Original Title: État des connaissances - Soins virtuels en psychiatrie

Authors' objectives: The aging of the population and the increasing prevalence of chronic diseases will, undoubtedly, lead to a significant increase in the demand for continuous home and institutional care, in the current context of limited professional resources in Québec. Furthermore, the COVID-19 pandemic has led to a major advance in the use of virtual care tools to ensure access to care and services and to promote care continuity. In addition to the information technologies that are now frequently used, the integration of virtual care modalities into care pathways is of growing interest for the evaluation, treatment, and follow-up of patients in specialty medicine. These modalities have the potential to improve access to health care for most patients, but also to foster their engagement in the management of their illness. In the context of a national project on virtual care, the Ministère de la Santé et des Services sociaux (MSSS) has requested the Institut national d'excellence en santé et en services sociaux (INESSS) to provide a state-of-knowledge report to guide the use of virtual care in specialty medicine. This work will help maintain or optimize care pathways and support clinical practices and the provision of care and services to patients. The objective of this work is to inform public decision-makers, medical associations, and health and social services professionals about virtual care practices in specialty medicine. The project involves the following seven reports: 1) Pediatrics, 2) Psychiatry (this report), 3) Neurology, 4) Hematology/Oncology, 5) Respirology, 6) General Surgery, and 7) Internal Medicine.

