Expert Roundtable: Adjusting to Telepsychiatry During COVID-19

Telemedicine, long championed as an ideal solution to the dearth of healthcare providers in remote areas, has suddenly been widely implemented in many settings due to the 2019 coronavirus disease (COVID-19) pandemic.¹

“Not only does telemedicine make it possible for patients to remain inside their homes to slow the spread of the virus, but hospitals can now better prepare for a surge of patients into our emergency rooms and intensive care units,” wrote Kathleen T. Jordan, MD, an infectious disease specialist and chief medical officer at Saint Francis Memorial Hospital in San Francisco, California, in the Washington Post.²

For providers and other advocates already familiar with telemedicine, it has likely come as a pleasant surprise that the modality has finally been adopted for widespread use. This shift can be mainly attributed to the drastic increase in the number of payors allowing reimbursement for telemedicine, presumably on a temporary basis, along with relaxed rules regarding geographical location and practicing across state lines.³

Psychiatry is often cited as the “perfect” specialty for delivery via telemedicine because of its reliance on conversation and relative lack of physical contact compared to other specialties.⁴ A large body of evidence supports the benefits of telepsychiatry in treating a wide range of conditions, including posttraumatic stress disorder, depression, anxiety, and psychotic disorders, across various inpatient and outpatient settings.^5,6

Even before the emergence of COVID-19, telepsychiatry had become so well-integrated in emergency departments (EDs) that it was used by 90% of EDs surveyed in a study and represented the only form of emergency psychiatric services in 59% of EDs in the United States.⁷ During the COVID-19 crisis, clinicians at Johns Hopkins University have described video consultation for the at-home management of patients with opioid use disorder.⁸

Although it is unclear whether rules regarding telemedicine will revert once the virus is under control, experts caution that the needs being met via telepsychiatry will persist and increase over time. “Harnessing this surge in interest, enthusiasm, and acceptance has immediately been recognized as an opportunity for the field,” according to a paper published in March 2020 in JMIR Mental Health.⁹ “Thus, the field’s next steps will also be critical in ensuring digital health is used today to deliver the best care during the current crisis, ready for any resulting mental health spike following the immediate crisis, and prepared to support future crises as well as care as usual.”

While some providers had been using telemedicine before the pandemic, others have had to adapt quickly to delivering care in this context. We checked in with the following clinicians to learn about their telemedicine experiences in recent months: Karen J. Jacobs, DO, associate staff physician in the department of psychiatry and psychology at the Cleveland Clinic in Ohio; Paul S. Nestadt, MD, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins School of Medicine in Baltimore, Maryland, and co-director of the Johns Hopkins Anxiety Disorders clinic; and Eddie Reece, MS, LPC, BC-TMH, a psychotherapist in private practice near Atlanta, Georgia.

What has been your experience adjusting to using telemedicine during this pandemic? Are you new to it or increasing use in light of COVID-19?

Dr Jacobs: I am brand spanking new to this! I have been delaying trying telemedicine, though I had been trained a couple times prior to the pandemic, but it’s not bad once you get the hang of it. As an outpatient psychiatrist I have seen many of my patients for years, and that sense of being in the moment with them is a little different using telemedicine since we are no longer in the same physical space. That said, I believe that using this format during the pandemic has been a welcome option to both the practitioners and the patients.

Dr Nestadt: I am new to telemedicine, as the tools that were previously required by regulators were unwieldy and expensive. It has been an adjustment, with many technical difficulties and some frankly hilarious accidental situations with webcams in the home. Overall, however, it is certainly better than the huge reduction in access to care that we would be facing without telemedicine. 

Reece: I’ve utilized video to conduct sessions for years, but most of my clients prefer using the phone instead. I have only one client who took a break from therapy due to “having too much to do” because of the stay at home order. I miss seeing my clients in person, and I’m also thankful we can meet remotely.

What are some of the key challenges regarding the use of telemedicine for mental health services? What are some of the main benefits? 

Dr Jacobs: Challenges include learning and having access to the required technology. Current rules are much more lenient, and there are many public platforms that can be used during this time, including FaceTime, Google Duo, and Doxy.me, for example.

