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Integrating Telepsychiatric Services into the Conventional Systems for Psychiatric Support to Health Care Workers and Their Children During COVID-19 Pandemics: Results from A National Experience

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Introduction

After the emergence of the first cases in Wuhan Province China, COVID-19 has been spreading worldwide rapidly. Now, with the current numbers, the world is dealing with >3 million cases and mourning for over hundreds of thousands of deaths.1 Not surprisingly, health systems are under the most pressure as in all previous global traumas such as wars and prior pandemics.2 Although the responses of governments, the health policies, the capacities of health systems, and even the methods to diagnose and treat the disease have been widely variable across the world, the common global truth was the fight of “the heroes of health armies” for saving people’s life regardless of their conditions and at the cost of getting seriously ill and even losing their lives. According to various official reports, health care workers (HCWs) constitute 6–13% of all COVID-19 cases.3

Beyond the pressure of getting infected, HCWs are subject to many other hazards, including long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence.4 Psychological well-being of HCWs are particularly important during a pandemic.5 Preliminary reports from China suggest that HCWs were more prone to severe insomnia, anxiety, depression, somatization, and obsessive–compulsive symptoms and thus the risk of allostatic overload and burnout.6

Because of the public health measures for COVID-19 and HCWs’ avoidance of contact with even psychiatrists, classical psychiatric services that depend on face-to-face psychiatric sessions fall behind providing the psychiatric help for HCWs during the pandemic. Not surprisingly, telehealth applications were the primary source of support recommended by most of the medical associations worldwide.7 Although previous research suggested that telehealth would help to overcome unique challenges to psychiatric delivery during pandemics, there was also research mentioning the concerns of clinicians and patients about its usage during crisis such as securing safety for patients.8 In this respect, there seemed to be a need for combined models for planning psychiatric help during pandemics, but there is hardly any evidence on sustainability and benefits of integrating telepsychiatric services into the conventional systems of mental health care, particularly during times the rapid organization is needed.9

Turkey was one of the countries that activated national plans in the earliest days of the COVID-19 outbreak. As the first reaction of the country, a scientific advisory board was set up on January 10, 2020, after the emergence of the COVID-19 outbreak before the World Health Organization confirmed it mid-March as a pandemic. The board initially consisted of 38 members, including university professors and medical experts specialized in different branches of medicine and law.10–12 The board’s recommendations, ranging from treatment guidelines to public health measures and border policies, strongly shaped the COVID-19 policy of the country. As a result of this evidence-based approach, the onset of the first case was delayed until mid-March, which provided time to make the necessary preparations in the health system. One of the priorities of the Turkish health system was supporting the mental health needs of >1 million HCWs in Turkey.

In this article, we present a system that was established to provide psychiatric help for HCWs that combined telehealth applications with local psychosocial support teams, allowing services from video calls to emergency interventions.

Materials and Methods

Ethics committee approval was received from Ankara State Hospital. The Ruh Sagligi Destek Sistemi-Mental Health Support System (RUHSAD) is one of the systems designed to provide psychiatric help to HCWs in Turkey. The system combines the telehealth applications with the services from local psychosocial intervention teams. A mobile application (MA), which has the same name RUHSAD, is in the center of the system. The MA was developed by the Turkish Ministry of Health and available in mobile stores. Only HCWs who are registered to the Turkish Ministry of Health can gain access to the system.

In Turkey, all medical staff members working in a state or private health unit are registered with ministry of health with ID numbers. When the application is downloaded to a mobile device, the system matches the given ID number with ministry of health records. In the second step, the system asks the individual about the type of support needed. There are two options: (1) “I need support for myself” and (2) “I need support for my child.” After the choice, live operators of the ministry of health welcome the health worker and ask the individual to text about the problem briefly for identifying initial complaint. The MA also shows the current localization of users that allows operators and psychiatrists to report the emergencies to local units. The operators then agree on an appointment with the HCW using the lists that were already scheduled by psychiatrists through text messages. The operators accept applications on a 24/7 basis. When the appointment time comes, a child or adult psychiatrist checks the availability of a HCW for a call by text messages of the system and makes a video call. Twenty-one adult psychiatrists and 17 child and adolescent psychiatrists voluntarily participated in the system.

