key: cord-342841-b1rucgmg authors: Di Carlo, Francesco; Sociali, Antonella; Picutti, Elena; Pettorruso, Mauro; Vellante, Federica; Verrastro, Valeria; Martinotti, Giovanni; di Giannantonio, Massimo title: Telepsychiatry and other cutting edge technologies in Covid‐19 pandemic: bridging the distance in mental health assistance date: 2020-09-18 journal: Int J Clin Pract DOI: 10.1111/ijcp.13716 sha: doc_id: 342841 cord_uid: b1rucgmg At the end of 2019 a novel coronavirus (COVID‐19) was identified in China. The high potential of human to human transmission led to subsequent COVID‐19 global pandemic. Public health strategies including reduced social contact and lockdown have been adopted in many countries. Nonetheless, social distancing and isolation could also represent risk factors for mental disorders, resulting in loneliness, reduced social support and under‐detection of mental health needs. Along with this, social distancing determines a relevant obstacle for direct access to psychiatric care services. The pandemic generates the urgent need for integrating technology into innovative models of mental healthcare. In this paper we discuss the potential role of telepsychiatry and other cutting‐edge technologies in the management of mental health assistance. We narratively review the literature to examine advantages and risks related to the extensive application of these new therapeutic settings, along with the possible limitations and ethical concerns. Telemental health services may be particularly feasible and appropriate for the support of patients, family members and health‐care providers during this COVID‐19 pandemic. The integration of telepsychiatry with other technological innovations (e.g., mobile apps, virtual reality, big data and artificial intelligence) opens up interesting future perspectives for the improvement of mental health assistance. Telepsychiatry is a promising and growing way to deliver mental health services but is still underused. The COVID‐19 pandemic may serve as an opportunity to introduce and promote, among numerous mental health professionals, the knowledge of the possibilities offered by the digital era. Initially identified in December 2019 in China, the 2019 Coronavirus disease is now affecting more than 200 countries and territories around the world. Given the current unavailability of an effective cure or vaccine for COVID-19, a public health strategy of reduced social contact and distancing has been adopted worldwide to slow the spread of the virus. This strategy may on the one hand achieve its goals, but on the other hand, it may undermine normal social support systems, yielding to loneliness and reduced support from family and friends. These conditions may be risk factors for the development of anxiety, stress, depressive symptoms [1] [2] [3] [4] in the general population, they may worsen previously diagnosed diseases [5] , as well as they may favor the onset of new problematic behaviors (e.g., internet misuse [6, 7] ). During the pandemic Ni Y. M. et al. (2020) found that almost one-fifth of respondents to their online survey, targeting Chinese adults, reported probable anxiety and depression. Another survey, carried out in the same time among Italian people, registered high/very high levels of depression, anxiety and stress in a large part of the sample [1] . Because of the contagiousness of COVID-19 [8] , physical access to the Mental Health Care System could increase the risk of infection. Fear of contracting the disease in a healthcare setting, transportation restrictions and isolation at home have become important barriers to treatment for many people [9] . Zohu et al (2020) reported that the decrease of hospital visits led to a reduction of routine psychiatric care for many patients with mental disorders in China, during the COVID-19 outbreak. Consequently, 18.1% of their sample self-reduced drugs dosages and 17.2% stopped taking their psychiatric drugs because they could not have a prescription from their doctor. They also found out that 24.5% of new patients with anxiety disorders, insomnia, psychosis or depression, could not receive timely diagnoses and treatment during this period. These data globally underline the urgency of quickly adapting to current situation, in order to guarantee continuity of care for at-risk populations, such as that of psychiatric patients. In this respect, the global concern about the psychosocial consequences of COVID-19 pandemic has led governments to call for suggestions to deal with these effects. The use of digital health technology has been proposed as an important strategy to reinforce heath systems [10] . This article is protected by copyright. All rights reserved According to the World Health Organization, telemedicine is "the delivery of health care services, where distance is a critical factor, by all health care professionals, using information and communication technologies" [11] . When applied in the field of psychiatry these methods are known as