key: cord-0944879-mryibea7
authors: Pires de Oliveira Padilha, Paula; Bertulies‐Esposito, Bastian; L'Heureux, Sophie; Olivier, David; Lal, Shalini; Abdel‐Baki, Amal
title: COVID‐19 pandemic's effects and telehealth in Early Psychosis Services of Quebec, Canada: Will changes last?
date: 2021-10-08
journal: Early Interv Psychiatry
DOI: 10.1111/eip.13227
sha: 8de04c8c7e5ee78808eea805bd664f9e5d77c9dc
doc_id: 944879
cord_uid: mryibea7

AIM: To explore the impacts of the COVID‐19 pandemic first wave in Quebec, Canada on practices in early intervention services (EIS) for first‐episode psychosis, including reorganization of clinical and administrative practices and teleconsultation use. METHODS: Adopting a cross‐sectional descriptive study design, a 41 questions online survey was sent to the team leaders of all the 33 Quebec EIS, of which 100% responded. Data were collected from 18 May to 4 June 2020 and analysed using descriptive statistics and content analysis. Programmes were categorized as urban/non‐urban and results were compared between these. RESULTS: All 33 existing Quebec EIS (16 urban and 17 non‐urban) completed the survey. Among them, 85% did not experience redeployment of EIS team staff and 58% reported stable frequency of patient interactions, either in‐person or through telemedicine. During the studied period, 64% of programmes reported that all professionals used teleconsultation at least occasionally. However, 73% of programmes, mostly in non‐urban areas, reported some limitations regarding clinicians' degree of ease with teleconferencing platforms and half of EIS could not access technical support to use them. The majority of EIS (94%) expressed interest to participate in a training program about the use of technologies for teleconsultations. Many smaller clinics reported interest in offering multiregional/multiclinics group teletherapy, therefore merging their pool of patients and clinical staff workforce. CONCLUSIONS: Further studies are warranted to improve access to and use of technology‐mediated treatment, which seems to be a promising alternative to provide high‐quality mental healthcare during the COVID‐19 pandemic and beyond.

patient outcomes (Birchwood et al., 1998) . Essential components of this approach have been identified and described in national and international guidelines with key issues being early detection, easy and rapid access to care, care continuity, intensive case management and adherence to recommended low patient-to-clinician ratios to provide appropriate intensity of services and outreach interventions (Addington et al., 2018; Bertulies-Esposito & Abdel-Baki, 2019; Delorme et al., 2019) .

The COVID-19 pandemic reached the Canadian province of Quebec in March 2020. In response, province-wide public health measures such as social distancing and a several-week-long lockdown were imposed. Organizational changes occurred in the health care system to provide acute care to people infected with COVID-19. For instance, mental healthcare professionals were temporarily trans- cine has played an increasingly important role in mental health services, notably during the pandemic, being considered effective in terms of cost and improved access to care (Kavoor et al., 2020; Lal et al., 2020; Sullivan et al., 2020 ). Yet, little is known about the impact of the pandemic on changes in practice from the perspectives of front-line mental health service providers.

Programmes pour Premiers Episodes Psychotiques (AQPPEP)-founded in 2004, aims to promote and support the implementation of highquality and accessible EIS, through a community of practice, developing continuing education opportunities, raising awareness among the general population and policy makers alike through constant advocacy for youth suffering from FEP (L'Heureux et al., 2007) . Currently, AQPPEP has 282 members (52 psychiatrists and 230 other mental health professionals including a few researchers), which are involved in one of the 33 EIS teams currently operating in the province (Bertulies-Esposito et al., 2020) .

In this context, this study aimed to explore the impact of the COVID-19 pandemic on EIS in Quebec, including on human resources, teamwork reorganization, teleconsultation use and access to videoconferencing platforms and other telework tools to provide EIS to youth with FEP in Quebec.

Adopting a cross-sectional descriptive study design, a link to an online 41 questions survey was sent by email to the team leaders of all 33 EIS operating in Quebec, on May 18 th 2020, through the AQPPEP.

Two email reminders were sent in the following 2 weeks. Data were collected from May 18 th to June 4 th 2020, during the end of the peak of the first wave of the COVID-19 pandemic in Quebec. The participants were asked to answer to the survey considering the period beginning on April 1 st , 2020 until the date they responded (i.e., between May 18 th and June 4 th ). The questionnaire aimed to better understand: (1) the pandemic's impacts on the functioning of EIS across the province and (2) the current use of teleconsultation and the availability of different technological tools and technical support.

