After the Pandemic: What Will the ‘New Normal’ Be in Psychiatry?
Abstract
Psychiatrists foresee a new hybrid practice blending phone, video, and in-person visits driven by patient need and preference rather than payment policy.
“In the spring of 2020, COVID-19 devastated New York City, where I live and work,” recalled APA President-elect Vivian Pender, M.D., in an interview. “The sound of sirens was continuous day and night. We saw tents erected in Central Park to take care of the sick unable to get care in the hospital. We saw the stacks of bodies in white bags lined up in a mass grave. Many people left the city; those who stayed were told to quarantine. Every night at 7 p.m., people came out for five minutes and banged pots to cheer on the health care workers starting their daily shifts.
“Now we know that the majority of those who died were members of minorities and people of color,” Pender said. “It was a new virus, it was global, and there was no central, coordinated response.”
More than a year later—later than anyone suspected back in March 2020—there is a shared sense of emerging finally from an extraordinary global experience of pandemic, economic devastation, and—in the United States—racial reckoning (see box). Though masks and physical distancing may be with us still for much of the year, it is time to ask: What will “normal” look like in the wake of the pandemic?
APA leaders and psychiatrists in diverse practice settings who spoke with Psychiatric News said that the aftereffects of the pandemic will be felt for years. All agreed that telepsychiatry has been transformative, dramatically reducing the “no-show” rate among patients, and that a return to only in-person visits is unlikely for most psychiatrists (see special report).
APA President Jeffrey Geller, M.D., expects psychiatric practice to be a hybrid model that uses video, telephone, and in-person visits as appropriate. “My hope is that this hybrid practice will be designed to meet individual needs and driven by patient preference rather than driven by funding.”
More generally, Geller and others agreed that whatever the “new normal” looks like after the pandemic, it won’t be like the world we knew in February 2020. “We are never going back to the way it was before,” Geller said.
Pender and other psychiatrists who live and work in New York City, where the pandemic first manifest in the United States in a terrifying way, said the effect of COVID-19 on people in the city rivaled that of the 9/11 terrorist attacks.
“I’ve been supervising therapists in a military veterans clinic, and all of the patients with PTSD and depression had symptom exacerbations with the upheaval of the pandemic,” said psychotherapist John Markowitz, M.D., a research psychiatrist at the New York State Psychiatric Institute and a professor of clinical psychiatry at Columbia University.
‘Have We Had Enough?’
It isn’t possible to think about the past pandemic year—or what the new normal will look like in its wake—without taking into account the extraordinary racial reckoning that is taking place across American institutions, agencies, and businesses.
The killing of George Floyd in Minneapolis last May ignited racial protests around the globe, while the pandemic highlighted racial and ethnic disparities in health care that have long existed. Yet changing the long history of systemic racism is challenged by the human tendency to revert to the status quo.
"I want to believe that the death of George Floyd, Breonna Taylor, Ahmed Aubrey and so many others will light a fire under our medical schools, health systems" and other institutions, said Frank Clark, M.D., medical director and division chief for adult inpatient and consultation/liaison services at the University of South Carolina School of Medicine, Greenville.
“My hope is that things will change, and we will be more intentional about diversity, equity, and inclusion,” continued Clark, who is also a member of the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. “My cynical side says we will revert back to our old ways.”
But Clark said he chooses to be hopeful. He noted that the Task Force to Address Structural Racism Throughout Psychiatry succeeded in having the APA Board of Trustees approve 26 action items aimed at creating a culture of diversity and inclusion at all levels of APA governance and administration and at APA meetings. “That to me is a success,” he said. “When I look back on this, I can say our group made an impact.”
In January, the Board issued a historic apology for a history of racism and for “enabling discriminatory and prejudicial actions within APA and racist practices in psychiatric treatment for Black, Indigenous, and People of Color (BIPOC).” The statement of apology—addressed to members, patients, their families, and the public—is accompanied by a document outlining specific practices and policies (including failures to speak out and protest racist practices) that have damaged minority patients and their families dating to the time of the founding of APA.