telepsychiatry (TP). Telemental health services can be particularly useful and appropriate for the support of both patients and health care workers during this pandemic, allowing providing assistance and care to those who need it by reducing the risk of infection. Illustrative of that is the case of a Californian psychiatric clinic in which all patients with existing appointments received care via TP, allowing to provide uninterrupted care while minimizing potential COVID-19 exposure to patients and clinicians [12] . Technology-based tools offer telemedicine visits for patients, as well as support for institutions, by facilitating the provision of information and data sharing, while creating virtual spaces for meetings and clinical briefings [13] . It is interesting to underline that psychiatric care is relatively unique: with only rare exceptions, psychiatrists are not expected to physically touch their patients to provide the best services. Verbal and visual assessments, which can easily occur via telemedicine, are all that is needed to engage with patients appropriately obtain full diagnostic accuracy and provide most types of treatments. This makes using a 2-way tele-videoconferencing for clinical assessments and treatment delivery a reasonable method for psychiatric treatment [14] . The aim of this narrative review is to evaluate TP utility and feasibility, updating and summarizing the most important findings about its use in the modern psychiatric practice, in order to inform the potential use of TP during the pandemic. This article is protected by copyright. All rights reserved pandemic. Only English-written papers were considered for inclusion. Resources were filtered using abstracts (where available), before evaluating full texts, and the included studies were selected based on their relevance to the aim of this review. The reference section of each examined article was also reviewed to identify other potential studies. A total of 426 records was found from bibliographic search. Of these, 214 record were excluded after abstract evaluation (n=9 because were not English written, n=12 because were other study types, n=193 because were not relevant to the aim of this review). Of For patients, TP improves access to care, reduces appointments' waiting time and decreases travel time and costs [15] . Some patients report feeling more comfortable, and can be more open and honest, when discussing difficult subjects from their devices, because the virtual space of the session instills a feeling of "protection". Another important advantage of TP in terms of rapport building is the possibility for patients (especially immigrants, refugees, and asylum seekers) to receive psychiatric assistance in their native language without the assistance of an interpreter [16] . In their review Cowan et al. [17] reported several advantages to TP, both from the patient's and the clinician's points of view. By working in different settings (schools, prisons, homes, and hospitals) and with different populations (prisoners, students, employees, hospital patients and outpatients) clinicians can have flexibility in scheduling appointments and an increased diversity of practice. They may also feel safer when This article is protected by copyright. All rights reserved evaluating patients without any risk of physical aggression. Furthermore, the use of TP allows clinicians to remotely consult other colleagues. Given a reasonable initial apprehension, discomfort and fear, patients generally report an increase in comfort and satisfaction after having used TP a few times. Comparably to patients, after a few trials, clinicians reveal an improved attitude toward TP as well, suggesting that increased exposure for clinicians may be important to alleviate their concerns about rapport [16] . With regards to efficacy, in a recent narrative review by Hilty et al. [18] , TP was found to be effective in terms of patient acceptance, ability to increase access to care and provision of good educational outcomes. Moreover, TP was found to be valid and reliable when compared to in-person services. Telemental health effectiveness compared to faceto-face treatment has been proven in various Randomized Controlled Trials (RCT). This has been proved to be valid also for psychotherapy. [19] [20] [21] . Both users and, particularly, nonusers of telemedicine reported disliking the loss of personal contact with patients. The decreased ability to detect nonverbal cues during video conferencing may limit the building of the relationship, since clinicians report some difficulties in picking up nuances and emotions [22] . Some clinicians may feel and look clumsy and uncomfortable or may have a hard time engaging with patients; eye contact can feel artificial across the screen as well. Clinicians have also expressed discomfort in being unable to take physical actions to reassure or assist their patients [18] . When randomly assigned to evaluate in-person vs videoconference therapy sessions psychiatrists