Donna M. Norris, MD

6 Things to Remember When Practicing Telemedicine

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What 6 things are important to keep telemedicine practice running smoothly? 

During the present COVID-19 pandemic, mental-health practitioners of all disciplines are becoming accustomed to a variety of telemedicine-enabled modalities for treatment and evaluation. A growing variety of telemedicine platforms are now in use. This development has produced an explosion of articles and other documents describing theoretical advantages and disadvantages of teletherapy in psychiatry and how it can best be carried out.

 For more than a decade we have practiced with the assistance of telecommunication technology for patient and examinee accessibility. Based on our own and our colleagues experience with clinical and forensic telepsychiatry, what follows are some practical pointers and potential pitfalls for clinical and forensic practitioners.

Over the past several decades, rural health care delivery, the courts, and prisons have increasingly relied on 

 to accomplish their work. This modality has increased access to examinations and improved care by medical professionals in remote geographic communities. However, it took the pandemic of 2020—and the suspension of some governmental regulations until an emergency no longer exists—to increase significantly the use of telemedicine. In forensic settings, telelinks are now used even by judges conducting trials, as well as in forensic competency evaluations, independent medical examinations, and tribunal hearings for evaluating claims of physician liability.

It is clear by now that telelink-enabled clinical and forensic evaluations are here to stay, given their evident convenience and cost savings. This is especially true in the forensic context, where the examiner and examinee, having no ongoing local treatment relationship, may be located in different regions of the country, or the examinee may be incarcerated or otherwise immobile. Moreover, elimination of the costs of travel allows for more frequent (virtual) meetings with patients, who can more easily maintain attention and concentration in shorter sessions. These may include persons suffering from psychosis, severe anxiety, depression, dissociation, fatigue, and/or lack of self-integration. Such meetings may routinely be preferred because the absence of travel, parking, and security requirements allows for more flexible scheduling and time- and cost-effectiveness.

Nonetheless, the authors believe that insufficient attention has been paid to concrete structural and behavioral details of this form of psychiatric work. There are practical issues to keep in mind that can increase the efficacy of clinical and forensic telepsychiatry, and steer clear of common pitfalls. (Except where otherwise specified, the term “interview” is meant to apply to both clinical and forensic interactions.)

It is important to establish appropriate video and audio platforms and to allow time to ensure that the preparatory technological setup for the interviews is working adequately. (When the interview is on the court premises, the setting and technical apparatus are predetermined.) As to what technological complaints need to be addressed, some evaluators have noted that poor lighting is a concern. Dark shadows, for example, can interfere with clarity of the visual image. In addition, disruptions in the video feed may interfere with accurate evaluation of the patient for abnormal involuntary movements (the AIMS test) used to monitor long-term effects of neuroleptics. On another sensory dimension, the sense of smell obviously cannot be utilized on video calls. For example, the odor of alcohol may go undetected—a significant potential omission. This limitation may necessitate alternative means of gathering otherwise olfactory-dependent data.

In the current COVID-19 emergency, free video platform setups, which have received HIPPA-compliant waivers from the federal government, may be used. However, the manufacturers may set time limits for the sessions that can compromise the needed length of an interview. Additionally, technical difficulties such as bandwidth and the absence of timely technical assistance may interrupt the flow of the interview. Such interruptions, if not adequately prepared for, may compromise the interview and affect the process of therapy or the findings of a forensic examination.

In forensic evaluations, problems may arise with connectivity for the attorney and/or the judge. The greater the number of persons on the video link, the greater the opportunities for technical interruptions, particularly when trying to connect with WIFI and cell phones. Allow time at the beginning of sessions to test and correct any audio or visual problems and plan for augmented bandwidth.

For a clinical interview, all participants have a role in establishing the appropriate guidelines. To begin with, it is important to establish who will schedule the sessions and provide the formal invitation. Some parties may prefer to originate the telecall interview to feel more in control of the session process. Generally, it is the party that initiates the link that is responsible for whether or not that link is HIPAA-compliant. Some patients who initiate telecommunication will wish to waive any applicable HIPAA-compliance requirement for the comfort of using a more familiar telecommunication pathway of their choice.