[Editor’s note: Due to the pandemic, the Office for Civil Rights at the Department of Health and Human Services is temporarily allowing providers to use popular video chat applications such as Skype, Zoom, Apple Facetime, and other programs for the provision of telehealth services without risking the usual penalties for HIPAA noncompliance.¹⁰]

Privacy is an additional concern. Will your patient have a private place to speak to you? Will you be learning only what they can comfortably share, given their space limitations? With patients on antipsychotics, conducting an Abnormal Involuntary Movement Scale (AIMS) assessment is more challenging when you can’t assist the patient. Additionally, if your patient requires an interpreter, this could be difficult.

Potential isolation for the provider is another potential issue. As for the benefits of telepsychiatry, it can be provided regardless of the weather, and transportation problems – long commutes, parking fees, or having to take public transportation – are now eliminated.

For patients who must be accompanied to appointments such as our group home patients due to physical or mental disability, they often require several persons to ready them and bring them to our appointments. This can be very disruptive to the patient’s routine, not to mention costly and time consuming, and telemedicine helps to eliminate some of these challenges. For practitioners, this modality can prove to be ideal if you need flexibility.

Dr Nestadt: There have been challenges. Mental health care requires a greater expectation of privacy, and so patients stuck at home with others sometimes need to log in from a car or bathroom. When I have patients who are very high risk, I am uncomfortable with the fact that if they endorsed crisis-level suicidality, I do not have the option of walking them right to the emergency room; in a telemedicine session, they could simply hang up.

I had a patient who called in from the state border because in her state my license would not have previously allowed interstate telemedicine. If she had required an emergency petition based on the assessment, bringing her to the emergency room, I would not have been able to file one in her state. Another time, a very fragile conversation was repeatedly interrupted by the sounds of my kids screaming at each other from upstairs.

There are also benefits to requiring an in-person appointment. It is often therapeutic for a patient who has been struggling to get up, get dressed, leave the house, and prove their agency by making an appointment. I have had appointments where I felt that the most benefit came from forcing a patient to be out in the world, beyond any therapy I was doing once they arrived.

However, the benefits of telemedicine during this pandemic are immense. Without telepsychiatry, many patients would be completely unable to access care at what is likely a particularly high-risk period. Suicide rates have been noted to go up in past pandemics, as they have during economic tumbles in general. Obviously, fear and anxiety run high right now, but also grief for a lost way of life and sometimes for lost loved ones, along with isolation, job loss, watching our lives and our children’s lives derail, and potentially increased substance use.

Since there have been dramatic increases in gun purchases, we can also worry that any suicide attempts made right now are much more likely to be lethal ones.¹¹ And then there are special populations at risk, such as victims of domestic or child abuse now trapped at home with their tormentors. Or healthcare workers embedded neck deep in this tragedy, rapidly losing patients to the same virus that they fear tracking home to their families. Access to mental healthcare is more important now than ever.

Reece: The only issue for me is with new clients – video doesn’t give me the same feel for folks, and I don’t think they get the same sense of connection from me. I suspect those who choose to use the phone don’t want to deal with the technology or perhaps don’t like the way they look on screen. In recent sessions, the conversation is about adapting to a new normal. With clients I know well, the phone works well. I have phone clients I haven’t seen in a year or two.

A major benefit is convenience for the client. I work at home, so it’s not so convenient for me – it’s much easier to walk into my office than to set up the video. A challenge is staying as focused as one would in an in-person meeting. It’s important for clients and providers to close any other programs that might prove distracting during sessions.

What do you recommend for other mental health clinicians who want to get started with telemedicine – for example, how to find the right platform, billing considerations, or sorting through legal and ethical considerations?

Dr Jacobs: I would recommend that anyone give telemedicine a try. In psychiatry, we are uniquely positioned for this platform to work easily and well. Finding the right platform may depend on if you are a single practitioner or not. Working for a large institution like the Cleveland Clinic, there is a contract in place with a very secure platform – American Well. However, since the need swelled to such huge numbers during the pandemic, any platform has been allowed. I always first attempt access through the most secure of options.

Legally, you must follow your state and employer’s regulations. Ethically, we all want to ensure that this is a secure, confidential method of delivery. In the past, billing was a huge issue as Medicare, Medicaid, nor many private insurers would pay for these options, but again, due to the pandemic, they are currently allowable, and there are specific billing guidelines. Hopefully, these services will still be covered once the pandemic is over.  

