To the editor,

I read with interest linked submissions in your journal by Olwill et al., and Ali et al., on the issue of telemedicine in psychiatry, use of which has been accelerated by the COVID-19 pandemic over the last number of months (Ali et al., Reference Ali, Majlöf and Fedorów2020; Olwill et al., Reference Olwill, Mc Nally and Douglas2021).

Many aspects of telemedicine are undoubtedly useful, including reduction of travel costs for service users and staff (Avidor et al., Reference Avidor, Loewenstein, Waisbourd and Nutman2020), increased flexibility for staff and greater access to specialist advice for rural service users and primary healthcare providers (Jordan et al., Reference Jordan, Jessen and Ferucci2021).

While Ali et al., make a valid point also about service user satisfaction with telemedicine, I note this does not necessarily correlate to outcomes. There is evidence that indicates service user adherence decreases when telemedicine is used for prolonged periods (Kinoshita et al., Reference Kinoshita, Cortright, Crawford, Mizuno, Yoshida and Hilty2020). This might be mitigated by using telepsychiatry solely as an intermittent add-on for those who express a preference for the medium.

Furthermore, Uscher-Pines et al., note clinician concerns about the impact of poor telehealth infrastructure and corresponding inconsistent internet access affecting more disadvantaged service users in particular (Uscher-Pines et al., Reference Uscher-Pines, Sousa, Raja, Mehrotra, Barnett and Huskamp2020). Given the risk of presenting later with schizophrenia has been demonstrated to be related to social class (Mulvany et al., Reference Mulvany, O'Callaghan, Takei, Byrne, Fearon and Larkin2001), there is a potential risk of further extending this gap by inadvertedly increasing discrimination by means. For example access to appropriate electronic technology such as appropriate computing hardware or adequate mobile data or broadband internet speeds, could disproportionately affect rural dwelling, socially isolated or financially impoverished service users.

The issue Olwill et al., raise of the potential impact on confidentiality could be relevant to service users living in more crowded dwellings. This is important in an Irish context, given current low levels of housing supply (Conefrey & Staunton, Reference Conefrey and Staunton2019). I note that clinician concerns over limited training received in telemedicine have also been recently articulated by Guinart et al. (Reference Guinart, Marcy, Hauser, Dwyer and Kane2021).

In future severity of illness could play a role in whether telehealth interventions are chosen. Lawes-Wickwar et al., have highlighted the poor quality of trials conducted into the effectiveness of telehealth interventions in those with severe mental illness. They also note a lack of investigation over acceptability and cost-effectiveness in this cohort, and identified research where telehealth patient education interventions had no benefit and were less acceptable to service users compared with traditional methods (Lawes-Wickwar et al, Reference Lawes-Wickwar, McBain and Mulligan2018).

By this letter, I hope to highlight some potential deleterious effects to the most severely unwell by a more marked shift to the practice of telepsychiatry, and a need to further investigate the impact of this shift. In light of healthcare time and cost savings of aspects of telemedicine, a hybrid model encompassing greater training for clinicians and taking into account accessibility of telehealth and severity of illness might be more beneficial to service users and service providers alike.