The visual environments of both parties can be expected to influence the dynamics of the interaction. While many interviewers practice in home offices, those are usually curated to some degree, with attention paid to the furnishings according to some concept of a professional space.

 By contrast, when practitioners who have not already set up home offices find themselves unexpectedly working from home in the pandemic, they may be working in their lived-in home. Both information and misinformation may emerge from this reality.

For this reason, some clinicians and evaluators, especially those who are novices to home office practice, prefer a blank screen that will not show personal effects in the office space or provide any indications of the geographic area of the assessment. Such details may expose clues to the whereabouts of secure locations needed in domestic violence or custody cases. Other practitioners use a virtual background, which, while reflecting an aspiration to neutrality, may also contribute to an aura of unreality. An inauthentic background can reinforce an interviewee’s predisposition to view Shakespeare’s metaphor of “All the world is a stage” (in “As You Like It”) in concrete terms. By contrast, appropriate objects visible in the office, such as works of art, can prompt helpful associations in psychotherapy or psychodynamically informed forensic examination. Regardless of the distinctive features of an interviewer’s office, it is often better that the background be the interviewer’s own authentic office.

The visual field of online practice has a number of potentially limiting factors. Awareness of these potential pitfalls is a vital step in increasing the efficacy of such practice.

For example, while video makes it easy to observe facial expressions and register tone of voice, the lower body, sometimes from the neck down, often is not visible. Some body language and aspects of dress are thus unavailable. This potential limitation may be particularly problematic in custody evaluations, where full body choreography in family evaluations is sometimes essential. The presence of the family can be a positive part of an online evaluation.

 However, if the interviewee is told to place him/herself far enough from the lens to permit such full viewing, facial expressions may be harder to see and the voice harder to hear. Varying the patient’s distance from the camera in the course of the interview is a potential remedial option when necessary. 

Telepsychiatry may not be the ideal or exclusive modality for young children, especially when they are overactive to the extent it is difficult to keep their attention or capture their interactions within the screen. However, evaluations for attention deficit disorders may be successfully accomplished using telehealth.

 The mindful observer may need to pay closer attention to information that may be more telepsychiatry-accessible, such as variation in eye movement, facial expression, and speech rhythm or tone, as well as to integrate this information into analysis of corroborative data.

In one such custody evaluation, a child being interviewed was noted to look away from the screen at times. It became clear that the parent, initially excused from the room, had returned, unnoticed by the interviewer, and witnessed (and perhaps influenced) the interview.

 screenings, it may help to visually take in the entire clinical gestalt of the family. Without an additional party running the cameras, many camera settings do not permit a full view of all parties at the same time. In such instances, more attention needs to be paid to the rhythm, timing, and tone of the family speech patterns. The visual gestalt may need to be further complemented by the auditory gestalt and corroborative data (eg, medical and school records, structured interviews, and psychological testing). 

Time may also be a relevant consideration, especially if clinician and patient are in different time zones. Some patients, uncertain about their appointment time, may be confused if placed in a digital waiting area until the doctor is available. Because of the recognized intensity of such meetings and the need for particular focus and attention, the session may need to be divided into 2 or more such meetings to allow breaks for either party.

In working with developmentally disabled individuals, some evaluators find that the lag in digital savvy can be a major holdup in the evaluation process, particularly with a deficit in WIFI and the staff’s inability to correct deficiencies. At times, the video feedback may be so distorted that the evaluator cannot get enough of the expressive language clues to understand the problem. This is made even more difficult when the staff is new and unfamiliar with the parties being assessed. The collegial relationship and teamwork between staff and evaluator are critical factors deciding the quality of the examination, particularly in agencies with increased staff turnover. With these patients, it is best to have a team in place, including a behavioral clinician, a nurse, and family members. However, be aware that some family members will not agree to participate in video sessions.

Some of the problems that emerge from online observations can be grouped under the rubric of potential distractions for both interviewer and interviewee.

Recording the session, as well as providing a record of the interview, may increase performance anxiety and attempts to manage one’s impression, especially in forensic examinations or adversarial proceedings, in which the examinee and others (family, attorney) have a stake in the outcome. The same applies to having a third party (such as an attorney) present. The distorting effect of recording or third-party presence in both the clinical and forensic contexts has been well studied.

