In the spring of 2020, COVID-19 brought rising levels of stress, anxiety and depression. But stay-at-home orders and a national emergency prompted many psychiatric and psychotherapy offices to shut down and cancel in-person appointments.
The country needed a robust — and fast — transition to mental health telemedicine. And the pandemic turned out to be just the thing to make it happen.
Changing tech, old idea
I was skeptical of telemedicine in 2015 when I began working at Wayne State University as a psychiatrist and researcher in the medical school. At that time, the department of psychiatry and its affiliated clinics were using telemedicine in primary and emergency care and for substance use recovery.
But the idea of seeing patients via video had been around since long before then. In 1973, a team of behavioral scientists studied the two-way interactive television system Massachusetts General Hospital started using in 1969. The hospital provided mental health evaluations at an off-site medical station at Logan International Airport in Boston and a Veterans Affairs hospital outside the city. “The system has proven to be feasible and acceptable to individuals and institutions in the community, providing psychiatric skills on a much wider scale, in a more accessible way, and faster than any other system,” researchers wrote in their analysis.
Telepsychiatry grew in the 1990s, providing remote mental health services to patients in rural areas, many of whom were not able to travel long distances for in-person treatment. To transmit video and sound, the systems used various technologies, including closed-circuit television, high-frequency radio waves, fiber optics, coaxial cable and phone lines.
The use of medical videoconferencing grew even more in the 2000s, particularly in psychiatry. By then, some patients were seeing their doctors with TV-top boxes connecting their televisions to what was then called the World Wide Web. Patients were generally satisfied with virtual appointments, and researchers found telepsychiatry was just as effective as face-to-face visits, for both adults and children. And even as medical teleconferencing raised concerns about patient privacy, doctor licensing and other legal issues, researchers took a fresh look at the idea previously dismissed as “unwieldy, unreliable and unaffordable.”
As the pandemic forced lockdowns around the country, health insurance companies quickly loosened restrictions and allowed doctors to provide care remotely, regardless of geographical location. A variety of software programs, such as FaceTime, Skype and Zoom, received approval for this purpose under relaxed federal restrictions.
According to a December 2021 report from the U.S. Department of Health and Human Services, the number of Medicare-covered visits conducted remotely over video rose from approximately 840,000 in 2019 to 52.7 million in 2020. Furthermore, almost all U.S. states relaxed medical licensing rules, allowing physicians to virtually see patients across state lines.
As the pandemic made remote videoconferencing a regular part of communicating with family and friends, patients became more comfortable and skilled in using telemedicine for their mental health care. Marko Geber/DigitalVision via Getty Images
Psychiatry calls for physical examination much less often than most other medical specialties, making it ideal for telemedicine. The pandemic also had a role in allaying previous concerns about patients’ being unable or unwilling to use video technology. As remote videoconferencing became a necessary and regular part of communication with workplaces, family members and friends, patients essentially trained themselves to use it in their mental health care.
Pandemic telehealth also solved one long-standing and seemingly intractable problem: that of patients forgetting or otherwise missing their appointments. A December 2021 study found that in pandemic-era telemedicine, the no-show rate at one Ohio clinic was only 7.5%, compared with a 30% no-show rate for in-person office visits before the pandemic. Where I work, our clinic’s own 30% missed-appointment rate dropped to almost zero.
The most obvious reason for that dramatic decline was that the appointments had become more convenient. Patients don’t have to take time off work, find a babysitter, fight traffic or take a bus. With a smartphone or laptop, they can see their psychiatrists or therapists from anywhere. They can have sessions while at home near their children. They can videoconference with mental health professionals during their lunch break at work, or even from their car in the parking lot.
This has turned out to be especially useful for people with complicated work schedules, like medical personnel and first responders who are facing struggles of their own during the pandemic.
Here to stay
Telepsychiatry has also opened a window into the home environments of patients. Seeing where and how they live gives therapists and psychiatrists important insights into a patient’s mental health needs.
