Psychiatric Consultations and Psychotherapy

The movement restrictions under COVID-19 lockdowns were intended to protect health care institutions and patients from the spread of infection that would otherwise compromise a health care system’s capacity to cope with patients’ needs. Telehealth is a commonly suggested workaround for disruptions during this period. ^{Reference Gruber, Prinstein and Abramowitz6,Reference Stefana, Youngstrom, Hopwood and Dakanalis9,Reference Ransing, Adiukwu and Pereira-Sanchez10–Reference Kannarkat, Smith and McLeod-Bryant12}

The extant literature generally refers to telehealth as consultations that are held through telephone calls or video conferencing. Telehealth may be especially suitable for psychiatry over other specialties as assessments are largely based on clinical interviews rather than physical examinations. ^{Reference Kannarkat, Smith and McLeod-Bryant12} However, the international experience with COVID-19 showed that the switch to telehealth was fraught with difficulties.

First, some Zoom online meetings were infiltrated by third parties as the demand for Zoom meetings spiked during the pandemic. ^{Reference Sebenius and Mehrota13} This is important as clinicians are ethically obliged to preserve patient confidentiality. Second, the health care sector was competing with other sectors for teleconferencing bandwidth. Corporations are likely to seek out the same remote working technologies during a lockdown, and telehealth services may not have the bandwidth to meet demand, especially if the surge in demand occurs globally as it did with COVID-19. ^{Reference Farr14,15} Third, financial and socioeconomic problems may impede patients’ engagement with telehealth services. ^{Reference Gruber, Prinstein and Abramowitz6,Reference Kannarkat, Smith and McLeod-Bryant12} Insurance providers were slow to provide telehealth reimbursements that matched in-person sessions. The assumption that patients have the knowledge and resources to access telehealth services also risks excluding poorer and less educated individuals. In our clinical experience, common challenges included limited data or telephone talk time or missed sessions because the patient could not pay for telecommunication bills. Fourth, clinicians or patients may be unfamiliar with telehealth, ^{Reference Gruber, Prinstein and Abramowitz6,Reference Ransing, Adiukwu and Pereira-Sanchez10,Reference Argulian16} resist its adoption, ^{Reference Vernig17} or lack a conducive environment for consultations (eg, lack of privacy when locked down at home). ^{Reference Inchausti, MacBeth, Hasson-Ohayon and Dimaggio11} In our experience, nearby construction, heavy rain, and similar issues can make telehealth sessions difficult or impossible to hold. This is true for patients, as well as staff who are working from home. Finally, telehealth can significantly limit the process of psychological assessment and therapy. While a physical examination is less emphasized in psychiatry, ^{Reference Kannarkat, Smith and McLeod-Bryant12} a patient’s appearance and behavior can provide important signs of illness (eg, hand tremors suggestive of medication side effects). These observations may not be readily apparent in a teleconsultation. Certain psychotherapies, like in vivo exposure for obsessive-compulsive or posttraumatic disorders, may not be done correctly or safely without the psychologist’s physical presence. The ability to monitor self-harm and intervene immediately is also limited and more community or emergency outreach services may be required. ^{Reference Gruber, Prinstein and Abramowitz6}

While continued in-person care might be preferred in light of the problems above, staff, union, and legal entities may protest against such arrangements without prior consent, protective measures, or added compensation. Staff buy-in is paramount to prevent further disruption. For example, Taiwan quarantined a hospital during the SARS period in 2003 and confined staff and infected patients within it. Staff tried to escape and clashed with police, stating that they are well and should not be kept together with infected patients. ^{Reference Han18} Further service disruption may ensue if staff have not agreed to working arrangements under emergency lockdowns.

Pharmacies

Pharmacies are essential for the acquisition, storage, and dispensation of medication. This involves logistical work (eg, temperature-controlled storage, inventory management) and patient interaction (eg, administering controlled drugs, counseling on side effects). Patients traditionally come to a pharmacy to obtain medication, but this is problematic in a lockdown.

First, lockdowns and closed borders can disrupt the global supply chain, ^{Reference Zhu, Chou and Tsai19} and increased international demand for certain drugs could result in shortages. The shortages are associated with difficulties in obtaining bioequivalent drugs, doing so at greater cost, and a higher risk of adverse patient reactions. ^{Reference Badreldin and Atallah20} This may be compounded by patients who stockpile medication for fear of shortages. Second, staff shortages may occur if pharmacists and other support staff are redeployed to serve in new settings during pandemics. This may lead to a backlog of prescriptions that prevents patients from receiving a continuous supply of medication, thus jeopardizing their health. Third, patients may also behave in an intimidating manner. Against a background of high public anxiety and uncertain drug supplies, some pharmacists wanted dedicated security staff as they dealt with difficult or frightening individuals during the COVID-19 outbreak. ^{Reference Gregory and Austin21} If some pharmacies are closed for safety reasons, the remaining pharmacies could face backlogs, uncertainties over the timely availability of medication, and prescribers may become unsure where prescriptions should be sent to. ^{Reference Fields and Shaw22} Thus, inadequate security during the broader emergency further disrupted the supply of pharmacy goods and services. Last, while in-pharmacy medication counseling and dispensation can be replaced by telehealth consultations and courier deliveries, the providers of these services may not be able to absorb a sudden spike in demand. The telehealth aspect was discussed previously. For couriers, an abrupt and large-scale transition to this mode of dispensation may be overwhelming. This is especially true when other sectors continue business operations by using couriers as well (eg, restaurant food deliveries when lockdowns prevent on-site dining). This last point is crucial as solutions to the aforementioned pharmacy problems are futile if medication cannot be delivered in a timely manner.

