Can Telemental Health Help Achieve Equity During the COVID-19 Pandemic?

By Abdou Simon Senghor and Eric Racine

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With the advent of COVID-19, patients with mental health disorders no longer have access to regular health services because of social distancing measures. Additionally, patients directly affected by COVID-19 are given priority in terms of health service access, even though individuals unaffected by the virus directly are still in need of medical help.1

This raises issues of equity involved in healthcare access, particularly in light of the on-going challenges that patients with mental health disorders experience, challenges manifested prior to the onset of COVID-19.  From an encompassing mental health perspective, ensuring that the health of different populations is equivalently and fairly cared for necessitates that there be a parity of access to resources for all individuals, for both physical and mental health services, alongside equal priority of mental health and other medical services for those in need.2 To meet challenges related to accessing services and resources and treating certain on-going diseases even prior to the COVID-19 pandemic, virtual technology has begun to play an important role in medical treatment, perhaps best exemplified through telemedicine. Telemedicine has made possible improvements in access to medicine by promoting home-based care as an alternative way of accessing medical resources and as a broader redesign of health-care services altogether.Such home-based care promotes access to remote care for patients living in rural or underserved areas, and for patients facing general barriers to access such as remoteness and containment.4 This home-based care, in the context of the COVID-19 pandemic, shows how telemedicine not only has the power to protect patients with mental illnesses from contamination, so too does it ensure the continuity of care for these individuals. The implementation of home-based care through telemedicine also allows patients to quarantine themselves and protect their community from possible infection.5 Likewise, telemedicine can also slow the often-overwhelming rush of patients that hospitals often face. Additionally, it can help with ethical problems at play in healthcare (such as shortage and allocation of personal protection equipment) by reducing the consumption of material goods and by ensuring preventative action through encouraging patients to stay home.

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The merits of telemedicine do not stand alone, however. Even if it appears to promote health equity, it can also itself constitute a cause of health inequity, this being due to several factors. Among these factors the impossibility for patients to benefit from care, to be unable to use telehealth and telemedicine, the inappropriate application of telemedicine for all types of diseases because the management of some patients requires a physical examination and some data can only be obtained through direct physical contact.4 From this perspective, we can ask whether telemedicine genuinely promotes equity in the management of patients with mental health problems, particularly within the context of COVID-19, even though its uses may themselves present barriers to achieving this equity?

Telemedicine, mental health and COVID-19: is equity achievable?

As mentioned, the situation experienced by patients living with mental health disorders in the context of COVID-19 favors telemedicine, given how these services avoid the risk of contamination between patients and clinicians by encouraging individuals to access medical help from home. These remote services are also more economical given how transport no longer becomes necessary for seeking out medical attention.6 In addition, Fletcher et alnote that telemedicine is cheaper than face-to-face consultations if patients know how to use it. It also saves money for patients who would have to travel long distances to reach the hospital.

For patients living with mental health problems in remote areas, access to care from home through telemedicine is relevant beyond just the purview of the current global health crisis. More precisely, in light of the decision of the US Congress to lift restrictions on the use of telemedicine strictly within the context of the COVID-19 pandemic, it has become clearer as to how telemedicine can contribute to the development of the healthcare system more widely given how health services in rural areas are.8  However, people living in rural areas may face a lack of broadband and Internet connectivity, which may call into question an equitable access to health care.9 Thus, there is a need for health authorities to support patients in making optimal use of telemedicine, seeing as access to home-based care via telemedicine for patients from disadvantaged backgrounds might well be unfeasible or problematic because patients may require with higher level care at hospital.10 As a response, some American health coverage systems, such as Medicaid, have changed their payment and reimbursement policies to adapt to the situation caused by COVID-19 to use telemedicine services to continue to provide routine care.5,6 

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There are other avenues that could also benefit from further investigation. One approach might involve suspending restrictions on licensing requirements to practice telehealth in the areas most affected by COVID-196 as a way of facilitating access to virtual medical services. As for patients who are not able to wield technological tools, family members could act as caregivers, and help by engaging relatives in teleconsultations alongside the potential benefits these bring forth. It would also be important for health authorities to subsidize the acquisition of technological resources for patients or families to promote the use of telemedicine at home. Given issues of equity and social justice, patients with mental health problems could also benefit from acquiring digital literacy skills11, though would benefit most by being supported in this learning process. Because of the COVD-19, they can make use of virtual training thanks to the easy usage of smartphones.11 Finally, health systems could consider covering training provided to caregivers in the use of equipment provided at home, particularly for patients who are not able to handle technological tools involved in using telemedicine services. 

