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Against a sea change in real-world practice of technology in psychiatry, John Torous, MD, MBI, shares what clinicians can expect next.

6 Predictions for Digital Psychiatry in 2021

Zoom fatigue” describes the tiredness, worry, or burnout associated with 

 Like other experiences associated with the coronavirus (

) pandemic, Zoom fatigue is widely prevalent, intense, and completely new.

 that may tax the more than 300 million daily participants of Zoom

, experts representing diverse disciplines including acoustics, business, and the social sciences have contributed their explanations. For instance, audio has been proposed as the main reason that video meetings are draining. It turns out that millisecond delays in virtual verbal responses negatively affect our interpersonal perceptions, even without any internet or technical issues.

Other explanations attribute the fatigue to an underlying predisposition painted by the pandemic backdrop, such as increased financial stress and unemployment. Cognitive factors are also likely to contribute to fatigue, as an increased ability to virtually multitask threatens our attentional capacity. Exploring such multifactorial etiologies has delved us into a deeper understanding of the fragile intricacies that make up the precious in-person social interactions we had before COVID-19.

What is the psychological explanation of Zoom fatigue? Wecan start the exploration by revisiting the process of mental fatigue. A core psychological component of fatigue is a rewards-costs tradeoff that happens in our minds unconsciously.

 Basically, at every level of behavior, a tradeoff is made between the likely rewards versus costs of engaging in a certain activity.

 Even minor decisions, such as pressing the “Delete” versus “Backspace” button to erase a typed word, are made on the basis of these unconscious estimates to maximize reward (eg, time) over cost (eg, effort).

 The link between this reward assessment and fatigue then comes here: activation of the 

 in brain structures associated with reward (eg, ventral striatum, anterior cingulate cortex [ACC], amygdala) increases subjective alertness, energy, and motivation

Is a lack of perceived reward relative to cost during videoconferencing a primary psychological mechanism of Zoom fatigue? Indeed, social interactions are very much associated with our reward circuits, as oxytocin—the hormone involved in social bonding—modulates these same dopaminergic pathways involved in reward processing.

 Moreover, how that social interaction happens seems to matter. For instance, functional MRI data reveal that live face-to-face interactions, compared to viewing recordings, are associated with greater activation in the same brain regions involved in reward (ie, ACC, ventral striatum, amygdala).

 So, more active social connection is associated with more perceived reward, which in turn affects the very neurological pathways modulating alertness versus fatigue.

This neuropathophysiology may explain Zoom fatigue. For example, if the audio delays inherent intechnology are associated with more negative perceptions and distrust between people

, there is likely decreased reward perceived when those people are videoconferencing. Another example is direct mutual gaze. There is robust 

 on how eye contact improves connection—faster responses

, and increased likeability and attractiveness.

 These tools that make interactions organically rewarding are compromised over video. On video, gaze must be directed at the camera to appear like making eye contact with an observer, and during conferences with 3 or more people, it can be impossible to distinguish mutual gaze between any 2 people.

Not only are rewards lessened via these social disconnections during videoconferencing, but there are also elevated costs in the form of cognitive effort. Much of communication is actually unconscious and nonverbal, as emotional content is rapidly processed through social cues like touch, joint attention, and body posture.

 These nonverbal cues are not only used to acquire information about others, but are also directly used to prepare an adaptive response and engage in reciprocal communication, all in a matter of milliseconds.

 However, on video, most of these cues are difficult to visualize, since the same environment is not shared (limiting joint attention) and both subtle facial expressions and full bodily gestures may not be captured. Without the help of these unconscious cues on which we have relied since infancy to socioemotionally assess each other and bond, compensatory cognitive and emotional effort is required. In addition, this increased cost competes for people’s attention with acutely elevated distractions such as multitasking, the home environment (eg, family, lack of privacy), and their mirror image on the screen. Simply put, videoconferences can be associated with low reward and high cost.

Further yet, there are undoubtedly many other factors contributing to Zoom fatigue. The biopsychosocial model commits our field of psychiatry to holistically consider all the hidden influences that make up our experiences. Biologically, videoconferencing is confounded by a more sedentary daily rhythm experienced during the pandemic. Notably, physical activity is associated with about a 40% reduced risk of fatigue.

