When the Covid-19 pandemic forced behavioral physicians to no longer see patients in person and instead hold therapy sessions remotely, the change led to an unintended positive consequence: fewer patients skipped appointments.
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This has long been a problem in mental health care. Some outpatient programs had previously had no-show rates of up to 60%, according to several studies.
According to a report by the American Psychiatric Association, only 9% of psychiatrists said all patients kept their pre-pandemic appointments. After providers switched to telepsychiatry, that number rose to 32%.
In addition, providers and patients say teletherapy has been an effective lifeline for people struggling with anxiety, depression, and other mental health issues during an extraordinarily difficult time, despite the fact that it has brought new challenges.
Many providers plan to continue offering teletherapy after the pandemic. Some states are making the temporary pandemic rules permanent, which allow vendors to reimburse the same rates as they would for face-to-face visits. This is welcome news for practitioners purchasing patient insurance.
“We are currently in a mental health crisis so more people are struggling and may be more open to access to services,” said psychologist Allison Dempsey, associate professor at the University of Colorado Medical School at Aurora. “It’s a lot easier to connect from your living room.”
The problem for patients who didn’t show was often as simple as a canceled ride, said Jody Long, a clinical social worker who managed the 60% no-show or late cancellation rate at the University of Tennessee’s Health Science Center mental hospital examined.
But sometimes it was the health problem itself. Lange recalls a first-time patient driving around the parking lot and then getting out. The patient called later and said to Long, “I just couldn’t get out of the car. Please forgive me and reschedule me. “
Long, now an assistant professor at Jacksonville State University in Alabama, said the incident changed his perspective. “I’ve found it difficult when you have panic attacks, anxiety attacks, or major depression,” he said. “It’s like you’ve built these walls for protection and then suddenly you’ve got to lower those walls.”
Absent stress providers whose supervisors set billing and productivity expectations and those in private practice who lose billable hours, said Dempsey, who leads a mental health care program for families with babies with serious medical complications. Psychotherapists have often overbooked patients with the expectation that some would not show up, she said.
Now Dempsey and her colleagues no longer have to overbook. Sometimes when patients fail to show up, staff can immediately contact a patient and conduct the session. In other cases, you can postpone it for a later day or another day.
Telepsychiatry is as good, if not better, than personal delivery of mental health services, according to a review of 452 studies by the World Journal of Psychiatry.
Virtual visits can also save patients money as they may not have to travel, take time to work, or pay for childcare, said Dr. Jay Shore, chairman of the American Psychiatric Association’s Telepsychiatric Committee and a psychiatrist at the University of Colorado Medical School.
Shore began studying the potential of video conferencing to reach rural patients in the late 1990s, and concluded that patients and providers can virtually create a relationship that is fundamental to effective therapy and drug management.
Before the pandemic, almost 64% of psychiatrists had never used telemedicine, according to the psychiatric association. Amid widespread skepticism, vendors then had to do “10 years of implementations in 10 days,” said Shore, who has consulted with Dempsey and other vendors.
Dempsey and her colleagues faced a steep learning curve. She said she recently held a video therapy session with a mother who “seemed very upset” before disappearing from the screen while her baby cried.
She wondered if the patient’s exit was related to the stress of new motherhood or “something more worrisome” like addiction, she said. She thinks she would have understood the woman’s condition better if they had been in the same room. The patient called Dempsey’s team that evening and told them she had relapsed into drug use and had been taken to the emergency room. Mental health providers referred them to a treatment program, Dempsey said.
“We spent a lot of time reviewing what happened to this case and thinking about what to do differently,” said Dempsey.
Providers now routinely ask for the name of someone to call if they lose a connection and can no longer reach the patient.
In another session, Dempsey noticed that a patient appeared to be guarded and saw her partner hovering in the background. She said she was concerned about the possibility of domestic violence or “some other form of behavior control”.
In such cases, Dempsey called after the appointments or sent patients safe messages to their online health portal. She asked if they felt safe and suggested they speak in person.
This inability to maintain privacy remains a concern.
In a Walmart parking lot, Western Illinois University psychologist Kristy Keefe recently overheard a patient talking to her therapist from her car. Keefe said she wondered if the patient “had no other safe place to go”.
To avoid this scenario, Keefe conducts 30-minute consultations with patients prior to their first telemedicine appointment. She asks if they have room to talk where no one can overhear them, and makes sure they have adequate internet access and know how to use video conferencing.
To make sure she was prepared too, Keefe upgraded her WiFi router, bought two white noise devices to drown out their conversations, and placed a stop sign on her door during appointments so her 5-year-old son would know she saw it patient.
Keefe concluded that audio alone sometimes works better than video, which often lags behind. On the phone, she and her psychology students became “very sensitive to fluctuations in tone” in a patient’s voice and were better able to “pick up” emotions than they would with video conferencing, she said.
During these telemedicine visits, their 20% no-show rate disappeared.
Kate Barnes, a 29-year-old Fayetteville, Arkansas middle school teacher struggling with anxiety and depression, has also found visits easier by phone than zooming because she doesn’t feel like she’s in the spotlight.
“I can focus more on what I want to say,” she said.
In one of Keefe’s video sessions, a patient reached out, touched the camera, and began to cry when she said how grateful she was that someone was there, Keefe recalled.
“I’m so grateful that they had something during this terrible time of loss, trauma, and isolation,” said Keefe.
The demand for mental health services is likely to continue after all covid restrictions are lifted. According to the US Census Bureau and the National Health Interview Survey, about 41% of adults had anxiety or depression in January, compared with about 11% two years ago.
“This won’t go away if we snap our fingers,” Dempsey said.
After the pandemic, Shore said, providers should review last year’s data and determine when virtual or face-to-face care is more effective. He also said the healthcare industry needs to work to bridge the digital divide created by lack of access to devices and broadband internet.
Although Barnes, the teacher, said she didn’t consider teletherapy to be any less effective than personal therapy, she would love to go back to her therapist.
“When you’re with someone in person, you can learn their body language better,” she said. “It’s much more difficult with a video call.”
KHN (Kaiser Health News) is a national newsroom that produces extensive journalism on health issues. Alongside Policy Analysis and Polling, KHN is one of the three most important operational programs of the KFF (Kaiser Family Foundation). KFF is a foundation that provides health information to the nation.
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