In short, even though telemedicine harbors some limitations in terms of its uses, it also holds the ability to empower vulnerable populations while contributing to the establishment of health equity. Nonetheless, this empowerment is not universal or unconditional. There are several situations that do not make the implementation of telemedicine possible. No matter, health structures must integrate these limitations of telemedicine and adopt strategies to promote the medical follow-up of patients with mental health disorders normally requiring treatment in hospital environments or within specialized medical services. To this end, it would be advisable to adapt health structures to the needs of these patients by reorganizing services to provide treatment to these patients in isolated boxes to protect them from contamination. These patients would be taken to hospital and taken home in ambulances while respecting social distancing.


References
  1. Yao, H., Chen, J. H., & Xu, Y. F. (2020). Patients with mental health disorders in the COVID-19 epidemic. The Lancet. Psychiatry, 7(4), e21.
  2. Stein, D. J., & Giordano, J. (2017). Neuroethics and global mental health: Establishing a dialogue. In Illes, J. (ed.), Neuroethics: Anticipating the Future, 591-602. Oxford University Press, Oxford.
  3. Gadelha, C.A.G., Costa, L.S., & Maldonado, J. (2015). The economic-industrial health care complex and the social and economic dimension of development. In Cassiolato, J. E., & Soares, M. C. C. (eds.) Health Innovation Systems, Equity and Development, 131-143. E-papers Serviços Editoriais, Rio de Janeiro. 
  4. Chaet, D., Clearfield, R., Sabin, J. E., Skimming, K., & Council on Ethical and Judicial Affairs American Medical Association (2017). Ethical practice in telehealth and telemedicine. Journal of general internal medicine, 32(10), 1136–1140.
  5. Hollander, J. E., & Carr, B. G. (2020). Virtually Perfect? Telemedicine for Covid-19. New England Journal of Medicine, 382(18), 1679–1681. 
  6. Whaibeh, E., Mahmoud, H., & Naal, H. (2020). Telemental Health in the Context of a Pandemic: the COVID-19 Experience. Current Treatment Options in Psychiatry, 1–5.
  7. Fletcher, T. L., Hogan, J. B., Keegan, F., Davis, M. L., Wassef, M., Day, S., & Lindsay, J. A. (2018). Recent Advances in Delivering Mental Health Treatment via Video to Home. Current Psychiatry Reports, 20(8), 56. 
  8. Keesara, S., Jonas, A., & Schulman, K. (2020). Covid-19 and health care's digital revolution. The New England Journal of Medicine, 382(23), e82.
  9. Ameh, G. G., Njoku, A., Inungu, J., & Younis, M. (2020). Rural America and coronavirus epidemic: Challenges and solutions. European Journal of Environment and Public Health, 4(2). 
  10. Golinelli, D., Boetto, E., Carullo, G., Nuzzolese, A. G., Landini, M. P., & Fantini, M. P. (2020). How the COVID-19 pandemic is favoring the adoption of digital technologies in healthcare: A literature review. doi: 10.1101/2020.04.26.20080341
  11. Torous, J., Jän Myrick, K., Rauseo-Ricupero, N., & Firth, J. (2020). Digital mental health and COVID-19: Using technology today to accelerate the curve on access and quality tomorrow. JMIR Mental Health, 7(3), e18848. 
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Abdou Simon Senghor is currently a postdoctoral researcher at the Pragmatic Health Ethics Research Unit based at the Montreal Clinical Research Institute (IRCM). He is working on a methodological conceptual development of pragmatic ethics. He obtained his PhD in sociology at the University of Toulouse Jean Jaurès (France) and is specialized in the sociology of health and illness.

Eric Racine is Full research professor and Director of the Pragmatic Health Ethics Research Unit with cross-appointments at Université de Montréal and McGill University. He is the co-editor with Ariel Cascio of Research Involving Participants with Cognitive Disability and Differences: Ethics, Autonomy, Inclusion, and Innovation published at Oxford University Press. Inspired by philosophical pragmatism, his research aims to understand and bring to the forefront the experience of ethically problematic situations by patients and stakeholders and then to resolve them collaboratively through deliberative and evidenced-informed processes.



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Senghor, A. S. and Racine, E. (2020). Can Telemental Health Help Achieve Equity During the COVID-19 Pandemic? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2020/06/can-telemental-health-help-achieve.html

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