Results were compared between urban and non-urban settings, as geographical realities and access to technological tools were thought to differ between those areas.

The survey was developed after a brief literature review on the pandemic impact on mental health services and on the use of technology to offermental health services, and it was also inspired from comments received by AQPPEP from some of its members on the impact of the pandemic and their increased need for support. Programs were categorized as operating in urban or non-urban areas, according to several criteria: catchment area location, population density, accessibility through public transportation and the size of the territory covered by EIS (which influences travel requirements for outreach interventions).

All the 33 existing Quebec EIS participated to the survey. Of these, 16 were classified as urban and 17 as non-urban.

Taking into account the government requirements of social distancing and instructions to maintain or increase service intensity during the pandemic period (Direction Générale Adjointe des Services de Santé Mentale et de Psychiatrie Légale, 2020), 58% of programs reported no change in clinician-patient interaction frequency, either in-person or using telemedicine, while 36% reported an increase in clinician-patient contacts.

During the COVID-19 pandemic period, five of the 33 programs (15%) experienced a reduction of their clinical workforce for more than 2 weeks, due to professionals being transferred to other services in response to the COVID-19 pandemic. Of these five programs, four were urban and one was non-urban. Furthermore, 25 programs (76%-10 urban and 15 non-urban) reported a reduction of their clinical workforce in order to avoid contamination of the entire team and 10 programs (30%; 6 urban and 4 non-urban) experienced a redeployment due to previous diseases of their professionals putting them at higher risk of health complications.

To comply with social distancing measures, 18 EIS (55%; 10 urban vs. 8 non-urban) held virtual clinical meetings only, whereas 10 EIS (30%) held on-site clinical meetings only (4 urban vs. 6 non-urban) and 4 EIS (12%) held clinical meetings both on site and virtually. One nonurban EIS (3%) did not hold any clinical meeting during that period.

Furthermore, 11 EIS (33%) held virtual administrative meetings only (5 urban vs. 6 non-urban), 7 EIS (21%) held on-site administrative meetings only (2 urban vs. 5 non-urban), 4 EIS (13%) held administrative meetings both on site and virtually (3 urban vs. 1 non-urban) and 11 EIS (33%) did not hold any administrative meeting during that period (6 urban vs. 5 non-urban).

In 42% of EIS, remote access to medical records was provided to psychiatrists (54% urban vs. 11% non-urban) and 39% to their other mental health professionals (42% urban vs. 33% non-urban). However, for 21% of EIS, remote access to electronic medical records was not made available to psychiatrists (13% urban vs. 33% non-urban) and for 24% of EIS to their other mental health professionals (21% urban vs. 22% non-urban EIS). Finally, 36% of EIS could not provide remote access to medical records to their staff due to the unavailability of digitized medical records (only paper medical files).

Twenty-one EIS (64%) reported that all mental health professionals and psychiatrists used teleconsultation at least occasionally during that period. Furthermore, 46% of EIS reported that 75%-90% of patients were seen by psychiatrists through teleconsultation in their programme, while 33% of EIS reported the same for consultations with other professionals. The main reasons for using teleconsultation were to avoid physical workplace contamination (74%) and to limit infection risks for professionals with pre-existing conditions (29%).

Twenty-nine EIS (88%) reported that an internet connection was offered to their psychiatrists and other professionals in their workplace. However, most programs reported some difficulties regarding the availability of appropriate workstations for teleconsultations: 5 EIS (15%) did not have workstations equipped for teleconsultation (i.e., computers with a camera, microphone and speakers, smartphones or tablets), 8 EIS (24%) reported that workstations were poorly equipped, therefore, making teleconsultation impossible (lack of adequate camera, microphone or speakers) and 5 EIS (15%) which were mostly in non-urban areas, reported that psychiatrists and professionals had to share the few workstations available, which limited access and therefore the use of teleconsultation in these settings.

Quebec EIS used a diversity of platforms for individual teleconsultation, mainly those recommended by the Quebec MHSS:

Zoom Healthcare (73%), Reacts (33%) and Microsoft Teams (24%).

However, unsecure platforms were also used: Zoom's free version, Skype, Facetime, Messenger and WhatsApp (15%). For group interventions, the most used platforms were Zoom Healthcare (58%), Microsoft Teams (9%) or other platforms such as free Zoom (6%) and

Reacts (3%).

Regarding the access to the computer technical support, 13 EIS (39%; 8/13 urban) had access to technical support for the installation of their technological tools and for assistance during teleconsultation platform use. However, 17 programs (52%; 10/17 non-urban) reported receiving technical support only for the installation of technological tools. Furthermore, 3 programs (9%; 1 urban and 2 nonurban) reported that technical support was unavailable.

