In a new article published in the Journal for Medical Ethics, Lisa Schölin and her colleagues examine the practice, ethics, and legal ramifications of conducting mental health assessments remotely.
While the Covid-19 pandemic has necessitated the increased use of telepsychiatry and video assessments, the authors argue that when the assessor is not familiar with the patient, or when the assessment may result in involuntary confinement, a face-to-face assessment is necessary.
“While evidence for the use of telepsychiatry in general is promising, its use for detention is lacking and has many ethical issues,” the authors explain. “The COVID-19 pandemic has made it necessary for clinicians to adapt to remote ways of working in order to protect themselves and their patients, but as we argue, there are limits to working remotely in mental healthcare and treatment.”
Mental health assessments, whether conducted face-to-face or remotely, show dubious accuracy. One such example comes from the practice of screening toddlers for autism. For every 100 toddlers that the MCHAT (Modified Checklist for Autism in Toddlers) screens positive for autism, only 18 go on to receive a diagnosis of autism. Additionally, 67% of the toddlers the test screens as negative do meet the criteria for an autism diagnosis. The result is many toddlers being exposed to labels and possibly psychotropic medications for conditions they do not have, while many others are denied treatment and resources they may need.
In addition to inaccurate screenings, there are also many screening tools developed by pharmaceutical companies and researchers in their employ. The Patient Health Questionnaire-9 (PHQ-9) is a depression inventory developed by Pfizer that is commonly used by general practitioners. This tool substantially overestimates depression prevalence. Similarly, a bipolar screening tool developed by researchers funded by the pharmaceutical company AbbVie systematically misinterprets the side effects of antidepressants as symptoms of bipolar disorder.
As noted in the current research, mental health assessments can sometimes result in involuntary confinement. In addition to the screenings with dubious accuracy, involuntary treatment can cause significant harm. For example, there is research suggesting that involuntary hospitalization increases suicide risk and leaves patients feeling disrespected, dehumanized, and humiliated.
After an involuntary hospitalization, young patients tend to lose trust in the mental health system. They are more likely to experience their stay in the hospital as punitive rather than as a form of care. Predictably, these people are less likely to seek mental healthcare in the future. The United Nations Special Rapporteur on Torture has such a grim view of involuntary hospitalizations they write:
The current research examines the Care and Treatment act passed in Scotland in 2003 and how psychiatrists practicing during a pandemic in 2021 can maintain the ethics enshrined there. Although the Care and Treatment act does not specifically say interviews must be conducted in person, pre-covid guidelines had most mental health assessments done face-to-face.
The authors note that before the pandemic, only 3% of healthcare providers offered video consultations. Since the pandemic, 98% offer video consultations. This is evidence for the authors that there are some screenings (at least 2%) that simply cannot occur through video conferencing. They argue that mental health assessments that can result in involuntary detention should fall into this category.
In the early days of the pandemic, the Care and Treatment act was amended to allow for longer involuntary hospitalizations. For the authors, this points to the development of a “new normal” in mental healthcare. However, due to the sometimes extreme consequences of assessment and diagnosis, the current research wants psychiatrists to carefully consider any adoption of “new normals” as they relate to the mental health field and especially to performing mental health assessments.
The authors believe psychiatrists should be very discerning in when and how to perform remote mental health assessments. In assessments where involuntary hospitalization cannot result (and in some extreme circumstances when they can), psychiatrists should perform remote assessments only after considering the overall circumstance of the assessment. This includes availability and reliability of the technology, patient consent to do a remote assessment, lack of someone able to perform a face-to-face assessment, and access (or lack thereof) to personal protective equipment, etc.
Ultimately, the new guidance for performing mental health assessments has three prongs. 1) whether the assessment is performed face-to-face or remotely, all criteria for involuntary hospitalization must be assessed. 2) Any assessment that could result in a new involuntary hospitalization (as opposed to an extension of involuntary hospitalization) should be performed face-to-face. 3) Patient consent must be given for remote mental health assessments.
During the pandemic, psychiatrists must balance public health with individual needs. Each case must be evaluated independently to determine the suitability of remote mental health assessment. Although some cases may point to the necessity of a face-to-face assessment, a remote assessment may be performed if the patient prefers not to come into close contact with clinical staff. There is no one size fits all answer to the question of how to perform mental health assessments during a pandemic ethically.
Schölin, L., Connolly, M., Morgan, G., Dunlop, L., Deshpande, M., & Chopra, A. (2021). Limits of remote working: The ethical challenges in conducting mental Health act assessments During covid-19. Journal of Medical Ethics, 47(9), 603–607. https://doi.org/10.1136/medethics-2021-107273 (Link)