Remote therapy was a lifeline for mental health during the pandemic. What is happening now?

When the Covid-19 pandemic forced behavioral health service providers to stop seeing patients in person and holding remote therapy sessions, the change produced an unintended positive consequence: fewer patients skipped appointments -you.

This has long been a problem in mental health care. Some outpatient programs 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 appointments before the pandemic. Once providers switched to telepsychiatry, that number jumped to 32%.

Not only that, but providers and patients alike claim that teletherapy has largely been an effective lifeline for people struggling with anxiety, depression, and other psychological issues during an extremely difficult time, even though it has been in short supply. created a new set of challenges.

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Many providers say they plan to continue offering teletherapy after the pandemic. Some states are making temporary pandemic rules permanent that allow providers to be reimbursed at the same rates as for in-person visits, which is good news for practitioners who purchase patient insurance.

“We are in a mental health crisis right now, so more people are struggling and may be more open to accessing services,” said psychologist Allison Dempsey, associate professor in the School of Medicine at the University of Colorado at Aurora. “It’s much easier to log in from your living room.”

The problem for patients who didn’t show up was often as simple as a canceled trip, said Jody Long, a clinical social worker who studied the 60% rate of no-show or late cancellations at the psychiatric clinic. from the Health Science Center at the University of Tennessee. .

But sometimes it was the health issue itself. Long remembers seeing a patient for the first time walk around the parking lot and then exit. The patient later called and said to Long, “I just couldn’t get out of the car; please forgive me and reprogram me.

Long, now an assistant professor at Jacksonville State University in Alabama, said the incident changed his perspective.

“I realized that when you have panic attacks or anxiety attacks or you have major depressive disorder, it’s difficult,” he says. “It’s like you’ve built these walls to protect yourself and all of a sudden you have to let go of those walls.”

Absences weigh on providers whose bosses set billing and productivity expectations and those in private practice who lose billable hours, said Dempsey, who runs a program to provide mental health care to families of babies. suffering from serious medical complications. Psychotherapists often overbooked patients in the hopes that some would not show up, she said.

Now Dempsey and his colleagues no longer need to overbook. When patients do not show up, staff can sometimes contact a patient immediately and hold the session. Other times, they can postpone them until later in the day or to another day.

And telepsychiatry works as well, if not better, than face-to-face mental health service delivery, according to a World Journal of Psychiatry review of 452 studies.

Virtual visits can also save patients money, as they may not need to travel, take time off work, or pay for child care, Dr Jay Shore said, chairman of the American Psychiatric Association telepsychiatry committee and a psychiatrist in the University of Colorado School of Medicine. .

Shore began examining the potential of video conferencing to reach rural patients in the late 1990s and concluded that patients and providers can virtually build relationships, which he believes is fundamental to therapy and management. effective drugs.

But before the pandemic, nearly 64% of psychiatrists had never used telehealth, according to the psychiatric association. Amid widespread skepticism, vendors then had to do “10 years of implementation in 10 days,” said Shore, who consulted with Dempsey and other vendors.

Dempsey and his colleagues faced a steep learning curve. She said she recently had a videotherapy session with a mother who “seemed very distraught” before disappearing from the screen as her baby cried.

She wondered if the patient’s discharge was related to the stress of the new motherhood or to “something more worrying,” like addiction, she said. She thinks she might have understood the woman’s condition better if they had been in the same room. The patient called Dempsey’s team that night and told them that she had relapsed into drug use and had been taken to the emergency room. Mental health care providers referred her to a treatment program, Dempsey said.

“We’ve spent a lot of time looking at what’s happened with this case and thinking about what we need to do differently,” Dempsey said.

Providers now regularly ask for the name of the person to call if they lose a connection and can no longer reach the patient.

Privacy challenges

During another session, Dempsey noticed that a patient seemed cautious and saw her partner hovering in the background. She said she was concerned about the possibility of domestic violence or “some other form of controlling behavior.”

In such cases, Dempsey called after appointments or sent patients secure messages on their online health portal. She asked if they felt safe and suggested speaking in person.

Such an inability to preserve privacy remains a concern.

Recently in a Walmart parking lot, Western Illinois University psychologist Kristy Keefe overheard a patient talking with her therapist from her car. Keefe said she wondered if the patient “didn’t have another safe place to go.”

To avoid this scenario, Keefe makes 30-minute consultations with patients before their first telehealth appointment. She asks if they have a space to talk where no one can hear them and makes sure they have sufficient internet access and know how to use video conferencing.

I am very grateful that they had something in this terrible time of loss, trauma and isolation.

To make sure she too was ready, Keefe upgraded her Wi-Fi router, bought two white noise machines to drown out her conversations, and placed a stop sign on her door during dates so that her 5 year old son knows she was seeing. the patients.

Keefe concluded that audio alone sometimes performs better than video, which often lags behind. On the phone, she and her psychology students “have become very sensitive to fluctuations in tone” in a patient’s voice and have been better able to “capture emotion” than with video conferencing, she said. declared.

With these telehealth visits, her 20% no-show rate evaporated.

More difficult to read body language?

Kate Barnes, a 29-year-old schoolteacher in Fayetteville, Arkansas, who suffers from anxiety and depression, also found visits easier over the phone than through Zoom because she doesn’t feel like she’s pointed at her .

“I can focus more on what I want to say,” she says.

In one of Keefe’s video sessions, however, a patient reached out, touched the camera, and began to cry, saying how grateful she was for someone to be there, Keefe recalls.

“I am very grateful that they had something in this terrible time of loss, trauma and isolation,” Keefe said.

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Demand for mental health services will likely continue even after all Covid-19 restrictions are lifted. About 41% of adults suffered from anxiety or depression in January, up from about 11% two years earlier, according to data from the US Census Bureau and the National Health Interview Survey.

“It’s not going to go away with a snap of your fingers,” Dempsey said.

After the pandemic, Shore said, providers should look at data from the past year and determine when virtual or in-person care is most effective. He also said that the healthcare industry must work to bridge the digital divide that exists due to lack of access to devices and broadband internet.

Although Barnes, the teacher, said she did not find teletherapy less effective than in-person therapy, she would like to return to see her therapist in person.

“When you’re in person with someone, you can better understand their body language,” she says. “It is much more difficult to do this on a video call.”

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