Considering that there might be many different problems, the online sessions were not structured or not based on a specific therapy method. The system allowed clinicians to set their session times themselves, set control visits, and contact patients again if needed. There were also coordinators from the ministry of health who were responsible to manage the system, connect with the field teams already established in all 81 cities of the country locally to coordinate the psychosocial support in case of a need for face-to-face psychiatric evaluation such as suicidal ideation and need for hospitalization. The field teams consisted of social workers, psychologists, and child development experts. Although RUHSAD coordinators contact the local psychosocial support teams, they were contacting the patient and set a face-to-face appointment with the closest psychiatrist. The operation scheme of the system is summarized in Figure 1.

Fig. 1.

Fig. 1. The operation scheme of the system.

On April 8, 2020, the system was announced to all health care units and media. On May 3, 2020, a brief telephone survey to determine the satisfaction level of users and possible feedbacks was conducted by the system managers. The HCWs were asked to rate the satisfaction level from the system out of 0–10, 10 being fully satisfied. They were also asked whether their psychiatric support needs were responded to or not.

Statistical Analysis

The data obtained from the study were analyzed using the Statistical Package for Social Sciences (SPSS) 24.0 package program. Although frequency and percentage were used for categorical data, mean and standard deviation values were used for continuous data. Chi-square test was used in the analysis of categorical data. While making tests on continuous variables, the assumptions were checked. According to the assumptions, although parametric tests were applied to normally distributed variables, nonparametric tests were applied to non-normally distributed variables. “Single sample t-test” and “independent sample t-test” were applied for parametric conditions. For nonparametric cases, “Wilcoxon sign test” and “Mann–Whitney U test” were used. The tests were examined at a 95% confidence level and significant differences were interpreted as a result of the tests. Values with p < 0.05 were considered to be statistically significant, and p-value was directly written to indicate the level of significance in the findings.

Results

Two thousand six hundred eighty-eight (n = 2,688) individuals downloaded the MA between April 8 and May 3, 2020. The number of individuals who asked for a psychiatrist appointment from operators after downloading the app was 1,076 (n = 879 [81.6%] support for self) (n = 197 [18.4%] support for child). Four hundred forty-nine (n = 449) HCWs (41.7%) replied to video calls and received psychiatric help from psychiatrists on the time of appointment (n = 351 [78.1%] support for self) (n = 98 [21.8%] support for child).

The sociodemographic factors of HCWs who received psychiatric support are summarized in Tables 1 and 2.

Table 1. Sociodemographic Factors of Health Care Workers
SOCIODEMOGRAPHIC VARIABLE SUPPORT FOR SELF (n = 351)
Age (year), mean + SD 34.7 (2.14)
Gender
 Female (%) n = 224 (63.8%)
 Male (%) n = 127 (36.2%)
Occupation
 Doctor/dentist (%) n = 96 (27.5%)
 Nurse (%) n = 144 (41.0%)
 Emergency medical technician (%) n = 35 (9.9%)
 Social worker (%) n = 12 (3.4%)
 Medical secretary (%) n = 21 (5.9%)
 Midwife (%) n = 18 (5.1%)
 Security guard (%) n = 12 (3.4%)
 Manager (%) n = 8 (2.2%)
 Others (%) n = 5 (1.4%)
Average years of professional experience (year), mean + SD 9.3 (1.1)
Risk of contamination
 High risk (%) n = 139 (39.6%)
 Low risk (%) n = 181 (51.5%)
 Missing n = 31 (8.8%)
Location
 Urban (%) n = 214 (60.9%)
 Rural (%) n = 137 (39.1%)

Table 2. Data Regarding Health Care Workers
VARIABLE SUPPORT FOR SELF (n = 351)
Satisfaction level, mean 8.16
Support needs responded
 Yes n = 314 (89.4%)
 No n = 6 (1.7%)
 Missing n = 31 (8.8%)
Need for control visit n = 48 (13.6%)
Need for local unit support n = 5 (1.4%)
Reason for referral
 Eccessive fear of contamination n = 178 (50.7%)
 Depressed mood n = 51 (14.5%)
 Psychosomatic symptoms n = 34 (9.6%)
 Sleep problems n = 59 (16.8%)
 Not related with pandemic n = 16 (4.5%)
 Not mentioned n = 13 (3.7%)
Previous diagnosis
 Bipolar disorder n = 6 (1.7%)
 Anxiety disorder n = 22 (6.2%)
 Depressive disorder n = 7 (1.9%)
 Obsessive compulsive disorder n = 14 (3.9%)
Total n = 49 (13.9%)

The overall satisfaction level of HCWs for the service they received was 8.1/10 (8.1/10 for support for self, 8.4/10 for support for the child). In total, 86.6% (n = 389) of the HCWs reported that their support need was responded. Although the psychiatrists needed control visits for 13.6% (n = 48) of their patients, child psychiatrists needed control visits for 14.2% (n = 14) of children. Psychiatrists reported a need for local unit support for 1.4% (n = 5) of their patients. These patients had severe symptoms (two manic attacks, two depression, and one trichotillomania) that they could not handle through video call. Child psychiatrists reported a need for local unit support for three cases (3.0%): two severe attention deficit hyperactivity disorder cases and one severe obsessive-compulsive disorder case.

