From the Editor

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A billion people are estimated to use TikTok on a monthly basis. The social media platform is incredibly popular here – and around the globe. And, as with other social media, people increasingly use it as a source of medical information.

To date, little research has been done on the credibility of that information. In a new Canadian Journal of Psychiatry paper, Dr. Anthony Yeung (of the University of British Columbia) and his co-authors focus on ADHD. They find uneven results: “In this analysis of popular TikTok videos about ADHD, there were over 2.8 million views per video and each video was shared on average 31,000 times. Approximately half of the videos analyzed (52%) were misleading…” We consider the paper and its clinical implications.

Continuing on the theme of technology and practice, in the second selection, we look at a new Psychiatric Services paper. Lori Uscher-Pines (of the RAND Corporation) and her co-authors do a qualitative analysis of why psychiatrists choose telemedicine for some patients and not others. The authors conclude: “psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.”


Selection 1: “TikTok and Attention-Deficit/Hyperactivity Disorder: A Cross-Sectional Study of Social Media Content Quality”

Anthony Yeung, Enoch Ng, Elia Abi-Jaoude

The Canadian Journal of Psychiatry, 23 February 2022  Online First

Social media platforms are a popular means of sharing medical information online. TikTok in particular is a relatively new social media platform that has seen rapid adoption by adolescents and young adults, becoming the most downloaded social media application in 2020 with more than 1 billion monthly active users. In particular, the popularity of the platform appears to have contributed to increased awareness of attention-deficit/hyperactivity disorder (ADHD), with some individuals seeking a diagnosis after watching videos about ADHD on the platform. The hashtag ‘#adhd’ is currently the seventh most popular health-related hashtag on the platform. Although social media can reduce mental health stigma and improve health literacy, there is also concern about misinformation and the potential for illness/health anxiety (‘cyberchondria’) due to the volume of unmoderated, user-generated content online. For example, TikTok videos have been implicated in a recent rise of tic-like behaviours in adolescents, and it is thought that exposure to tic-related videos is responsible for this phenomenon.

Additionally, social media platforms use proprietary algorithms that focus on increasing user engagement and may promote videos that do not necessarily reflect accurate health information. A recent systematic review found that the prevalence of health misinformation was high across almost all social media platforms. With TikTok being a relatively new social media platform, there is little research on the quality and accuracy of its content.

So begins a new paper by Yeung et al.

Here’s what they did:

  • The authors looked at popular TikTok videos.
  • “Our inclusion criteria were videos that specifically described or educated viewers about: ADHD symptoms/diagnosis, lived experience with ADHD, or ADHD management.”
  • “Exclusion criteria were videos with no audio or text, non-English videos, videos unrelated to ADHD, or duplicate videos.”
  • “Videos were sorted in descending order by view count, and the inclusion criteria were applied until 100 videos were identified.”
  • “A psychiatrist and a resident of psychiatry reviewed all the videos.”
  • “The Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V) and Journal of American Medical Association (JAMA) benchmark criteria were used to assess the overall quality, understandability, and actionability of the videos.

Here’s what they found?

  • “Prior to applying the exclusion criteria, there were a total of 4.3 billion views on videos tagged with ‘#adhd’ at the time of the query.” 
  • “The 100 videos meeting inclusion criteria had a total of 283,459,400 views; 89 videos were uploaded by non-HCPs, while 11 were uploaded by individuals identifying as HCPs (i.e., licensed therapists, nurses, psychologists, or physicians).”
  • “There was an average of 2.8 million views (range: 892,100–14,800,000) and 31,175 shares (range: 1,249–245,200) per video.”
  • “Of the 100 videos analyzed, 52% were classified as misleading, 27% as personal experience, and 21% as useful. Agreement between the raters on the classification was 86%, with a kappa statistic of 0.7766 (P < 0.001).”
  • “Of the 52 misleading videos, 37 videos (71%) misattributed transdiagnostic psychiatric symptoms as being specific only to ADHD, including anxiety, depression, anger, relationship conflicts, dissociation, and mood swings. None of the misleading videos recommended viewers to seek out a medical, psychiatric, or psychological assessment before attributing these symptoms to ADHD. Eight videos (15%) misrepresented the pathophysiology of ADHD, including oversimplifying the disorder as a purely dopamine-deficient state. Four videos (7%) provided incorrect information about the approach to diagnosing ADHD, such as including an audio quiz to determine whether an individual has ADHD.”
  • “Of the 21 useful videos, 17 videos (81%) described signs and symptoms of ADHD specific to the disorder, or informed viewers that transdiagnostic symptoms may be due to other medical conditions or comorbid psychiatric disorders. Three videos (14%) provided information on treatments or strategies for coping with ADHD that have been validated. One video (5%) accurately described the prognosis and risk factors for ADHD.”

