Despite the increased awareness of schizophrenia in Hong Kong, there remains considerable stigma attached with the illness that prevents patients from receiving the appropriate treatment. A paradigm shift of the healthcare system with telemedicine is the next step to optimizing the management of schizophrenia in the post coronavirus disease 2019 (COVID-19) era. The United States (US) has taken initiatives to adopt artificial intelligence (AI) technologies in terms of telemedicine, treatment delivery, and treatment monitoring. As the technologies become mature, the issues of ethics and privacy must also be addressed. In a recent interview with Omnihealth Practice, Dr. Keith Hariman shared his views on the application of such technologies in the management of schizophrenia in Hong Kong.

The management of schizophrenia in Hong Kong

Schizophrenia is a very heterogeneous disease with varying degrees of prognosis, dependent on factors such as the level of medication adherence and the patients’ attitudes towards the disease. NICE guidelines in the management of schizophrenia are still broadly followed in Hong Kong, with pharmacotherapy, primarily second-generation antipsychotics (SGAs), and cognitive behavioral therapy (CBT) forming the main basis of treatment.¹ When asked about the goal of treatment, Dr. Hariman commented that, “The goal of treatment is not just the remission of symptoms or the removal of hallucinations and delusions, but also to help them reach their potential as much as they can, hopefully back to premorbid functioning.”

Most schizophrenia patients in Hong Kong receive treatments in the public sector, which is largely attributed to financial difficulties as it might be difficult for some patients to maintain a stable job and afford private healthcare.² The multidisciplinary and overarching support, from occupational therapists to social workers offered by the public sector, is also a major pull factor.³ Currently, in-person consultation is still the predominant mode of treatment delivery, but it is believed that the telemedicine model can be more widely adopted as well.

Telepsychiatry in the post COVID-19 world

In a cohort study, patients with schizophrenia were found to be associated with an increased risk for 45-day COVID-19 mortality after adjustment for known risk factors (Odds ratio: 2.67; 95% Cl: 1.48-4.80).⁴ This may be due to both biological and socioeconomic reasons. Patients with schizophrenia might have deficits in cellular immunity resulting in dysfunctional T cell-mediated immune responses, inadvertently increasing COVID-19 severity and mortality.⁴ Some patients also might have poor self-care and lack healthcare insurance coverage which, when compounded with financial difficulties, create barriers to treatment.⁴

The concept of telemedicine is not novel , the term has been coined as early as in 1950, being defined as the remote diagnosis and treatment of patients by means of telecommunications technology and has been a part of the vernacular since then.⁵ Telepsychiatry, which is a branch of telemedicine that provides a range of healthcare services via the telephone or video conferencing facilities, can be applied to increase the rate of treatment compliance and reduce the chance of contracting COVID-19 among psychiatric patients.^5,6 However, despite the ever-advancing technologies in communication, real-life widespread applications of telemedicine have yet to be realized.⁵

Practical applications of telepsychiatry and its revolutionary role

COVID-19 has led to a massive acceleration in the application of telemedicine, encompassing the entire process from diagnosis, treatment, to monitoring.⁶ The delivery of telemedicine is effective in relieving the burden of healthcare system in dealing with COVID-19, particularly in terms of reducing unnecessary human contacts.⁶

Consultations with healthcare professionals are the most straightforward application of telemedicine. Patients can communicate with their physicians and receive advice on treatment through videoconferencing without having to visit the clinic.⁵ In the past, this form of telemedicine was used to overcome problems with geographic distance or transportation, which were the major barriers to treatments overseas as it often took hours for patients to visit the closest clinic. At present, telemedicine is also used much more broadly to avoid overcrowding at locations of high infection risk, such as hospitals.⁶ In some instances where the internet connection may not be stable or fast enough, asynchronous virtual care can be employed where patients can upload information, such as a video illustrating the signs and symptoms, for the physicians to download and review later.⁷ This approach would be useful when scheduling may be difficult, or when there is a need for translators in order to overcome language and cultural barriers.⁷