reported lower therapeutic alliance in telemental health settings; they also persisted on being hesitant to use video conference for their therapy sessions because they believed that the therapeutic alliance was at risk [22] . Concerns have been voiced about certain patients possibly being non-suitable for TP, including individuals with psychotic symptoms, acute crisis or at risk of self-harm [17] . Patients with auditive, visual or cognitive impairments appear not to be eligible for telemental health services [17] . Furthermore, it has been proposed to carefully consider the role of substance abuse and past episodes of self-injurious or violent behavior before selecting a patient for a TP intervention [23] . Technical difficulties such as transmission unable to start, spontaneous This article is protected by copyright. All rights reserved disconnections, poor audio/visual quality and audio/visual delay may seriously affect the TP session. Sound quality may affect more substantially the interaction; although audio quality may be prioritized, poor visual transmission, resulting in decreased ability to detect nonverbal cues, remains a concern [24] . Clinicians are often reluctant to try TP because it is not something they are accustomed to [25] . New approaches to professional techniques require deliberate conscious efforts. There are deep-rooted cultural traditions in medicine that impede the diffusion of TP. Physical proximity has an important part in clinical practice, with an enormous cultural significance. Over the course of two thousand years, a doctor's physical presence has been regarded as necessary for clinical practice and patients' healing. Telemental health is not equally distributed among professional categories other than psychiatrists. For example, more than two-thirds of psychologists in the US have never used videoconferencing to deliver their therapeutic services in 2018 [26] . Finally, despite easier and cheaper access to the Internet the so called "digital divide" remains often reported in the literature and can impede TP diffusion [27] . These reports still reveal that the elderly, racial/ethnic minorities, and individuals from lower socioeconomic classes continue to trail behind in access to the Internet and thus in taking advantage of TP opportunities [28] . To address this limitation the Lancet Commission on Global Mental Health recommended adoption of digital interventions alongside traditional in-person treatments, rather than as replacements [29] . A relevant concern about using TP is privacy. It is important to ensure conversations' confidentiality and to protect health information and sensitive data. Another confidentiality issue is of technological nature, concerning network security and encryption [17] ; in fact, videoconferencing occurs through the Internet connection, it is therefore essential to guarantee that the meeting will not be easily hacked into, or viewed by others [14] . Clinicians and organizations who are supplying telemental health services must adapt their connection pathways and equipment to the health information protection laws, such as the USA's Health Insurance Portability and Accountability Act (HIPAA). In recent years a variety of platforms (like Zoom, Bluejeans, SimplePractice and others) have been developed with opportune security and confidentiality [30] , but privacy cannot be This article is protected by copyright. All rights reserved guaranteed in its entirety. In fact, the FBI warned about the weakness of such platforms after some unidentified users invaded several school-sessions, a phenomenon called "zoombombing". Because of the COVID-19 pandemic, some governments have issued an emergency waiver suspending the requirement to comply with information protection laws, as it happened in the USA for HIPPA, in order to facilitate access to telemedicine services [30] . However, the privacy issue remains a compelling one. Similar with in-person interventions, clinicians are legally obligated to seek informed consent and review possible risks and benefits of the treatment [31] . Nittari et al. [32] recently reviewed legal issues related to informed consent, data protection, confidentiality, physician's malpractice, and liability in telemedicine. The main issue reported by the authors is the global uncertainty of the legislation in the field. It has been suggested that clinicians need to update their knowledge and adapt to the newest regulations related to online interventions [31] . TP has been proven to be valid and reliable in a variety of psychiatric disorders. Depression is one of the most studied, and the evidence supporting the treatment of depressive disorders via TP is robust [33] . A large number of systematic reviews and meta-analyses have examined technology-based interventions for depression, but only few of those have attempted to synthesize the data with the purpose of determining the admissibility and influencing factors of the implementation of TP [34] . There