 Psychologically, a filtering of our stimuli through a fundamental rewards-costs analysis may explain how our dopaminergic pathways contribute. Socially, a perfect storm of vast unemployment, school shutdowns, racial injustices, political divisions, physical distancing, and loneliness predisposes everyone in our nation vulnerably.

The purpose of the biopsychosocial formulation, however, is to guide the treatment plan. Although the factors contributing to Zoom fatigue are complicated and multidimensional, a closer examination can lead to hope. The contributing factors, depending on their adjustability, serve as potential therapeutic targets to alleviate fatigue and salvage the aspects of social interaction that were once unconscious and taken for granted. Exploring alternative and more explicit ways to improve perceived reward psychologically during virtual communication may be a therapeutic approach for not only Zoom fatigue, but the mental and physical toll that come with it.

 is Assistant Professor at the David Geffen School of Medicine at University of California at Los Angeles and the Directorof the Pediatric Consult-Liaison Service and Pediatric Emergency Psychiatry at UCLA Mattel Children's Hospital. She has nothing to disclose regarding this article.

This article was originally posted on June 27, 2020, under the title

"A Psychological Exploration of Zoom Fatigue," and has since been updated. -Ed

1. Wolf CR. Virtual platforms are helpful tools but can add to our stress. Psychology Today. May 14, 2020. Accessed October 19, 2020. 

https://www.psychologytoday.com/us/blog/the-desk-the-mental-health-lawyer/202005/virtual-platforms-are-helpful-tools-can-add-our-stress

2. Patnaik S, Malara N, Mukherjee S. Zoom says it has 300 million daily meeting participants, not users. Reuters. April 30, 2020. Accessed October 19, 2020. 

https://www.reuters.com/article/us-zoom-video-commn-encryption/zoom-says-it-has-300-million-daily-meeting-participants-not-users-idUSKBN22C1T4

3. Zoom Company News. 90-Day Security Plan Progress Report: April 22. Accessed October 19, 2020. 

https://blog.zoom.us/90-day-security-plan-progress-report-april-22/

4. Roberts F, Francis AL. Identifying a temporal threshold of tolerance for silent gaps after requests. 

5. Johnson. Why zoom meetings are so dissatisfying. 

May 16, 2020. Accessed October 19, 2020. 

https://www.economist.com/books-and-arts/2020/05/16/why-zoom-meetings-are-so-dissatisfying

6. Boksem MA, Tops M. Mental fatigue: costs and benefits. 

7. van der Linden, D. The urge to stop: The cognitive and biological nature of acute mental fatigue. In: Ackerman PL, ed. Decade of Behavior/Science Conference. Cognitive fatigue: Multidisciplinary perspectives on current research and future applications. American Psychological Association; 2011: 149-164.

8. Dix A, Finlay J, Abowd G, Beale R. Human-computer interaction. Prentice Hall; 1993.

9. Lorist MM, Tops M. Caffeine, fatigue, and cognition. 

10. Lorist MM, Boksem MAS, Ridderinkhof KR. Impaired cognitive control and reduced cingulate activity during mental fatigue. 

11. Donaldson ZR, Young LJ. Oxytocin, vasopressin, and the neurogenetics of sociality. 

12. Redcay E, Dodell-Feder D, Pearrow MJ, et al. Live face-to-face interaction during fMRI: A new tool for social cognitive neuroscience. 

The detection of gaze direction: a stare-in-the-crowd effect

14. Mason MF, Hood BM, Macrae CN. Look into my eyes: gaze direction and person memory. 

15. Nurmsoo E, Einav S, Hood BM. Best friends: children use mutual gaze to identify friendships in others. 

16. Conty L, Dezecache G, et al. Early binding of gaze, gesture, and emotion: neural time course and correlates. 

17. Schilbach L. Eye to eye, face to face and brain to brain: novel approaches to study the behavioral dynamics and neural mechanisms of social interactions. 

18. Puetz TW. Physical activity and feeling of energy and fatigue. 

What is Zoom fatigue and is there a biopsychosocial explanation for this COVID-inspired phenomenon? The answer might surprise—and comfort—you.

A Neuropsychological Exploration of Zoom Fatigue

Experts discuss the latest in digital mental health smartphone apps, digital clinics, and online therapies and telehealth, topics that are especially relevant as we are experiencing a radical transformation of health care.