Reaching clients at home can also be challenging: A patient of mine was a mom with a big family in a small house. She had to connect with me sitting in her bathroom in order to have privacy. With patients connecting from anywhere, there can be concerns about confidentiality, especially for those without access to private space.
Another issue is that for some patients, the easier access of telehealth can make their visits feel like a less serious routine task rather than treatment. My colleagues and I have had to warn patients not to connect with us while driving or shopping or while in the middle of a conversation with others. Some also had to be reminded to dress appropriately for their online appointments with us; a patient showed up onscreen in a bathrobe.
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And there are other glitches: Sound quality or other technical issues take time out of sessions to fix, or can’t be fixed at all. Some patients still aren’t familiar or comfortable with videoconferencing. Others did not have the necessary high-speed internet at home. For these patients, sessions often take place over the phone instead. Then we can’t see their nonverbal behavior, which is a part of assessing mental health conditions. But none of that changed the fact that telemedicine generally works for mental health care.
As COVID-19 restrictions have eased, some clinics are offering face-to-face visits again. Others are offering the option of in-person or video visits. I still see all my patients remotely, and only a couple have even brought up having sessions in person again. The pandemic gave telemedicine an opportunity to prove itself. And in psychiatry, at least, there’s more certainty about telemedicine’s place in the future of health care.
Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
This article is republished from The Conversation under a Creative Commons license.
insta_photos // Shutterstock
Telehealth has existed in various forms for decades, and more recently, has been a boon to both health care providers and patients amid the coronavirus pandemic. Telehealth and telemedicine exploded to fill a health care vacuum left in the wake of lockdowns, social distancing measures, and new variants that have overwhelmed the United States’ physical health care infrastructure.
According to a 2021 Health and Human Services report, the number of telehealth visits among Medicare beneficiaries in 2020 was about 63 times higher than in 2019. In real numbers, that’s 840,000 visits in 2019 and 52.7 million visits conducted remotely roughly one year later.
Despite having been around for decades, the data-driven impacts of telehealth on every subgroup of society are still emerging. Health care and telehealth industry leaders are conducting small-scale studies around the country, analyzing the impact of telehealth as a pandemic response and tool for the future. Directionally, their results paint a picture of telemedicine’s irreplicable value. Telemedicine is transforming health care for some groups more than others.
The efficacy of telehealth can be defined and refined by the people it serves. Before—and now exacerbated by—the pandemic, health care inequalities existed predominantly among people of color. But, according to a 2021 AARP study, telehealth adoption rates have been highest in many of these same communities, suggesting that remote consultation is one way to remove certain health care disparities and access barriers like transportation, time off from work, and mobility.
Members of the LGBTQ+ community have also been more likely—by 25%— to utilize telehealth for mental health services compared to non-LGTBQ+ peers since the start of the pandemic. This is largely due to the fact that LGBTQ+ users have experienced disproportionately higher rates of mental health challenges since the pandemic began.
Right now, in its nascent, formative stages, telehealth should also be defined by the groups it does not serve. According to the FCC, 6% of the total U.S. population—roughly 19 million people— live without access to the minimum fixed broadband speeds, an essential tool for utilizing telehealth services. Rural and tribal communities are disproportionately affected, with one quarter and one-third of those populations lacking access, respectively.
With pandemic-related emergency restrictions being removed in health care facilities across the country, the future of telehealth and its staying power among providers and patients is in question. In addition, debates around payment parity may also mean that cost-saving is no longer a benefit of telehealth, particularly for populations that use and need it most. Women from various backgrounds fall into this category.
Citing statistics collected from its own 1,000-person study and research from other organizations, including the CDC, Kaiser Family Foundation, and American Medical Association, CirrusMD compiled seven statistics on how telemedicine impacts women's health care.
Over one year, 24% of women, on average, scheduled at least one telemedicine appointment compared to 19% of men. However, women were also more likely to skip routine appointments than men. Both of these facts could be attributed to the disproportionate burden placed on women during the pandemic. Women were more likely to worry about illness, savings, and loss of income. More mothers, particularly single mothers, quit their jobs due to the pandemic compared to fathers. It is not difficult to see why skipping appointments altogether or opting for the convenience of telehealth are on the rise among women in the United States. The CDC data did not collect information on nonbinary individuals.