are different forms of internet-delivered treatments for depression. One approach, based on bibliotherapy and the therapist's guidance via email or phone, uses primarily text-based materials. There are also short treatments that are not generally delivered with guidance and do not usually target people with clinical depression; although they can reach more people at a lower cost, they do so with a presumably diminished effect [35] . Globally, it seems that computerized treatments, administered with the support of a therapist, are much more effective than the unsupported ones, and that is confirmed in many open studies [36] . Patients with depressive disorders have been shown to benefit from TP, as reported by several studies in which patients' symptoms improved more in the telemental health group than in the traditional setting ones. A 2015 study evidenced how patients taking This article is protected by copyright. All rights reserved antidepressant in a high-intensity telemedicine-based collaborative care model reported less drug-related side effects than the low-intensity practice-based collaborative care patients [37] . Evidence from several studies has underlined that the use of TP for delivering mental healthcare services can improve symptoms of depression among older adults. The effects are the reduction of depression symptoms and the improvement of comorbid health conditions. A 2013 review analyzed the combination of TP with mobile apps targeting depression, anxiety disorders and substance abuse, reporting similar results [38] . Stanmore et al., in a meta-analytic review, showed that TP improves not only the patient's global cognition score, but also his/her cognitive functioning, which is often affected in depressive disorders [39] . In 2019 Pruitt and colleagues assessed patients' satisfaction in a group of military personnel with depression , who were included in a randomized clinical trial that utilized a type of psychotherapy known as Behavioral Activation Therapy for Depression (BATD); this was delivered in-office and at home by videoconferencing [40] . They discovered that patients' satisfaction was very high, with no significant difference between the two modalities, which is indicative of a comparable quality of care, and a satisfying level of Contrary to popular belief, higher levels of end-of-treatment satisfaction for in-person care were detected to be mostly associated with younger age patients. Conversely, the satisfaction for in-home care was more frequently associated with older and symptomatic individuals. Plausible explanations for such results include stigma, symptom severity and convenience. Younger patients, or those with less debilitating symptoms, may be more satisfied with traditional care treatments, while the elderly, or more symptomatic patients, may prefer a home-based care setting [40] . It has been proposed that telemental health strategies could be a useful resource in the treatment of patients with Obsessive Compulsive Disorder (OCD). With this kind of This article is protected by copyright. All rights reserved patients several barriers to treatment, such as logistic and financial barriers, as well as shame and fear of stigmatization or discrimination [41] , could lead to the customary long delay from the onset of the disorder to the first treatment delivery [42] ; telemental health therapies have the potential to overcome these barriers [43] . In their extensive review Videoconference-based CBT. All these approaches were based on the CBT principles. Therapists' level of involvement ranged from direct contact through video or phone, to completely automated computer programs with no direct involvement. All telemental health interventions resulted in a decrease in OCD symptoms for active participants. They observed that the most efficient studies included contact with the therapist (higher effect size and lower dropout rate), although approaches that did not include visual or The use of TP has been tested in patients with Schizophrenia as well. In their review, Kasckow et al. [50] summarized many studies involving telephone-based, internet-based and videoconference-based interventions and concluded that TP approaches were feasible with this kind of patients and that they could improve treatment outcomes. TP may help to engage these patients, to improve their medication adherence rates, to detect the exacerbation of psychotic symptoms and to prevent hospitalizations; nonetheless, only a strong patient-clinician engagement seems to guarantee an improvement in clinical and social functioning and an adequate relapse prevention [51] . Patients with Schizophrenia exhibited high satisfaction levels when using telepsychiatry approaches; in fact, many patients reported feeling more comfortable using TP methods to connect with their psychiatrist and, additionally, anonymous web-based interventions may help them reduce stigmatization feelings. This article is protected by copyright. All rights reserved prompts