 If such distortion is unavoidable (eg, by court order), special consideration needs to be given to minimizing it. In some states, such as Massachusetts, the recording of clinical interviews without permission of all parties is prohibited by law.

Some patients of all ages are more comfortable with audio transmission alone, as they are then less distracted by the close-up of the therapist’s face as well as their own. As in all therapy and evaluation, being aware and respectful of the wide range of individual variability, as well as of one’s own countertransference, is vital.

By contrast, the absence of the interviewer’s picture or the substitution of a photo for a live image may be experienced by some interviewees as inattentiveness or lack of interest on the part of the interviewer, much like analytic patients who cannot tolerate being unable to see the analyst. When an interviewer is aware of such a risk, asking the interviewee to describe their experience of the interview can be helpful. 

The picture-in-picture effect may have several valences, pro and con. For some interviewees it is a potent distraction. For others it may convey the reassuring presence of the examiner and/or an intrusive pressure to influence behavior. Not using picture-in-picture, especially in forensic contexts, may decrease some interviewees’ less authentic tendency to play to an audience. Clinicians and forensic examiners likewise may be distracted by their own faces or facial reactions, splitting attention from the interviewee. Alternatively, some interviewers find it helpful to see themselves as the process evolves, perhaps detecting their own countertransference reactions (eg, blind spots) and distractions. An interviewer’s awareness of these effects can help support the therapeutic alliance or the validity of a forensic examination.

How Therapeutic Issues Can Manifest in Telepsychiatry

Sometimes it is difficult to distinguish between interruptions or distractions attributable to technical imperfections or mishaps and those that have a deeper dynamic origin.

The session started on time, but when the questions moved into more affect-laden material, the examinee complained that they could no longer hear the examiner. After several attempts to resolve the difficulty, the interview was rescheduled. This change resulted in lost time for all parties. In this case, one might conclude that telepsychiatry was no longer time efficient. On the other hand, the ostensible technical breakdown might serve as an opening for exploration of sensitive material.

Awareness of a potential distraction can turn a potential video call pitfall into a therapeutic insight. Exploring the meaning of telelink-enabled communications in the course of treatment can be helpful not only for avoiding telelink-related pitfalls, but also for furthering the therapeutic process itself.

A patient who is a childhood survivor of the Shoah invariably kept her eyes glued to her therapist’s face on telelink. At one point she noted less cyberspace traffic than usual as background noise. Her associations to the changed transmission noise included the bombing she heard as a very young child in hiding. This exploration opened the path for a safer cyberspace discussion. Having less need to keep her eyes on the therapist’s face, she spoke more freely and with great insight into how her experience of social isolation as a hidden child at times shadowed her experience of danger and social isolation during the pandemic.

In telelink-enabled psychotherapy with an adolescent patient who had early issues around separation anxiety due to the father’s medical problems and a mother who felt the need to be immersed in work, processing the feelings of both being there and not being there opened up an avenue for more effective use of teletherapy.

When the patient is present in one’s office, one always knows what local emergency services to call in, which is not the case when the individual is a distance away. In virtual sessions, it is still sometimes necessary to have an appropriate emergency support network and backup plan at the patient’s site. In the rush to adapt to telehealth, there is a risk of omitting this step. Thus, for new patients, for some ongoing patients when indicated, and in high-risk populations of forensic examinees, a risk assessment should be completed at the beginning of every session, along with the standard brief technical check-in (“How’s the WIFI? Can you see me, hear me okay?”). Since interviews may occur at some distance from the practitioner’s location, and may even cross state lines, the practitioner should obtain phone numbers of local emergency services, police, family members, or significant others to assist in times of crisis. When indicated, the availability of such resources should be assessed and documented. 

During a teletherapy session, the patient became distressed and threw a chair at the monitor. A limit was set on this behavior, as it would have been had the patient and therapist shared the same physical space. The behavior was then explored for its meaning for the patient and the relationship.

, interviewers should know whether other parties are in the home or within earshot, and whether the session is being recorded. The use of HIPAA-compliant or -noncompliant telecommunications should also be identified. It is important to establish behavior limits, ensuring that the meeting is a safe time for communication without domination, bullying, or intimidation.