Most people have access to both the internet and devices that can connect to providers, but do patients have tools to make digital health work for them? We are in a pivotal time now with COVID-19 where we have seen wider access being provided at least in highly populated areas. We are still at the beginning stages as we strive to provide wide access to a lot of different people. 

 can be properly converted to a new platform in the form of digital technology apps. Additionally, some interventions might be a easier than others. Cognitive behavioral therapy and dialectical behavior therapy are more formulaic and provide homework for patients. Psychodynamic approaches may be more nuanced than some of the shorter term interventions that we are seeing. 

For some patients, it may be unclear exactly what happens in that translation. One useful analogy is comparing a book with a movie. Sometimes, the book is better than the movie; sometimes vice versa. But there is still a lot that we don't know as to why in-person therapy works for some and not for others. The principles are there but we are still learning about the evidence.

Sometimes, the book is better than the movie; sometimes vice versa. But there is a lot we don't know as to why in-person therapy works for some and why digital works for others. In this video, experts discuss the evidence.


Digital Technologies in Mental Health Care

The US Food and Drug Administration (FDA) has 

the first-ever video game to treat ADHD in children.

 EndeavorRxTM (AKL-T01) is a prescription therapeutic gaming 

designed to improve inattention or combined-type ADHD in youths between the ages of 8 and 12.

FDA approval was based on 5 clinical studies involving over 600 participants who had ADHD, including one 

 This prospective, randomized, controlled STARS-ADHD study showed that AKL-T01 improved objective measures of attention in children with ADHD. Of 857 children screened for the study, a total of 348 patients with confirmed ADHD were randomly assigned to receive AKL-T01.

The video game-like interface was used 25 minutes a day, 5 days a week, for 4 weeks and was found to improve attentional functioning significantly as reported by both patients and parents. After one month of use, roughly half of parents reported clinically meaningful improvement in their child’s daily impairments. “Moreover, this increased to 68% after a second month of treatment. Following a month of treatment, improvements in ADHD impairments were maintained for up to 1 month,” according to the Akili news release.

 A small percentage of participants experienced minor adverse effects that included frustration, headache, dizziness, emotional reaction, nausea, or aggression.

EndeavorRx, built on the Akili Selective Stimulus Management engine (SSMETM), is intended for clinical use in concert with therapy, pharmaceutical treatment, and patient education. Playing the game targets neural networks to improve inattention, a central component of ADHD. While hyperactivity is not particularly addressed by the platform, the video game experience activates parts of the brain that compromise cognitive function.

“With EndeavorRx, we’re using technology to help treat a condition in an entirely new way as we directly target neurological function through medicine that feels like entertainment,” said Eddie Martucci, PhD, Chief Executive Officer of Akili.

Elysa Marco, MD, Assistant Clinical Professor of Neurology and Director of Research, Autism and Neurodevelopmental Center, at UCSF, and Executive Director of Neurodevelopmental Medicine at Cortica Healthcare, added, “Unlike traditional ADHD medications, EndeavorRx is designed to specifically target inattention. Based on the benefits of my research participants and patients have experienced, I am thrilled that EndeavorRx is moving from the lab to the clinic to play an essential role as part of a comprehensive treatment plan for children with ADHD.”

Digital therapeutics for neuropsychiatric disorders have gained momentum since at least 2010, but this is the first-ever device approved by the FDA to be marketed for any condition.

 “Cognitive neuroscience research has the potential to inform the development of novel interventions for specific disorders, such as ADHD, by linking implicated brain systems with specifically-targeted digital interventions, which can be optimally designed to operate within game interfaces,” according to 

 Since the COVID-19 pandemic, early approvals of treatments have been made by the FDA, and this is no exception—perhaps because families are looking for alternatives to traditional medications that may or may not work.

The EndeavorRx treatment will be available with a prescription in the near future, according to Akili. The device will be part of the Endeavor Care Program, which includes the EndeavorRx treatment, to be used in conjunction with a mobile app (Akili Care). Information can be found at 

1. FDA Permits Marketing of First Game-Based Digital Therapeutic to Improve Attention Function in Children with ADHD. Press Release. Federal Drug Administration. June 15, 2020. Accessed June 17, 2020. 

https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-first-game-based-digital-therapeutic-improve-attention-function-children-adhd

2. Akili Announces FDA Clearance of EndeavorRx for Children with ADHD, the First Prescription Treatment Delivered Through a Video Game. Press Release. Akili Interactive; June 15, 2020. Accessed June 17, 2020. 

