While telehealth has long been generally regarded as equivalent to in-person care (Godleski et al., 2008; Pruitt et al., 2021), legal and ethical concerns related to suicide screening and prevention, combined with limited research (McGinn et al., 2019), restricted its use among high-acuity populations (Gilmore & Ward-Ciesielski, 2019; Godleski et al., 2008). By 2020, the rapid spread of COVID-19 necessitated the use of telehealth across populations. At the beginning of the pandemic, researchers and health organizations cautioned that a global outbreak of COVID-19 was likely to have a profound influence on mental health outcomes and increase many factors that are predictive of suicide attempts and deaths (Gunnell et al., 2020; Khan et al., 2020; World Health Organization, 2020). Lockdowns, fear of infection, social isolation, political turmoil, and individual, familial, and communal losses throughout 2020 and 2021 produced critical increases in mental health symptoms alongside accompanying decreases in quality of life (Creswell et al., 2021; Jenkins et al., 2021; Rains et al., 2020). People and communities facing political and/or economic marginalization, mental and/or physical health difficulties, ableism, racism, sexism and/or heterosexism, and other structural inequalities were particularly impacted (Jenkins et al., 2021; Ruprecht et al., 2021; Santos et al., 2020; Shakespeare et al., 2021).

The increase in mental and behavioral health difficulties associated with the COVID-19 pandemic necessitates high quality, ethically informed suicide risk assessment and prevention strategies. Still, suicide risk assessment remains one of the most complicated tasks in psychology and other allied healthcare disciplines. Researchers have identified few suicide risk measures with strong predictive validity or diagnostic accuracy rates above 50%, and research related to suicide prevention overall appears to have a high level of methodological limitations (O’Shea & Dickens, 2014; Roos et al., 2013; Runeson et al., 2017). In addition, some treatment and preventive measures, such as involuntary hospitalization, are traumatic, costly, and potentially associated with post-intervention increased risk of suicide (Coyle et al. 2018; Luxton et al., 2013; Ward-Ciesielski & Rizvi, 2021). These dynamics are further complicated by the necessary adoption of telehealth practice due to the COVID-19 pandemic. Despite wide acceptance of telehealth, ethical concerns related to suicide assessment and prevention remain (Jobes et al., 2020).

Remote assessment is perhaps chief among telehealth related ethical issues. Prior to the pandemic, mental health care providers reported reticence in working with patients experiencing suicidal ideation (SI) due to doubts around assessing non-verbal indicators of risk, as well as lack of control over their patients’ environments (Gilmore & Ward-Ciesielski, 2019; Jobes et al., 2020). Furthermore, patients who live with others and receive care at home may have less privacy than in traditional behavioral and mental health settings, which could influence their likelihood of reporting self-harming or suicidal behaviors and SI. In addition, even when providers carefully assess for SI, it is not always possible to account for SI that develops throughout the course of treatment. Given the difficulty involved in telehealth-based suicide risk assessment, psychologists may benefit from reviewing the following ethical considerations (American Psychological Association [APA], 2017).

Providing telehealth services in emergencies. In response to an influx of mental health crises, psychologists without specialized telehealth training quickly transitioned their patients to telehealth, while also developing their competencies in this area (Standard 2.02, Providing Services in Emergencies). However, as the pandemic will likely continue for some time, psychologists should place additional emphasis on, assessing their own skills (Standard 2.01, Boundaries of Competence), expanding and maintaining their competencies (Standard 2.03, Maintaining Competence), and rooting their practice in science (Standard 2.04, Bases for Scientific and Professional Judgments). Consistent with these standards, psychologists practicing telehealth are expected to be critical consumers of research on remote suicide prevention and apply new standards appropriately.

Knowledge of suicide risk measures. Psychologists should be aware of validity issues in suicide risk assessment, utilize appropriately validated instruments (Standard 9.02, Use of Assessments) and be mindful of anxieties around about telehealth risk assessment, including uncertainty based on the medium of the assessment instead of on a patient’s endorsement of severe risk, which may increase the likelihood of unnecessary interventions.