Kyle Lee // Shutterstock
Among women who have received telemedicine care, 62.8% said it was comparable to in-person care, and 25.9% said it was better than in-person appointments according to a CirrusMD study. Both CirrusMD and the Kaiser Family Foundation report favorable views on telehealth among women. More than 70% of women rated their telehealth experience with mental health services as very good or excellent. In no health care category did ratings of fair or poor surpass 15%. These similar, independent findings suggest that a comfort and even preference for telehealth exists among users.
A Kaiser Family Foundation survey found 38% of women respondents skipped routine check-ups and tests during the pandemic, with women in fair or poor health skipping at the highest rates. About 46% of women in fair or poor health were more likely to have skipped routine care than women who reported being in good or excellent health. Women with worse health were also more likely to skip recommended tests, treatments, and prescription refills. They also reported the highest rates of difficulty even getting an appointment—double that of men. Delays in essential care are leading to long-term health issues for many women. About 27% of women in fair or poor health have reported worsening conditions. Low-income women were also more likely to report health deterioration due to skipped care.
During the pandemic, the number of women who had telehealth visits nearly tripled, with women aged 50-64 showing the most significant increase. Prior to the pandemic, just 13% of women between the ages of 50-64 ever had a telehealth appointment, according to a Kaiser Family Foundation survey. Between March and December of 2020, that number rose to 42%. When broken down by other sociodemographic factors, women with a college degree and insurance were more likely to have had a telehealth visit during the pandemic.
The top reasons women sought telehealth appointments were for minor illness or injury (21%), management of a chronic condition (18%), and mental health services (17%). According to a Kaiser Family Foundation survey, less than 10% of telehealth appointments for women were for COVID-related symptoms. This number was equally low for men. Instead, primary reasons included minor or chronic issues and mental health services. More than half of women reported that COVID-related stress negatively impacted their mental health. Additionally, according to CirrusMD, more than 25% of their study respondents stated they sought a telehealth appointment because they did not believe their issue required in-person treatment. COVID-19 restrictions early in the pandemic deemed issues like chronic pain management as non-urgent, and in-person services were paused. For many, telehealth was able to serve as an alternative treatment option.
Among women telehealth users surveyed by CirrusMD, respondents also said they would be less likely to delay care if they had access to text-based telehealth services. Text-based telehealth reduces the need for appointments, virtual waiting rooms, access to broadband services, or private space for video calls. According to a CirrusMD survey, more than 50% of women reported that scheduling conflicts with health care providers delayed care. About 23% of respondents cited financial hardship due to missing work as a reason for missing an appointment. The survey also found that 62% of women said they would delay care less often if text-based telehealth services were available and would most frequently use them to questions that arise between regular appointments.
Almost 80% of surveyed women telehealth users said they would consider using telehealth services to consult with their OB/GYN in between regular appointments. According to a Kaiser Family Foundation survey, 86% of OB/GYNs said they did not conduct telehealth visits before March 2020. Just three months later, 84% reported having telehealth offerings. However, the majority of OB/GYN’s cited challenges with telehealth, mainly relating to their inability to conduct physical examinations and diagnostic testing as well as user (patient) error. They also reported that fewer patients were seeking care during the pandemic. While some practitioners were able to provide contraceptive and STI consultations via telehealth, the vast majority of OB/GYN’s said it was at least somewhat more difficult to address a patient’s chronic gynecological conditions or preventative reproductive care. Despite these barriers from the practitioner’s perspective, a CirrusMD survey found that most women are willing to consider virtual consultations with their OB/GYN. This suggests that updated processes and technological infrastructure could help bridge the gap between patient interest and the OB/GYN experience.
This story originally appeared on CirrusMD and was produced and distributed in partnership with Stacker Studio.