The Benefits and Challenges of Telehealth for Clinicians and Patients

In this Q&A, Victor JA Buwalda, MD, PhD, William E. Narrow, MD, MPH, Eve K. Mościcki, ScD, MPH, Renée Cookson, CTRS, and Rogena Abdelraham, B.S. discuss the main takeaways from their recent virtual APA session “Zooming Through COVID-19: Achievements and Challenges in Telemental Health Services and Patient-Centered Treatment” as well as the primary challenges for both clinicians and patients when utilizing telehealth and telepsychiatry services. 

Q: Introduction

A: For this Q & A we would like to introduce the readers to our research collaboration. In 2014 Victor J.A. Buwalda, MD, PhD, IDFAPA and William E. Narrow, MD, MPH, associate professor in the Johns Hopkins University School of Medicine, started to collaborate on outcome assessment. This collaboration was quite effective and resulted in several sessions on outcome measurements, developing applications, and, over Zoom during COVID-19, at the annual meeting of the American Psychiatric Association. Drs. Narrow and Buwalda expanded the research group to include Eve K. Mościcki, ScD, MPH, psychiatric epidemiologist, a highly respected colleague, and two experienced consumer advocates who have volunteered their time to work with us: Renée Cookson, CTRS, Community Development Director for the National Alliance on Mental Illness (NAMI) San Diego affiliate, and Rogena Abdelrahman, Technology/Community Development Specialist at NAMI San Diego.

With this diverse group we developed our successful submission to this year's 177th annual meeting of the American Psychiatric Association. Our session was entitled “Zooming Through COVID-19: Achievements and Challenges in Telemental Health Services and Patient-Centered Treatment”.

Gratified by the great interest in our session we wanted to address some important issues for a larger audience. The Psychiatry and Behavioral Health Learning Network asked us to share more of our ideas to guide mental health providers in this COVID-19 era. We hope that it will help them in their daily clinical work. If you still have questions, please let us know and we will get back to you.

What were the main takeaways from your APA session “Zooming Through COVID-19: Achievements and Challenges in Telemental Health Services and Patient-Centered Treatment”?

There are 4 main takeaways from our session. First, technology is an important tool for mental health care. Knowledge of different health care technologies is expanding. The internet and the use of smartphones have expanded the possibilities and accessibility of mental healthcare enormously. Consumers and patients are willing to use their devices to track their mental health status (Torous et al., JMIR mHealth uHealth, 2014) and substance use (Buwalda et al., APA annual meeting, 2021). Many apps for mental health are available, but there is little information on their clinical utility. The American Psychiatric Association has developed broad criteria for whether an app meets requirements of safety, efficacy, usability, and interoperability.  Therefore it is important for clinicians to be aware of these standards so they can counsel their patients when requested.

Second, a patient-centered approach to mental health treatment leads to improved outcomes. By “patient-centered” we mean an approach that focuses on the outcomes that matter most to patients or consumers and involves patients as partners in their treatment.

A third takeaway is that there are many benefits to telemental health. Beyond the immediate benefit of reducing risk of exposure to and transmission of SARS-CoV-2, telemental health can maintain and potentially improve access to care, conserve scarce medical resources that would otherwise be used for routine clinical visits, and reduce strain on health care facilities. In addition, telemental health can support continuity of care for patients with chronic conditions, including mental health conditions.

Finally, before the full promise of telemental health can be realized, there is work to do to address challenges. Technological requirements such as the lack of technical skills among clinicians or patients, or the need for reliable devices and reliable broadband, can pose a major hurdle. We have to assure both patients and clinicians that their privacy and confidentiality outside the clinical setting is protected. Reimbursement issues need to be resolved. And cultural and language barriers need to be acknowledged and addressed.

In summary, the 4 main takeaways from our session:

●      First, technology is an important tool for mental health care.

●      Second, a patient-centered approach that focuses on the outcomes that matter most to patients or consumers and involves the patient as a partner in their treatment can lead to improved treatment outcomes.

●      Third, there are many benefits to telemental health, including risk reduction for SARS-CoV-2, improved access to care, and reduced strain on health care facilities.

●      Fourth, before the full promise of telemental health can be realized, there is work to do to address technological, reimbursement, and cultural challenges.

Q: What are the primary challenges for clinicians working with patients through telehealth services?

A: A national survey (Guinart et al., Psychiatric Services, 2021) of different mental health professionals including psychiatrists, psychologists, social workers, case managers, and nurses, found that these professionals had a positive overall experience in using tele-mental health during the pandemic, with 73% rating their experience with two-way videoconferencing as excellent or good, and 66 % giving this rating for telephone-only sessions. The most frequently mentioned advantages of telepsychiatry were flexible scheduling or rescheduling (77%), timely appointment starts (69%), lack or reduction in no-shows (52%), and increased patient engagement or comfort with their sessions (41%).

However, the use of telehealth was not without challenges in the early stages of the pandemic. Among the challenges mentioned by the professionals in the survey were: patients’ difficulty in using the technology or the conferencing app (52%), the providers’ lack of a sense of comfort or connection compared to in-person visits (46%), and technical problems in establishing or maintaining the remote connection (39%). Respondents felt that diagnostic groups differed in their suitability for telehealth services. Psychotic disorders and substance use disorders were considered the least appropriate diagnoses to conduct telehealth, while anxiety and mood disorders were considered the most suitable .

Asked about their projected use of telehealth services after resolution of the COVID-19 pandemic, about one-third of respondents indicated that they would want to continue using telepsychiatry for more than half of their caseloads. Another one-third would use telehealth for less than 25% of their caseloads, and an additional 30% expected to use telehealth for 25 to 50% of their caseload.

Q: What are the primary challenges for patients working with clinicians through telehealth services?

Although telehealth services have been a phenomenal addition to our toolbox, there are some drawbacks to consider for diverse patient populations. Technology can transpire as a hurdle for individuals trying to seek treatment. This can be due to: discomfort or inability to use devices, socioeconomic status preventing acquisition of reliable equipment, or even faulty connections during appointments.

Fear of privacy breaches is discouraging. Secure and HIPPA compliant platforms are key to keeping patient information confidential and providing peace of mind. In addition, humans are social creatures, relying on both verbal and nonverbal cues for communication. Virtual based conversations can often lead to miscommunication. The connections and messages can become emotionless.

Clinicians may need to develop new ways to physically express warmth, empathy, or understanding. Lastly, not all patients have a safe and quiet space at home or in the community for these visits. There can often be distractions and lack of confidentiality.

Victor JA Buwalda, MD, PhD, is Chief Medical Officer and Training and Research Director at CDC Amsterdam, Netherlands. He is also the President of the American Association for Psychiatric Administration and Leadership (AAPAL).

William E. Narrow, MD, MPH, is an associate professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, Baltimore, Maryland. He is also the Medical Director for Behavioral Health at Johns Hopkins Medicine Alliance for Patients.

Eve K. Mościcki, ScD, MPH, is a Psychiatric Epidemiologist and research consultant based in Washington, DC.

Renée Cookson, CTRS, is the director of the Community Development Department at NAMI San Diego, California.

Rogena Abdelraham, B.S. is the Technology Community Development Specialist at NAMI San Diego, California.