We briefly frame challenges and steps to overcoming those challenges in delivering care for patients with bipolar disorder via telehealth or telephone during COVID-19. Telehealth provides an invaluable opportunity to provide care for patients even under circumstances of social isolation. The issues discussed in this debate are intended to guide and assist clinicians, both in assessment and intervention, in adjusting to the use of virtual care for patients with bipolar disorder

Abel, Erica A.

Bauer, Mark

Burgess, Claire

Connolly, Samantha

Franz, Aleda

Godleski, Linda

Gyulai, Laszlo

Krawczyk, Lois

Miller, Christopher

Osser, David

Smith, Eric G.

English

eScholarship@UMMS

UMass Chan Medical School eScholarship@UMassChan COVID-19 Publications by UMMS Authors 2020-07-01 Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic Claire Burgess Harvard Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/covid19  Part of the Infectious Disease Commons, Mental and Social Health Commons, Psychiatry Commons, Psychiatry and Psychology Commons, Telemedicine Commons, and the Virus Diseases Commons Repository Citation Burgess C, Miller C, Franz A, Abel EA, Gyulai L, Osser D, Smith EG, Connolly S, Krawczyk L, Bauer M, Godleski L. (2020). Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic. COVID-19 Publications by UMMS Authors. https://doi.org/10.1111/bdi.12969. Retrieved from https://escholarship.umassmed.edu/covid19/59 This material is brought to you by eScholarship@UMassChan. It has been accepted for inclusion in COVID-19 Publications by UMMS Authors by an authorized administrator of eScholarship@UMassChan. For more information, please contact Lisa.Palmer@umassmed.edu. This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/BDI.12969 This article is protected by copyright. All rights reservedTitle: Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemicRunning head: Use of Telehealth during COVID-19Authors & Affiliations below: Claire Burgess, PhD1,2; Christopher Miller, PhD1,2; Aleda Franz, PhD3,4; Erica A Abel, PhD3,4; Laszlo Gyulai, MD5,6; David Osser, MD1,2; Eric G Smith, MD, PhD, MPH7,8; Samantha Connolly, PhD1,2; Lois Krawczyk, PhD1,2; Mark Bauer, MD1,2; Linda Godleski, MD3,4Affiliations listed numerically:1 VA Boston Healthcare System, Boston MA2 Harvard Medical School, Boston, MA3 VA Connecticut Health System, West Haven, CT4 Yale School of Medicine, New Haven, CT5 Philadelphia VAMC, Philadelphia, PA6 University of Pennsylvania Perelman School of Medicine, Philadelphia, PA7 Bedford VAMC, Bedford,MA8 University of Massachusetts Medical School, Worcester, MACorresponding author: Claire Burgess VA Boston Healthcare System 940 Belmont St. Brockton MA 02301 claire.burgess@va.govKeywords: COVID-19, telemedicine, telehealth, bipolar disorders, Note: The views reflected in this paper are those of the authors as individuals are not those of the United States Government. Abstract: We briefly frame challenges and steps to overcoming those challenges in delivering care for patients with bipolar disorder via telehealth or telephone during COVID-19. Telehealth provides an invaluable opportunity to provide care for patients even under circumstances of social isolation. The issues discussed in Accepted Articlethis debate are intended to guide and assist clinicians, both in assessment and intervention, in adjusting to the use of virtual care for patients with bipolar disorder. This article is protected by copyright. All rights reserved  DR. CLAIRE MICHELLE BURGESS (Orcid ID : 0000-0001-6774-7035) DR. CHRISTOPHER J. MILLER (Orcid ID : 0000-0002-8695-6833)   Article type      : Debate   Title: Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic In August of 2019 we published a brief commentary in Bipolar Disorders concerning the role of telemental health via videoconferencing (TMH-V) in the treatment of bipolar disorder1. We concluded that this technology has great potential to improve access to evidence-based mental health treatment.  With the onset of the COVID-19 pandemic, distance care (including phone and TMH-V) is now becoming the default treatment modality for many mental health clinicians. Given our longstanding experience delivering TMH-V to patients with bipolar disorder in the US Department of Veterans Affairs2,3, we wanted to provide some practical guidance for clinicians who may be new to treating patients diagnosed with bipolar disorder virtually.  First, we note that there are several foundational steps to take when delivering TMH-V or treatment by phone regardless of the patient’s diagnosis. These steps are intended to maximize patient safety while minimizing ethical and legal risks for clinicians (e.g., developing clear procedures for handling behavioral emergencies is paramount). Other authors cover these steps in more detail elsewhere4 and we recommend that practitioners familiarize themselves with these practices. We also recommend that clinicians periodically revisit the mandates and regulations that may apply to them, as many state and organizational policies have been changing rapidly during the COVID-19 pandemic.  Beyond these general considerations common to virtual care, there are special considerations relevant to the evaluation and treatment of patients with bipolar disorder via TMH-V. In cases where wireless Accepted Article This article is protected by copyright. All rights reserved connectivity or equipment issues may require a conversion of a video session into a telephone session, we have also included telephone considerations as well.   