The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

In August of 2019 we published a brief commentary in Bipolar Disorders concerning the role of telemental health via videoconferencing (TMH‐V) in the treatment of bipolar disorder.1 We concluded that this technology has great potential to improve access to evidence‐based mental health treatment.

With the onset of the COVID‐19 pandemic, distance care (including phone and TMH‐V) is now becoming the default treatment modality for many mental health clinicians. Given our longstanding experience delivering TMH‐V to patients with bipolar disorder in the US Department of Veterans Affairs,2, 3 we wanted to provide some practical guidance for clinicians who may be new to treating patients diagnosed with bipolar disorder virtually.

First, we note that there are several foundational steps to take when delivering TMH‐V or treatment by phone regardless of the patient’s diagnosis. These steps are intended to maximize patient safety while minimizing ethical and legal risks for clinicians (eg, developing clear procedures for handling behavioral emergencies is paramount). Other authors cover these steps in more detail elsewhere4 and we recommend that practitioners familiarize themselves with these practices. We also recommend that clinicians periodically revisit the mandates and regulations that may apply to them, as many state and organizational policies have been changing rapidly during the COVID‐19 pandemic.

Beyond these general considerations common to virtual care, there are special considerations relevant to the evaluation and treatment of patients with bipolar disorder via TMH‐V. In cases where wireless connectivity or equipment issues may require a conversion of a video session into a telephone session, we have also included telephone considerations as well.

Assessing certain aspects of speech, affect, and psychomotor agitation may require more effort when delivering virtual care compared to in‐person care. For instance, apparent changes in speech volume or tone may be an artifact of microphone placement or speaker quality. Clarifying a patient’s words, slowing down the conversation, adjusting volume or position of the patient to the microphone will help diffuse any trouble in hearing the patient. Similarly, if you are unsure if a patient is tearing up, trembling, or experiencing psychomotor agitation, it is important to ask them directly. If you cannot see the patient in a TMH‐V session clearly due to poor lighting, camera angle, or the patient carrying the device in their hand, ask them to reposition themselves or set the device down on a flat surface. Asking the patient to stand up and walk a few steps in front of the camera can be used to assess motor performance.5 In fact, seeing symptoms of restlessness may be enhanced during TMH‐V sessions, especially if someone is standing or walking around in their home during a visit.

When TMH‐V or telephone connections feature significant lag, it may be difficult to interpret apparent interruptions or changes in voice prosody. The patient may be attempting to speak during lulls in the conversation, and may sound to the clinician like they are cutting in or not listening. Patients may be harder to interrupt due to pressured speech, simply because visual cues that the clinician is trying to talk may be absent or delayed. One should be aware of these possibilities, and talk about them directly with the patient, rather than assuming that such instances indicate manic symptoms.

For patients who may experience paranoia, derealization, or hallucinations, TMH‐V modalities may be particularly stressful, especially if the focus of the patient’s paranoia is on issues of surveillance. A patient may ask that the TMH‐V provider’s camera pan the room to demonstrate that no one else is surreptitiously watching the session. In these cases, clinicians must take time to process novel experiences with the patients afterward and discuss healthy strategies for coping after the session. The clinician may have the opportunity to present grounding exercises, inquire about self‐management skills the patient routinely uses, and provide psychoeducation on how their treatment model will assist the patient in working with these symptoms.

With the emergence of COVID‐19, many people are reporting a loss of coping strategies at present (eg, the gym, more easily accessible social interactions). Social isolation and self‐quarantine may be particularly disruptive given the importance of routines and predictability around social rhythms and sleep for many patients with bipolar disorder. Treatments may need to emphasize alternative activities that can be done at home (eg, participating in online groups, engagement with in‐home activities, etc.). The simple loss of usual routine may be a trigger for manic/hypomanic or depressive episodes for patients with bipolar disorder. Certain symptoms, such as shopping behaviors, may have migrated online, whereas other symptoms (eg, impulsive relationships) may have decreased. It is important to not assume; instead, assess for changes in functioning given novel outlets for various habits in the time of COVID‐19.

Delivering care for patients with bipolar disorder via TMH‐V or telephone presents unique opportunities and challenges. In addition, COVID‐19 and the associated public health and social responses pose its own challenges for patients with bipolar disorder. TMH‐V provides an invaluable opportunity to interact with and support patients even under circumstances of social isolation. It is our hope that the issues discussed herein will be helpful for those clinicians who are adjusting to the use of virtual care for patients with bipolar disorder.