https://www.akiliinteractive.com/news-collection/akili-announces-endeavortm-attention-treatment-is-now-available-for-children-with-attention-deficit-hyperactivity-disorder-adhd-al3pw

3. Kollins SH; DeLoss, PhD; Cañadas E; Lutz J. A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial. 

 2020;4:e168-e178. Accessed June 19, 2020. 

https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30017-0/fulltext

4. Robbins R. In a landmark decision, FDA greenlights a video game for kids with ADHD. Stat News. June 15, 2020. 

https://www.statnews.com/2020/06/15/fda-akili-adhd-endeavorrx

5. Davis NO, Bower J, Kollins SH. Proof-of-concept study of an at-home, engaging, digital intervention for pediatric ADHD. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764249

FDA approves video game as treatment for ADHD.

The Video Game Will See You Now

There is a massive effort in the US to curb the spread of 

. But the US has been behind other countries in part because of lack of testing capacity. As testing capacity accelerates, the number of confirmed cases has grown. Singapore and South Korea have flattened the curve more quickly through efficiently identifying cases and exposures and promoting quarantine. This public health strategy, contact tracing, is old but their method is novel. They use phones.

Countries are using Bluetooth or mobility data (eg, Global Positioning System [GPS], cell tower) collected by the phone for contact tracing. One method of contact tracing involves scanning and recording Bluetooth signals from other nearby phones, usually within a 30 feet diameter. The real time data offer a novel means to track proximity and potential interaction with others. Another method for contact tracing involves use of mobility data (often GPS) collected by the phone that allows a digital trail of timestamped locations visited to be easily recreated.

Public health officials can leverage either approach, Bluetooth or mobility, to determine who an infected person may have been in close contact with—and then notify those exposed of possible risk. Countries have taken different approaches in what information they share with individuals identified as being at risk.

, where the age, gender, and location history of those infected are disclosed to those who may have been exposed. On the other end of the spectrum is Singapore, where people are only informed that they may have been exposed. Both South Korea and 

 have been successful in flattening the cure and their use of phone-based contact tracing offers clear potential to better understand how COVID-19 spreads and can be stopped. With increasing interest in using contact tracing in other countries, it is important to understand the potential risks and benefits of use in the US.


During these unprecedented times it is necessary to consider the benefits of disclosure to exposed third parties against the risks of not respecting individual privacy—everyone’s right to control their health information. People are reluctant to share their health information for various reasons, such us harm to one’s reputation, employment problems, and access to insurance.

In the US, health care professionals do not break confidentiality to disclose a patient’s disease status even for communicable diseases like COVID-19 that present a risk to others. One exception is HIV where many state laws encourage or mandate disclosure to public health identities and/or sexual partners. This HIV status disclosure is justified because public health benefits are thought to outweigh the risks to the individual, though this is not without controversy. For COVID-19, one’s personal data (such as age, gender, location, and health status) is shared with others in a public fashion. Yet a discussion about COVID-19 status disclosure does not appear to be happening in many countries where phone-based contract tracing is deployed. In other words, personal data is being shared without the input of people whose information is being shared—in this case those infected.

The current pandemic-related disclosed data can be very sensitive, especially if linked to GPS mobility data collected by phones. Intimate details like where a person sleeps, shops, and even eats can be easily inferred. Later secondary uses of this data can have numerous unintended consequences around employment, social standing, and health insurance coverage. People have already been assaulted because of suspected or confirmed COVID-19—now imagine their home address being shared too. While efforts to deidentify data can be undertaken, history seems to always show that in the near future reidentification is possible. It is assumed that the data are encrypted and secure. But is it? We do not know, key details are lacking.


The legal implications cannot be ignored either; will there be criminal consequences for spreading coronavirus? It may sound fantastical, but in the US there are criminal laws against certain high-risk behaviors that could spread HIV. In Singapore, refusal to share COVID-19 related data requested by the Ministry of Health can lead to prosecution. These consequences have likely led to people avoiding testing or care.

Ethically based solutions offer a path forward. One pathway is to simply ask for 

 to collect data. This could be done in multiple ways including an opt-in system (Singapore) or even opt-out in some circumstances. Although Iranian officials used an opt-in system, the consent was displayed in a non-native language or not at all for many users. Regardless of the system, to respect privacy, it is important that the data collected, shared, and where data are stored is clearly explained to users. Alternatively, it could be an opt-out consent, which may be more coercive because people are less likely to change from the default. If an infected person’s consent is required before his or her data are shared, an opt-in system could be more palatable. Another solution is to aggregate data at the community level to examine trends rather than an individual’s data. This does not necessarily preclude obtaining consent. Although less advantageous for contact tracing, storing contact data on the phone of an infected person rather than a centralized database lets that individual decide whether he or she want to share the data with public health officials.


