Continuing our occasional articles on telepsychiatry, ACLP News has been talking with Hindi Mermelstein, MD, FACLP, who is chair of the Community-Based Psychosomatics Physician Practice Issues SIG and a member of the Telepsychiatry SIG
…younger generations are so used to technological exchange there is a hesitancy for face-to-face care’
What circumstances suit telepsychiatry—compared with when only in-person treatment feels appropriate?
According to the overwhelming majority of studies, telepsychiatry can provide the same benefit as face-to-face treatment for common, and not so common, psychiatric conditions. However, there are times when one or the other may be preferable.
Telepsychiatry is not only the “way to go” when access is a problem but, in my clinical experience, it has sometimes been useful for patients who had trouble with intimacy and require the development of trust in the therapeutic relationship before face-to-face treatment can begin…
For example, the woman whose chemo-induced alopecia horrified her, resulting in her avoidance of social situations and her cancelling of face-to-face treatment. Telepsychiatry allowed her to receive treatment in a way she felt was safe until she trusted that we would not reject her, with hair or without, and consequently returned to my office—and to society.
Conversely, there are patients who “hide” from the treatment and should not be well suited to telepsychiatry, such as my patient who would close the lens [of the camera] to limit the connection and the exchange of information. Or some older persons for whom the technological requirements impede the therapeutic process.
Does telepsychiatry sometimes get used for the professional’s benefit, rather than the patient’s benefit—perhaps to manage heavy caseloads, or because there are too few psychiatrists to go around, or to avoid spend on extra in-person resource as demand increases?
The lack of access to psychiatric services affects both patients and practitioners. It may de facto be the only means to provide clinical care to cover wide geographic areas, or to provide specialty care.
Increasingly, the new telepsychiatry programs are a means to expand the provision of care, in a consulting or collaborating manner, to areas that would otherwise lack access to care for a variety of reasons.
For the practitioners, it allows them to spend clinical hours providing care versus travel; to be more available and at a cost; and within a fee schedule that does not have to incorporate travel costs, time costs, and can add flexibility. For systems, it allows for care to be provided “on demand” even when the flows of cases are unpredictable or the specialty requirements very specific. This can allow for consultation and care which would otherwise be too difficult or costly to staff.
Or, is telepsychiatry gaining ground as the treatment of choice—that it can be as good as, or better than, in-person psychiatry for certain profiles of patient, or for certain conditions?
Time and time again, studies have shown that—from both patient satisfaction and practitioner factors—outcome data from treatment delivered via telepsychiatry is no different from face-to-face treatment.
Take a look at just a couple of the many references:
The Application of Technology to Health: The Evolution of Telephone to Telemedicine and Telepsychiatry: A Historical Review and Look at Human Factors by Mermelstein, Rabinowitz, Guzman, Krapinski and Hilty
This review article, from members of the Academy’s Telepsychiatry SIG, takes a look at the development of the field from ancient times to the present.
As the field has advanced and as the practice of telepsychiatry has become ubiquitous, both the American Psychiatric Association (APA) and the American Telemedicine Association (ATA) updated their guidelines to understand and to implement telepsychiatry in practice.
Do you see any differences in response to telepsychiatry treatment across different age groups, among both patients and colleagues?
Satisfaction in the use of telepsychiatry is generally high. There are differences that stratify across groups. Older physicians and geriatric patients tend to have a harder time adjusting to telepsychiatry means in terms of the technology, the comfort with the concept, and a full integration of this modality into their practice and the way they prefer care delivery. The younger generations are so used to technological exchange there is sometimes a lack of appreciation for the differences, however subtle they seem, between the care delivery modes, accompanied by a hesitancy for face-to-face care as it requires more resource allocation, be it time, money, or effort.
Telepsychiatry has also been credited with rapid improvement in timeliness (i.e.: patients are diagnosed and treated sooner), leading to reduction in boarding and improved safety for patients, families and care teams. Is that your experience?
Telepsychiatry allows for an improvement in real-time treatment. In the early work in telepsychiatry, consultations, collaborations for care, and even family visits could take place remotely. Today, telepsychiatry allows for care to be increasingly delivered in “real time” without the delay caused by limited physician availability or access. Furthermore, consultations, case conferences, family meetings, and discharge planning can take place virtually, increasing this timeliness benefit. This can result in shorter length of stay, improved discharge processes, and increased possibility for post discharge follow-up.
Would it be fair to say that telepsychiatry was first adopted as a means of reaching more remote neighborhoods in community-based practice, but now it has been adopted as much in heavily populated areas?
It is still most widely used as a means of reaching more remote areas, not well served by traditional modalities. However, the dearth of psychiatrists continues to plague many areas, irrespective of size, impelling the adoption of telepsychiatry in these areas as well.
The APA in its updated policy in 2018 approved use of telepsychiatry subject to certain provisos: one was that patient autonomy, confidentiality and privacy are protected. Are patients put any more at risk than from documentation from in-person visits? Are there evidenced benefits over standard documentation—e.g.: it’s been said that telepsychiatry offers improved rates of patient acceptance by in-patient psychiatric facilities because of more vigorous documented evaluation through telepsychiatry, and these patients are likely to have been started on medications before they arrive.
There are ethical, legal, and logistical issues that require careful consideration in all areas of medicine with factors specific to telepsychiatry. For example, in the office there is better control of who is present, who is included, and better safeguards as to who can hear or listen to the conversations than in telepsychiatry. Whether it is in the hospital or institutional setting where the number of staff is increased, or in the community setting where there is limited control as to who is present from the patient side, the risk of inadvertent or accidental exposure is increased.
In your crystal ball, where do you see the future for telepsychiatry in community-based care—say over the next five years?
Crystal ball-wise, I think that the adoption of telepsychiatry will grow in community-based care for the reasons outlined: it is beneficial, patients and providers report satisfaction with this modality of care, and it adds to the availability and ease of receiving and delivering care.
At the same time, there will be increased awareness of the risk of this expansion, such as inadequate triage of cases that are, or are not, suited for this modality; a better understanding of how to, or how to not, apply the technology; as well a recognition that along with the technology there needs to be concomitant quality improvement to make sure the care we provide continues to be the best care we can deliver.
So, I think there will be growth and expansion but with increasing awareness of the issues that arise.