A systematic review of the literature on telepsychiatry for bipolar disorder

Abstract Objective Bipolar (BP) disorder is a highly morbid disorder that is often misdiagnosed or undiagnosed and affects a large number of adults and children. Due to the coronavirus disease 2019 public health emergency stay at home orders, most outpatient mental health care was provided via telepsychiatry, and the many benefits of virtual care ensure that this will continue as an ongoing practice. The main aim of this review was to investigate what is currently known about the use of telepsychiatry services in the diagnosis and treatment of BP disorder across the lifespan. Method A systematic literature review assessing the use of telepsychiatry in BP disorder was conducted in PubMed, PsychINFO, and Medline. Results Six articles were included in the final review. All included articles assessed populations aged 17 years or older. The literature indicates that BP disorder was addressed in telepsychiatry services at a similar rate as in‐person services, reliable diagnoses can be made using remote interviews, satisfaction rates are comparable to in‐person services, telepsychiatry services are able to reach and impact patients with BP disorder, are sustainable, and patient outcomes can improve using a telepsychiatry intervention. Conclusions Given the morbidity of BP disorder, the research addressing the telepsychiatry diagnosis and treatment of BP disorder is sparse, with only emerging evidence of its reliability, effectiveness, and acceptance. There is no research assessing the safety and efficacy of telepsychiatry in pediatric populations with BP disorder. Given the morbidity associated with BP disorder at any age, further research is needed to determine how to safely and effectively incorporate telepsychiatry into clinical care for BP adult and pediatric patients.


INTRODUCTION
The outbreak of severe acute respiratory syndrome coronavirus 2, a pathogen that causes coronavirus disease 2019 , led to a transformation of mental health care. In response to social distancing directives in March 2020, psychiatrists and psychologists as well as other mental health clinicians converted their work from predominantly in-person encounters to encounters via remote audiovisual platforms, a practice referred to as telepsychiatry. While this change has affected the delivery of health care, these virtual visits are especially well suited to psychiatry, which does not require a hands-on physical exam.
Telepsychiatry dates back to the 1950s (Chakrabarti, 2015) and the term itself was coined in 1973 (Dwyer, 1973), but its use by state agencies has rapidly increased in recent years, from 15.2% in 2010 to 29.2% in 2017 (Spivak et al., 2020). In 2012, telepsychiatry was reported to be the second most practiced form of virtual health care (Chipps et al., 2012). Our large academic medical center has been utilizing telepsychiatry virtual visits since 2013, with increasing adoption by psychiatrists and psychologists each year and nearly 100% adoption during the early months of the public health emergency March 2020.
Several studies have demonstrated patient and clinician satisfaction with this form of treatment (Hilty et al., 2013;Kroenke et al., 2014;Salmoiraghi & Hussain, 2015) as well as efficacy in a variety of specific patient populations such as underserved minorities, veterans, rural populations, and pediatrics (Lauckner & Whitten, 2016;Spivak et al., 2020;Yeung et al., 2016). While the use of telepsychiatry has been evaluated in several specific disorders including attentiondeficit/hyperactivity disorder (ADHD), anxiety disorders, schizophrenia, and posttraumatic stress disorder (Kasckow et al., 2014;Romijn et al., 2019;Spencer et al., 2020;Sunjaya et al., 2020), it remains unclear whether telepsychiatry can be used safely and effectively in the context of bipolar (BP) disorder.
BP disorder is a highly morbid condition and affects a significant number of adults with an estimated prevalence of 1.3%−5.0% (Dome et al., 2019) in addition to its recognized prevalence in youth of 2.9%-3.9% (Biederman et al., 2001;Lewinsohn et al., 1995;Merikangas et al., 2010;Van Meter et al., 2019). BP disorder affects up to 4.3% of primary care patients (Cerimele et al., 2014) and comprises a significant portion of mental health clinic populations. Because of its morbidity, these patients require intensive psychiatry and psychology services. Diagnosing BP disorder can be difficult (Berk et al., 2005;Smith & Ghaemi, 2010) and only 52% of adults with BP disorder are accurately diagnosed by their first or second mental health professional (Lish et al., 1994). A significant minority of adults with BP disorder, 34%, are not accurately diagnosed for 10 years of illness or longer (Lish et al., 1994).
This may be because clinicians often diagnose and treat depression without recognizing mania . In fact, 25% of adults with BP disorder are initially given a diagnosis of unipolar depression (Lish et al., 1994), and it is estimated that up to 30% of patients presenting with depression are better diagnosed as having BP disorder (Piver et al., 2002). The problem of underdiagnosis in youth is even worse.