related to follow up appointments, hygiene, physical exercise, symptom management and supporting messages [52] . Psychotherapy is now the front line, gold standard treatment for common mental health disorders in evidence-based medicine [53] . Yet, due to barriers including access, cost and stigma, estimates suggest that up to two-thirds of individuals do not access or receive evidence-based care [54] . TP could help overcome those barriers. Herbst et al. [43] showed how, in a population of 34 patients, an Internet-based, therapist-guided CBT with Exposure and Response Prevention led to significant reductions in the main symptoms of OCD; they also observed that this improvement remained stable throughout the 6-month follow-up period after treatment. The i-CBT did not inhibit a solid patient-therapist working alliance; in fact, a strong and stable patienttherapist relation was established [55] . Matsumoto et al. [56] examined the feasibility of videoconference-delivered CBT in 30 adult patients with mild to severe OCD, Panic Disorder (PD) and Social Anxiety Disorder (SAD). They determined that there was a significant reduction in symptoms for each group, with a remission rate of 40% for OCD, 50% for PD and 22% for SAD. The therapeutic alliance significantly improved throughout the treatment and its scores were comparable to those of in-person CBT. The dropout rate was very low (3%), since 97% of patients completed the videoconference-delivered CBT treatment. Interestingly, 83% of the participants affirmed to prefer videoconferencedelivered CBT to face-to-face CBT. Additionally to tele-health services, in recent years digital technologies have found other Secondly, the applications of Virtual Reality (VR) are very promising for the mental health field. VR is defined as a computer-generated simulation, a set of computer generated images and sounds, representing a place or situation with which the person can interact utilizing special electronic equipment [58] . Immersion in VR allows the patient to savor emotions he has already experienced in the real world, yet also to face dysfunctional behaviors and traumatic situations in a safe setting. It allows each individual to act as the protagonist and to regain control of his actions, to feel as the active builder of his own experience and, over time, of the changes he brings into his own life [59] . The best applications of VR are found in PTSD, specific phobias, body-image disorders, such as nervous anorexia, and autism spectrum disorders. Finally, today psychiatrists have the unprecedented opportunity to benefit from the use of Artificial Intelligence (AI) and, more specifically, of Machine Learning. This technique allows the clinicians to analyze huge amounts of data with the aim of producing a biologically founded re-classification of Major Psychiatric Disorders. Increasing evidence suggests that the sub-classifications obtained from Machine Learning data analysis have better predictive power of treatment outcome than the traditional DSM/ICD models. In a new era of evidence-based psychiatry these objectively measurable transdiagnostic endophenotypes will allow the clinicians to make an early diagnosis, to individualize treatment and to make therapeutic adjustments to reduce disease relapses that are tailored for each individual. This has been called Computational Psychiatry [60] . COVID-19 pandemic brought to reduced social contact and impeded face-to-face interactions, also in delivering psychiatric assistance. The purpose of this paper was to review our knowledge about TP to inform its use during this pandemic, still lacking original studies addressing this topic. As shown, many are the advantages of TP, such as This article is protected by copyright. All rights reserved an improved access to care, the possibility for patients to receive psychiatric assistance in their native language, a reduction of travel time and costs and a comparable effectiveness to in-person care [17] . However, is also important to consider some limitations of telehealth. First of all, more studies are needed to ensure a broader and more reliable validation of TP, in terms of diagnostic reliability and therapeutic efficiency in the short and long term. Secondly, it is necessary to consider that TP is not suitable for all patients. Moreover, some concerns remain about TP use during acute crisis: important cues such as facial expressions, tone and posture can be missed in the TP consultation. For this reason, there must be regular screenings for adverse events and a procedure for crisis intervention must be readily available [43] . An important recommendation is to connect with on-site staff who may intervene if necessary [16] . The privacy issue is also not to be underestimated: patients should be educated about personal privacy problems rising from using TP services outside the traditional clinical setting, like when speaking in rooms where family members can hear the conversation, or in public places where anyone