Involuntary hospitalization. Before the COVID-19 pandemic, involuntary hospitalization carried significant risks, such as insufficient treatment, trauma from the loss of personal autonomy, and frequent lack of post-hospitalization follow-up (Luxton et al., 2013). In addition, police officers are frequently involved in responding to mental health crises. Data indicate that in 1999, 10% of all police encounters were with people with significant mental health difficulties (Watson & Fulambarker, 2012). Researchers have found that police are involved in the journey to mental health services for 12% of people with psychiatric diagnoses (Livingstone, 2016). Many police officers are not adequately trained to intervene in behavioral health crises and existing evidence on the quality and effectiveness of police training programs indicates that such trainings do not reduce police use of force (Rogers et al., 2019). Police involvement in such crises, particularly when Black, Indigenous, or other people of color (BIPOC) are those in crisis, can lead to violence, traumatization, and even death (Rogers et al., 2019; Shadravan et al., 2021).

Encounters with police officers and emergency service workers, and exposure to medical settings with high levels of COVID-19 positive individuals, increase the risk of viral transmission to patients already in crisis. Therefore, psychologists should consider not only the general risk of harm and infection for their patients, but also the risk of transmission from inpatient treatment settings to other individuals in their patients’ lives or communities (Principle A, Beneficence and Nonmaleficence). Healthcare workers and researchers must contend with the impact of these risks on the ethics of involuntary hospitalization. In fact, many involuntary treatment settings have been sites for high COVID-19 infection rates, prompting some health systems to cease civil commitments early in the pandemic (Morris & Kleinman, 2020).

Given the increased risk of infection for people who are hospitalized or in contact with emergency services, some researchers suggest more stringent criteria to justify restricting a person’s rights (Gather et al., 2020; Morris & Kleinman, 2020). Psychologists should be particularly conscious of their ethical obligations when making clinical decisions which may involve restriction of a patient’s liberty and increase their risk of contracting COVID-19 (Principle A, Beneficence and Nonmaleficence; Principle E, Respect for People’s Rights and Dignity).

In addition to being aware of potential risks of involuntary commitment, psychologists must also consider the influence of their own biases and emotional reactions, including anxiety and uncertainty about telehealth risk assessment and suicide prevention. As always, psychologists may benefit from consultation with other professionals to further consider whether a patient will benefit from involuntary hospitalization (Standard 4.06, Consultations).

Informed consent related to telehealth suicide prevention policies. The informed consent process around risk of harm assessments may have increased importance due to these concerns. Psychologists can reduce potential harm to patients, as well as minimize potential ruptures in the therapeutic relationship, by being open and honest with patients about the ways in which they remotely assess and respond to SI (Standard 3.10, Informed Consent; Standard 9.03, Informed Consent in Assessments; Standard 10.01, Informed Consent to Therapy). Along these lines, psychologists can better serve their patients by maintaining awareness of COVID-19 policies, procedures, and precautions at nearby psychiatric units and by monitoring the potential infection risk to patients. Psychologists who provide telehealth services outside their localities are also ethically responsible for knowing the relevant resources local to their patients (Jobes et al., 2020).

Pandemic-related increases in mental health distress, coupled with the rapid adaptation and habituation to telehealth for many health professionals and patients, has significantly changed the ways in which psychologists approach suicide risk assessment and prevention efforts. Psychologists working via telehealth should be prepared to develop and maintain competency in telehealth, while also striving to meet the standard of care in their assessment procedures. They must also assess the increased risk of harm inherent in crisis interventions by police or emergency services workers and inpatient hospitalization, while being particularly mindful of their own emotions regarding suicide risk assessment and prevention. Psychologists should also be prepared for open and ongoing informed consent discussions with patients that include consideration of the ongoing spread of COVID-19 variants and new waves of infections. Finally, psychologists can respond to the ongoing COVID-19 pandemic and minimize harm to patients experiencing SI by continuing to align their practice with the APA’s Ethical Principles and Code of Conduct (APA, 2017).