Pediatric onset BP disorder was largely neglected until recent decades.
Children with BP disorder present with features different from the classic presentation (Geller & Luby, 1997;Singh, 2008), and many clinicians still doubt whether BP disorder can present in prepubertal or early adolescent youth (Geller et al., 2004;Ghaemi & Martin, 2007).
Telepsychiatry reduces barriers to psychiatric treatment, making contact with mental health professionals convenient, with briefer interruptions to daily life and work routines. Traveling to appointments with children is especially stressful, and telepsychiatry improves access to mental health care for pediatric populations. Telepsychiatry is especially well suited to the treatment of BP disorder, as these patients often need frequent mental health visits for titration of multiple medications to treat mania, depression, and the many comorbid conditions.
In addition, frequent visits for safety monitoring of the pharmacotherapy for BP disorder is necessary due to high rates of adverse events seen in mood stabilizing medications (Baldessarini et al., 2019;Liu et al., 2011

Selection criteria
For this literature search, we included articles that investigated the use of telepsychiatry services in relation to BP disorder and that were published in peer-reviewed journals and written in the English language. Telepsychiatry services were defined as synchronous meetings between a patient and provider for which both audio and visual technology were utilized. Studies involving services delivered asynchronously (e.g., via a mobile phone application or clinician review of patient-completed rating scales) or using only audio (e.g., check-ins via phone call) were not included in this review, as these types of services offer different levels and types of care from face-to-face telepsychiatry.
We excluded any papers not related to telepsychiatry services, papers that examined a non-BP disorder sample, papers related to a different type of media (i.e., mobile phone applications or wearable technology), review articles, case reports, and opinion papers. Studies examining a non-BP disorder sample were defined as those studies F I G U R E 1 PRISMA diagram: Summary of databases used and articles deemed ineligible with explanations which either had a primary focus other than BP disorder or studies which did not explicitly report on a subset of individuals with a diagnosis of BP disorder. The senior author and the lead author screened the articles by abstract for relevance and eligibility. We then reviewed the full texts of articles appearing to be eligible based on the abstract review for inclusion.

RESULTS
As shown in Figure 1, our search identified 2438 articles (100 PubMed articles, 1869 PsycINFO articles, 30 MEDLINE articles, and 439 crossreferenced articles), 139 of which were duplicates. From the 2299 potential articles remaining after duplicates were removed, only six met our inclusion and exclusion criteria following abstract review. We excluded 1555 articles because they did not relate to telepsychiatry services, 146 articles because they examined a non-BP disorder sample, 106 articles because they were related to a different type of media, and 486 articles because they were theoretical papers.
Of the studies excluded from this analysis, and those that examined a non-BP disorder sample, a large number of these studies exam-ined a sample with schizophrenia (N = 41) or symptoms of psychosis (N = 13). Four studies included samples with multiple diagnoses and five included those with serious/severe mental illness. None of these studies were included because they either did not specifically include any participants diagnosed with BP disorder (N = 6) or were primarily focused on an aspect of health other than BP disorder (N = 3; i.e., smoking cessation, weight loss). There was a small number of studies (N = 4) which included participants with both BP disorder and posttraumatic stress disorder (PTSD). These were not included because they did not report results specific to the participants with BP disorder.
Another 13 studies involved samples with depression, either alone or with participants with one other type of psychiatric diagnosis (i.e., anxiety, psychosis, schizophrenia). These were not included as BP disorder involves additional morbidity and risks associated with manic symptomology. Additionally, 22 examined a non-psychiatric sample (i.e., surgical or otherwise medical), one focused on providers rather than patients, 13 examined general mental health (i.e., no disorders specified), 24 examined other non-related psychiatric disorders (i.e., anxiety, autism spectrum disorder, ADHD, PTSD, eating disorders, borderline personality disorder), and five were specifically related to suicide and one to self-harm behavior.
Of the excluded studies that examined a different type of media, After reviewing the full texts of the six remaining articles, no article were excluded. Therefore, we included six articles in our final literature review.
The characteristics of each study included in this review are presented in Table 1. Almost all of the identified studies included only adult patients; only one study included some pediatric patients, and the youngest participant was 17 years old (Sankar et al., 2021). Three studies provided information on the age of the patients receiving mental health care. Based on these studies, the age range of patients was 17 (Sankar et al., 2021) to 83 years old (Bauer et al., 2016). Three of the studies provided information on the gender of the patients. These samples were 64.38% (Seidel & Kilgus, 2014), 81.41% (Bauer et al., 2016), and 10% (Sankar et al., 2021) male, respectively.