Many students are now spending much more time in the family home. One recalled that he had to go to a local coffeeshop or sit in the car to get needed WIFI for his session via cellphone and to be out of the hearing of family members. Obviously, a public setting poses its own privacy issues.

In one session a patient was discussing a sensitive marital issue when the spouse walked into the room.

Clearly, family privacy rules need to be set early in treatment. The patient may wish to bring others into the session; ideally, this would be discussed in advance. However, since the patient is already there, the opportunity for this step may be missed or scanted.

In addition, telepsychiatry poses some questions that the clinician or examiner needs to reflect upon, since a single size does not fit all patients or examinees; nor is telepsychiatry any more of a rote diagnostic-checklist exercise than in-person psychiatry. How does the new remote distancing process affect people of diverse cultures? How is rapport established between parties to encourage truthful disclosure? These are questions that need to be considered early in the process. Clinicians should inquire about the patient’s or examinee’s comfort during the process. 

Whenever possible, encourage patients to decide how and where the virtual interview will occur and proceed only with their agreement. They may have concerns about allowing someone into their home space; for example, an interviewee may be self-conscious about the appearance of their home environment. Inquire about what other options may be available for the interview: is there private space in a library or other accessible public building? For individuals needing an interpreter, how is this use accounted for in the responses to questions? How does this affect the 

It is essential to maintain a professional environment when working from home while connecting with the interviewee’s home space. Doing so requires an appropriate setting and attire, even if one is not fully visible to the patient. For example, interviewing from a bedroom or while wearing pajama bottoms is unwise.

It is the authors’ view that in some instances the casualness of the setting does present potential obstacles for maintaining appropriate boundaries, even when online. A messy environment in either the clinician’s or patient’s room may generate an atmosphere of laxity about the clinical work, leading to a loss of focus. On the other hand, with increased self-awareness and experience, a casual atmosphere can have the advantage of freeing all concerned from rigid formulations or habitual preconceptions.

The patient was interviewed at home. During the course of the session, the patient was suddenly lost from view. The patient had decided to take the therapist on a tour of the home and yard and was not aware that the WIFI did not extend outdoors.

A clinician reported that a patient partially disrobed in the session and had to be reminded of her state of undress and of the expected appropriate decorum.

 is not the same as in-person visits. Some patients feel that some things have been lost, such as empathy and respect. The shift to a virtual environment has shocked some patients, and some claim that physicians are seemingly less available and less empathic about patients’ concerns. One person complained that physicians seemed to be keeping their distance—even when the office was back up and running with appropriate personal protective equipment. Another patient, who had undergone major surgery for cancer, recalled that when they arrived for a follow-up visit, the treating physician spoke from the doorway and never came into the examining room

Has the patient-physician relationship suffered from this imposed distancing? Historically, it has been recognized that an emotionally vital and mutually respectful professional relationship between physician and patient offers some protection from lawsuits. The physician’s commitment to caring for the patient, even within the safe distancing of this pandemic, must be maintained.

Articles

When meeting patients online, mental-health practitioners must confront a host of issues. 

Telepsychiatry: Practical Pointers and Potential Pitfalls

The right of American citizens to own, register, and carry firearms has a significant history of federal and/or local regulation dating to the early 18th century.

 With the passage of the federal Gun Control Act of 1968, persons who have been treated for mental illness and/or substance abuse are among a defined group restricted from owning and carrying firearms.

While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea.

In the past several decades, US firearms legislation has followed high-profile instances of violent acts. The shootings of President Reagan and James Brady in 1981 resulted in the passage and implementation of the Brady Handgun Violence Prevention Act (1994). This Act provides for background checks for handgun sales and a 5-day waiting period. In addition, it provided the impetus for the establishment of the National Instant Criminal Background Check System (NICS).

With the NICS in place (voluntarily by the states), the Federal Bureau of Investigation (FBI) can potentially receive information within minutes as to whether the purchase violates any federal or state laws.

A press release by the FBI dated April 9, 2007, noted that only 22 states voluntarily contribute mental health records to the NICS. The system contained only 235,000 mental health records as of January 2006, although it was estimated that 2.7 million people had been involuntarily institutionalized for mental health disorders.