might listen [14] . The clinician himself must maintain privacy rules and ensure that no one will interrupt the session [22] . Despite the advantages and the technological progress TP is globally underused: in 2009, only about 2% of psychiatrists in the United States had used TP [12] . A recent article examining a large population of subjects from 2005 to 2017 concluded that, although telemedicine care had substantially increased during that time, its use was still not widespread in 2017 [61] . In addition, in 2014, the same 100 clinicians accounted for more than half of all tele-mental health visits that year [62] , suggesting that TP practice had been undertaken by very few, selected clinicians. During this pandemic period several Authors all over the world underlined the need to promote online mental health care services and encourage their use [13, 63, 64] . In fact, TP can capably respond to the mental health needs of people in isolation or quarantine, reducing infection risk. TP observes social distancing, avoids care interruptions and increases public health outcomes [65] . Considering that psychiatric population is more vulnerable to stress than general population, a disruption in care is concerning as it may increase the risk of symptom exacerbation and relapse. TP is precious to ensure continuity of care for these populations at higher risk of decompensation [63] . In this regard, recently the US Centers for Medicare and Medicaid Services waived restrictions This article is protected by copyright. All rights reserved on originating sites for telehealth [66] and the ability of healthcare professionals to prescribe remotely has been expanded to cover controlled substances [67] . In China, in addition, artificial intelligence programs have been used as interventions for psychological crises during the pandemic. Furthermore, online psychological counselling services have been widely established 24-h services on all days of the week [68] . Considering the experiences from past serious virus pandemics, improvement of mental health care are needed [69] . The increasing demand for psychiatric services in the overburdened mental health care system presents a risk of creating a global public mental health crisis throughout the world [70] . Despite initial difficulties to adapt the system to TP requirements, this crisis can be an opportunity to improve the healthcare system and to expand its accessibility for patients also for the future [63] . The review here presented has some limitations. Mainly, it has been conducted in a narrative way and using only one electronic database to search for articles. This decision has been undertaken in order to rapidly review the literature to inform the unfolding pandemic situation, but possibly limited the number of references obtained. There is the need for future research to investigate the topic in a systematic way, in order to rigorously assess the contribution of TP in COVID-19 pandemic. Focused and continuous trainings of clinicians are required to increase the awareness of the benefits and risks of TP. In relation to this, and considering the present pandemic, formally teaching TP in medical schools, residency trainings and continuing medical education programs should be encouraged. Among other benefits, this may be a way to help cultural acceptance of TP both among patients and medical staff. In conclusion, TP is destined to expand in the future and mental health professionals have a strategic role to help ensure that these technologies respect the therapeutic relationship and remain rigorous in their scientific foundation. Accepted Article Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan, China: Cross-Sectional Survey Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain Epidemic of COVID-19 in China and associated Psychological Problems Patients with mental health disorders in the COVID-19 epidemic Preventing problematic internet use during the COVID-19 pandemic: Consensus guidance Problematic Internet use (PIU), personality profiles and emotion dysregulation in a cohort of young adults: trajectories from risky behaviors to addiction Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2) Mental Health Response to the COVID-19 Outbreak in China Global mental health and COVID-19. The Lancet Psychiatry A health telematics policy in support of WHO's Health-For-All strategy for global health development: report of the WHO group consultation on health telematics The psychiatrist-patient relationship of the future: anytime, Accepted Article This article is protected by copyright. All rights reserved anywhere? A Viewpoint From Paris on the COVID-19 Pandemic: A Necessary Turn to Telepsychiatry Telemedicine for Child Collaborative or Integrated Care Current Directions in Videoconferencing Tele-Mental Health Research Therapeutic alliance in videoconferencing psychotherapy : A review Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers International Review of Psychiatry Telepsychiatry and