All studies used video conferencing methods to provide telepsychiatry services. Of the five studies included in this review, three looked at use of telepsychiatry across multiple mental health disorders including BP disorder (Grubbs et al., 2015;Ruskin et al., 1998;Seidel & Kilgus, 2014) and three looked at only patients with BP disorder (Bauer et al., 2016(Bauer et al., , 2018Sankar et al., 2021). Two of the studies examining only BP disorder patients were part of the Bipolar Disorders Telehealth Program established by the U.S. Department of Veterans Affairs (VA) to expand outpatient care to veterans (Bauer et al., 2016(Bauer et al., , 2018. The other was part of a larger research study entitled "Brain Emotion Circuitry-Targeted Self-Monitoring and Regulation Therapy (BE-SMART)," which was designed for adolescents and young adults with BP disorder and also included imaging procedures (Sankar et al., 2021). Of the other studies, one was conducted with data on relevant mental health encounters in an outpatient program in the Veterans Health Administration (VHA) (Grubbs et al., 2015), one was conducted with psychiatric inpatients (Ruskin et al., 1998) and one was conducted with psychiatric patients presenting in the emergency department (Seidel & Kilgus, 2014).
The efficacy and acceptability of telepsychiatry services were assessed using a variety of different methods across the different studies. For example, telepsychiatry services were evaluated using quantitative (implementation and maintenance/sustainability) and qualitative (provider interview data) assessments (Bauer et al., 2018), retention rates and quantitative scales related to client satisfaction and therapeutic alliance as well as improvements in mood and social rhythms (Sankar et al., 2021), records of telepsychiatry participation and clinical impact (Bauer et al., 2016), and comparative participation in face-to-face versus telepsychiatry settings (Grubbs et al., 2015). These studies also differed in their measurements of interest, as two studies took suicide propensity or suicidal ideation and risk into consideration (Sankar et al., 2021;Seidel & Kilgus, 2014), while another also assessed patient satisfaction at the end of the intervention (Ruskin et al., 1998).
Through these various assessment methods, these five studies were able to create a multi-faceted, although limited, review of the benefits of telepsychiatry services in providing psychiatric care to adult patients with BP disorder.
In one study, Grubbs et al. (2015) investigated which psychiatric diagnoses are most commonly treated using telepsychiatry services.
To do so, they compared the diagnoses associated with face-to- In another study, Ruskin et al. (1998)   as well as suicidal ideation, dangerousness, and their recommendation to discharge or hospitalize. There were no significant differences in the agreement of the two interviewers' diagnoses and assessments of suicidal ideation, dangerousness, or need for hospitalization between the face-to-face condition and the telemedicine condition. These authors concluded that remote video telemedicine assessments can be reliably and safely employed in the emergency department setting.
In a study of the Bipolar Disorders Telehealth Program, Bauer et al. Additionally, the estimated suicide attempt rate per year was 2.2% during enrollment in the telepsychiatry program, similar to the estimated rate of 2% stemming from summary data in BP disorder samples (Baldessarini et al., 2001). These results suggest that telepsychiatry- and, due to their convenience and popularity, will continue to be implemented in treatment plans. In addition, we chose studies specifically addressing BP disorder as this population carries especially high risks of suicide, substance use disorders, and conduct/antisocial behaviors which pose large personal and public health risks.
It is expected that the public health emergency caused by COVID-19 will result in persistent changes to treatment delivery, including an increase in the use of telepsychiatry. In fact, de Siqueira Rotenberg et al.
