key: cord-341624-02bmonj6
authors: Liem, Andrian; Sit, Hao Fong; Arjadi, Retha; Patel, Anushka R.; Elhai, Jon D.; Hall, Brian J.
title: Ethical standards for telemental health must be maintained during the COVID-19 pandemic
date: 2020-06-12
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102218
sha: 
doc_id: 341624
cord_uid: 02bmonj6

nan

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. 1, 2 Telemental health is also a strategy to close the global mental health treatment gap, especially within low-and middle-income countries. 1, 3, 4 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 highincome country like the US have never conducted videoconferencing to deliver their therapeutic services. 5 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. 6 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. 1 Neophyte online clinicians might not be aware of possible ethical and privacy concerns related to technology use in their practice. 7, 8, 9 Additionally, telemental health services may not be regulated yet in health law, particularly in Asian countries. 10 There are five key ethical concerns clinicians need to be aware of before engaging in telemental health. 11 First is to ensure confidentiality due to the complexities inherent in online treatment. 9 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 J o u r n a l P r e -p r o o f challenged on its stated privacy policy. 12 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. 7 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. 1, 2, 13 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.

We declare no competing interests.

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

We declare no competing interests.  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.

 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.  Clinicians should be culturally sensitive, approaching patients with cultural humility, regardless the modality of intervention.

 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.

 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.

 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.  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.

Mental Health Interventions during the COVID-19 Pandemic: A Conceptual Framework by Early Career Psychiatrists

Remote consultations in the era of COVID-19 pandemic: Preliminary experience in a regional Australian public acute mental health care setting

Internet-based behavioural activation with lay counsellor support versus online minimal psychoeducation without support for treatment of depression: a randomised controlled trial in Indonesia

Psychiatrist in post-COVID-19 era -Are we prepared?

Survey of psychologists' telebehavioral health practices: Technology use, ethical issues, and training needs

A survey on the assessment of the present states and opportunities of telemedicine in Bangladesh

What the COVID-19 telehealth waiver means for psychology practitioners

How secure is mental health providers' electronic patient communication? An empirical investigation

Technology use in mental health practice and research: Legal and ethical risks

Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine

Digital health applications in mental health care for immigrants and refugees: A rapid review

Zoom, the video conferencing app everyone is using, faces questions over privacy

The COVID-19 pandemic personal reflections on editorial responsibility. Asian journal of psychiatry

References:
