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Rocksheng Zhong MD, MHS

COVID-19 and the Future of Telepsychiatry

Telemedicine enables mental health care during the pandemic, but at what cost?

The COVID-19 pandemic has suddenly elevated telepsychiatry—the use of audio- and video-conferencing for psychotherapy and medication management—from a niche practice to the standard way of providing behavioral healthcare.

Although telepsychiatry promises improvements in access and efficiency and arguably empowers patients, it sacrifices some of the essential human qualities of the doctor-patient relationship. These tradeoffs can be worthwhile, and telepsychiatry is almost certainly here to stay. However, we must be aware of the costs as we move forward.

Are we approaching a future where video-conferencing with your psychiatrist on your phone hearkens back to the pastoral ideal of the house calls of old? Or is this the next step in an increasingly technology-oriented, physician-optional approach that ends with the types of automated medical bays envisioned in science fiction?

The Evolution of Telepsychiatry

The World Health Organization defines telemedicine as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”1

Telepsychiatry is not new. Since the 1960s, psychiatrists have conducted consultations, forensic evaluations, and training remotely by telephone or closed-circuit television.2 For at least the past 20 years, telepsychiatry has been used to reach places otherwise lacking access to psychiatric services, such as rural areas or smaller community hospitals.3 But now faced with a public health crisis, clinicians of all stripes, including psychiatrists, have been forced to adopt, almost overnight, this mode of practice in order to continue providing services while also minimizing the risks of disease exposure to patients and staff.

Telemedicine in general, and telepsychiatry in particular, can have many forms. Clinic-based systems require patients to go to a clinic, get checked in, see a nurse who obtains vital signs and other basic information, and then connect to the psychiatrist using the clinic’s videoconferencing equipment in an examination room. It is essentially the same as an ordinary doctor’s appointment, except that instead of walking through the door, the psychiatrist appears onscreen. But the far more common system in the era of COVID-19 is in-home.4 With the proliferation of mobile devices with built-in cameras, it is now possible for patients to use their own smartphones to connect quickly and directly with their psychiatrists without having to risk exposure to COVID-19.

Edward Jenner/Pexels
Source: Edward Jenner/Pexels

Enhanced Access and Efficiency

The expansion of telemedicine is a great boon for access and efficiency. Proximity is no longer a requirement, and patients and doctors are not tethered to a specific location. Individuals in underserved areas can, in theory, consult experts around the country.

Telepsychiatry can also circumvent the limits of traditional business hours. Doctors working in a home office, freed from commuting or maintaining expensive overhead and staff, may have more flexibility in offering non-traditional hours in the morning, evening, or weekends. Moreover, conducting visits across time zones can open even more options. A busy woman in Atlanta working full-time might never have the opportunity to see a local psychiatrist whose office closes at 5:00 PM Eastern Time, but she could videoconference with a clinician in Seattle at 7:00 PM Eastern Time/4:00 PM Pacific Time.

Telepsychiatry lowers the practical barriers to entry as well. What’s more convenient than picking up the phone for a 15- or 30-minute video call? Patients need not take time off from work to see the doctor, arrange transportation and childcare, wait for hours in a lobby when the doctor is running late, or even remember their appointment times.

Conversely, psychiatrists can worry less about no-show rates. Patients are more likely to attend their appointments when there are fewer obstacles to navigate and things to remember.5 Furthermore, with high attendance, doctors will have less need to overbook appointment slots to compensate and be more likely to run on schedule.6

Quantity at the Expense of Quality

From a numbers perspective, telepsychiatry is surely appealing, but this emphasis on quantity sacrifices some important qualities that are fundamental to the doctor-patient relationship. Some of the challenges are straightforward technological shortcomings and will probably resolve as technology improves, but others are more abstract and, dare I say, eternal.

To start with, technology is not always reliable. Depending on the strength of connection and available bandwidth, videoconferencing can be a frustrating way to communicate, particularly when dealing with sensitive and emotional topics. The picture may freeze or stutter, sound may cut out, or the call may be dropped entirely. More than once, I have had the sound fail in the middle of a patient relating their trauma, and I am faced with the uncomfortable choice of asking the patient to retell their story or accepting that I possibly missed important details.

