Q&A: Telepsychiatry plays vital role in combating mental health effects of COVID-19

Hossam Mahmoud

The novel coronavirus pandemic has led to numerous quarantine and social isolation measures throughout the United States and the world. Thus, psychiatric patients may be unable to attend an in-person appointment with their clinician. Although they are not new services, telepsychiatry and telemedicine in general have been ushered to the forefront of the health care industry as many patients and clinicians find virtual meetings a sensible way to help reduce COVID-19 risks.

Healio Psychiatry spoke with Hossam Mahmoud, MD, MPH, senior vice president and medical director of the Scheduled Services and Inpathy divisions at the telepsychiatry company InSight + Regroup, and president of the Illinois Psychiatric Society, about the role of telepsychiatry during this pandemic and how clinicians can best implement it with their patients. – by Joe Gramigna

Question: What unmet needs might psychiatric patients face during this pandemic?

Answer: There is a lot of increased anxiety associated with fear regarding the virus, the economy, one's health and the health of loved ones. A recent American Psychiatric Association study showed approximately 50% of respondents felt anxiety about COVID-19. Even more people said they felt anxiety about a loved one or a family member getting the virus. On top of these anxieties, there's the social isolation. Studies have demonstrated that quarantine or self-isolation measures can be associated with feelings of depression, anxiety or even hopelessness. Some have shown increases in irritability and anger, as well. Those are the contributing and precipitating factors, but we also have what we call propagating factors. People who have a history of mental illness or currently are developing mental health conditions because of pandemic-related stress have significant difficulties accessing care for a couple of reasons. We already have many barriers to access, such as the cost of care and shortages of mental health professionals. Right now, in addition to the long-term barriers, many people are too afraid to go to a health care facility and a lot of health care facilities are shutting down, at least temporarily, to protect patients and staff. A lot of cities and states have lockdown measures that really limit travel. Although none of these measure has limited travel to health care facilities, they can cause fear about leaving their home. We have a stressful situation, and in conjunction, we have even more barriers to accessing care. That's why we have seen a spike in demand for telepsychiatry services.

There are three approaches to telepsychiatry. One is called scheduled services, which are delivered to health care facilities typically in an outpatient setting. The second is on-demand telepsychiatry, which is usually delivered in emergency rooms and inpatient units. The third is in-home care. Because a lot of health care facilities, especially outpatient ones, are temporarily shutting down, we've seen a lot of patients who are unable to receive the scheduled telepsychiatry service. Thus, the demand for this has decreased somewhat. On the other hand, the demand for in-home care has skyrocketed. The demand for on-demand care has also increased because the hospitals don't want any patients being boarded with long wait times in the emergency room. The more people you have in a closed room or a closed area, the higher likelihood there's someone who's infected who may infect others.

Q: How can in-home telepsychiatry address patient needs?

A: Before the pandemic, we were a bit more selective in the delivery of in-home telepsychiatry services for a few reasons. One reason is the Ryan Haight Online Pharmacy Consumer Protection Act, a federal law that prohibits the prescribing of controlled substances unless there's an in-person evaluation, with some exceptions, such as when a videoconferencing session happens when a patient is at a DEA-registered health care facility Because of that, until the act was suspended during this pandemic, prescribing controlled substances via telepsychiatry was restricted. That limited the pool of patients that could be seen. For example, if someone needed a benzodiazepine for anxiety, or if someone needed stimulants for ADHD, they wouldn't be able to get these medications prescribed by the psychiatrist who sees them. That limited in-home care to some degree. The other factor that limited in-home care is reimbursement. For example, Medicare, until this pandemic, was only reimbursing for telehealth if the patient was at a health care facility located in a county that is either designated as a shortage county or as a rural county, with few exceptions to this rule. These two factors — the prescribing and reimbursement restrictions — limited in-home services to patients who were able to pay out-of-pocket or who had private insurance that was willing to pay for services provided in the home, and patients who didn't need controlled substances. The restrictions on reimbursement have been lifted, at least temporarily. Medicare, many Medicaid programs and many private insurers have now allowed for reimbursement for in-home care. Regarding the Ryan Haight Act, there are several exceptions. The fourth exception is for when a public health emergency is declared. Since one was declared, the Drug Enforcement Administration lifted the ban on the prescribing of controlled substances when patients are seen via telehealth at home. These two factors have really contributed to the increase in in-home care, in both the demand and the ability to deliver the services.

Q: Do you have any tips for clinicians or mental health care professionals when using telepsychiatry during this pandemic?

A: It's very important for clinicians to practice social distancing. In keeping themselves healthy, they empower themselves to take care of as many patients as possible. If clinicians are sick, they won't be able to care for patients. It is also important to stay up to date on the regulatory and reimbursement landscapes because they're changing pretty quickly, and to rely on reliable sources of information, such as the APA and American Telemedicine Association.

Another consideration during this pandemic is the current enforcement of HIPAA for when clinicians videoconference with patients. When we communicate with patients via telepsychiatry, it has to be on a HIPAA-compliant platform. Right now, HIPAA is not suspended by any means, but if someone uses Skype, for example, to communicate with patients, the government isn't going to go after them. The enforcement of HIPAA, when it comes to communicating with patients remotely, is not going to be as scrutinized. That is one example of regulatory nuances that clinicians need to pay attention to.

Clinicians should ensure that both they and their patients are comfortable with the technology, to troubleshoot if necessary and to have a backup plan if the technology fails. That becomes even more important when clinicians see patients at home. Although many patients might be comfortable with certain technologies, it's sometimes hard to get a crash course in a new mode of communication overnight when a patient hasn't used it before. Learning to do remote work is not that hard because telepsychiatry is basically psychiatry performed from a distance. There are factors that affect the provision of care, but overall, it really is basic psychiatry and mental health. It's not very difficult to learn.

Finally, there are occupational risk factors associated with doing completely remote work. One of them is social isolation, but we're going through that anyway as a society. The other one is having a sedentary lifestyle, which is exacerbated with the closing of many gyms and public places, so self-care for clinicians is critical during this time

Disclosures: Mahmoud reports being senior vice president and medical director of a telepsychiatry company.