3 Jun 2021

Wyler H et al. BMC Psychiatry 2021; 21: 237

The COVID-19 pandemic brought significant changes to the administration of psychological and psychiatric care. In Switzerland, the Society of Swiss psychiatrists and the Confederation of Swiss psychologists recommended that treatment via telephone or videoconferencing tools should be implemented and chosen over face-to-face sessions. However, if an in-person session was necessary, patients were required to follow hygiene rules before the session, social distancing rules were observed during the session and the therapist was required to wear a face mask. The aim of the current study was to investigate how adult patients with ADHD and their therapists experienced therapy sessions under the adjustments necessary due to the COVID-19 pandemic in one of the following three treatment modalities: face-to-face with the therapist wearing a face mask; videoconferencing; or telephone.

In this exploratory, quantitatively driven mixed-method study, which combined quantitative questionnaire data and qualitative data from responses to open-ended questions, adult patients with a diagnosis of ADHD according to the International Statistical Classification of Diseases and Related Health problems, 10th Revision (ICD-10) who were receiving treatment at a specialised outpatient clinic were enrolled. The study assessed patients’ evaluation of the session, their treatment satisfaction and patients’ and therapists’ ratings of therapeutic alliance. Qualitative comments from the patient and therapist on their experience of the session were also collected. For statistical analysis, data from the telephone group and the videoconferencing group were combined into a single ‘telepsychiatry’ group.

Patient questionnaires:

  • Session Evaluation Questionnaire (SEQ) – to assess their self-reported immediate session experience
  • Client Satisfaction Questionnaire (CSQ) – to assess patient satisfaction with the mental health services
  • Working Alliance Inventory – short revised version for patients (WAI-SR-P) – to assess therapeutic alliance
  • A four-item questionnaire designed to assess patient experience with the COVID-19 pandemic, as well as specific closed and open-ended questions about the session

Therapist questionnaires:

  • Global Assessment of Functioning (GAF) Scale – to assess overall patient functioning from the therapist’s perspective
  • Working Alliance Inventory – short revised version for therapists (WAI-SR-T) – to assess therapeutic alliance
  • Specific closed and open-ended questions about the session

Overall, therapists completed 97 questionnaires, of which 66 (68%) were returned by patients. Data from six patients were excluded; therefore, the final sample size was 60 patients (face-to-face, n=29; videoconferencing, n=11; telephone, n=20). The mean (standard deviation [SD]) age of the participants was 39.1 (11.19) years (55% male), and participants had attended a mean (SD) of 2.42 (1.49) sessions in the relevant modality. Patients had a mean (SD) of 1.68 (0.65) psychiatric diagnoses including a diagnosis of ADHD. The most common comorbidity was mood disorders (27%), neurotic, stress-related and somatoform disorders (22%), substance-use disorders (7%) and personality disorders, impulse-control and ‘habit’ disorders (7%). Patients in the telepsychiatry group had attended more sessions in that modality than patients in the face-to-face group (p<0.001); otherwise, the groups were similar.

Analysis of the data revealed that patients in the telepsychiatry sessions rated these as significantly less deep as compared with face-to-face sessions (p=0.001). However, patients in the videoconferencing group experienced more depth to their session as the number of the sessions increased. No statistically significant differences regarding session flow, post-session positivity, satisfaction and therapeutic alliance were observed. In terms of patient preference regarding pre-COVID-19 pandemic therapy sessions versus current sessions, 56.7% of patients indicated no difference, whereas 38.8% preferred the sessions as they were prior to the pandemic. Approximately 17% of patients in the face-to-face group indicated that mask-wearing by the therapist inhibited communication, due to difficulty reading facial expressions and harder to understand acoustically. Patients in the videoconferencing group appreciated organisational advantages regarding scheduling, and no travel time to sessions.

Similarly, therapists noted the complicating factors associated with mask wearing; however, for approximately 40% of patients, therapists felt that face-to-face sessions were largely comparable with pre-COVID-19 pandemic sessions. The negative effects of mask wearing were minimised for those patients who had a pre-existing bond of trust with their therapist. Issues associated with telepsychiatry sessions related to limited ability to assess the patient, their reactions and body language, and inability to utilise certain therapeutic tools such as whiteboards.

This study contains several limitations. For example, the results of this study are limited to patients who are already in treatment and are familiar with their therapists, and who were able to express preference regarding continuing therapy during the COVID-19 pandemic in a setting which they felt comfortable with. The generalisability of the results are also limited as all patients were treated by 1‒2 therapists. Due to the small number of cases in the videoconferencing group, these data were combined with the telephone group; therefore, future studies are recommended to include large sample sizes to distinguish between different types of telepsychiatry.

In this study, according to the authors, face-to-face sessions with a therapist wearing a face mask and telepsychiatry sessions appeared to be valid options for the continuity of care for adults with ADHD during the COVID-19 pandemic. In identifying the most suitable modality, patient preference, session content and therapeutic methods are recommended to be considered.

Read more about face-to-face versus telepsychiatry sessions for adults with ADHD during the COVID-19 pandemic here

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Wyler H, Liebrenz M, Ajdacic-Gross V, et al. Treatment provision for adults with ADHD during the COVID-19 pandemic: an exploratory study on patient and therapist experience with on-site sessions using face masks vs. telepsychiatric sessions. BMC Psychiatry 2021; 21(1): 237.

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