The most common reason for referral to psychiatrists was excessive fear of contamination (50.7%, n = 178) and the need for counseling on telling children about the pandemic (41.8%, n = 41) to child psychiatrists. Forty-nine (13.9%) of adults and 13.2% (n = 13) of children had previous psychiatric disorders (Tables 3 and 4).

Table 3. Sociodemographic Factors of Health Care Workers and Their Chidren
SOCIODEMOGRAPHIC VARIABLE SUPPORT FOR MY CHILD (n = 98)
Age of child (year), mean + SD 10.2 (3.7)
Gender
 Female (%) n = 57 (58.5%)
 Male (%) n = 41 (41.5%)
Client
 Mother (%) n = 95 (96.9%)
 Father (%) n = 3 (3.0%)
Age of mother (year), mean + SD 36.2 (2.8)
No. of children
 1 (%) n = 30 (30.6%)
 2 (%) n = 39 (39.7%)
 3 (%) n = 15 (15.3%)
 4 (%) n = 5 (5.1%)
 >4 (%) n = 0 (0%)
 Missing (%) n = 9 (9.1%)
Occupation of parents
 Doctor/dentist (%) n = 21 (21.4%)
 Nurse (%) n = 32 (32.6%)
 Emergency medical technician (%) n = 10 (10.2%)
 Social worker (%) n = 5 (5.1%)
 Medical secretary (%) n = 9 (9.1%)
 Midwife (%) n = 11 (11.2%)
 Security guard (%) n = 0 (0%)
 Manager (%) n = 0 (0%)
 Others n = 3 (3.0%)
 Missing n = 7 (7.1%)
Average years of professional experience of parents (year), mean + SD 10.2 (4.4)
Risk of contamination
 High n = 37 (37.7%)
 Low n = 52 (53.0%)
 Missing n = 9 (9.1%)
Location
 Urban area n = 55 (56.1%)
 Rural area n = 44 (44.8%)

Table 4. Data Regarding Health Care Workers and Their Children
VARIABLE SUPPORT FOR MY CHILD (n = 98)
Satisfaction level, mean 8.42
Support needs responded
 Yes n = 75 (76.5%)
 No n = 14 (14.2%)
 Missing n = 9 (9.1%)
Need for control visit n = 14 (14.2%)
Need for local unit support n = 3 (3.0%)
Reason for referral
 Pandemic related with anxiety n = 15 (15.3%)
 Hyperactivity and behavioral problems n = 24 (24.4%)
 Sleep problems n = 11 (11.2%)
 Bedwetting n = 4 (4.08%)
 Psychosomatic symptoms n = 3 (3.06%)
 Counseling on telling children about the pandemic/parenting support n = 41 (41.8%)
Previous diagnosis
 Pervasive developmental disorder n = 1 (1.0%)
 Anxiety disorder n = 3 (3.0%)
 Learning disabilities n = 1 (1.0%)
 Obsessive compulsive disorder n = 2 (2.0%)
 Attention deficit hyperactivity disorder n = 6 (6.1%)
Total n = 13 (13.2)

In contrast, there was no significant relationship between satisfaction level and sociodemographic characteristics of all examples. This applies both to those who seek support for their child and to themselves. Also, there was no significant correlation between the reason for referral, previous diagnosis, and satisfaction level. Those who received local unit support and the need for control visits were compared with other variables and no statistically significant difference was found.

