I am by no means telepsychiatry’s biggest fan. But since March 2020, when my practice of outpatient psychiatry changed overnight, I have adapted to it. I have learned to get up between appointments so I don’t sit in front of a computer all day and how to fit in patient visits while on a work trip. I still prefer being in the actual room with a patient, but I accept this is the way my job looks now. I accept it because it expands access and decreases barriers, two things desperately needed in mental health.
I tend to see college students, healthcare workers, and faculty and staff at a university system, and they all love virtual visits. They tell me often about the convenience of not having to drive to an appointment and miss work for longer, or the benefits of not leaving home and having to find child care. As Covid-19 rates have declined, I have tried to open in-person days, but I can’t fill them with IRL visits. My patients aren’t alone in preferring online sessions, as the data show. In a study of more than 38,600, patient satisfaction numbers for video visits were significantly higher than in-person ones. Studies also show that patients are less likely to no-show for an appointment virtually, which can save time and money for both the provider and staff.
But, despite what my patients prefer and what the data indicate, we’re about to face a major challenge to continuing telehealth psychiatric appointments. On May 11, the Biden administration will formally end the Public Health Emergency designation implemented at the start of the pandemic, which also allowed prescriptions of controlled substances via telehealth. That same day, it appears that a proposed rule from the Drug Enforcement Agency will likely go into effect, requiring an in-person visit for prescription of controlled substances. (I asked the DEA for clarification on this, but a spokesperson told me they are unable to comment during the rulemaking process or timing.) In psychiatry, this most affects stimulant prescriptions for ADHD, benzodiazepine prescriptions for anxiety, and sleep medications like Ambien, Sonata, and Lunesta.
I see patients for about 13.5 hours a week, and patients on these medications, even as needed and irregularly, probably make up about half of my total patient population. You might think half is high, but ADHD is the third most common diagnosis in our clinic (after anxiety and depression), in part because the undergraduate campus stopped prescribing ADHD medication, and the primary care doctors refer to us to prescribe stimulants instead. We aren’t overdiagnosing it, we are simply the only ones treating it. Rules like this will just make more psychiatrists say they want to not see this group of patients, so they don’t have to bother with seeing anyone in person at all. For the rest of us, it will lead to an administrative disaster.
And this change is coming just as telepsychiatry has made mental health care, including medication, more accessible for more people, period. In a cohort study of the experiences of more than 5 million adults with private health insurance during the first year of the pandemic, the authors found that the rapid increase in telehealth services not only offset the decline in in-person care, but also generated higher rates of use for several mental health conditions (anxiety, major depressive disorder, and adjustment disorder) compared to pre-pandemic levels. In other words, telehealth didn’t simply retain access for people, it expanded it. This is particularly critical for the more than 150 million people in the United States who live in mental health professional shortage areas, or the more than half of U.S. counties that lack a single psychiatrist.
The DEA has attempted to make this change a little easier on patients and providers, but in an extremely ineffective way. The agency’s proposed rules provide various scenarios with some leniency. For example, if a patient was seen in person by their referring provider, I can prescribe a controlled substance during a telehealth visit. Or, if their visit was first over telehealth during the pandemic — that is, between Jan. 31, 2020, when the Public Health Emergency was declared, and May 11, 2023, when it will be lifted — then they have 180 days to be seen in person, but they will require additional recordkeeping, which no physician needs. It will be extremely difficult for administrative staff to manage these various exceptions and identify patients correctly. It is simply impossible to go through the caseloads of multiple psychiatrists, patient by patient, to see which scenario someone might qualify for and whether they need to be seen at all, seen in the next month, or seen in the next six months. Truthfully, it was even hard for me to find these specific details at all.
As a result, the only possible administrative response becomes: As fast as possible before May 11, every patient on a controlled substance needs to be seen in person, and probably now, to avoid future issues, every new patient should as well. While it appears we can then see patients over telehealth for follow-up visits, which vary in frequency according to their needs and state regulations from two weeks to six months, the backlog is no small task. It may also seem like one visit per person is not a big deal, but this really fundamentally changes access for a large proportion of my patients, who currently can be scattered throughout Missouri and Illinois (where I am licensed).
Looking at my future, I am overwhelmed just thinking about it. Even if I do technically have six months to catch up, I have to make up for three years of seeing four to five new patients in person every week. To get them all in and for them not to have gaps in their medications, I might have to pause seeing new patients, or at least see fewer of them, and even move some of my nonurgent follow-ups to after May 11. It is basically like putting everyone on a mental health hold, except this group, and that is not realistic when other patients need me and there is no lack of new ones. Currently, I’m in-person one day a week, but I’ll have to step that up, likely indefinitely. Don’t even get me started on the extra burden to patients, particularly those with ADHD who have already been running around all year trying to find their medications at pharmacies across the country due to the shortage.
As a burnout expert, I would also be remiss if I didn’t point out that these administrative changes and burdens are a recipe for burnout in a profession ripe with it to begin with. In fact, long before Covid, 78% of psychiatrists had high levels of burnout, and more than 16% had major depression. Since March 2020, this work has become even more difficult, and the demand for our services has only increased. This change will make the mental health field more demanding at a time when we should be doing everything we can to maintain and recruit a happy, healthy workforce.
Don’t get me wrong, I understand the impetus for the rule, with investigations of telehealth companies and their prescribing of stimulants. I also know that the changes aren’t even official yet (comments are due by March 31), and it is really just resuming an old rule that was paused for the pandemic. However, the landscape is completely different now.
If I can accept that telepsychiatry is a needed option, so can everyone else, including the DEA. When it’s already raining, the only thing you can do is grab an umbrella. The “temporary” pandemic measures have been in place for three years, and we can’t just go back now.
Jessica Gold, M.D. is an assistant professor of psychiatry at Washington University in St. Louis.
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