The author doing telepsychiatry from his home office
Source: Arash Javanbakht
The COVID-19 pandemic created an enormous level of stress on a global scale, leading to elevated levels of anxiety, depression, and other mental illnesses. Along with this, was a disruption and challenges in the delivery of mental health services that were traditionally provided in the office. This disruption, increasing need, and the already limited access to mental health services, especially in underserved areas, could create a very challenging situation. To prevent that, we had to make a robust transition in our ways of delivering services to videoconferencing and allowing coverage by the payors.
Telepsychiatry before the pandemic
I am an academic psychiatrist and expert in outpatient psychiatry. When I started working at Wayne State University Department of Psychiatry in 2015, this department was already a pioneer in telemedicine. I was initially skeptical, but when I was offered research evidence showing equal effectiveness and started treating patients via telepsychiatry, I quickly got comfortable with this practice and saw the advantages.
The first evidence of telepsychiatry I found in the literature was in 1973 suggesting the use of interactive television communication. Telepsychiatry research picked up in the ’90s when it was seen as an opportunity to provide service to patients in rural areas.
Telepsychiatry is basically a secure and HIPAA-compliant video-conferencing meeting between the patient and the psychiatrist or therapist. In a specialty where most of the medical examination is via observation and talking to the patient, this method seems more viable than specialties that require a comprehensive physical examination.
Major limiting factors for use of telemedicine before the pandemic were resistance to change, lack of access to and comfort with technology, and that major payors did not cover such services.
Pandemic expedited what was already happening slowly
When the pandemic happened, most of the outpatient psychiatric clinics were temporarily closed along with other outpatient services. But telemedicine seemed to be an excellent opportunity for preventing disruption in mental health care, which was even more needed then. The payors quickly loosened the restrictions to allow providing care remotely regardless of geographical location. Restrictions on platforms that could be used for telemedicine were also adjusted and a variety of software from Facetime to Skype to Zoom was approved for this purpose; most clinics I know adopted telepsychiatry. According to an HHS report on December 21, there has been a 63-fold increase in Medicare telehealth utilization during the pandemic. Furthermore, almost all states relaxed their licensing rules to allow out-of-state physicians to provide services in their state.
Challenges and Opportunities
Like other transitions, adopting the use of technology was challenging for many, especially in the absence of high-speed internet infrastructure for some patients. For those with limited logistics or knowledge of video-conferencing, often the sessions take place over the phone, which reduces access to a patient’s nonverbal behavior. Sound quality might not be great, leading to extended time for enabling sufficient communication. Although in psychiatry physical examination is used less often than in most other medical specialties, when it is needed, telepsychiatry is a barrier.
Despite these challenges, telepsychiatry has provided enormous opportunities, especially for less economically privileged patients. For an office visit, one must take time off work, find child support, and have access to reliable transportation to make it to the visit. For those with limited resources, or in areas far from psychiatric services, this would lead to frequent interruptions in care and economic cost. Telepsychiatry has overcome those barriers. Patients can connect to providers regardless of their geographical location, and connect while at home near their children, during their lunch break, or even from their car in the parking lot.
This also allows better access for those with complicated work schedules such as first responders and medical personnel, as well as patients with physical disabilities. This, in my experience, has led to a significant reduction in the no-show rate for visits from nearly 30 percent to virtually 0 in my clinic. A recent study found a 7.5 percent no-show rate for telepsychiatry, compared to 30 percent no-show to office visits pre-pandemic. This widespread acceptance of this new norm by both providers and patients has been beyond expectations, which might have been made more easily possible because all other ways of communication (work, family, and friend gathering) also transitioned to remote video-conferencing. In other words, people were trained in this, in other areas of life. The time saved also benefits providers, as they will have fewer no-show rates, late arrivals, and don’t need transportation to and from work. From an equity standpoint, patients who had much less access due to geographical distance now can have easier access to psychiatric care.
Telepsychiatry has also opened a window for the providers to the patients’ real-life environment, allowing important insight useful in treatment. We can see patients’ living situations, level of organization, crowdedness, their children, their pets, and other contextual information that are helpful in better understanding one’s real-life stressors and support.
Lack of restriction on where the patient can connect from, can of course create concerns about confidentiality, especially for those without access to private space. I remember a mother having to connect with me when sitting in her bathroom, to have privacy from a crowded family in a small house. Additionally, for some patients, such easy access seems to have reduced the “seriousness” of the procedure. Colleagues and I have had to remind patients to not connect with us while driving, shopping, or being in a middle of a conversation with their family members, or dress appropriately for the visit.
As the pandemic is waning, clinics begin to offer face-to-face visits, but many stay in the hybrid stage. Both providers and patients seem fine with telepsychiatry. I still see all my patients remotely, and only a couple have even brought up interest in the possibility of face-to-face visits.
Major determinants of the future of telemedicine post-pandemic would be regulatory: some states seem to be retightening their rules to not allow a physician licensed in another state to treat patients in their state remotely. There is hope that insurers will continue to cover telemedicine services, which has allowed access to care for so many, but we still do not know what the decision will be. Organizations like American Medical Associations have been working with legislators to make permanent access to care remotely, regardless of geographical location and setting.
Some of the revolutionary surprises this trend could bring would be large telemedicine corporations with a national service range (Amazons of psychiatry), and the use of cutting-edge technologies such as virtual reality and augmented reality for in vivo treatment.