COVID-19 has spurred many changes leading to wider adoption of various technologies to support public health efforts. But even data collected for the greater good such as phone-based contact tracing can have unintended negative or punitive consequences. There is always a risk when sensitive information is collected. Ultimately, US public health officials must weigh these risks against potential benefits in an informed fashion.

is a Child and Adolescent Psychiatry Fellow, University of California Los Angeles Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA.

is Director, Digital Psychiatry Division, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. He is Digital Psychiatry Section Editor for 

COVID-19 has spurred many changes leading to wider adoption of various technologies to support public health efforts. But even data collected for the greater good can have unintended negative or punitive consequences.

A Novel Approach to Contact Tracing

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers Peter Yellowlees, MMBS, MD, Chief Wellness Officer at UC Davis Health and Professor of General Psychiatry at the University of California, and Jay Shore, MD, MPH, Professor at the Department of Psychiatry and Family Medicine at Colorado School of Public Health, joined moderator Chris Aiken, MD, Director of the Mood Treatment Center and 

 Section Editor for Bipolar Disorder, to discuss tips and tricks in making telepsychiatry work in this era of COVID and beyond. The webinar, which was recorded live on May 18, 2020, is available online at 

https://event.on24.com/wcc/r/2359555/FAB61DFA865C680B16BE9C42AF7BAF30

Yellowlees, who has authored more than 80 articles on telepsychiatry and health informatics, has been conducting telemedicine since 1991. Recognizing the need to address mental health in more rural areas, his first session was with an Aboriginal women with depression in a distant part of Australia. Since then, he has refined his approach and gained much experience. In 2009, he was the lead author on the telemental health guidelines published by the American Telemedicine Association; he is a Fellow and Past President of the 

Although there are a number of things that can make telepsychiatry easier for the clinician, Yellowlees said a clinician could easily get a good setup for about $200. A noiseless keyboard, for example, will make it easier to take notes during a session without disrupting the flow of the conversation. This, in turn, makes post-appointment paperwork quicker and easier. Similarly, an echo-cancelling microphone improves audio quality-it can be easily connected to a desktop computer and eliminates the need for headphones. Throw in a camera, and you are good to go. Even simpler, forgo the desktop computer for a laptop or a tablet, which has a built in camera and speakers.

Yellowlees also likes to use multiple screens during telepsychiatry sessions. “I have one screen for the video, I have another screen to the EMR, and I typically have my email or something else going on the third screen,” he explained. “And it’s actually less tiring to have two or three screens, because you don’t have to constantly change the picture, or change the shape of your screen as you’re doing different functions; you literally use each screen for a different function. And that’s a much, much easier way of working.”

According to Yellowlees, clinicians often overlook things like proper lighting and video presentation issues. He suggested havinf a light overhead, almost directed between you and the camera screen, and to avoid having too much light behind you to avoid shadows. Always check to see that you are centered properly, with your head about two-thirds of the way up the screen. “You don’t want your eyes to be far away from the actual camera,” he explained. Since the camera is a few inches above the eyes, this placement allows the clinician to make “eye contact” with the patient in a more natural way.

Choosing an appropriate telepsychiatry platform is also important. Despite the flexibility being afforded to health care providers during COVID, both Shore and Yellowlees noted it is best to use platforms that are HIPAA-compliant. “You know, the government can easily change the rules and decide they want to come and prosecute people [for not being HIPAA-compliant]. They really haven’t changed the HIPAA rules at all; they’ve just decided that they weren’t going to prosecute.”