Psychiatric Consultations and Psychotherapy

On the technological front, appropriate telehealth providers and the prerequisite hardware could be sourced for beforehand. This concerns both the quality of the technology (eg, security, reliability), its quantity (eg, spare bandwidth, extra devices in case of damage), and training in its secure and effective use. Once these are addressed, telehealth can even be incorporated into routine care outside an emergency for patients who cannot travel to treatment sites safely or conveniently (eg, those with ambulatory problems).

Telehealth is also free from the limitations of a fixed number of consultation rooms in a clinic. If a physical room is not needed, clinicians and patients can schedule teleconsults at a mutually convenient time instead of relying on room vacancies. The schedule can avoid times where environmental distractors are absent (eg, external noise, other family members). As such, the incorporation of telehealth services into routine care improves both treatment capacity and convenience. However, telehealth needs to be a routine practice if it is to be used effectively during emergencies. ^{Reference Smith, Thomas and Snoswell23} The effectiveness and operational benefits of telehealth led our institute to incorporate it into routine care even after Singapore exited its “circuit breaker.”

Environmental and behavioral obstacles to telehealth can also be addressed beforehand. Clinics should brief patients on appropriate preparations for constructive teleconsultations. Table 1 provides some helpful information for patients who are new to telehealth. This is derived from our own experience and should be modified to fit local circumstances and data protection laws.

Table 1. Suggested leaflet for patients who are new to telehealth ^a

^a This should be modified to fit local circumstances and data protection laws.

Financially, insurance providers can provide reimbursement for telehealth services during lockdowns. For instance, on March 6, 2020, the “1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act” in the United States temporarily expanded Medicare insurance coverage to include telehealth services for a broad swathe of health care professions. ²⁴ However, lasting telehealth insurance coverage could facilitate a faster transition to telehealth during emergencies.

Patients with financial difficulties that impede telehealth engagement can be identified beforehand. Appropriate financial support can then be set aside. Alternatively, telehealth stations for patients may be set up outside danger zones. The booths can be disinfected between sessions or guarded by security personnel, depending on the nature of the emergency.

However, telehealth also implies a physical distance between the patient and the clinician or hospital. Risk management will thus depend on community or emergency outreach services. ^{Reference Gruber, Prinstein and Abramowitz6} Organizations can consider setting up direct lines between telehealth clinicians and these services, as well as increasing these services’ capacity to meet increased callouts over suicide or domestic violence during a lockdown.

Finally, staff buy-in is paramount to prevent further disruption. Staff, unions, and employers need to agree on treatment arrangements, adequate compensation and safeguards for extraordinary work-related risks, along with additional costs (eg, for telehealth infrastructure while working from home). The conflict between hospital staff and police in Taiwan over a SARS outbreak in 2003¹⁸ underscores the importance of developing a consensus before it is needed in a lockdown.

Pharmacies

For COVID-19, pharmacies have attempted to meet patients’ needs through teleconsultations, temporary pick-up locations within a locked-down region, medication home delivery, and drive-through collection points, among others. ^{Reference Hussain, Dawoud and Babar25,Reference Thorakkattil, Nemr and Al-Ghamdi26} These may be implemented for lockdowns, in general, if the following are addressed.

First, pharmacies need adequate stockpiles of medication before lockdowns disrupt supply chains. Creating a “reserve bank” of medications for pandemics has been previously suggested, ^{Reference Zhu, Chou and Tsai19} and this can be extended to other drugs that may face supply disruptions.

Movement restrictions are commonly used during lockdowns so medication must be delivered to patients who cannot come to a physical pharmacy. Timely delivery ensures that patients can continue to take their medication at the prescribed dose and frequency. Organizations need to ensure that the logistics sector can meet the increased demand for medication deliveries during lockdowns, especially if other industries are using similar services to deliver goods. The military can be mobilized if the commercial logistics sector cannot accommodate demand. Militaries tend to have extensive logistical capabilities and personnel that can be adapted for humanitarian purposes like medication delivery. ^{Reference Apte, Goncalves and Yoho27} Military logistics can also be used if existing stockpiles are nearing depletion. Militaries can manage and rapidly transport large quantities of supplies, and this has been used to respond to humanitarian disasters before. ^{Reference Apte, Goncalves and Yoho27} The same capabilities can be used to restock medical supplies (inter)nationally. For instance, the United States Air Force and Indian Air Force flew oxygen supplies to India to alleviate shortages amidst an overwhelming surge of COVID-19 cases. ^{28,Reference Cunningham and Farzan29}

Second, pharmacies can hire dedicated security personnel. Security guards who are trained to manage human behavior and aggression can reduce the threatening behavior of visitors, although they need to be informed of site-specific risks and appropriate responses. ^{Reference Mayhew and Chappell30} For example, restraining an elderly osteoporotic patient as if he were a strong young man could cause serious injury. The appropriate management of threatening persons can prevent further disruption to pharmacy operations.

Third, target hardening refers to architectural or engineering designs to control access to specific areas and impede violence. ^{Reference Mayhew and Chappell30} Police officers who are familiar with violence prevention can conduct shopfloor audits and advise pharmacies on appropriate security measures. Of the strategies discussed by Mayhew and Chappell, ^{Reference Mayhew and Chappell30} locked staff working areas and designated safe escape rooms may be the most versatile way of securing staff and drugs alike if security guards are overwhelmed. At the very least, evacuated staff can be redeployed to manage the spill-over demand at other pharmacies, thereby minimizing disruptions to the pharmacy sector in general.