 The Department of Justice noted that the law was not fully implemented because of state fiscal concerns.

 presents a brief overview of firearm restrictions and mental illness data banks.)

A recent review of state and federal firearm laws noted that firearm statutes vary considerably regarding ownership and/or carry restrictions and depend on the manner in which restricted individuals are defined.

 In all 50 states, as well as Puerto Rico and the District of Columbia, persons prohibited from owning and carrying firearms include those who receive outpatient psychiatric treatment, those who have been civilly committed to treatment settings, and those found not guilty by reason of insanity. Some state statutes further restrict individuals with a history of alcohol or substance abuse. If a state does not have statutes that identify restricted individuals, federal laws provide guidance for prohibiting the sale of firearms to individuals with a specifically defined history of mental illness and substance abuse. And, in states with less restrictive statutes, federal law supersedes state statutes.

In view of the large variance in state laws, it is important that psychiatrists and other physicians review the governing laws of the state or territory in which they practice if asked to provide information to the FBI or other law enforcement officials regarding a patient.

Violent acts capture the nation’s attention and often provide the impetus needed for new laws and regulations that may differentially affect persons with mental illness. In December 2005, a Virginia judge found Seung-Hui Cho, the Virginia Tech gunman, to be mentally ill and a danger to himself. He was directed to undergo outpatient treatment. Because of the judge’s adjudication of dangerousness, Cho would have met the criteria for disqualification on a federal level. However, records of the outpatient commitment were not placed into the Virginia mental health database that forwards information to the NICS. As a result, Cho was able to purchase 2 handguns.

After the shootings on April 16, 2007, that left 32 people dead, Virginia Governor Timothy Kaine issued Executive Order 50, which directed all executive branch employees to consider involuntary outpatient treatment as involuntary admission to a mental health facility (

). The original law spoke to inpatient admission only; the new law addressed mandated outpatient treatment as well. Therefore, the names of individuals ordered into outpatient treatment would be included in the federal database. The order further directed law enforcement agents to enter records of involuntary outpatient care into the state database and to forward such records to federal law enforcement.

The federal response to the Virginia Tech tragedy was to pass the NICS Improvement Act, which will have significant impact on persons with mental illness. It provides states with significant financial incentives to release to the Attorney General all relevant records on individuals who are prohibited by federal law from possessing firearms. The records covered include automated information needed by the NICS to identify felony convictions, felony indictments, fugitives from justice, drug arrests and convictions, prohibiting mental health adjudications and commitments, domestic violence protection orders, and misdemeanor crimes of domestic violence.

Several states currently have specific laws addressing firearm access of individuals with mental illness and/or substance abuse and clearly define the roles of health care professionals.

Connecticut laws permit legal authorities to confiscate fire-arms of individuals adjudicated to be a danger to themselves or others.

In California, persons who are admitted to a psychiatric hospital (public or private) and who are designated a danger to themselves or others must be reported to the local law enforcement agency by an attending health care professional. The reports are used to build a data bank of persons with mental illnesses and substance abuse. The legal authorities of the state are notified by the medical facility.

In Washington State, a new law broadens the firearms prohibition to include adults and youths who have 14-day commitments. Prior law mandated that the firearm prohibition only include persons who received 90-day or 180-day involuntary treatment for mental illnesses.

As the public calls for increased control in matters of firearm licensure to persons with mental illnesses and to substance abusers, other states may implement similar laws and obligations for mental health professionals.

Certain provisions exist that allow persons with mental illnesses some recourse after their names are placed in a national mental health database. The federal Gun Control Act requires all federal agencies that impose mental health adjudications or commitments to provide a process for “relief from disabilities.” It prevents reporting of mental adjudications or commitments by federal agencies when those adjudications or commitments have been removed. The law further requires removal of expired, incorrect, or otherwise irrelevant records, and it provides persons with mental illness an opportunity to appeal when there has been an inappropriate commitment or finding of incompetence by a federal agency.

Persons with mental illnesses and/or substance abuse disorders are frequently perceived by the public to be dangerous, and their inclusion in the NICS data bank is controversial. The vast majority of violent events are not perpetrated by persons with mental illness. However, there is a well-documented correlation of violence for individuals with substance abuse disorders.