本文所表达的观点是作者的观点，并不一定反映退伍军人事务部或美国政府的立场或政策。

2019 年 8 月，我们在《双相情感障碍》杂志上发表了一篇简短评论，内容涉及通过视频会议 (TMH-V) 进行的远程心理健康在双相情感障碍治疗中的作用。1我们得出的结论是，这项技术在改善获得循证心理健康治疗方面具有巨大潜力。

随着 COVID-19 大流行的爆发，远程护理（包括电话和 TMH-V）现在正成为许多心理健康临床医生的默认治疗方式。鉴于我们在美国退伍军人事务部为双相情感障碍患者提供 TMH-V 的长期经验，2, 3我们希望为可能不熟悉虚拟治疗双相情感障碍患者的临床医生提供一些实用指导。

首先，我们注意到无论患者的诊断如何，在通过电话提供 TMH-V 或治疗时都需要采取几个基本步骤。这些步骤旨在最大限度地提高患者安全，同时最大限度地降低临床医生的道德和法律风险（例如，制定处理紧急行为的明确程序至关重要）。其他作者在其他地方更详细地介绍了这些步骤4，我们建议从业者熟悉这些做法。我们还建议临床医生定期重新审视可能适用于他们的授权和法规，因为在 COVID-19 大流行期间，许多州和组织的政策一直在迅速变化。

除了虚拟护理常见的这些一般考虑因素外，还有一些与通过 TMH-V 评估和治疗双相情感障碍患者相关的特殊考虑因素。在无线连接或设备问题可能需要将视频会话转换为电话会话的情况下，我们还包括电话注意事项。

与面对面护理相比，在提供虚拟护理时，评估言语、情感和精神运动激动的某些方面可能需要更多的努力。例如，语音音量或语调的明显变化可能是麦克风放置或扬声器质量的伪影。澄清病人的话、放慢谈话速度、调整病人的音量或对着麦克风的位置将有助于消除病人听力方面的任何问题。同样，如果您不确定患者是否在流泪、颤抖或出现精神运动性激越，直接询问他们很重要。如果由于光线不足、摄像机角度或患者手持设备而无法在 TMH-V 会话中清楚地看到患者，请让他们重新定位自己或将设备放在平坦的表面上。5事实上，在 TMH-V 会议期间，看到不安的症状可能会加剧，特别是如果有人在访问期间站在或在家中走动。

当 TMH-V 或电话连接具有明显滞后时，可能难以解释语音韵律的明显中断或变化。患者可能会在谈话的间歇期间试图说话，并且可能对临床医生来说听起来像是在插话或不听。患者可能由于言语压力而更难打断，这仅仅是因为临床医生试图说话的视觉提示可能缺失或延迟。人们应该意识到这些可能性，并直接与患者讨论它们，而不是假设这些情况表明躁狂症状。

对于可能出现妄想症、幻觉或幻觉的患者，TMH-V 模式可能特别有压力，尤其是当患者的妄想症的焦点是监视问题时。患者可能会要求 TMH-V 提供者的摄像头平移房间以证明没有其他人在偷偷地观看会议。在这些情况下，临床医生必须花时间在事后处理与患者的新体验，并在会后讨论应对的健康策略。临床医生可能有机会进行基础练习，询问患者日常使用的自我管理技能，并就他们的治疗模式如何帮助患者应对这些症状提供心理教育。

随着 COVID-19 的出现，许多人报告目前缺乏应对策略（例如，健身房、更容易进行的社交互动）。考虑到对许多双相情感障碍患者来说，围绕社交节奏和睡眠的常规和可预测性的重要性，社会隔离和自我隔离可能尤其具有破坏性。治疗可能需要强调可以在家中进行的替代活动（例如，参加在线团体、参与家庭活动等）。对于双相情感障碍患者来说，简单地失去常规可能是躁狂/轻躁狂或抑郁发作的触发因素。某些症状，例如购物行为，可能已经转移到网上，而其他症状（例如，冲动的关系）可能已经减少。重要的是不要假设；反而，

通过 TMH-V 或电话为双相情感障碍患者提供护理带来了独特的机遇和挑战。此外，COVID-19 以及相关的公共卫生和社会反应对双相情感障碍患者构成了自身的挑战。即使在社会孤立的情况下，TMH-V 也提供了与患者互动和支持患者的宝贵机会。我们希望本文讨论的问题对那些正在适应对双相情感障碍患者使用虚拟护理的临床医生有所帮助。