key: cord-0922172-zckdbr2b
authors: O’Keeffe, Donal; Clarke, Mary
title: Letter to the Editor: Consolidating learning for the evolution of mental health services for psychosis post-COVID-19
date: 2022-04-28
journal: Ir J Med Sci
DOI: 10.1007/s11845-022-03015-9
sha: a312dc23ce69293b4b69d9d02a5bcf2f1ff81ca6
doc_id: 922172
cord_uid: zckdbr2b

nan

To the editor:

COVID-19 has caused profound changes to the delivery of mental health services for people experiencing psychosis. Decisions have to be made as to whether assessments are conducted in-person with personal protective equipment (PPE) or online. Such decisions are based on clinical risk, patient preference, and patient access and capacity to use technology. Often a hybrid approach is adopted, with initial assessments occurring in-person and follow-up taking place by phone or online.

PPE use has brought psychosis-specific obstacles to developing the rapport needed to comprehensively assess mental health. It can compound the features of psychosis (e.g. thought disorder and paranoia) that already act as barriers to human connection, trust building, and empathy [1] . Providing verbal reassurance and demonstrating compassion in ways that do not require facial expressions have become priorities, when conducting assessments, to ensure that patients are comfortable disclosing and sharing the personal details of their lives. In the process of rapport building over time, staff may not be recognised and have to reintroduce themselves to the patient. This compounds the mistrust of others, isolation, and alienation that can frequently accompany psychosis [2, 3] .

For intervention delivery, telemental health affords the advantages of broadening the geographical reach of a service, enhancing accessibility and engagement, and reducing the need for staff and patients to travel [4] . However, there are psychosis-specific challenges to its implementation. There is a lack of empirical data on the appropriateness and effectiveness of telemental health interventions for people actively experiencing psychosis [5] . Fear of technology can also be a feature of psychosis-derived belief systems [6] .

Conducting therapy online means that clinicians are deprived of the opportunity to assess risk with the informal engagement and body language that comes from providing in-person support. When gauging risk over the internet, only a small snapshot of a person's wellbeing is quantifiable. Moreover, as psychosis is associated with social disadvantage and poverty [7] , those who are socially isolated or struggling financially may not be able to avail of telemental health interventions. The cognitive effects of psychosis [8] may also combine with cognitive decline in old age, making the navigation of new technologies and online platforms inaccessible to a cohort of older patients. Consequently, limiting services to telemental health care has the effect of further marginalising people who are already excluded from aspects of society [9] .

The path forward in consolidating learning for the evolution of mental health services for psychosis post-COVID-19 exists at the nexus of two conflicting forces. On the one hand, the drive to implement a hybrid service model in psychosis, where patients are given the option of in-person or online services, in order to promote choice, inclusivity, and service engagement. On the other, the motivation to consider risk, the potential for compounding marginalisation, and psychosis-specific considerations for assessment and treatment to determine if and how patients should be categorised on the basis of suitability for service delivery modalities.

As we gradually emerge out of the pandemic, a wellresourced, robust research programme designed to generate knowledge to guide service planning and decision-making regarding these issues is now warranted. Only following the generation of empirical data will we learn how best to be sensitive and responsive to the clinical need of this unique group of patients in the post-COVID-19 era.

Expanding traditional paradigms: an integrative approach to the psychotherapeutic treatment of psychosis

Many die in the hurricane': an interpretative phenomenological analysis of adults with psychosis and a history of childhood physical abuse

Loneliness in psychosis: a meta-analytical review

COVID-19 and telemental health: benefits, challenges, and future directions

Application and effectiveness of telehealth to support severe mental illness management: systematic review

Internet-related psychosis -a sign of the times?

Predicting psychosis-spectrum diagnoses in adulthood from social behaviors and neighborhood contexts in childhood

Cognitive impairments in psychotic disorders: common mechanisms and measurement

Friendship and money: a qualitative study of service users' experiences of participating in a supported socialisation programme