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code/ 

Coyle, T. N., Shaver, J. A., & Linehan, M. M. (2018). On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder. Journal of Consulting and Clinical Psychology, 86(2), 116-124. https://doi.org/10.1037/ccp0000275  

Creswell, C., Shum, A., Pearcey, S., Skrikauskaite, S., Patalay, P., & Waite, P. (2021). Young people’s mental health during the COVID-19 pandemic. The Lancet Child & Adolescent Health, 5(8), 535-537. https://doi.org/10.1016/S2352-4642(21)00177-2 

Gather, J., Juckel, G., Henking, T., Efkemann, S. A., Vollman, J., & Scholten, M. (2020). Under which conditions are changes in the treatment of people under involuntary commitment justified during the COVID-19 pandemic? An ethical evaluation of current developments in Germany. International Journal of Law and Psychiatry, 73. https://doi.org/10.1016/j.ijlp.2020.101615 

Godleski, L., Nieves, J. E., Darkins, A., & Lehmann, L. (2008). VA telemental health: Suicide assessment. Behavioral Sciences & the Law, 26(3), 271-286. https://doi.org/10.1002/bsl.811

Gilmore, A. K., & Ward-Ciesielski, E. F. (2019). Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide. Journal of Telemedicine and Telecare 25(1), 59-63. https://doi.org/10.1177/1357633X17735559 

Gunnell, D., Appleby, L., Arensman, E., Hawton, K., John, A., Kapur, N., Khan, M., O’Connor, R. C., Pirkis, J., & the COVID-19 Suicide Prevention Research Collaboration (2020). Suicide risk and prevention during the COVID-19 pandemic. The Lancet Psychiatry, 7(6), 468-471. https://doi.org/10.1016/S2215-0366(20)30171-1 

Jenkins, E. K., McAuliffe, C., Hirani, S., Richardson, C., Thomson, K. C., McGuiness, L., Morris, J., Kousoulis, A., & Gadermann, A. (2021). A portrait of the early and differential mental health impacts of the COVID-19 pandemic in Canada: Findings from the first wave of a nationally representative cross-sectional survey. Preventive Medicine, 145. https://doi.org/10.1016/j.ypmed.2020.106333 

Jobes, D. A., Crumlish, J. A., & Evans, A. D. (2020). The COVID-19 pandemic and treating suicidal risk: The telepsychotherapy use of CAMS. Journal of Psychotherapy Integration, 30(2), 226-237. http://dx.doi.org/10.1037/int0000208 

Khan, K. S., Mamun, M. A., Griffiths. M. D., & Ullah, I. (2020). The mental health impact of the COVID-19 pandemic across different cohorts. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00367-0 

Livingston, J. (2016). Contact between police and people with mental disorders: A review of rates. Psychiatric Services, 67(8), 850-857. https://doi.org/10.1176/appi.ps.201500312 

Luxton, D. D., Trofimovich, L., & Clark, L. L. (2013). Suicide risk among U.S. service members after psychiatric hospitalization 2001-2011. Psychiatric Services, 64(7), 626-629. https://doi.org/10.1176/appi.ps.201200413 

McGinn, M. M., Roussev, M. S., Shearer, E. M., McCann, R. A., Rojas, S. M., & Felker, B. L. (2019). Recommendations for using clinical video telehealth with patients at high risk for suicide. The Psychiatric Clinics of North America, 42(4), 587–595. https://doi.org/10.1016/j.psc.2019.08.009 

Morris, N. P., & Kleinman, R. A. (2020). Involuntary hospitalization during the COVID-19 pandemic. The American Journal of Psychiatry, Residents’ Journal, 16(1), 3-5. https://doi.org/10.1176/appi.ajp-rj.2020.160102 

O'Shea, L. E., & Dickens, G. L. (2014). Short-Term Assessment of Risk and Treatability (START): Systematic review and meta-analysis. Psychological Assessment, 26(3), 990–1002. https://doi.org/10.1037/a0036794 