Twelve programs (36%), of which nine were non-urban EIS, reported that their staff felt a low degree of ease in using teleconsultation platforms. In contrast, 9 programmes (28%), of which 7 were urban EIS, reported high degree of ease, while 36% reported a medium degree of ease when using these platforms. The majority of EIS (94%)-similarly for rural or urban areas-were interested in participating in a training program about the use of technologies for teleconsultation.

Furthermore, 46% of EIS reported that only 10%-30% of patients continued to be seen by their psychiatrist and other professionals in face-to-face consultations. For 91% of programs (urban and rural programs alike), in-person consultations were warranted due to clinical instability, patients requiring hospitalization, administration of injectable medication and nursing follow-ups (e.g., clozapine and side-effect monitoring). In addition, 85% of programs reported seeing new patients in face-to-face consultations, a period when therapeutic alliance is possibly more difficult to establish virtually.

Twenty-one of the surveyed programs (64%) reported offering group therapy before the pandemic, both in urban and non-urban settings.

The main reasons reported by 12 EIS for not offering group therapeutic interventions before the pandemic period were: insufficient clinical staff (43% urban vs. 57% non-urban), too few patients under the program's care (33% urban vs. 67% non-urban) and prioritization of other types of interventions (60% urban vs. 40% non-urban). During this first wave of the COVID-19 pandemic period, nine programs (27%) reported offering or planning to offer group psychoeducation for patients and their families through teleconsultation platforms. Two thirds of these programs were in urban areas. Five programs (15%), all located in urban settings, reported offering or planning to offer group teletherapy (e.g., cognitive behavioural therapy) for patients during this period.

Four non-urban EIS, which reported not offering or not planning to offer group teleinterventions in the near future, reported interest in collaborating with other clinics to offer multiregional groups. This interest arose from an insufficient pool of patients and/or staff to offer group therapy on their own. Seventeen of the 21 (81%) EIS, which responded to this question reported that they would be willing for professionals from other EIS, to observe their teleintervention group sessions, while 77% expressed interest in opening their teleintervention groups to patients from other EIS and for training purposes.

In the spring of 2020, several major public health measures were urgently adopted in Quebec, Canada, and there was a redeployment of many mental healthcare staff towards COVID-19 units, due to a lack of clinical workforce (Direction Générale Adjointe des Services de Santé Mentale et de Psychiatrie Légale, 2020), similarly to reports from other countries (Kavoor et al., 2020; Pacchiarotti et al., 2020) . Conversely, 85%

of Quebec EIS reported that they did not experience redeployment of their workforce as per the government directives (Direction Générale Adjointe des Services de Santé Mentale et de Psychiatrie Légale, 2020), since EIS were considered essential mental health services for vulnerable populations. Indeed, people with severe mental health problems were at increased risk of suffering from social isolation during lockdowns, as they are more likely to be single and to have a reduced social network (Ma et al., 2020) . Therefore, in line with government directives, 94% of surveyed programs maintained or increased service intensity to provide continuous monitoring and support for their patients, preventing psychiatric relapses and consequent risk of congestion of emergency rooms 

Since the World Health Organization declared the COVID-19 pandemic, several countries promoted telehealth services (Nath et al., 2020; Sullivan et al., 2020) . Indeed, the use of telemedicine massively increased during the pandemic as it has allowed rapid access and has simplified communication between patients and care providers (Idris, 2020; Lal et al., 2017) . The rationale for mental health teleconsultations during the COVID-19 pandemic includes reducing pressure on health services' capacity, reducing the risk of viral transmission in hospital settings, and ensuring continuity of care for psychiatric patients (Amerio et al., 2020) , which our study also suggests. A study focusing on FEP patients' perspectives on teleconsultation conducted before the COVID-19 pandemic reported that they considered telepsychiatry as an interesting tool to help them with service engagement in EIS, especially when they have competing priorities (e.g., school/work schedules, taking care of their children, limited time and financial resources for transportation), which were identified as barriers to face-to-face appointments (Lal et al., 2020) .

In line with our findings, a qualitative study on the frequency of use of telemedicine tools before and since the COVID-19 pandemic showed that all mental health practitioners have used digital tools to some extent, with the majority using telemedicine every day. Videoconference was the main telemedicine tool, either through Skype, Zoom or secured applications in an online platform (Feijt et al., 2020) .

