Feel Well Again Blog

The COVID-19 pandemic has changed a lot about how we work and live. Exactly which changes will be long-lasting is yet to be determined. In outpatient psychiatry, for example, virtual visits have become the norm, rather than the exception for the past year now. 

For my patients, the benefits of virtual visits vastly outweigh the drawbacks. So I’m a strong advocate for virtual visits remaining as a treatment option even after the pandemic is over. Let’s explore why my patients are having success and how you can get the most out of your virtual sessions.

Why were virtual visits limited before the pandemic?

Prior to the pandemic, psychiatrists, therapists and other health care providers could do virtual visits, but only on a limited basis. This is largely because insurance didn’t cover these types of visits. 

As a result, psychiatrists could only see patients remotely if: 

1. Their insurance provider gave special permission for virtual visits, usually because a patient was living in a remote place without reasonable access to in-office treatment, or 
2. The patient was paying with cash.   

Further, psychiatrists always saw the patient in-person, for at least the initial evaluation, before transitioning to virtual visits. 

Since March 2020, all of our sessions have been virtual including all new patient evaluations, as the public health emergency has forced insurance companies to cover virtual visits the same as they would in-person visits. 

Also, certain regulations have been suspended because of the pandemic. For instance, prior to COVID-19, psychiatrists were mandated to see a patient in-person at least once before prescribing controlled substances. Now, we can see patients from the initial evaluation onward completely virtually and if we decide a controlled substance prescription is necessary, we aren’t required to see the patient in-person.

The Benefits of Virtual Visits

As mentioned above, I’m pro virtual visits and I’d love to see this option continue once we return to (the new) normal. The following are the major benefits for my patients and others with mental health challenges.

1. Expanded Access to Care

With the new rules in place, anyone from the state of Illinois can see one of the specialists in our clinic, regardless of their proximity to the office. From the western edge, just over the Iowa border, to the southern edge, just outside of St. Louis, our specialists can help. 

This is a huge benefit, especially for folks living in rural areas. With the best medical and psychiatric treatment often being available in large cities, virtual visits are a lifeline for patients, who would otherwise not have access to care or not have access to the best care.

2. More Convenient Access to Care

In addition to benefiting those without access, virtual visits also benefit those for whom care was inconvenient. Here I’m thinking of adults who would need to take a half day off of work or children who would need to take a half day off from school in order to commute to an office.

Before the pandemic, this posed a major roadblock to delivering the best quality care, as most outpatient psychiatric treatment requires visits every 1-2 weeks for the first 2-3 months before intervals between appointments can slowly expand to every 4, 6, or 8 weeks onward. 

The same benefits also apply to patients on extended vacations lasting several months (due to COVID-19 travel restrictions, for instance).  

3. Consistent Treatment for Teens Transitioning to College

For our teen patients who started with us while they were in high school, virtual visits allow treatment to remain consistent even after they go out of state to college. This has been extremely beneficial, especially because the transition from high school to college can be a major psychological stressor. And with social distancing guidelines, excessive isolation compounds these challenges.

During the fall of 2020, virtual visits enabled me to continue and modify treatment swiftly for those who were struggling while away for their first semester of college. Through weekly remote visits with these patients, many individuals were also prevented from needing to take time off or being hospitalized for psychiatric reasons. Virtual visits ensure consistent treatment.

4. Better Treatment for Those in Crisis

There is one other major benefit to remote visits. They give psychiatrists the ability to take urgent visits that could otherwise lead to psychiatric hospitalization. In the past, rapid coordination of care for patients in crisis was a serious challenge. When patients needed to be seen in person, it was not always feasible to fit them in during a busy day. 

With virtual visits, though, I can easily log on and see a patient on the verge of needing to go to the E.R. the same day or even within hours of a crisis. Then, I can modify their treatment plan and schedule another remote appointment to monitor progress within 48 hours. Patients in crisis can often be stabilized much more quickly and avoid hospitalization this way.

The Drawbacks of Virtual Visits

Even with these important benefits, there are some drawbacks to consider.

