Amid the mental and behavioral challenges fueled by COVID-19, expanded telehealth capabilities have contributed to a surge in mental health care. Use of the technology appears to have contributed to fewer no-show psychiatric and other counseling appointments among both new and existing patients and expanded access to care for patients in regions that pre-pandemic were bearing the brunt of the nation’s lack of mental health providers.

Once we’re safely past this pandemic, at least some emergency telemedicine expansions, granted through the U.S. Department of Health and Human Services and state governors, likely will remain. As that future is being sorted out, it’s important to consider what’s beneficial and what’s concerning about treating mental illnesses from a distance.

“Audio and video have limitations,” said Andrew Sperling, director of legislative and policy advocacy for the National Alliance on Mental Illness. “People with schizophrenia, especially ones who’ve been exposed to older medications, are at risk for tardive dyskinesia, facial tics, twitching of hands and feet. If you are only seeing a patient’s face or only hearing audio, you will not get all of that. To physically touch or take vital signs, you cannot do that over the phone.”

COVID has highlighted the challenges of telemental health, said Dr. Jay Shore, who chairs the telepsychiatry committee of the American Psychiatric Association.

Shore, who also directs telemedicine for the University of Colorado Anschutz Medical Campus’s psychiatry department, said those current challenges include a shortage of adequate, affordable Wi-Fi and computer hardware for current and would-be patients; a lack of tech literacy among some providers and patients alike; and inadequate tech support for when a FaceTime, Zoom or Google Hangout connection gets glitchy.

“It’s not just enough to give out a free computer with a Wi-Fi card,” Shore said. “We knew the digital divide was there … but we’ve realized that the problem can be pretty startling.”

Nevertheless, telemental health “in some ways, is a game-changer, he said “Obviously, as we get safer, we will have more in-person sessions. We will need to find the balance … based on the diagnoses, circumstances, barriers to care that existed before COVID and will remain after COVID.”

The American Psychiatric Association published a toolkit on telepsychiatry after the Nebraska Psychiatry Institute in 1959 began video-conferencing for group therapy sessions.

Likewise, the American Psychological Association (APA) offers how-to guidance to clinicians and patients alike. Among them are these:

• Insurance companies cannot refuse to cover telehealth services for mental illness.
• Reimbursement rates for in-person and telehealth services must be the same.
• Each state’s licensing requirements for out-of-state health providers have been waived during the COVID-19 emergency

Additional resources

• American Psychiatric Association/American Telemed Association’s 2018 Best Practices in Videoconferencing-Based Telemental Health guidance
• American Psychological Association Telehealth guidance by state during COVID-19 lists regulations in the 50 states
• American Telemed Association has a telemental health group
• National Consortium of Telehealth Resources Centers provides various assistance to organizations and individuals providing or interested in providing remote health care
• National State Governors Association published a November 2020 statement on The Future of State Telehealth Policy

Story ideas

• To what extent is telehealth effectively/ineffectively serving a broad range of patients, from the severely mentally ill to those with episodic anxiety, depression, etc., prompted by COVID-19? How are patients and clinicians alike adjusting? What’s being lost and gained during this time?
• How has telehealth expanded access in rural America, where, according to this 2019 Pew analysis, a third of residents don’t have broadband access? What barriers in Wi-Fi access, bandwidth and costs remain? What are the innovations on this front? (In October 2020, the Federal Communications Commission launched the multibillion-dollar Rural Digital Opportunity Fund.)
• How many potential clients are clinicians turning away because they can’t add to their patient load? Conversely, who, potentially, is accepting more clients than they can reasonably manage, simply because they recognize how great is the need?
• What are the next trends in telehealth? The tensions between providing competent telehealth services and building telehealth as a profit-making commodity?
• What are the malpractice concerns and liabilities for telehealth providers of mental health care?

Katti Gray (@kattigray) is AHCJ's core topic leader for behavioral and mental health. A former Rosalynn Carter Mental Health Journalism Fellow, Gray is providing resources to help AHCJ members expand their coverage of mental health amid ongoing efforts to de-stigmatize mental illness and to place mental health care on par with all health care.