Even when the technology is working properly, the format has inherent limitations. The level of human connection we feel when sitting with another person in an intimate moment is hard to replicate when physical distance and an electronic screen separate the two parties. Psychiatrists try to remain open and empathetic, but much of the nonverbal subtleties are lost. There is simply no way for video to reproduce perfectly the timing, tone of voice, facial cues, body language, subtext, and innuendo that are present in in-person encounters.7 And that is assuming the camera is even facing the right direction and properly zoomed. Sometimes, I will only see the person’s forehead or chin or torso or ceiling.

Remote connection further impairs the psychiatrist’s ability to conduct a thorough physical assessment and thereby provide good care. Although conversation is the primary focus of a psychiatric visit, physical details, such as blood pressure, weight, appearance, gait and bearing, and the presence of abnormal muscle movements, are important markers of mental health and response to treatment.

In addition, the environment can intrude upon a telepsychiatry appointment. Doctors’ offices are controlled settings designed to be private and insulated against distractions. Patients’ homes are filled with distractions, in the form of children or spouses, pets, television, chores, and so on. Some of my patients have had to lock themselves in their bathrooms or cars because those are the only places where they can have privacy. Even more concerning are those individuals living in traumatic or abusive homes, who lack a safe space altogether.

Conclusion

In spite of all the drawbacks, telepsychiatry may still be worth it. Certainly, it is appropriate in the many situations where the alternative is no care at all—underserved populations, persons who would face difficult barriers in attending in-person visits. But for those patients who have the capacity to go to a clinic, we must recognize that the advantages of telepsychiatry must be weighed against its constraints. Quantity at the expense of quality may be a good deal, but it will likely change the character of the psychiatrist-patient relationship. Studies have shown that one of the “active ingredients” of psychiatric care is the relationship itself.8 What will happen when this relationship is modified and mediated by the glowing screen of a smartphone?

At the end of the day, telepsychiatry is the future of the field. Our society is increasingly reliant on technologies to augment all aspects of human experience, and healthcare should be no exception. As noted cybernetics theorist Donna Haraway has said, “we are all chimeras, theorized and fabricated hybrids of machine and organism; in short, we are cyborgs.”9 Perhaps one day, advances in virtual reality or holographic projectors will erase the differences between virtual and in-person doctors’ appointments. But until then, patients and doctors alike should be aware of the technological and relational limitations of the medium and their associated harms. We may even need an updated informed consent for telepsychiatry that acknowledges the risks produced by dropped connections, missed or missing information, and the nature of relationships formed through a screen.

With telepsychiatry moving into the mainstream of medical practice, now is the time to have a public conversation about the potential pitfalls as well as the benefits.

References

1. World Health Organization. Telemedicine: Opportunities and Developments in Member States. Report on the Second Global Survey on eHealth. Geneva: World Health Organization; 2010.

2. Doarn CR. Telemedicine and psychiatry-a natural match. Mhealth. 2018;4:60.

3. Fortney JC, Pyne JM, Turner EE, et al. Telepsychiatry integration of mental health services into rural primary care settings. Int Rev Psychiatry. 2015;27(6):525-539.

4. Calton B, Abedini N, Fratkin M. Telemedicine in the Time of Coronavirus. J Pain Symptom Manage. 2020;60(1):e12-e14.

5. Mitchell AJ, Selmes T. Why don't patients attend their appointments? Maintaining engagement with psychiatric services. Advances in psychiatric treatment. 2007;13(6):423-434.

6. LaGanga LR, Lawrence SR. Clinic overbooking to improve patient access and increase provider productivity. Decision Sciences. 2007;38(2):251-276.

7. Grondin F, Lomanowska AM, Jackson PL. Empathy in computer‐mediated interactions: A conceptual framework for research and clinical practice. Clinical Psychology: Science and Practice. 2019;26(4):e12298.

8. Zuroff DC, Blatt SJ. The therapeutic relationship in the brief treatment of depression: contributions to clinical improvement and enhanced adaptive capacities. J Consult Clin Psychol. 2006;74(1):130-140.

9. Haraway D. Manifesto for cyborgs: Science, technology, and socialist feminism in the 1980s. Socialist Review. 1985;80:65-108.

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About the Author

Rocksheng Zhong, MD, MHS, is Medical Director of Northern Arizona at Southwest Behavioral and Health Services, as well as Lecturer in the Law and Psychiatry Division of the Yale School of Medicine.