The Pros and Cons of Telepsychiatry Practice

In this exclusive video, Psych Congress Network Geriatric Psychiatry Section Editor Marc Agronin, MD, CMO, MIND Institute, Miami Jewish Health, discusses the advantages and limitations of telepsychiatry practice with older patients. He offers thoughts on how to work around potential barriers to effective virtual practice as well as cases where in-person visits might ultimately be the best approach.

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Read the Transcript:

Marc Agronin, MD: Hi, my name is Dr. Marc Agronin. I'm a geriatric psychiatrist. I currently work as the chief medical officer for the Frank C. and Lynn Scaduto MIND Institute at Miami Jewish Health, I also oversee behavioral health there and I've been at Miami Jewish Health for the past 23 years. I'm also the geriatric psychiatry section editor for the Psych Congress Network.

I'd like to talk to you about telepsychiatry with a focus on older patients in particular. I'll talk a little bit about some of the advantages, some of the limitations.

 If we look at some of the advantages of telepsychiatry in particular, I mean off the bat it's really clear that there's overall better access, especially individuals living in rural areas, in prisons and ICUs, all areas which were really underserved before now can be opened up and using different telepsychiatry platforms can really give equal access. I think about this all the time. I grew up in Wisconsin and I often had a family member who's a physician who call me asking questions, and I always said, you know, got to have the person see the local psychiatrist, and he reminded me that in a more rural area, it could be months before someone could actually see someone. Now that's different given telepsychiatry. People can live in a rural area and still visit with someone on a frequent basis. And that speaks to another advantage, it's more flexible. Individuals in terms of the times they meet the doctor, in terms of the location they meet them, that flexibility makes an enormous difference in terms of access.

One study showed that individuals with anxiety, mood disorders, with adjustment disorders actually were seen on a more frequent basis with telepsychiatry. So if anything, it expanded access at a time when people were concerned that maybe would truncate, especially during the COVID pandemic, it costs less. It increased the frequency that people can be seen. You can not only see the patient, but if you need to see caregivers or multiple family members, especially when they live in different areas, they can have access through different telepsychiatry platforms. You can see people in a home environment before and that can give you lots of information that you might not get when someone comes into the office. And in general, I'd say there are individuals who either were unable to see a psychiatrist or at least be able to see maybe a specialist given a particular diagnosis and that access has been expanded greatly.

Still at the end of the day, I think in general, a person has to be relatively technology savvy to do this or someone who can help them with that. It's ideal for people who have really busy schedules or maybe an unusual work schedule. To one extent, I assumed initially that this was going to be ideal and better served for younger people. But actually when you look at the number of individuals who've been using telepsychiatry, the higher rates are among older individuals, and that may be a function of the fact that older individuals maybe need to be seen more in terms of either medicine or psychiatry. But in general, it really speaks to the advantages of this.

Now, at the same time, you really should think about what are some of the limitations. So it's difficult, obviously you can't do a physical neurologic examination, that physical presence, there's some magic to it and not having that for some people can be a loss and might not have the same depth. There's power to someone's presence, and when that's not there that can change the nature of the session. Some people, the technology is not always available, it's not accessible or they have trouble accessing it. Telepsychiatry, some people can be a little more intrusive because it is coming right into their home, especially with older individuals that might be imposed upon them by other individuals, by a family member or caregiver. On the one hand where you think we're increasing privacy through telepsychiatry, for other people it may actually be decreasing privacy.

Also, people sometimes hide things more, it's easier to put up defenses or be resistant because you're not there with the person and again, there's that power of presence that sometimes can be very helpful. There's potential for fraud and abuse, and we know that there've been some telemedicine companies in particular that have been investigated for that. In particular, we know that there's been a lot of concern about prescriptions for controlled substances. In fact, with the ending of the Public Health Emergency this past May, the DEA is looking to impose actually more mandates in terms of when people have to be seen in person if they're prescribed a controlled substance. I think we'd all agree that it makes sense that especially for certain pharmacologic treatments that in-person visit is really essential and that in-depth visit. So individuals at the end of the day who have some limitations in terms of technology or they really need that physical contact or there's something about the ethos of going to someone's office, making it a trip there, for those individuals, that might not be ideal.

Marc E. Agronin, MD, board-certified adult and geriatric psychiatrist, is the chief medical officer of the Frank C. and Lynn Scaduto MIND Institute and for Behavioral Health at Miami Jewish Health. Dr Agronin is an Affiliate Associate Professor of Psychiatry and Neurology at the University of Miami Miller School of Medicine. Being a national expert in Alzheimer disease and geriatric mental health, he serves as the Geriatric Psychiatry Section Editor for the Psych Congress Network.