(2020) have published a recommendation for a "swift transition" to digitally based approaches for the treatment of BP disorder. Therefore, it is critical to understand what is gained and what is lost during the delivery of treatment using telepsychiatry in place of traditional in-person visits. The very sparse existing literature shows that telepsychiatry may be utilized as frequently as in-person services for adults with BP disorder, indicating acceptance by clinicians and patients (Grubbs et al., 2015). Additional evidence supports telepsychiatry as reliable for the purpose of accurate diagnosis of BP disorder in adults, but this was studied only in psychiatric inpatient and ED settings (Ruskin et al., 1998;Seidel & Kilgus, 2014). For psychiatric inpatients with BP disorder, telepsychiatry was found to be as satisfactory as in-person services (Ruskin et al., 1998), consistent with recent reports of acceptability of other forms of digital health interventions among patients with serious mental health problems, but this satisfaction survey was based on only one virtual visit done in conjunction with an in-person visit (Berry et al., 2019;Vaidyam et al., 2019). Psychotherapy services delivered via video teleconferencing methods were found to be feasible and acceptable (as measured by retention rates, client satisfaction, and therapeutic alliance ratings) and to be clinically effective for mood, social rhythms, and suicidality in older adolescents and young adults (Sankar et al., 2021). However, this study provided no direct comparison to similar services provided in person. Finally, the most extensive use of telepsychiatry services was in the VA system. In this extensive 6-month time-limited treatment program, telepsychiatry was found to be clinically effective and feasible, indicated by increased implementation, sustainability over time, and acceptability among providers (Bauer et al., 2016(Bauer et al., , 2018. Some of the articles excluded from review for various reasons also provided useful information about the effectiveness of telepsychiatry for more general populations including those with BP disorder (Fortney et al., 2021). Taken together, this emerging evidence supports the idea that telepsychiatry services can be used safely and effectively for the treatment of older adolescents and adults with BP disorder, but the evidence is sparse and leaves many questions unanswered for this highly morbid population.  Sankar et al. (2021) provide evidence that the therapeutic alliance is strong in telepsychiatry-based services, but these authors did not provide a comparison to in-person treatment, limiting the ability to draw generalized conclusions. Given the rapid, widespread, and extensive adoption of telepsychiatry during the COVID-19 public health crisis, future psychiatric assessment and treatment will likely continue to utilize this modality. For clinicians and patients, this brings both gains and losses which have been minimally delineated, and awareness of these can inform more responsible treatment planning and better outcomes.
For example, patient satisfaction may be excellent for telepsychiatry services (Sankar et al., 2021) and may not differ overall between services delivered in person and via telepsychiatry (Ruskin et al., 1998) (Sankar et al., 2021), the characteristics of this alliance and how to best design digital interventions to cultivate a positive alliance remain unclear (Tremain et al., 2020). How these factors might impact adherence to and effectiveness of treatment for BP patients is unknown.
An additional important consideration in high-risk populations such as BP disorder is safety, including assessment of suicide risk and risk mitigation. Of the six studies reviewed here, three included mention of suicide risk in some way (Bauer et al., 2016;Sankar et al., 2021;Seidel & Kilgus, 2014). In one study comparing a face-to-face encounter with a telepsychiatry-based encounter, assessment of suicidal risk was found to be comparable (Seidel & Kilgus, 2014), providing key initial evidence that risk assessment via telepsychiatry is adequate. Additionally, in the VA's large telepsychiatry program for BP disorder, rates of suicide attempts while enrolled were found to be equal compared to large, aggregated samples of BP disorder patients not in treatment (Bauer et al., 2016). The authors note that it is surprising that suicide attempts were not more frequent in the program due to the increased complexity and unstable nature of the cases that required them to be referred to specialty care. Further, in their evaluation of a telepsychiatry-based SRT, Sankar et al. (2021) found an improvement in suicide propensity from pre-to posttreatment. Overall, there is a significant need to ensure that safety is a priority both when utilizing telepsychiatry and when using traditional face-to-face services. Unfortunately, there is little research on this topic, and a recent comprehensive review of suicide risk reported that our ability to predict suicide attempts is only slightly better than chance (Franklin et al., 2017). Further research is certainly needed to improve our ability to maintain patient safety through suicide risk assessment, both in general and specifically in regard to telepsychiatry-based services, as these continue to increase in popularity.  (Bauer et al., 2016;Sankar et al., 2021), there was no indication of how this compared to clinical improvements seen when in-person services are employed, or when a combination of in-person and telepsychiatry visits are used. Research which directly compares the clinical efficacy of telepsychiatry visits versus in-person services can improve trust in telepsychiatry by demonstrating that it is on par with traditional practice. In fact, a recent review of telepsychiatry directly compared to in-person services similarly found no existing studies focused on a BP disorder population, and these authors also noted the need for such upcoming research (Greenwood et al., 2022).
In conclusion, the very small amount of emerging evidence on telepsychiatry indicates that it holds to promise to be a reliable, effective, and accepted method of delivering services for BP disorder in older adolescent and adult populations. However, further research is required to assess whether its demonstrated utility expands to pediatric populations, who could benefit greatly from telepsychiatry services, and to further investigate for each population exactly what is gained and what is lost when delivering services via telepsychiatry versus in person. Such information is key to the successful development of hybrid treatment plans combining virtual and in-person care.