinicians should then collaboratively problem-solve for anticipated barriers (e.g., strategic use of the chat function on secure videoconferencing apps when family members may be in rooms).

Note. * = may also applied for patients. Clinician should not rely on this table only and should seek more detail ethical standards from their government and professional organisation before providing telemental health services.

Telemental health is promising for use during the COVID-19 pandemic, including in Asian countries. Therefore, clinicians must maintain the highest ethical standards in order to deliver quality treatment that safeguards the welfare and best interests of their patients. Professional organisations and educational institutions should also include training in telemental health in the future.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

We declare no competing interests.