Dr Nestadt: For right now, I would make the most of the regulatory flexibility so that you can use a platform that is most accessible for your patients. Whatever you use, make sure to put up adequate privacy protections, including passworded rooms, encrypted connections, and as private a physical space as possible for your patients and yourself. Always make sure you know where your patient is calling from, so that in an emergency you may have recourse. For patients where it is appropriate, insist that they are up and dressed for the appointment – and the same applies to providers – because the trappings of professionality on both ends of the webcam are key components of the therapeutic alliance.

Reece: There has been a lot of discussion about this on the professional listservs. It seems that therapists don’t want to spend the money to get secure, HIPAA-compliant technology. Even though the Georgia board says it’s okay to use Facetime and such, why would a therapist want to jeopardize confidentiality? Whenever possible, just spend the money and meet the standard criteria of ethical telemental health.

What are the remaining needs in terms of research, education, or technology to improve and expand telemedicine for mental health care?

Dr Jacobs: While there have been some earlier studies indicating that patients typically enjoyed telepsychiatry and felt the quality was good, we need to assess this further. Patients need to understand limitations if providers must use less than secure platforms. We need to be certain our patients have the privacy they need for their sessions so that we are treating them accurately. We still need to determine which patients would benefit most from this type of treatment.

Dr Nestadt: It would be useful to evaluate patient and clinician attitudes towards this telemedicine shift in a systematic way in this unique situation of forced adoption. Will this demonstrate the benefits of telemedicine to those who would have been slow adopters? Or will the forced rapid expansion lead to imperfect rollouts, turning people off of the technology? There is already a rich literature on the efficacy of telemedicine, but the unique context of the pandemic and the relaxed regulatory environment will open new avenues of investigation. Will patients be more or less comfortable with video platforms that they are already familiar with, such as Zoom or Facetime, which in the past were not permitted for healthcare use? We currently have no choice but to operate remotely. But it remains to be seen how these experiences will permanently change the practice of psychiatry.

Reece: Up front, folks need some education about how and where to place the camera and have good lighting. Video is better than the phone because you get to see the person, but you lose that if the lighting is inadequate and the camera captures only part of their face. It also helps to see at least the top half of the torso so you can see hand and arm movements.

I don’t see the need for more research to show that meeting remotely is effective; it should be obvious that it’s more effective than not meeting. If you have a choice, meet in person. If not, meet remotely – just meet. I hope this time of sheltering in place helps to put remote therapy more firmly on the map.

References

1. Centers for Disease Control and Prevention. Telehealth in rural communities. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/telehealth-in-rural-communities.htm Accessed on May 1, 2020.

2. Jordan KT. An unexpected benefit of the pandemic: The doctor will virtually see you now. The Washington Post. April 14, 2020.

3. American Psychiatric Association. Telepsychiatry and COVID-19. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19 Accessed on May 1, 2020.

4. Barnett ML, Huskamp HA. Telemedicine for mental health in the United States: making progress, still a long way to go. Psychiatr Serv. 2020;71(2):197-198.

5. Zhou X, Snoswell CL, Harding LE, et al. The role of telehealth in reducing the mental health burden from COVID-19. Telemed J E Health. 2020;26(4):377-379.

6. Santesteban-Echarri O, Piskulic D, Nyman RK, Addington J. Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. J Telemed Telecare. 2020;26(1-2):14-20.

7. Freeman RE, Boggs KM, Zachrison KS, et al. National study of telepsychiatry use in U.S. emergency departments. [Published online February 5, 2020] Psychiatr Serv. doi:10.1176/appi.ps.201900237

8. Johns Hopkins University Newsroom. COVID-19 tip sheet: story ideas from Johns Hopkins. April 21, 2020.

9. Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital mental health and COVID-19: using technology today to accelerate the curve on access and quality tomorrow. JMIR Ment Health. 2020;7(3):e18848.

10.  US Department of Health and Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html Accessed on May 4, 2020.

11.  Stockler A. Coronavirus pandemic and surging gun sales may increase suicide risk in US, researchers say. Newsweek. April 30, 2020.