In addition, picking the best platform right off the bat will allow for a seamless transition in a post-COVID world. Just as it may take time for clinicians to learn new platforms, patients may have a similar adjustment period. Since the rules will likely change after the COVID crisis, they added, it makes sense to acclimate your patients to something you can use moving forward. Fortunately, there are a number of user-friendly platforms from which to choose (

Not surprisingly, many of the attendees’ questions surrounded reimbursement issues. Also not surprisingly, Shore, who also got his start in telemedicine to treat patients in rural areas noted the situation is complex, as insurance companies may have their own set of rules and CPT codes. Shore currently serves as the Director of Telemedicine Programming for the Department of Psychiatry, School of Medicine; as Director of Telemedicine for the Helen and Arthur E. Johnson Depression Center University of Colorado Anschutz Medical Campus; and as Chief Medical Officer of AccessCare, a provider of telemental health services of rural and underserved populations. As such, he is well aware of the intricacies of the reimbursement tango.

Shore reported that there is a loosening of requirements in the federal programs, including additional codes in Medicare and Medicaid. Yet, there have been weekly if not daily changes in coding, so he suggests clinicians check for specific directions on insurance company websites. Similarly, the American Psychiatric Association’s telepsychiatry page has many resources to help clinicians.

Certainly, as the COVID pandemic evolves, both Shore and Yellowless expect the reimbursement rules to change and evolve. Before the pandemic, Yellowlees routinely obtained prior authorization for telepsychiatry visits for each new patient. He noted this would be good practice moving forward for all clinicians to consider.

All speakers agreed that telepsychiatry requires a degree of flexibility and creativity to make it work. For instance, psychiatrists should aim to be more animated during a telepsychiatry visit, Yellowlees noted. “Try to be lively and be reasonably friendly, you know, perhaps a bit more than you necessarily would in your own clinic. I normally say to people to be about 110% of normal-just slightly more lively, slightly more intonation in your voice. . . . And, that may be why some people also find telepsychiatry a little bit more tiring initially, because they’re actually having to speak and enunciate more loudly and more carefully.”

Similarly, clinicians may need to ask patients to be more creative. For example, clinicians can ask patients to weight themselves or use a blood pressure monitor during the video visit-many of the tools used to assess patients’ vital signs can be obtained inexpensively online. Patients with limited funds might be able to visit a local drug store to assess blood pressure and pulse readings.

Shore also had some suggestions for patients worried about their privacy. “One of the places that many of my colleagues and I have found useful is car therapy. When the car is not moving and the patient is not driving, it provides a private secure space,” he explained. “I actually have patients who park near places like a local library or health care center with good bandwidth . . . I have had patients park in front of their relatives’ houses and use their WiFi passwords.”

On the other hand, telepsychiatry opens up a world of possibilities. Yellowlees shared, “I’ll get them to deliberately use an iPad or a phone or mobile device, and I’ll have them show me around the house and walk me out in the garden. I’ll talk to them about their pictures or what they’re having for supper. I’ll get to see their pets, and potentially I’ll meet other members of the family-of course with appropriate discussion beforehand with a patient.”

This can be particularly helpful when doing therapy, Shore explained. “You’re doing [therapy] in this artificial environment, not in the environment where they live and they’re dealing with their symptoms. And so, I think there’s a real power to move the treatment into the place where the patient lives.”

Similarly, telepsychiatry also allows for greater insights and ability to help patients with specific disorders. For instance, if you’re working with someone with ADHD, you can see the state of their homes. In patients with eating disorders, clinicians can ask to see the pantry to see what might tempt them. For patients with a hoarding disorder, you can monitor their progress and watch as they sort through things.

Other special patient populations can also benefit from telepsychiatry. The most obvious group includes older and immunosuppressed patients during the COVID environment, who benefit from care that does not endanger their lives. Telepsychiatry also evens out the playing field and provides a more egalitarian approach. Patients with anxiety can meet with their physician in a more comfortable environment, which in turn allows them to share more freely. It also benefits children and adolescents, Aiken added. “It can be intimidating to be in an older doctor’s office when you’re an adolescent. In telepsychiatry, we are on their media-this is their domain, the electronic media, so they take it and run with it.”

According to the experts, the literature to date suggests very high levels of patient satisfaction, most likely due to its flexibility. It becomes easier for patients to show up for appointments, with minimal disruptions to their schedule.

The flexibility goes both ways. In the past, taking an extended vacation or attending a convention meant leaving your patients behind, finding coverage, and the like. With telepsychiatry, clinicians can schedule appointments around their travel schedules, appointments, and leisure time and still be able to monitor their patients.