1. More Distractions to Contend With

The convenience of these virtual visits also comes with some trade offs. When patients log on to their computers or phones, there are many more distractions to contend with (e.g., email, DM’s, social media notifications) than when they unplug and meet with their psychiatrist face-to-face in the office. 

Also, both patients and their psychiatrists have to deal with the human tendency not to take what’s happening on a screen as seriously as they would a real life interaction. Patients sometimes try to participate in virtual visits while driving, in the middle of folding laundry or making dinner, or while actively working on the job and fielding requests from coworkers, etc. This doesn’t work.

2. Patients Who Don’t Want to Turn On Their Cameras

For various reasons, patients sometimes want to do their virtual sessions with their cameras turned off. In some ways, this may seem like a good option. For example, it can feel too intense to talk about sensitive topics while on camera and looking at a screen.

However, your psychiatrist needs concurrent audio and visual communication for several reasons:

• Insurance requires this for reimbursement. Otherwise, you might have to pay out-of-pocket for the session.
• If your psychiatrist is prescribing controlled substances, he or she needs to document the sessions through concurrent audio and visual communication per DEA regulations.
• Your psychiatrist needs to see you to do a mental status exam during each visit. This assessment involves an evaluation of your appearance, attire, hygiene, grooming, behavior, eye contact, body movements, facial expressions, motor activity (i.e., pacing, inability to sit still, tremors, slowing of physical/emotional reactions).
3. Alone Time for Patients Can Be Difficult

Depending on a patient’s living situation, it can be difficult to find a quiet place at home where a patient can meet with their psychiatrist alone. When loved ones are listening in on the remote session, they may interject or intervene, which is not what’s best for treatment. 

This can be especially problematic when dealing with a child or adolescent living with an abusive or dominant parent, adults closely involved with the care of a loved one, or spousal relationships. Disruptions from third parties are much easier to control with in-person sessions.

4. Connectivity Challenges

When patients have a poor internet connection (either because of a temporary problem with their home internet or because the patient must meet outside), this is tough. Imagine a patient revealing something especially difficult right before their connection cuts off or their screen freezes. This is a terrible situation for the patient, the doctor, and for their relationship. It can also slow or stop treatment progression.

In addition, if a patient reveals something serious and key to their treatment when their connection is paused, the doctor may not hear it. The bottomline here is connectivity issues can cause a myriad of problems for continuity of patient care during virtual sessions.

5. Lack of Access to or Difficulty Using Technology

The final drawback to virtual visits has to do with patients who have lack of access or difficulty using technology. Particularly for elderly individuals, technology can be an obstacle to care. If a patient doesn’t have access to a smartphone or a computer, clearly virtual visits will not work for them. But difficulty using Zoom or difficulties using the features on their phones or computers can also interfere with treatment and progress.

How to Get the Most Out of Your Virtual Visits

Although there have been relatively few studies (so far) researching the effectiveness of psychotherapy at a distance compared with in-person sessions, anecdotal evidence tells us that there are things patients and doctors can do to make remote visits more effective.

First, as a patient, you should treat your virtual visit the same way you would treat your in-person visit with your psychiatrist (although wearing your pajamas is completely acceptable!). This means find a quiet room in your home where you can shut the door and be alone if at all possible. It also means if you are the parent of a child or adolescent in need of care, it’s important to give them the space they need and only appear on screen with your child when needed.

As a psychiatrist, I’m finding that shorter virtual visits work well. Classic therapy visits are often 40-60 minutes long and involve long observation periods. These types of sessions are difficult to do well in a virtual setting. 

Because my work combines medication management and therapy (40 minutes for the initial evaluation and 20 minutes for all subsequent follow-ups), my patients find success with shorter, more focused sessions. With virtual visits, we can get right down to the core of what’s happening. I can give practical recommendations involving lifestyle, habit, sleep pattern, diet, and exercise changes. And I can quickly check for side effects of medication or treatment. 

We likely won’t know the full impact of the pandemic on our lives for years. But one thing is for sure, it’s up to all of us to decide what we want to take into the future.

The pandemic has serious implications for mental health. If you or your child would benefit from a psychiatric consult, please contact our office. Our team of specialists is here to help you feel well again.