other technologies for integrated care : evidence base , best practice models and competencies Psychotherapy for depression in older veterans via telemedicine: A randomised, open-label, non-inferiority trial Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment Resisting and promoting new technologies in clinical practice : the case of telepsychiatry Practical issues in delivery of clinicianto-patient telemental health in an academic medical center Original article ~ An evaluation of the use of interactive television in an acute psychiatric service Specialist Physicians' Knowledge and Beliefs about Telemedicine: A Comparison of Users and Nonusers of the Technology. Telemed e-health Survey of Psychologists ' Telebehavioral Health Practices : Technology Use , Ethical Issues , and Training Needs The Digital Divide Among Low-Income Homebound Older Adults : Internet Use Patterns , eHealth Literacy , and Attitudes Toward Computer / Internet Use Navigating the digital divide : a systematic review of eHealth literacy in underserved populations in the United States The Lancet Commission on global mental health and sustainable development Ethical standards for telemental health must be maintained during the COVID-19 pandemic Telemedicine Practice: Review of the Current Ethical and Legal Challenges Internet-based and other computerized psychological treatments for adult depression: a meta-analysis The use of technology for mental healthcare Accepted Article This article is protected by copyright. All rights reserved delivery among older adults with depressive symptoms : A systematic literature review Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis Free range users and one hit wonders : community users of an Internet-based cognitive behaviour therapy program Smartphones for smarter delivery of mental health programs: A systematic review The effect of active video games on cognitive functioning in clinical and non-clinical populations : A meta-analysis of randomized controlled trials Predicting post treatment client satisfaction between behavioural activation for depression delivered either inperson or via home-based telehealth Barriers to treatment and service utilization in an internet sample of individuals with obsessive-compulsive symptoms The Brown Longitudinal Obsessive Compulsive Study: Clinical features and symptoms of the sample at intake No talking, just writing! efficacy of an internet-based cognitive behavioral therapy with exposure and response prevention in obsessive compulsive disorder The potential of telemental health Accepted Article 466 Self-help with minimal therapist contact for obsessivecompulsive disorder: A review Stepped care versus standard cognitivebehavioral therapy for obsessive-compulsive disorder: A preliminary study of efficacy and costs Telepsychology for Posttraumatic Stress Disorder: A systematic review BDNF concentration and impulsiveness level in post-traumatic stress disorder Telepsychiatry-based care for the treatment follow-up of iranian war veterans with post-traumatic stress disorder: A randomized controlled trial Telepsychiatry in the assessment and treatment of schizophrenia Treatment Compliance in the Long-Term Paranoid Schizophrenia Telemedicine Study mHealth based interventions for the assessment and treatment of psychotic disorders : a systematic review Depression in Adults: Treatment and Management Urgent Need for Improved Mental Health Care and a More Collaborative Model of Care Working Alliance in Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder Internet-based cognitive behavioral therapy Accepted Article This article is protected by copyright. All rights reserved with real-time therapist support via videoconference for patients with obsessivecompulsive disorder, panic disorder, and social anxiety disorder: Pilot single-arm trial Using science to sell apps : Evaluation of mental health app store quality claims A Literature Overview of Virtual Reality ( VR ) in Treatment of Psychiatric Disorders : Recent Advances and Limitations Transforming experience : The Potential of Augmented Reality and virtual Reality for enhancing Personal and Clinical Change Review Machine Learning for Precision Psychiatry : Opportunities and Challenges Telemedicine Use in a Large Commercially Insured Population Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Aff Mobilization of Telepsychiatry in Response to COVID-19-Moving Toward 21st Century Access to Care The Role of Telehealth in Reducing the Mental Health Burden from COVID-19 Telemental Health in the Context of a Pandemic: the COVID-19 Experience Available from: Accepted Article This article is protected by copyright DEA Okays Telehealth to Prescribe Opioids Amid COVID-19 Emergency Online mental health services in China during the COVID-19 outbreak. The Lancet Psychiatry Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet Psychiatry Impact of human disasters and Covid-19 pandemic on mental health: Potential of digital psychiatry ijcp_13716_f1.pdf