Discussion

In this article, we used a comprehensive mental health delivery system for HCWs combining telehealth and local interventions during the COVID-19 pandemic. Considering ∼13% of patients’ need for a control visit with the same psychiatrist and some severe patients’ need for local team’s intervention, using a MA that allows seeing the current location and arranging control visits seems to be a better choice compared with other telehealth tools such as telephone helplines that all systems are dependent on individual’s self-report. This approach covering different ranges of support needs might also be an explanation for the high ratios of “needs being responded by system.” Although local support was needed for only eight patients, considering the severity of their problems and the possible burden on individuals and their institutions, early and effective intervention had critical importance. The existence of these cases in this study was supporting the telehealth literature recommending the employment of support staff where the patient is located who may intervene in case of an emergency.8

One of the most important findings of the study is the high satisfaction levels of HCWs who used the system. In their survey with HCWs during the first days of the pandemic, Shanafelt et al. asked health care professionals about their concerns, messaging, and behaviors they needed from their leaders, and sources of support they believed would be most helpful to them. The results underlined five requests from health care professionals to their organization that were “hear me, protect me, prepare me, support me, and cares for me.” The HCWs also mentioned the psychological support system as one of the key components of their needs.13 In this study, we used a free-of-charge, unique to HCWs, 24/7 operating, and easy to use the system that allows us to reach psychiatrists. Although we do not have direct data, beyond the quality of service gathered from experienced psychiatrists, getting help from such an official system might address a need for being supported by their organization and thus increase the high satisfaction levels.14

With respect to the sociodemographic factors, it was shown that the majority of applicants were nurses, this was consistent with and representing the Turkish health workforce statistics that shows that nurses are the leading professional health care practitioners in Turkey. In contrast, we received applications from most of the professions working in the health system and all cities of the country that may underline the importance of covering all allied professions wide distribution of systems around the country.15

İnitial psychiatric complaints were consistent with the expectations mentioned in the public health emergency literatüre.16 Although the fear of contamination or anxiety ratios seems to be similar, depression and sleep disturbance ratios seem to be lower than surveys from China. This may be explained by different working conditions in countries such as working time and also, studies conducted that “uncertainty” which is one of the main factors provoking mental health problems was more prominent in the early days of the pandemic.17

Considering the more challenging physical and emotional conditions and enhanced infection risk, it might be expected that HCWs from the units with high exposure risk would seek more psychiatric help. İnterestingly the need for psychiatric help was not significantly higher among HCWs working in units with more COVID-19 exposure risk such as emergency, intensive care, and special COVID-19 inpatient units. This may be explained in two ways. Mitchell and Bray’s rescue personality theory claims that the staff members who choose to work in emergency settings have better stress management skills and less neuroticism, which might have reduced anxiety and depression. Another explanation may be about the hard schedules that might cause difficulty accessing the system of the HCWs working in these units.18,19

Another important finding is that one-fourth of users asked to seek support for their children. Although nearly all of the early studies during the COVID-19 pandemic examining the psychiatric needs of HCWs focus on an individual’s problems, the dynamics of a pandemic should be putting a great burden on children of HCWs as well. In this study, the most common reason for referral to child psychiatrists was a need for counseling on telling the children about the pandemic. Considering that there are many resources from the beginning of the pandemic on “how to tell pandemic to children” in countries including Turkey, for preventing parental stress related to this issue, there should be unique tools that policy makers ensure that HCWs who have children are properly informed.20 Considering the large literature showing the negative correlation between children’s mental well-being and parental stress,21–23 it must be taken into account that reducing parental stress and ensuring HCWs’ children’s psychological well-being would increase workforce confidence and prevent psychopathology among their children.24

Conclusion

The findings of this study suggest that although telepsychiatry may be useful in public health emergencies such as the COVID-19 pandemics, it should not consist of only telephone lines or video calls. Systems combining telehealth applications and local intervention teams may be more effective, and establishing such organizations is possible in short intervals. MAs may be a useful tool considering the advantages of easy access, determining current location, and control visits with the same psychiatrists.

The results of this research also support the idea that psychiatric help for children of HCWs should be an indispensable part of support systems.

The most important limitation of this study and the system seems to be the dropouts after asking for an appointment. Nearly half of the HCWs, who asked for a psychiatric help, did not attend the video calls. Many factors might affect this result including interchangeable work schedules preventing to comply with the given time, the resistance to change the habits on getting face-to-face psychiatric help, and motivation for trying the system rather than a real need for help in some individuals. Although the system was suitable for asking another appointment by the user, we did not try to contact with nonattenders because of the hard schedule of psychiatrists as well. Contacting after the missed appointment could increase the attendance.25

Acknowledgments

We thank all of our staff and colleagues who volunteered individually or as an institution such as Bakırköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, İstanbul University Department of Child Psychiatry, and Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital for supporting health care workers.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.

References





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