Think back to March 2020. Suddenly, instead of seeing your family doctor in person, your appointments were by telephone or video call. The phone rang. You waited one … two … three rings and then picked up. “Hello, it’s your family doctor. What can I help you with today?”
It was all new to you and to your family doctor, as well. Primary care adapted quickly to virtual appointments. Today, many patients with mental health concerns still prefer them, allowing patients to remain in the comfort and privacy of their own homes.
However, questions remain about how to best provide virtual mental health care, especially since virtual care is here to stay. Over the past two years, our team has conducted a research project to provide guidance for patients living with mental health conditions, and for primary care providers on how to make the most of virtual mental health care appointments.
When our team searched the literature, we did not find any clear, comprehensive guidance for patients or health-care providers on how to conduct virtual mental health appointments. We gathered as many recommendations as we could find and held focus groups with people who have lived experience of mental health concerns, and with primary care providers.
One common theme was training to use virtual platforms. While this was less of an issue for those using the phone (which remains the most common modality for mental health appointments), there was a major learning curve for video calls. Family medicine offices use different platforms so we could not develop a training manual on how to use a specific platform. In a team-based care environment, we recommend that a champion be appointed for understanding the full functionality of the video platform being used and to provide training – if primary care providers or patients are struggling with the technology, they have someone specific to turn to. Many video platforms have functionalities that facilitate communication, such as the use of captions and real-time language translation. When we reviewed studies about this, we found that seeing what their provider was saying written on the screen made the communications easier to understand for patients and their treatment plan more straightforward. This could even enhance health equity: developments in real-time language translation could allow patients to talk about their mental health in the language that is most comfortable and familiar to them, without the need for a translator.
Given that privacy was a concern for many in our focus groups, it is important for patients to know that the internet link their provider gives them for a virtual appointment is safe, secure and confidential. Providers must be explicit about this when using platforms like Zoom that can be used by the general public but has a more secure form for health-care providers.
Anticipating patient concerns and putting patients’ minds at ease is an important first step for a productive virtual mental health visit. Some focus-group participants told us they thought they were being observed by their family doctor when they opened the video platform because it showed provider’s camera was active:
“She’s on the other end watching me for about 10 minutes … And then she starts the meeting and she talks to me. So, she has about a 10-minute lead time of just watching me and, you know, noticing differences. I don’t know what she’s looking for. But she’s noticing me.”
“I don’t know what she’s looking for. But she’s noticing me.”
At the same time, providers in the group said they had no idea people were having this experience. This simple misunderstanding provoked substantial anxiety instead of supporting a therapeutic environment.
For both patients and providers, ending the appointment proved problematic. Patients said they felt appointments ended abruptly, especially when using the phone. Again, this seemed related to a simple misunderstanding, where patients explained no one told them how long appointments were booked for. As one participant explained:
“So, I’m just saying what I have to say, and then all of a sudden, they go, “Oh, I have to go now.’ That re-traumatizes me. I’d rather they give a heads up. I know in therapy sessions, sometimes the therapist will say, ‘OK, we have 10 minutes to unlock, we have to wind down,’ so I know when to wind down … so that I’m not feeling rushed and re-traumatized.”
Providers explained they had their own challenges in ending appointments because they could not use physical cues to indicate the appointment was coming to an end, such as standing up or walking the patient to the door. This communication breakdown left patients feeling uncomfortable and providers feeling awkward. The solution is simple – transparently communicating the appointment length. This would allow patients to plan their time accordingly and get all their needs met within the scheduled time.
Lags in the timing of communications were also a source of frustration. When patients need to get in touch with their provider between appointments, either to book a follow-up or communicate an urgent medical concern, they wanted to know when they could expect a response. It was less important to have a rapid response than it was to know when the response would come, so they could plan.
Though many of these suggestions are simple and can be implemented by primary care providers or their offices, we have created a video to empower patients with mental health conditions to advocate for what they can do to improve care.
Virtual care is here to stay. Before the COVID-19 pandemic, 58 per cent of Canadians were interested in trying virtual mental health tools. In 2022, roughly the same percentage of people were interested in seeing their health-care provider via video call and 72 per cent were interested in a telephone visit. Even as the pandemic waned, the number of virtual appointments remained steady; this was true across provinces, with family physicians using virtual care the most among medical specialties.
With profound shifts in how mental health care is delivered, and a clear interest in the continued use of virtual care, these simple recommendations can help everyone have a better experience in our “new normal.”
