Unmask the mind! Importance of video consultations in psychiatry during COVID-19 pandemic

Dear Editor

Mehta et al. (2020) rightly express concerns about challenges that patients and psychiatrists face due to the ubiquitous use of facemasks. In addition to mental status examination, facemasks pose impediment to, more critically, therapeutic alliance. The latter plays a crucial role not just in psychiatric practice but also in any doctor-patient relationship. The authors suggest several solutions to overcome this difficulty and make a passing mention about the use of digital technology. We wish to elaborate on the role that digital technology and ‘virtual assessments’ could play in overcoming the challenge that users and professionals in the healing profession would face increasingly, given that the advice regarding universal use of facemasks is going to stay for long.

Incidentally, the pandemic that is forcing patients and therapists to wear facemasks is pushing the healing profession towards digital consultations. Majority of the countries are going through complete or partial lockdowns and severe restrictions in the movement of people. With in-person consultations becoming increasingly difficult, the importance of telemedicine is being felt by patients as well as professionals like never before (Hollander and Carr, 2020) (Greenhalgh et al., 2020). Several countries have released telemedicine guidelines with a sense of urgency (Miliard, 2020) (Medical Council of India, 2020). The “Telepsychiatry operational guidelines - 2020”, released recently by the National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru, India in association with Indian Psychiatric Society and Telemedicine Society of India, encourages video consultation over other modes of consultation (Math et al., 2020a). In this background, clinicians are serendipitously observing the advantage that telemedicine could offer to overcome the difficulties posed by the facemasks. Video consultations can overcome most of the challenges highlighted by Mehta et al. (2020).

NIMHANS caters to patients from across India as well as neighboring countries. For the past four years, we have been providing video consultations for ensuring continuity of care of patients with psychiatric disorders from across India (Telepsychiatric After Care Clinic) (Das et al., 2020) (Math et al., 2020b). We have anecdotally observed that the therapeutic alliance established during in-person consultations is fostered even during video consultations. In the presence of optimal audio-visual technology, appropriate background and good bandwidth of digital signals, mental status examination of patients can be conducted without much compromise. This can easily overcome the difficulties posed by the use of facemasks.

A valid concern, specifically in the case of individuals with psychotic disorders, is about the suitability of tele-assessment of their mental status. Are psychotic patients willing to be interviewed remotely? Are there chances that video-interviewing could exacerbate their psychotic symptoms? Are assessments done through video-interviewing reliable? These questions have been systematically examined in research studies. Scholarly reviews show that videoconferencing-based assessments – clinical as well as with standard rating scales – are not only safe and reliable, but they are overwhelmingly perceived as acceptable and satisfactory (Sharp et al., 2011). Physical examination also forms important part of clinical assessment of persons with psychotic disorders. In this context, we have recently proposed the concept of “virtual physical examination” (VPE) covering predominantly the ‘inspection’ part of general physical examination (Manjunatha et al., 2020a, Manjunatha et al., 2020b) and are currently in the process of validating this through rigorous research. VPE includes inspection on rest as well as inspection on instruction (tremor, deglutition, gait, etc.). For example, extrapyramidal side effects (EPS) such as tremor, slurred speech, salivation, and rigidity (slowness in gait) can be assessed in VPE with reasonable clinical confidence. To assess tremor, tele-psychiatrist can instruct patients to stand in front of their camera at 1–2 m distance and ask them to show their outstretched hand (if need, tele-psychiatrist can demonstrate this manoeuvre) and observe for presence/absence of tremor in video consultation. Similarly, gait can be assessed in VPE for the rigidity. Instruct patients to walk for a short distance in their home in front of camera (both outbound and return walk) to observe for slowness in walking. Salivation and slurred speech of EPS are easily observed in the inspection while interacting with patients. Important part of neurological examination of patients with psychotic disorders involves examination of abnormal involuntary movements. The rating scale, Abnormal Involuntary Movement Scale (AIMS), an examination that relies on visual judgments, can be reliably measured via video consultations (Amarendran et al., 2011).

Video consultations have drawbacks (digital illiteracy, sustainable connectivity, etc.). However, they have many advantages over in-person consultations (lower cost, convenience, possibility for family informants to join through multi-point video conference, etc.) (Das et al., 2020). Lower risk of infection with least compromise on the quality of mental status examination and therapeutic alliance are additional advantages. Mehta et al. (2020) see the obstacle of the masks as a path to rediscover the importance of ‘personalized empathic communication’. We could not agree more with them on this. Additionally, we believe that the obstacle of masks, lockdown and risk of infection as potential path to widen the reach of telemedicine. Governments and other stakeholders of health in general, and mental health in particular, should work towards equitable access of the benefits of telemedicine to everyone who deserves to enjoy the fruits of this potentially revolutionary technology.

Declaration of competing interest

None of the authors have any conflict of interest to report.