Authors' results and conclusions: RESULTS (#1 GENERAL FINDINGS): Several of the virtual care interventions noted in the different care pathways involve a number of combined modalities: teleintervention, teleconsultation, telemonitoring, etc. • Cognitive behavioral therapy via teleintervention or the Internet (iCBT) is the most commonly studied virtual care modality in the identified systematic reviews and practice guidelines. • Many authors of the selected reviews conclude that additional good-quality studies (design, size, and duration) will be needed. (#2.1 VIRTUAL CARE PATHWAYS REPORTED AS BEING CLINICALLY EFFECTIVE): • Therapeutic support and treatment via teleintervention (psychotherapy) for individuals with depressive disorders, social anxiety, panic disorder with or without agoraphobia, or post-traumatic stress. • Follow-up by teleconsultation for the following conditions: - Depressive disorders; - Bipolar and related disorders (euthymic patients) via a mood self-evaluation using a mobile app. (#2.2 VIRTUAL CARE PATHWAYS REPORTED AS HAVING POTENTIAL CLINICAL EFFICACY, WHICH IS TO BE CONFIRMED BY FUTURE EVIDENCE): The teleconsultation diagnosis of depressive disorders using a digital version of the PHQ-9 instrument. • Therapeutic support and treatment via teleintervention in the following clinical conditions: - Bipolar and related disorders, using a smartphone; - Binge-eating disorders, via guided iCBT; - Substance-related and addictive disorders (drug-addicted patients).(#2.3 VIRTUAL CARE PATHWAYS REPORTED AS HAVING POTENTIAL ORGANIZATIONAL EFFICACY, WHICH IS TO BE CONFIRMED BY FUTURE EVIDENCE): A possible reduction in the number of missed appointments and healthcare consumption with teleintervention and teleconsultation for depressive disorders compared to in-person care; • Teleintervention and telemonitoring could provide objective data as important support for clinical decision-making and permit self-management in patients with severe mental illness to prevent it from becoming chronic; • Teleintervention seemed to be potentially effective in improving the retention of drug-addicted patients in the healthcare system. (#2.4 POTENTIAL BENEFITS OF VIRTUAL CARE FOR SPECIFIC POPULATIONS OR IN PARTICULAR SETTINGS OR CONTEXTS:): In individuals over 50 years of age, virtual care appeared to reduce the common symptoms of mental disorders and psychosocial problems; • For criminal justice populations, virtual care appeared to reduce psychiatric symptoms and promote better coping strategies. (#2.5 VIRTUAL CARE MODALITIES REPORTED AS HAVING A POSITIVE IMPACT ON EQUITY OF ACCESS TO CARE): Via teleintervention for patients: - With social anxiety, who often avoid asking for help, given their condition; - With post-traumatic stress disorder, who may experience stigma. • Through telemonitoring for patients: - With schizophrenia spectrum and other psychotic disorders and who are economically disadvantaged; - With mental health disorders and who face geographical obstacles or who live in underserved areas; - Living in long-term care facilities. (#2.6 SATISFACTION REPORTED BY PATIENTS AND HEALTHCARE PROVIDERS): For teleintervention involving patients with: - Depressive disorders, the level of satisfaction generally seemed to be higher or the same as that for in-person care; - Anxiety disorders, the level of satisfaction appeared to be higher, but with a preference for communication with the support of a professional compared to an unguided virtual care intervention. • For the telemonitoring of patients with schizophrenia spectrum and other psychotic disorders, overall, the level of satisfaction and acceptability appeared to be high. (#2.7 FEW RESULTS CONCERNING THE SAFETY OF VIRTUAL CARE): For anxiety disorders, it appears that between 0% and 5% of the participants reported the therapy they received via teleintervention as having a negative impact; • The safety of the full range of new technologies for treating schizophrenia spectrum and other psychotic disorders is not fully assured. Although no significant harm seemed to be associated with text-messaging interventions, avatar therapy could, for example, lead to increased anxiety; • Confidentiality remains a major concern for non-patient teleconsultation, especially for small rural communities. (#2.8 FEW PUBLISHED CLINICAL PRACTICE GUIDELINES REGARDING VIRTUAL PSYCHIATRIC CARE): All of the selected guidelines focused on iCBT for post-traumatic stress disorder, social anxiety disorder, or general mental health disorders. LIMITATIONS: This report is limited by the following methodological constraints: the type of items selected, the period covered by the literature, the fact that independent study selection was used for only 10% of the studies, the absence of a formal evidence assessment, and the descriptive data synthesis with no meta-analysis. Most of the selected systematic reviews aggregate or examine, without distinction, data from primary studies conducted in various care settings with a variety of comparators, clinical situations, and technologies. When meta-analyses are included, the heterogeneity of the studies and interventions, the small number of studies compared and/or the small number of participants, and the poor quality of the studies are often listed in the limitations.In addition, the results of psychiatric systematic reviews are generally from short-term or, at most, 12-month data, whereas psychiatric disorders are often treated for several years. Also, the subjects in many of the studies were predominantly females, yet the incidence of the disorders concerned is not necessarily higher in women. In addition, cultural sensitivity or cultural adaptation and collaborative care, which are topics that should not be overlooked for equity in virtual care, were very rarely discussed. Lastly, selection, confounding, and measurement biases observed in the studies also need to be taken into consideration. CONCLUSION: In the field of psychiatry, the care pathways most studied in the literature for the use of virtual care are depressive disorders and anxiety disorders. Teleintervention is the most frequently used virtual care modality in the care pathways studied. Several other results from the systematic reviews examined indicated that other psychiatric care pathways could benefit from the use of virtual care, but the data are often too limited to be conclusive. Additional good-quality studies in terms of design, size, and duration will be needed to accurately identify the optimal modalities for using virtual care in the different psychiatric care pathways. In any event, the modalities are used alone or in combination with other modalities, and virtual care can be utilized in place of or in addition to standard care.

Authors' methods: A scoping review of the scientific and grey literature was conducted for the past five years to portray the care pathways that might be supported or optimized with the use of virtual care. The interval was subsequently downscaled to two years (2020-2022) for scientific literature because of the breadth of the available literature in psychiatry. The existing national and international guidelines, guidance and discussion papers, and health technology assessment (HTA) reports published on the topic during the five-year period (2017-2022) were also consulted to identify additional care pathways or confirm those mentioned in the systematic reviews. Documents were selected according to predefined inclusion and exclusion criteria. These steps were carried out by one reviewer, and 10% of the titles and abstracts evaluated were independently re-evaluated by a second reviewer. The literature selection process led to evidence extraction by a reviewer. The extracted data were analyzed and presented in the form of a narrative synthesis and outcome tables for each of the identified care pathways. Because of the rapid nature of the work and the type of review conducted, the methodological quality of the selected documentation was not assessed. In addition, the consistency of the study results, the number of studies and their perceived quality, the biases noted, and the statistical analyses of the meta-analyses were considered when drawing up the findings concerning care pathways and virtual care modalities that maintain or optimize clinical practices in specialty medicine.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Psychiatrie_EC.pdf

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Psychiatrie_EC.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)