When the pandemic hit, many psychiatry departments across the United States had to rapidly adapt and respond in innovative ways to serve the needs of their patient population. After an initial struggle, many found a platform best-suited for this need and transitioned to telepsychiatry as a way to see and treat patients. Telepsychiatry was initially developed specifically to make mental health care accessible to underserved populations, including the severely depressed, prison populations and students.
Seeing patients from a distance via video or audio works wonders for those patients who live far away from their mental health provider and for those whose tight schedules and demanding jobs won’t excuse a medical appointment. Certain patient populations, notably those with agoraphobia and obsessive compulsive disorder, have embraced this change with open arms. Unfortunately (and conspicuously), patients with schizophrenia and neurocognitive disorders have been absent for their telepsychiatry visits at alarming rates or struggle through their appointments.
For this group of patients, the loss of both an organized day as well as personal freedom brought on by the pandemic has been devastating. Patients with serious mental illness and dementias are at increased risk of suffering psychological sorrow while social distancing. For many, an in-person doctor visit may be the highlight of the day and the deliberate deprivation of human interaction gives pause.
Patients with severe mental illnesses often lack self-motivation. It is difficult to connect with their clinicians even during a face-to-face visit, let alone through video. The subtleties of a face-to-face medication or therapy visit in patients with schizophrenia, like that split second when they look over their shoulder or respond to unseen stimuli, are gravely missed when telepsychiatry is the only option. Medication side effects such as fine tremors, hypersalivation or a parkinsonian-type gait may be difficult to appreciate on video. Finally, many patients with schizophrenia lack the organization needed to set up a telepsychiatry visit. Simple tasks such as turning on a computer or tablet and connecting to the internet may seem insurmountable.
Questions arise, too, regarding privacy during telepsychiatry visits. When we ask parents to leave the room so we can talk to an adolescent alone, do we really know if they are not listening right outside the door? The debate around HIPAA-compliant chat applications is ongoing.
In addition, utilization of telepsychiatry has also significantly impacted medical student education in psychiatry settings. Having multiple medical students “zoom in” while patients are being interviewed further complicates privacy and therapeutic rapport. Many residents must master the balancing act of ensuring medical students, attendings and patients connect to the same video link. Disruption of internet connectivity has not helped matters.
When utilized in the appropriate setting, telepsychiatry can be life-saving and can allow us to access the most underserved populations. Despite technical challenges and limitations, it has revolutionized health care delivery, especially in psychiatry. It allows us to reach to more technologically advanced age groups such as adolescents and also the less technologically savvy elderly. Telemedicine allows care for patients across state borders and cultures. Given the current pandemic (and the unspoken fear of another), it may just be a necessary evil. It is up to us to recognize that one model of telemedicine may not work for every patient, and that we have to ensure the diverse needs of our patient population are met.