Another perk of telepsychiatry is that patients may find it easier to divulge sensitive information. “There’s a big computer science literature showing that people tend to be more honest if they’re talking about sensitive topics to a computer, filling in a questionnaire, or to someone on video on a computer as opposed to in person,” Yellowlees said. “Imagine if you’re a female and you’ve been raped recently. It’s much easier to talk to someone like Jay or myself on video than to come into our clinics and see us there as sort of physically large males.”

With greater opportunities to connect with patients and high levels of patient satisfaction, all three experts agreed the future of psychiatry should consist of a hybrid model of care. Aiken noted, “As we emerge [from this pandemic], psychiatry will have this tremendous opportunity to figure out the right balance [of telepsychiatry and in-person care].” This balanced hybrid approach should really be the standard of care, he added.

“I tend to look at it like video and in-person visits, each has their own strengths and challenges, and it’s variable by the patient population,” Shore explained. “As Peter [Yellowlees] mentioned, I’ve worked with victims of domestic violence and see them first in video to establish a relationship where they feel safer and more comfortable. Now, there are other patients where you may want to see them in person first to establish the relationship, and then do video.”

“What I’m hearing is that in the hybrid model patients might feel more secure in their connection with us, knowing that they can reach us when they’re at the beach, when their car is broken,” Aiken said. “We just have to turn it up a bit, 110%, in our own attunement and energy involvement, and we can actually connect to patients in different ways.”

Telepsychiatry and Health Technologies A Guide for Mental Health Professionals

Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals.

 American Psychiatric Association Publishing; 2018.

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers

Making Telepsychiatry Work for You and Your Patients

A novel approach is believed to be remarkably accurate in predicting first-episode psychosis (FEP). According to the article, 

“Dynamic ElecTronic hEalth reCord deTection (DETECT) of Individuals at Risk of a First Episode of Psychosis: A Case Control Development and Validations Study

 FEP can be detected nearly a year before onset in asymptomatic individuals.

The study was based on electronic health records (EHR) data from the IBM Explorys Platform that included people who received a diagnosis of FEP and subsequent schizophrenia from 1990 to 2018. A dataset of more than 60 million unidentifiable individuals was used to devise a model known as Dynamic ElecTronic hEalth reCord deTection (DETECT).

With this model, the researchers sought to determine whether EHR together with artificial intelligence could predict risk of developing FEP with some measure of precision: “DETECT was developed to reliably identify individuals potentially at risk of FEP 1 year in advance to ensure that risk prediction was done before the manifestation of more obvious behavioural [sic] pathology and functional morbidity,” according to the researchers.

The authors of the study who were both from  Kings College in London and 

, which funded the study, noted several limitations. The model design and validation methods may have compromised results because they were conducted in a case-control setting. Further study is needed to establish true analysis of an entire population of individuals with schizophrenia.

There is promise in the results, however, which point to the need for more research: “DETECT could potentially be useful to screen EHRs on a large scale. The primary purpose of such large-scale screening would be to detect individuals at risk of FEP who might be missed by the current health-care pathways.”

Further reading about the ethics of large-scale population screening can be found in an article by Ioana Alina Cristea and Florian Naudet in their accompanying piece in 

Is large-scale population screening coming to psychiatry?

1. Raket RR, Jaskolowski J, Kinon BJ. Dynamic ElecTronic hEalth reCord deTection (DETECT) of individuals at risk of a first episode of psychosis: a case-control development and validation study. 

https://doi.org/10.1016/S2589-7500(20)30024-8

Artificial intelligence combined with electronic health records may detect FEP a year before onset in asymptomatic adults.

Machine-Learning Holds Promise for Identifying First-Episode Psychosis

Isolation does not mean disconnection. Our souls and spirits need to feel part of a bigger family-the human family. Dr John Miller shares his thoughts with his peers during these challenging times. Dr Miller is Medical Director, 

, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

Isolation does not mean disconnection. Our souls and spirits need to feel part of the bigger family that we are. More in this video.

A Whole New Territory: Staying Connected in Real Time

Nearly a thousand registrants signed up for the 

Telepsychiatry Webinar: Prepare Your Practice for COVID and Beyond

, on May 18, 2020. It was hosted by Chris Aiken, MD, with special guests, Jay H. Shore, MD, MPH, and Peter Yellowlees, MBBS, MD.