Will the future be different? “In order for us to be hopeful, there has to be a commitment beyond words,” Clark said. “Whenever there is a tragedy of some kind we mourn, we say ‘thoughts and prayers’ … then we go back to our daily life. So, my question for my colleagues and our country is, Have we had enough?”
Markowitz is the author of the book After the Pandemic: Interpersonal Psychotherapy for Anxiety, Depression, and PTSD, which focuses on the “long tail” of mental illness that will follow the pandemic.
“We knew at Columbia that inasmuch as 9/11 had led to lasting psychopathology, this much more persistent and ubiquitous trauma would have still more lasting effects,” he told Psychiatric News.
As a psychotherapist, he looks forward to in-person psychotherapy, and so do many of his patients. “I will probably do somewhat more telepsychiatry, assuming that the requirements for state-by-state licensure don’t resume,” he said. “I have also noticed that my already busy part-time practice has been flooded in the past year, and I expect that will continue given the afterwave of psychiatric illness.”
For psychiatrists who practice psychopharmacology, telepsychiatry is likely to continue to be prominent. “Many of my patients like the way it is now and do not necessarily want to come back to the office,” said Anthony Rothschild, M.D., editor of the Journal of Clinical Psychopharmacology. “They don’t like taking the time to fight traffic, and the no-show rate has dropped dramatically because of telepsychiatry.”
He is a professor of psychiatry at the University of Massachusetts Medical School.
Some patients—especially those with serious mental illness—will need or want to be seen in person. But psychiatrists who no longer see all of their patients in person may not need to rent as much office time, he said.
A topic of ongoing research is sure to be the long-term effects of the COVID-19 virus on the brain. “There is the phenomenon of ‘long haul’ COVID that seems to entail some aspects of cognitive dulling, as well as more depression and anxiety,” Rothschild said. “We don’t fully understand this.”
For community psychiatrists, the diversity of patients they see will require a lot of flexibility in terms of practice venue. “It’s going to be a blend because of the severity of illness in the patients we see,” said Lori Raney, M.D., a principal at Health Management Associates in Denver, Colo.
Raney said there are seriously mentally ill patients she needs to see in person—because they lack the technology or social skills for navigating phone or video and/or because she needs to visually assess their health and mental health status.
Raney said the extension of Medicaid and private insurance coverage for telephone therapy has been a game-changer for her practice in terms of access and worries that this coverage will end, along with the relaxation of telehealth rules that went into effect early in the pandemic. “We all hope to have a hybrid practice, but if we can’t use the telephone, we are going back to in-person only and a high no-show rate.”
‘Life Will Not Return to the Way It Was’
Geller said that the past year has made many people focus in a powerful way on mental health—their own and that of those around them. He recounted his work with a patient of many years who has always been profoundly isolated, talking to few others and always eating out alone. When the lockdown began, he had to change his habits, cooking for himself or carrying out.
“I realized that while he and I had been working together for a very long time to engage him with others, we were now living lives like him, and this man who had never thought he could change was now living more like us,” Geller said. “That struck me very powerfully.”
He pointed with hope to what he called a new “appreciation of the centrality of mental health”—as well as the billions of dollars in new federal support for prevention and treatment of mental illness. “I think it’s a very optimistic time for people with serious mental illness,” he said.
APA CEO and Medical Director Saul Levin, M.D., M.P.A., said thatAPA business after the pandemic will likely be some hybrid of in-person and virtual meetings. However, he added, “the chance to meet in person, break bread, and network with our colleagues is so important to the work of psychiatrists and of APA. But during this extraordinary period everyone—members, leadership, and staff—have come together and accomplished much under very trying circumstances.”
All those who spoke with Psychiatric News agreed the pandemic has left almost nothing unchanged. “Life will not return to the way it was before,” said Pender, who will inherit in her presidential year whatever the new normal looks like. “People will have had a chance to take stock of their lives, what is considered normal, and what is meaningful and reflect on their biases and how they envision their future.” ■
