Telemental Health Use Remains Robust, But What Does Future Hold?

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In January 1925, a team of dog sleds braved the harsh Alaska winter to transport antibodies to the town of Nome to help stave off a diphtheria outbreak. Nearly a century later, phones and computers served to connect patients to psychiatrists and other physicians when U.S. communities went into lockdown to stop the spread of COVID-19. This new world of virtual psychiatry was the focus of a session at APA’s 2021 online Annual Meeting.

William Narrow, M.D., M.P.H., an associate professor of psychiatry at Johns Hopkins Medicine, discussed how changes in reimbursement rules, patient privacy rules, and interstate license requirements related to virtual care enabled unprecedented uptake of videoconference, phone, email, and/or text-based communications between patients and health care professionals during the pandemic.

Multiple surveys have shown that psychiatry adapted particularly well to this brave new world. An analysis released in April by Vizient (a health care performance improvement company) reported that while ambulatory care visits in the United States overall fell by 41% between February and April 2020, behavioral health visits (which include visits with psychiatrists, psychologists, and social workers) fell only 13% due to rapid uptake of telemedicine. Vizient’s analysis also estimated that about 165,000 behavioral health visits would have been lost in April if not for a robust telemedicine presence.

The Vizient analysis also found that telemedicine in behavioral health remained robust as the pandemic wore on; 80% of all behavioral health visits were virtual in April 2020, and the rate was still 69% in December.

The continued widespread use of telemental health shows that it is well received by both health care professionals and patients, Narrow said. He cited the results of another survey, published in Psychiatric Services, which found that only 4% and 3% of mental health professionals reported having a poor or very poor experience with videoconference- or phone-based care, respectively.

However, Narrow and other presenters cautioned that telemedicine is not a panacea for psychiatric practice. For instance, the survey data published in Psychiatric Services suggested that while most mental health care professionals agreed that virtual care could be beneficial for patients with anxiety, depression, and/or posttraumatic stress disorder, there was less agreement that telemedicine was appropriate for patients with psychotic disorders or substance use disorders.

Complications from the use of telemedicine arise even when treating patients who are most likely to benefit from virtual appointments, explained Rogena Abdelrahman, a technology and community development specialist at the National Alliance on Mental Illness (NAMI) San Diego. For instance, there are privacy concerns related to the use of new platforms that are not compliant with the Health Insurance Portability and Accountability Act. Also, video and especially audio discussions prevent psychiatrists from reading nonverbal cues (for example, fidgety hands) that help them assess a patient’s state of mind. Finally, there is always the risk that a session can be cut short by an unexpected loss of Wi-Fi or power.

There are also less obvious conundrums related to the less personal nature of virtual care, Abdelrahman continued. “How do we use these technologies for sensitive communications like telling patients you can no longer be their clinician? Is that appropriate over email?”

All of these factors must be considered when weighing the risks and benefits of in-person visits versus remote visits for each patient, explained Renee Cookson, C.T.R.S., the community development director for NAMI San Diego.

“Remember to consider what is a meaningful environment from the client’s perspective,” she said. “Younger generations were born into a world of technology, but many older patients still prefer in-person communication.” Cookson added that telemedicine has not been the only mode of care expanding during the pandemic; there has been increased interest in conducting in-person sessions at outdoor settings such as at parks.

She suggested that such community-based visits might remain a popular treatment format even after the pandemic subsides, since they offer the personal touch of an office visit but in a comfortable and/or more accessible setting.

One size will not fit all, the panelists concurred, as each treatment setting (office, community, virtual) has advantages and disadvantages that individual patients will weigh differently. The future of mental health will likely see psychiatrists use a hybrid approach that blends together in-person and online visits with asynchronous communication (texts and emails) to meet patients where they are. ■