Below is the URL for the OnDemand version. All that is needed is a quick login to view the presentation: 

A number of psychiatrists have contributed submissions about telepsychiatry during COVID-19, highlighting the need for information as our society transitions to technological formats to communicate during and after the pandemic. The following is just a sampling of resources at 

Research in the Time of COVID-19: Virtual and Digital Technology in Studies of Early Psychosis

The use of technology that supports remote methods of communication, assessment, and mental health care has become timelier, and important for researchers to adopt, refine, and implement. Authors who contributed are Rachel Loewy, PhD; Dost Ongur, MD, PhD; Tara A. Niendam, PhD; Piper Meyer-Kalos, PhD, LP; Sophia Vinogradov, MD; and Ragy R. Girgis, MD, MS.

Many physicians thought we could not overestimate the value of having a patient’s full, in-person attention, nonverbal cues and all. In the current crisis, all of that seems quaint. Robert Boland, MD.

In an Instant: The Changing Face of Psychiatry

FaceTime, Skype, and other video chat functions are the new normal in the COVID-19 era and allow this community psychiatrist to serve the underserved. P Priyanka, MD, explains in this special video.

Mental Health Issues When College Students Are Sent Home by COVID-19

Dr John Greden discusses many issues around college mental health and the upheaval the COVID-19 pandemic is causing in this population.

Practical tips to help clinicians get started or to hone skills in telepsychiatry. A video by Chris Aiken, MD.

Developing the Capability for Virtual Consultation in the Age of COVID-19

Psychiatry is being thrown, ready or not, into the world of telemedicine. Here you will find lessons, tips, and answers to common questions from psychiatrists who have successfully taken the leap. This article was written by Sejal B. Shah, MD; Josepha A. Cheong, MD; and Robert Boland, MD.

Here is a sampling of contributions about telepsychiatry submitted during the pandemic, as well as on-demand information from the Psychiatric Times Webinar that took place in May, in case you missed it.

Resources From the Psychiatric Times Telepsychiatry-COVID Webinar

You are cordially invited to the Psychiatric Times Webinar, 

Telepsychiatry: Ready Your Practice for COVID and Beyond

Cost: Free of charge. Sponsored by Supernus, Team ADHD.

Learn tips from leading psychiatrists on how to make telepsychiatry work for you, your practice, and your patients. In this interactive webinar, you’ll learn:

    Which tools and equipment make the experience better and easier for you and your patients

    How to handle billing to ensure and expedite compensation and avoid paperwork hassles

    Tips for addressing special issues in psychiatric disorders, including  depression, ADHD, psychosis, and eating disorders

    Strategies for working with special patient populations, like children, older patients, and domestic violence victims

    How to leverage telepsychiatry’s advantages beyond the COVID pandemic


	Dr Aiken is Director of the Mood Treatment Center, Editor in Chief of The Carlat Psychiatry Report, and Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He is the author of The Depression and Bipolar Workbook and coauthor, with Jim Phelps, MD, of Bipolar, Not So Much. He can be heard in the weekly Carlat Psychiatry Podcast with his co-host Kellie Newsome, PMH-NP. Dr Aiken is the Bipolar Section Editor of Psychiatric Times.


	Dr Shore is professor at the Department of Psychiatry and Family Medicine, Colorado School of Public Health, School of Medicine and Centers for American Indian and Alaska Native Health, Colorado School of Public Health. He is Director of Telemedicine Programming for Department of Psychiatry, School of Medicine; Director of Telemedicine for the Helen and Arthur E. Johnson Depression Center University of Colorado Anschutz Medical Campus, as well as Chief Medical Officer of AccessCare, a provider of telemental health services of rural and underserved populations. He has served in leadership positions for the American Telemedicine Association and current Chair of the American Psychiatric Association Telepsychiatry Committee.


	Dr Yellowlees is Chief Wellness Officer at UC Davis Health and Professor of General Psychiatry at University of California, Davis. He is also the Vice Chair for Faculty Development in the Department of Psychiatry and Behavioral Sciences at UC Davis. He holds the Alan Stoudemire Endowed Chair in Psychiatry and is the Director of Physician Health Program at UC Davis Psychiatry. His interest in rural mental health services led him to start implementing telemedicine systems, and then on to research in telemedicine and health informatics. He has published more than 80 papers in these two areas. Dr Yellowlees was the lead author on the telemental health guidelines published by the American Telemedicine Association in 2009. He is a Fellow and past President of the American Telemedicine Association.

You are cordially invited to the Psychiatric Times Webinar, Telepsychiatry: Ready Your Practice for COVID and Beyond.