Teleconsultation seemed not only to be considered a replacement but a complementary form of remote treatment with its own advantages and restrictions. Therefore, a combination or hybrid treatment could become the most successful approach in mental health in the future (Smith et al., 2020) .

Literature about group teletherapy for youth with FEP during the COVID-19 pandemic is scarce. Results of a pilot study highlight group teletherapy's advantages, as an effective, accessible and recoveryoriented treatment approach (Wood et al., 2021) . Furthermore, the virtual format could also allow to bring together patients and clinicians of different clinics, which could potentially greatly expand access for individuals in underserved rural areas (Wood et al., 2021) . Such an opportunity appears to be of interest to some EIS in our study.

Despite some challenges for which solutions were proposed, a pilot study conducted in Quebec showed that group teletherapy gathering patients from different EIS was feasible and likely to improve access to psychotherapy for people who live in remote areas, are unable to travel to attend the group, or are confined due to a pandemic (Lecomte et al., 2020) . Nevertheless, only a minority of EIS offered or planned to offer group interventions for patients and their families through teleconsultation. Some differences in services offered by EIS may be attributed to specific clinical or geographical realities. A greater understanding of these specific barriers (e.g., small patient pool and/or limited clinical human resources) is required to address them and improve access to youth mental health services. It seems that collaboration between EIS could provide a solution to these issues. According to our results, a majority of EIS would agree to pool their patients in multiregional teletherapy groups and to contribute to training staff from other clinics by allowing them to observe their group teletherapy sessions. This also suggests a need for more research to address the various clinical, administrative, ethical, and safety issues of bringing together patients and service providers from different healthcare settings for therapeutic interventions.

Our study highlights several potential barriers reported by the majority of EIS, preventing increased group interventions and individual interventions through telemedicine: low degree of ease using the teleconsultation platforms, insufficient technical support for their use and the limited availability of adequate telehealth equipment. Similarly, technological difficulties (insufficient technological infrastructure and lacking organizational and procedural support) were reported in a mental health care service in the Netherlands during the COVID-19 pandemic (Feijt et al., 2020) . Therefore, challenges such as lack of access to and expertise with technology, confidentiality requirements and insufficient technological infrastructure must be identified early on and addressed, with the aim of promoting better patients' engagement to health care programs (Lal, 2019; Wright & Caudill, 2020) .

Moreover, our results show that the majority of EIS (94%) were interested to participate in a training programm about the use of technologies for teleconsultations. Due to the continuous changes in response to the pandemic period, clinicians are encouraged to remain up to date on the current rules and regulations regarding privacy, product licensing, insurance and other issues related to a regulated use of virtual meeting platforms (Lal, 2019; Wright & Caudill, 2020) .

Although all 33 Quebec EIS responded to the survey, ensuring a complete picture of the situation, our study presents some limitations.

First, it evaluated only EIS from Quebec, a province of Canada, a highincome country where technology is easily accessible (although the quality of internet access for patients was highly variable, notably in remote rural areas), and where mental healthcare is mostly publicly funded and free to users. Moreover, EIS was widely implemented in the last few years across the province with governmental support et al., 2020) . Consequently, the situation described in this article might differ from contexts and experiences of other EIS across the world or to other types of mental health services. Furthermore, this study focused on team leaders' perspective, which may induce a social desirability bias in the data and did not evaluate the opinion of patients and their families who received services from EIS, nor from other clinicians who faced everyday challenges in offering mental health care, although team leaders are also involved in clinical care. In addition, our survey did not include open questions and due to time constraints related to the ongoing management of challenges related to the pandemic, the research team was unable to conduct interviews with survey respondents to develop more in-depth understanding of service changes during this period. Finally, our study did not compare the use of telehealth services before and during the pandemic. All these limitations should be addressed in further studies.

Quebec EIS had to implement clinical and administrative changes during the first few months of the COVID-19 pandemic, transporting clinical and administrative meetings to a virtual setting, reducing face-toface consultations and prioritizing teleconsultations to avoid widespread infection among EIS team members.

Further studies are warranted to improve the understanding of factors influencing the uptake of technology-mediated services, and promote its use, since it seems to be a promising alternative for providing high-quality mental health care during a pandemic crisis. Developing such alternatives could globally improve mental health services beyond the acute needs exposed by the pandemic. This study represents an initial step in monitoring the implementation of mental health teleconsultations and outlines some of the challenges faced by EIS along the way.

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We would like to thank all the team leaders of Quebec EIS who accepted to participate and answer to this survey.

The authors declare no conflicts of interest.

Data sharing is not applicable to this article. Amal Abdel-Baki https://orcid.org/0000-0003-3333-9652