I I’ve never been the biggest fan of telepsychiatry. However, since March 2020, outpatient psychiatric practice has changed overnight, and I have adapted. I learned how to get up between appointments so that I wasn’t sitting at the computer all day and how to accommodate patient visits while traveling. work as it is. I accept it because it expands access and reduces barriers. These are two things that are desperately needed for your mental health.
I often see college students, health care workers, and university system faculty members, and they all love virtual visits. They often talk about the convenience of not having to drive to appointments, not having to take long breaks from work, or the benefits of not having to leave the house to take care of the kids. With the Covid-19 infection rate dropping, we tried to open an in-person day, but we can’t fill it with an in-person visit. As the data shows, my patients aren’t the only ones who prefer online sessions. in a study More than 38,600 patients were significantly more satisfied with the video visit than with the face-to-face visit.Studies also show that patients are less likely to not show at all This saves both provider and staff time and money.
But despite what my patients prefer and what the data shows, continuing telemedicine psychiatric appointments is about to face major challenges. Formally ends the public health emergency designation that was in effect at the beginning. This has also enabled the prescription of controlled substances via telemedicine.On that same day, a proposed regulation from the government Drug Enforcement Administration It is likely to go into effect and require in-person visits for prescriptions of controlled substances. (I asked the DEA for clarification on this, but a spokesperson told me he could not comment during the rulemaking process regarding timing. Sonata, Lunesta.
I see patients about 13.5 hours a week, and they probably make up about half of my total patient population, even if they take these medications on an irregular basis as needed. increase. Half high you might think, but ADHD is his third most common diagnosis in our clinic (after anxiety and depression). One reason is that the undergraduate campus has stopped prescribing his ADHD meds, and primary care doctors are recommending us to prescribe stimulants instead. We are not overdiagnosing it. We are the only ones who are simply treating it. A rule like this just says that more psychiatrists don’t want to see this group of patients, so they don’t have to worry about seeing anyone in person at all. lead to disasters above.
And this shift is coming just as telepsychiatry has made mental health care, including medication, more accessible to more people. cohort study From the experience of more than 5 million adults with private health insurance in the first year of the pandemic, the authors found that a rapid increase in telemedicine services not only offset the decline in in-person care, but also resulted in higher utilization. found that it produced a rate Several mental health conditions compared to pre-pandemic levels (anxiety, major depressive disorder, and adjustment disorders). In other words, telemedicine didn’t just maintain people’s access, it expanded it. this is, is more than 150 million people in the United States live in areas with a shortage of mental health professionals, and more than half of the counties in the United States have no psychiatrists.
The DEA tried to make this change a little easier for patients and providers, but in a very ineffective way. The Agency’s proposed rule would: different scenarios with some generosity. For example, if a patient was seen in person by a reference provider, a controlled substance could be prescribed during a telemedicine visit. They would have 180 days if the state of emergency was declared between 31 January 2020 and lifted on 11 May 2023. It can be seen directly, but it requires additional record keeping that the doctor does not need. Managing these various exceptions and correctly identifying patients is very difficult for administrative staff. Examining a caseload of multiple psychiatrists patient by patient to see which scenarios someone might fall into and whether they need to see a doctor at all, next month or in the next 6 months It is simply impossible to know if you need to see a doctor. To be honest, it was difficult even to find these specific details at all.
As a result, the only possible administrative response is: We need to see all patients taking controlled substances in person as soon as possible by May 11, and perhaps now all new patients as well, to avoid future problems. After that, it appears that the patient can be seen via telemedicine for follow-up visits, although the frequency varies from 2 weeks to 6 months depending on the need and state regulations, but the backlog is brief. It’s not work. A one-on-one visit may not seem like a big deal, but this is currently the case with my 1000s scattered across Missouri and Illinois (where I have my license). Radically change access for the majority of patients.
Just looking at my future and thinking about it can be overwhelming. Even though he has six months to catch up technically, he has to see four to five new patients in person every week for three years. In order to accommodate them all and ensure there are no gaps in their medications, I am suspending new patient visits, or at least reducing the number of patients, and scheduling some of the non-urgent follow-ups May 11. I may need to move onwards. It’s basically like putting everyone on mental health hold except for this group, and other patients need me and I’m running out of new patients. If not, it’s not realistic. Right now I’m seeing in person one day a week, but I’ll have to increase that, probably indefinitely. Don’t even get me started on the extra burden on patients, especially those with ADHD who already run all year round trying to find medicine in pharmacies across the country because of the shortage.
As a burnout expert, I would be negligent if I didn’t point out that these administrative changes and burdens are a recipe for burnout in a mature profession in the first place. Long before Covid, 78% of psychiatrists had high levels of burnout and more than 16% had major depression. Since March 2020, this task has become even more difficult and the demand for our services is only increasing. This change will make the mental health field more demanding at a time when we need to do everything we can to maintain and recruit a happy and healthy workforce.
Don’t get me wrong, I understand the dynamics of this rule from telehealth company research and methamphetamine prescribing. I also know that the changes are not yet official (comments must be submitted by March 31st). This just resumes the old rules that have been suspended due to the pandemic. However, the landscape was completely different from what it is now.
If I can accept that telepsychiatry is a necessary option, so can everyone else, including the DEA. “Temporary” pandemic measures he has been in place for three years and cannot be reversed now.
Jessica Gold, MD is an Assistant Professor of Psychiatry at Washington University in St. Louis.