Thus, it is unclear whether a database of mentally ill persons is a deterrent. It is estimated that more than 40% of American households have a firearm. A recent manufacturing report from the Bureau of Alcohol, Tobacco, and Firearms evidences the growing firearms industry in this country (

Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway

 report that “in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides.” Ilgen and colleagues

 used data from the National Comorbidity Survey to report on new research linking violence and mental illness. The results of their examination of the relationship between mental disorders, past suicidality, gun access, and safety practices show that persons with lifetime mental disorders were as likely as those without a mental disorder to have access to a gun, carry a gun, or store a gun in an unsafe manner. However, individuals with prior suicide attempts were less likely to have access to a firearm.

All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household.

Psychiatrists may have a role in the process by which their patients apply for permission to purchase, possess, or transfer a handgun, as well as in the appeals process for those with mental illness and/or alcohol or drug abuse. There is variability in the appeals process, and some states may require a 5-year period of stability before considering the application.

Some states use the concepts of the remission and stabilization of mental illness or substance abuse in their statutes and impose more clinically based expectations on the clinical documentation needed; others ask for an opinion regarding “cure” of illnesses. The legal standard of “cure” is used in some state statutes and is inconsistent with the relapsing and remitting course of many psychiatric disorders. The issue of an attestation of the patient’s “cure,” may impose potential legal liability for a patient’s future acts.

 Zimring FE. Firearms and federal law: the Gun Control Act of 1968. 

 Federal Gun Control Act, 18 USC §922 (1968), et seq.


 Norris DM, Price M, Gutheil T, Reid WH. Firearm laws, patients, and the roles of psychiatrists. 

 Appelbaum P. Violence and mental disorders: data and public policy. 

https://www.cfda.gov/index?s=program&mode=form&tab=step1&id=73b63eff9ff46fd7c8d897c8b90180c0&cck=1&au=&ck=

 Federal Bureau of Investigation. Response to inquires on the FBI’s National Instant Criminal Background Check System (press releases). 

http://www.fbi.gov/pressrel/pressrel07/nics041907.htm

 NRA/ILA: Gun Laws: US DOJ Letter on Interstate Firearms Transport. 

 Price M, Norris DM. National Instant Criminal Background Check Improvement Act: implications for persons with mental illness. 

 Urbina I. Virginia ends a loophole in gun laws. 

http://www.iht.com/articles/2007/05/01/news/gun.php

 US Department of Justice. The NICS Improvement Amendments Act of 2007. 

http://www.ojp.usdoj. gov/bjs/niaa.htm#NICS

 Cal Welf & Inst Code §8100–8105 (2004), et seq.


 Simpson JR. Issues related to possession of firearms by individuals with mental illness: an overview using California as an example. 

 Conn Gen Stat §29-27 (2003), et seq; 53-202 et seq; 53a-211 et seq; 17a-500 et seq.


 Washington Legislature OKs gun restrictions for mentally ill. 

http://seattletimes. nwsource.com/html/localnews/2009034400_apwaxgrgunsmentallyunstable.html

 Wash Rev Code (ARCW) §71.05.240 (2009).


 Wallace C, Mullen PE, Burgess P. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. 

 Beck JC. Delusions, substance abuse, and serious violence. 

 Miller M, Hemenway D. Guns and suicide in the United States. 

 Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Mental illness, previous suicidality, and acess to guns in the United States. 

 US Department of Justice. Survey of State Procedures Related to Firearm Sales, Mid-year 2003. 

http://www.ojp.usdoj.gov/bjs/pub/pdf/ssprfsm03.pdf

 Bureau of Alcohol, Tobacco, Firearms and Ex-plosives. Annual Firearms Manufacturing and Ex-port Report. 

http://www.atf.gov/firearms/stats/afmer/afmer2007.pdf

While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea. This article reviews laws and obligations for mental health professionals.

Donna M. Norris, MD

Articles

6 Things to Remember When Practicing Telemedicine

Telepsychiatry: Practical Pointers and Potential Pitfalls

Firearms and Mental Illness