Assessing certain aspects of speech, affect, and psychomotor agitation may require more effort when delivering virtual care compared to in-person care. For instance, apparent changes in speech volume or tone may be an artifact of microphone placement or speaker quality. Clarifying a patient’s words, slowing down the conversation, adjusting volume or position of the patient to the microphone will help diffuse any trouble in hearing the patient. Similarly, if you’re unsure if a patient is tearing up, trembling, or experiencing psychomotor agitation, it is important to ask them directly. If you cannot see the patient in a TMH-V session clearly due to poor lighting, camera angle, or the patient carrying the device in their hand, ask them to reposition themselves or set the device down on a flat surface.  Asking the patient to stand up and walk a few steps in front of the camera can be used to assess motor performance5. In fact, seeing symptoms of restlessness may be enhanced during TMH-V sessions, especially if someone is standing or walking around in their home during a visit.  When TMH-V or telephone connections feature significant lag, it may be difficult to interpret apparent interruptions or changes in voice prosody. The patient may be attempting to speak during lulls in the conversation, and may sound to the clinician like they are cutting in or not listening. Patients may be harder to interrupt due to pressured speech, simply because visual cues that the clinician is trying to talk may be absent or delayed. One should be aware of these possibilities, and talk about them directly with the patient, rather than assuming that such instances indicate manic symptoms.  For patients who may experience paranoia, derealization, or hallucinations, TMH-V modalities may be particularly stressful, especially if the focus of the patient’s paranoia is on issues of surveillance. A patient may ask that the TMH-V provider’s camera pan the room to demonstrate that no one else is surreptitiously watching the session. In these cases, clinicians must take time to process novel experiences with the patients afterward and discuss healthy strategies for coping after the session. The clinician may have the opportunity to present grounding exercises, inquire about self-management skills the patient routinely uses, and provide psychoeducation on how their treatment model will assist the patient in working with these symptoms.  With the emergence of COVID-19, many people are reporting a loss of coping strategies at present (e.g. the gym, more easily accessible social interactions). Social isolation and self-quarantine may be particularly disruptive given the importance of routines and predictability around social rhythms and Accepted Article This article is protected by copyright. All rights reserved sleep for many patients with bipolar disorder. Treatments may need to emphasize alternative activities that can be done at home (e.g., participating in online groups, engagement with in-home activities, etc.). The simple loss of usual routine may be a trigger for manic/hypomanic or depressive episodes for patients with bipolar disorder. Certain symptoms, such as shopping behaviors, may have migrated online, whereas other symptoms (e.g., impulsive relationships) may have decreased. It is important to not assume; instead, assess for changes in functioning given novel outlets for various habits in the time of COVID-19.  Delivering care for patients with bipolar disorder via TMH-V or telephone presents unique opportunities and challenges. In addition, COVID-19 and the associated public health and social responses pose its own challenges for patients with bipolar disorder. TMH-V provides an invaluable opportunity to interact with and support patients even under circumstances of social isolation. It is our hope that the issues discussed herein will be helpful for those clinicians who are adjusting to the use of virtual care for patients with bipolar disorder.  References 1. XXX Author Hidden. Telemental Health via videoconferencing: A promising method for improving access to evidence‐based mental health care for bipolar disorder. Bipolar Disord 2020; XXX details. 2. XXX Author Hidden. Telemedicine and e-Health 2016; XXX details. 3. XXX Author Hidden. Implementing and sustaining team-based telecare for bipolar disorder: Lessons learned from a model-guided, mixed methods analysis. Telemedicine and e-Health Jan 2018. XXX details. 4. Turvey C, Coleman M, Dennison O, et al.. ATA practice guidelines for video-based online mental health services. Telemedicine and e-Health 2013;19(9);722-730. 5. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis as catalyst for telemedicine for chronic neurological disorders. JAMA Neurol 2020. Published online April 24, 2020. doi:10.1001/jamaneurol.2020.1452 Accepted Article This article is protected by copyright. All rights reserved References 1. Miller CJ. Telemental Health via videoconferencing: A promising method for improving access to evidence‐based mental health care for bipolar disorder. Bipolar Disord 2020;22:93-93. doi:10.1111/bdi.12824 2. Bauer MS, Krawczyk L, Miller CJ et al. Team-based telecare for bipolar disorder. Telemedicine and e-Health 2016; 855-864. 3. Bauer MS, Krawczyk L, Tuozzo K et al. Implementing and sustaining team-based telecare for bipolar disorder: Lessons learned from a model-guided, mixed methods analysis. Telemedicine and e-Health Jan 2018.45-53. 4. Turvey C, Coleman M, Dennison O, et al.. ATA practice guidelines for video-based online mental health services. Telemedicine and e-Health 2013;19(9);722-730. 5. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis as catalyst for telemedicine for chronic neurological disorders. JAMA Neurol 2020. Published online April 24, 2020. doi:10.1001/jamaneurol.2020.1452 Accepted Article

Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic

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Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic

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