Advantages and disadvantages of the long-term use of telepsychiatry

To the Editor,

Evidence regarding the long-term use of telemedicine remains inadequate not only in the field of psychiatry, but in other areas of medicine as well. According to the Health Working Papers published by the OECD in January 2020, the use of telemedicine in countries such as Canada, Australia, and Portugal, where figures on the use of telemedicine have been published, represented about 0.1% to 0.2% of face-to-face care visits (Hashiguchi 2020). Prior to the COVID-19 pandemic, telemedicine was a small component of each country’s healthcare system, even in developed countries. As telemedicine becomes more widespread and reports on its long-term use are expected to increase, the accumulation of further evidence is needed before we can accurately discuss the pros and cons of its long-term use.

Psychiatric disorders commonly have a chronic course, with repeated relapses and flare-ups requiring long-term treatment. A recent study in the United States during the COVID-19 pandemic showed that telemedicine was more often used for existing patients, rather than for first-time patients, and for patients requiring long-term treatment, rather than short-term; these trends were especially true for patients with psychiatric disorders (Cortez et al. 2021). Therefore, the benefits of telepsychiatry could be substantial if it is used appropriately over the long term.

In many diseases, telemedicine has been shown to be as effective as face-to-face care (Snoswell et al. 2021). In the psychiatric field, there is evidence that telepsychiatry may improve treatment adherence in patients with depression, bipolar disorder, and schizophrenia (Basit et al. 2020). Particularly for patients with depression, a recent review reported that telepsychiatry may improve quality-of-life scores and prevent relapses and recurrences (Sharma & Devan 2021). As such evidence accumulates in the future, it may be possible to establish specific diseases and case presentations for which telepsychiatry should be used more actively for follow-up care.

In addition, low household income and declining income are associated with the prevalence and risk of developing mental disorders (Sareen et al. 2011). Although the initial hardware cost and the availability of an Internet connection must be considered, telepsychiatry is generally considered to be less expensive and less time-consuming than face-to-face care (Hubley et al. 2016), and the longer the treatment, the greater the economic benefit to the patient.

On the other hand, when the disadvantages of the long-term use of telepsychiatry are considered, these disadvantages that are also seen in short-term use may become more apparent. For example, the use of telepsychiatry can make it difficult to establish a good rapport (Shore 2013). For this reason, the long-term use of telepsychiatry may make it longer to establish a good rapport or may decrease the quality of an established rapport, compared with face-to-face practice. When considering the use of long-term telepsychiatry, the targeting of patients with whom a good rapport has been sufficiently established in face-to-face practice might be advisable.

Nevertheless, telepsychiatry is thought to be an effective means of continuing to deliver medical care to patients with obsessive-compulsive disorder, social withdrawal (e.g. hikikomori), and other conditions that make it difficult for them to go out or use public transportation (Aboujaoude et al. 2015; Rooksby et al. 2020). These patients may welcome the long-term use of telepsychiatry; for these patients, however, exposures such as going out are also considered necessary processes for their treatment (Teo 2016; Tandt et al. 2021). Hence, telepsychiatry should be combined with face-to-face care in an appropriate manner so that the long-term application of telepsychiatry does not reduce such opportunities.

As mentioned above, both the advantages and the disadvantages of the long-term use of telepsychiatry must be kept in mind. In any case, the use of telepsychiatry in accordance with the wishes of the patient and the patient’s medical condition, while keeping in mind the need to maintain a good rapport, will undoubtedly provide benefits that cannot be obtained by face-to-face treatment alone. In the COVID-19 pandemic, the long-term use of telepsychiatry has become necessary, and primary physicians need to be flexible in using telepsychiatry depending on the situation, rather than strictly limiting its use to target patients and diseases.