A few thoughts:

1. This is a good study.

2. Ouch.

3. To summarize the results in six words: the majority of videos were misleading.

4. The numbers of views are incredible. The typical top-100 video had nearly 3 million views. (Yes, you read that correctly.)

5. How does the core finding compare to other studies? While more and more patients and their families look to the Internet, the quality of information is heterogenous at best. The authors note a recent paper considering another social media platform: “Our results are also similar to a study by Thapa et al. that analyzed YouTube videos about ADHD and found that 38% of analyzed videos were misleading and only 5% were useful.” In another paper on apps and depression/suicide prevention, the authors note false information: “Six apps (6/69, 9%), including two apps available in both app stores and downloaded more than one million times each, provided an erroneous crisis helpline number.” That paper can be found here:

6. Like all studies, there are limitations. The authors note several, including the challenges of studying this social media platform as it relies on “TikTok’s proprietary search algorithm results, which exclude video ads and do not allow for systematic searching of all videos or deleted videos.”

7. The clinical implications? You may not be on TikTok – or ever have seen a TikTok video. But some of our patients and their families look to TikTok. As clinicians, we need to help them find reliable information for disorders like ADHD. If we aren’t recommending good sources of information (including on social media), are we taking ourselves out of the conversations that patients and their families are already having?

The full CJP paper can be found here:

Selection 2: “Appropriateness of Telemedicine Versus In-Person Care: A Qualitative Exploration of Psychiatrists’ Decision Making”

Lori Uscher-Pines, Amanda M. Parks, Jessica Sousa, et al.

Psychiatric Services, 26 January 2022  Online First

The pace of adoption of telemedicine by U.S. psychiatrists has been staggering. Most psychiatrists reported no experience with telemedicine before the COVID-19 pandemic, but in the spring of 2020, 85% reported seeing more than three-fourths of their patients via telemedicine. Although overall telemedicine use has declined from its peak early in the COVID-19 pandemic, it has remained a dominant model among specialty behavioral health providers. As of December 2020, more than half of all behavioral health visits were estimated to be via telemedicine.

It is clear that telemedicine will become a permanent feature of practice and that psychiatrists will increasingly offer hybrid care models consisting of both telemedicine and in-person visits. Although the future of telemedicine policy in other clinical areas is uncertain, payers appear to be committed to covering telemedicine visits for behavioral health care in a hybrid model. In the Consolidated Appropriations Act of 2021, Congress permanently expanded telemedicine coverage for behavioral health but required that clinicians have some in-person visits.

The potential advantage of a hybrid approach is that it allows clinicians and their patients to leverage the relative strengths of each modality. For example, telemedicine can increase access and convenience, and in-person visits can better support general medical examinations and onsite laboratory testing. However, hybrid models add another layer of complexity, requiring clinicians to use their judgment to make individualized decisions about the appropriateness of different modalities.

So begins a paper by Uscher-Pines et al.

Here’s what they did:

“From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists’ decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data.”

Here’s what they found:

  • “A total of 20 psychiatrists representing 13 different U.S. states participated in the interviews. On average, participants reported that they had provided 59% of their visits via telemedicine.”
  • Preference. “Patient preferences drove a significant fraction of in-person care.”
  • Candidates. “Psychiatrists believed that almost all patients are good candidates for telemedicine and that telemedicine is appropriate for most patients.”
  • Appropriateness. “Participants disagreed on the appropriateness of telemedicine alone versus hybrid models in the long term. Some participants thought that some patients could be treated exclusively through telemedicine; however, others reported that for provision of high-quality care, it is necessary to offer hybrid models and mix telemedicine with in-person care.”
  • Frequency of visits. “Psychiatrists argued that the frequency of visits is more important than the modality and that some telemedicine care (if that is the only option) is preferable to no care. Participants pointed out that because telemedicine removes certain treatment access barriers, it can allow patients to be seen more often.”

A few thoughts:

1. This is an interesting and timely paper.

2. As we mull the post-pandemic future, a key finding here: psychiatrist believe that telemedicine can cover most patients. As the authors note in the discussion: “What drove telemedicine versus in-person care was patient preference and situational factors such as access to a private space, rather than any particular diagnosis or patient demographic characteristic.”

3. Is that your experience? Or is something lost in the video experience?

The full Psychiatric Services paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.