Pruitt, Z., Chapin, K. P., Eakin, H., & Glover, A. L. (2021). Telehealth during COVID-19: Suicide prevention and American Indian communities in Montana. Telemedicine and e-Health. Advance online publication. https://doi.org/10.1089/tmj.2021.0104 

Rains, L. S., Johnson, S., Barnette, P., Steare, T., Needle, J. J., Carr, S., Taylor, B. L., Bentivegna, F., Edbrooke-Childs, J., Scott, H. R., Rees, J., Shah, P., Lomani, J., Chipp, B., Barber, N., Dedat, Z., Oram, S., Morant, N., & Simpson, A. (2020). Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: Framework synthesis of international experiences and responses. Social Psychiatry and Psychiatric Epidemiology, 56, 13-24. https://doi.org/10.1007/s00127-020-01924-7

Rogers, M., McNiel, D. E., & Binder, R. L. (2019). Effectiveness of police crisis intervention training programs. Journal of the American Academy of Psychiatry and Law, 47(4), 1-8. https://pubmed.ncbi.nlm.nih.gov/31551327/  

Roos, L., Sareen, J., & Bolton, J. M. (2013). Suicide risk assessment tools, predictive validity findings and utility today: Time for a revamp? Neuropsychiatry, 3(5), 483-495.  https://www.jneuropsychiatry.org/peer-review/from-objectivity-to-subjectivity-conceptualization-and-measurement-of-wellbeing-in-mental-health-neuropsychiatry.pdf 

Runeson, B., Odeberg, J., Pettersson, A., Edbom, T., Adamsson, I. J., & Waern, M. (2017). Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence. PLoS One, 12(7). https://doi.org/10.1371/journal.pone.0180292 

Ruprecht, M. M., Wang, X., Johnson, A. K., Xu, J., Felt, D., Ihenacho, S., Stonehouse, P., Curry, C. W., DeBroux, C., Costa, D., & Phillips, G. (2021). Evidence of social and structural COVID-19 disparities by sexual orientation, gender identity, and race/ethnicity in an urban environment. Journal of Urban Health, 98, 27-40. https://doi.org/10.1007/s11524-020-00497-9 

Santos, G. M., Ackerman, B., Rao, A., Wallach, S., Ayala, G., Lamontage, E., Garner, A., Holloway, I. W., Arreola, S., Silenzio, V., Stromdahl, S., Yu, C., Strong, C., Adamson, T., Yakusik, A., Thu Doan, T., Huang, P., Cerasuolo, D., Bishop, A., …  Howell, S. (2020). Economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 treatment response on a global sample of cisgender gay men and other men who have sex with men. AIDS and Behavior 25, 311–321. https://doi.org/10.1007/s10461-020-02969-0 

Shakespeare, T., Ndagire, F., & Seketi, Q. E. (2021). Triple jeopardy: Disabled people and the COVID-19 pandemic. The Lancet, 397, 1331–1333. https://doi.org/10.1016/S0140-6736(21)00625-5 

Shadravan, S. M., Edwards, M. L., & Vinson, S. Y. (2021). Dying at the intersections: Police-involved killings of black people with mental illness. Psychiatric Services, 72(6), 623-625. https://doi.org/10.1176/appi.ps.202000942 

Ward-Ciesielski, E. F., & Rizvi, S. L. (2021). The potential iatrogenic effects of psychiatric hospitalization for suicidal behavior: A critical review and recommendations for research. Clinical Psychology: Science and Practice, 28(1), 60–71. https://doi.org/10.1111/cpsp.12332 

Watson, A., & Fulambarker, A. (2012). The Crisis Intervention Team model of police response to mental health crises: A primer for mental health practitioners. Best Practices in Mental Health, 8(2), 71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769782/ 

World Health Organization. (2020). Mental health and psychosocial considerations during the COVID-19 outbreak. https://apps.who.int/iris/bitstream/handle/10665/331490/WHO-2019-nCoV%20-MentalHealth-2020.1-eng.pdf?sequence=1