Mobile delivery of treatment is the relatively new mode of telemedicine. In recent years, an ample number of mental health-related mobile apps have been made available on the market.⁸  Given the imbalance between the supply and demand for convenient modes of treatment, many tech companies have tried to obtain a foothold into the mental healthcare market.⁸ Digital interventions themselves are not new to mental health treatment, as internet-based CBT has been available for a long time. Yet, with the advent of smartphones and mobile apps, patients can readily access mobile therapeutic programs without having to sit through lengthy sessions in front of a conventional computer screen.⁸ For patients with schizophrenia, receiving treatment online may even be superior to traditional face-to-face consultations in certain aspects. For example, some patients with schizophrenia might not want to be seen at a conventional clinic because of the associated stigma, or find it difficult to be motivated to leave the house and see a doctor due to their negative symptoms.⁹ Those with severe delusions of persecution or reference might even fear leaving the house, worrying about the scrutiny of others on the street. Online treatment might make these patients less averse to interacting with physicians.⁸ Apart from CBT, technology can help with ensuring treatment compliance, an example of which are mobile apps that can be used as a reminder or tracker on whether the patient has taken their medications.¹⁰

Though the current application of telemedicine is largely limited to consultations and delivery of treatment, there has been research looking into how technology can facilitate the initial screening and diagnostic process.¹¹ Data on how a person interacts with technology, such as posts and activities on various social media such as Twitter, Reddit, and Facebook, or even just the use of their mobile phones, has been found to be useful in predicting certain mental disorders or behavior.⁹ Furthermore, what one person posts on social media might also be a better real time indication of their mental state than a recall of their overall mental status in the preceding weeks asked during a follow up visit. By leveraging these predictive signals and additional information, treatment for individuals at risk or already suffering from mental disorders may be improved with new data supplementing clinical care, for example through real time monitoring of mental state, identification of risky behaviors such as suicidal ideation or alcohol consumption, provision of timely interventions, or reaching populations that are difficult to access via the traditional clinical approaches.¹¹

Barriers of telemedicine development in Hong Kong

Telemedicine is not new to Hong Kong, but it has yet to see large scale adoption here. Partly due to the relative ease of access to healthcare services given the geographical proximity. However, privacy and confidentiality remain major concerns.¹² Debate persists in terms of how to handle the digital information properly. Both the system providers and patients should be assured that the transmission of information via the telemedicine remains private and secure.¹² From the medical practitioner’s perspective, in December 2019, the Medical Council of Hong Kong issued Ethical Guidelines on Practice of Telemedicine to guide doctors on how to engage in telemedicine.¹³ Firstly, doctors must exercise the same standard of care for both online and in-person consultation, i.e., they should ensure that the patient is suitable for a telemedicine interaction and the standard of care delivered is not compromised.¹³ It is also advisable to arrange a prior in-person consultation with patient before practicing telemedicine for the first time.¹³ If a physical examination is likely to provide critical clinical insights, the doctor should not proceed telemedicine until a physical examination can be arranged.¹³ These regulations have placed full accountability on the doctor that might have discouraged the adoption of telemedicine in Hong Kong further.¹³

Message to physicians

As with other revolutions in medical technology, the application of telemedicine needs more scrutiny, but technology can help bridge the gap between patients with schizophrenia and doctors more efficiently in the long run. Dr. Hariman emphasized by saying that “I don’t think technologies will replace doctors in the near future, but I think it will supplement and augment health practices to deliver optimal care to the patients with schizophrenia”.

Conclusion

By leveraging the advantages of telemedicine, patients with schizophrenia can achieve better mental health outcomes, with timely interventions as well as reduced risk of exposure to the COVID-19 pandemic. Online physician reviews and the delivery of treatment might reach more schizophrenic patients who are unwilling or unable to properly receive treatment via the traditional method, thus increasing the chance of treatment success and compliance. Physicians should be open to the benefits that telemedicine may bring to the treatment of schizophrenia and other mental disorders.