Assessing Suitability of Telepsychiatry for Patients

A mental health clinician’s decision to see a patient virtually largely depends on what is customary for the practice as well as the patient’s preference – if the patient desires an in person visit and the clinician is typically seeing patients in person, then they’ll see the patient in the office. However, there are instances in which a virtual setting may not be most suitable for that patient’s mental health status. The patient’s assent to virtual care is necessary but not sufficient; it should not be the only element of the evaluation. Unfortunately, there is no published standard for who should be seen in person or not, but state laws generally require that the same standard of care is met online as it would in person, so the burden is on the clinician to make the best decision that would meet the standard of care. It can be difficult to make that determination prior to the appointment, before having enough information. By the time the appointment is underway, it is too late to switch venues. Furthermore, an in-person visit may not be possible for the patient in the future, even if it’s requested.
 
During COVID, many clinicians were suddenly providing virtual care with patients who were not accustomed to it. Thus, clinicians needed to quickly develop strategies to meet the standard of care of an in person visit. As a result, many developed electronic alternatives to accomplish tasks that would otherwise be done very easily in person, such as cognitive testing or involuntary movement testing. Virtual care became seen as a replacement for in person care, rather than an additional modality of treatment on the continuum of care. Psychiatrists who follow nationally recognized addiction guidelines (such those published by the American Society of Addiction Medicine) generally conceptualize level of care as a continuum, dependent on the patient’s status, and thus is not a one-time permanent choice. Therefore, it is in the best interest of the patient to be able to assess suitability for telepsychiatry.
 
What are some barriers to virtual psychiatric care?
 
Technologic Barriers. Some individuals may think that appointments can be done solely over the phone, so they may not be expecting a video requirement. But in most states, to meet the standard of care for a synchronous appointment, a video feed is necessary. There may be instances where a camera phone or laptop are not available, nor is high speed internet connection such as in rural parts of the country. A patient may have an aversion to seeing themselves on the screen (you can now hide self-view) or might not be amenable to using the technology. These technology barriers disproportionately affect those in a lower socioeconomic status who may not have certain amenities.  
 
Cognitive Difficulties. It’s possible that despite high motivation, there are cognitive barriers to setting up the appointment with the technology. To obtain informed consent, the patient must also have the capacity to understand the risks and benefits of a virtual visit, the alternatives to a virtual visit, and the reasons for discontinuation. It is also necessary to assess if the patient understands the reasons to use a backup plan, and how to communicate that with the office. Some platforms provide a “test session” where the user can join an empty virtual room and test their equipment. Non-clinical staff could guide them over the phone and help make a determination of appropriateness.  
 
Safety Concerns. Although there are ways to contact local law enforcement to do a safety check during a virtual appointment, the process of evaluation for involuntary admission is much more difficult than if the patient is in the office. Some patients with paranoia may not want to share their location due to skepticism of the process. Virtually, there is no guarantee that law enforcement would arrive in a timely manner, whereas in person the patient could wait with another staff member until law enforcement arrives. The patient’s safety would be reassured without disruption to the subsequent appointments.  
 
Communication Issues. Difficulties with communication can arise due to differences in native language, disability, cognitive impairments, or psychosis. None of these are unique to a virtual session but are made more difficult to overcome with this format. Speaking virtually to an individual with cognitive impairments is more difficult because you don’t always have the real-time feedback about whether part of the sentence dropped out or if the volume is just not loud enough. Modulating the volume of your voice in Zoom does not change the volume that they perceive, eliminating another option for improving communication. Individuals with psychosis can be paranoid with virtual providers and develop a delusion about a clinician’s affiliation or intentions. In addition, they may be suspicious of your requests for a release of information to obtain collateral from family members, which is standard practice to help clinicians formulate an accurate diagnosis. All these concerns may also be present in person, but the more steps that are involved virtually makes them more difficult to overcome.
 
Overall, the benefits of telehealth far outweigh its drawbacks. Naturally, one usually feels they have a choice of either virtual or in person care. Despite the appearance of choice, the clinician needs to meet the standard of care to treat the patient most appropriately. The two are not exactly equivalent, and it is often not possible to switch between the two quickly during an appointment. As much as telepsychiatry is seen as a replacement for in person care, it should be considered another modality of care on the care continuum, along with intensive outpatient or partial hospitalization.