Virtual or In-Person Care? Factors to Consider

The COVID-19 pandemic accelerated the implementation and adoption of telehealth. The significant acceptance of virtual services by both patients and clinicians has transformed the landscape of how clinicians provide psychiatric care, and offering patient-centered care requires psychiatrists to also understand and consider patient preferences in telepsychiatry along with applicable state and federal laws. Patients tend to use telehealth for behavioral health more than for other types of care—in 2022, for example, about 64% of telehealth visits were for behavioral health reasons, about 30 percentage points higher than in 2019, according to a report by Trilliant Health. In this article, we will share some key considerations around patient need and preference in telepsychiatry.

Improved Access

Patients can connect with a clinician with a few clicks on their electronic device from the comfort of their home or other private location. Patients with mobility issues, lack of reliable transportation, job and family care responsibilities, or those who reside in areas with no local psychiatric services are able to access essential care. Convenience not only increases access but can also decrease no-show rates—telehealth visits are associated with a 30% decrease in no-shows, according to a report in the August 2023 Journal of Urban Health. In clinic, it is easy to call patients, remind them of an appointment, and have them connect within minutes. Patients can receive care with minimal disruption to their work or school schedule, which can be valuable for reducing disparities in access to care.

Support

The importance of patient comfort is worth emphasizing. At baseline, it can be difficult for patients to discuss suicidal ideation, hallucinations, end of life, and other topics that we must commonly address. The ability to attend an appointment from a place of safety and comfort—such as a bed or couch with personal belongings nearby—can help facilitate these tough conversations. Some patients, such as those with significant anxiety or a trauma history, may feel more comfortable seeing their clinician by telepsychiatry. However, clinicians should also provide guidance to patients about the importance of connecting from a private space, having no one else in the space unless they inform their clinician, and treating this visit as they would an in-person visit to achieve clinical objectives from the visit.

Collateral

Obtaining collateral information is an important part of a psychiatric assessment. With patient consent, family members or other individuals can join the visit either physically or remotely from the same or different location. Connecting with patients virtually can also offer valuable insight into their home environment and family. We have been able to meet parents, siblings, children, significant others, and pets simply because they are present in the home.

Contingencies

Psychiatry lends itself well to virtual care, but clinicians should discuss with patients that there may be situations where it will be recommended that they come into the office, an emergency room, or other local facility. These situations include necessary blood tests, an urgent safety assessment, or certain parts of the patient examination. There may also be factors beyond the patients’ or clinicians’ control that can impact telehealth, including a poor internet connection, malfunctioning technology, or limited technological knowledge, and clinicians should prepare alternatives in case of common issues.

Some patients may prefer in-person care if they feel that they are better able to connect with their clinician when they are in the same room. Patients with limited technology access, comfort, or proficiency may also prefer or need in-person care. At this point, it is common for telehealth practices to offer only virtual visits, but practices should incorporate patient preference and offer both in-person and virtual visits at each point in the patient’s care. In a recent study, 32% of patients reported that they did not typically receive their preferred modality, and perceived lack of choice negatively impacted patient satisfaction with their care, according to a report in the September 2023 Health Affairs.

A thoughtful approach, including consideration of patients’ perceptions of and preferences in telehealth, allows us to provide optimal care to our patients. ■

Jessica Membreno, M.D., M.B.A., is a third-year psychiatry resident at UCLA Health and an APA/APAF Public Psychiatry Fellow.

Shabana Khan, M.D., is chair of APA’s Committee on Telepsychiatry. She is also an assistant professor of child and adolescent psychiatry and director of Child and Adolescent Telepsychiatry at NYU Grossman School of Medicine.