The COVID-19 Pandemic And Virtual Care: The Transformation of Psychiatry

Psychiatry has gone through several waves of technology adoption. The concept of distance medicine is not new with examples dating back throughout the centuries including the use of smoke signals in Medieval Europe to warn of quarantines during the Black Death. Live, interactive videoconferencing, commonly referred to as telepsychiatry, began with successful research projects in the early 1960s. This demonstration phase, largely supported by government grants, continued until the 1990s, when a new era was spurred by advances in computing and the internet revolution.

The cost of videoconferencing decreased enough to make telepsychiatry services sustainable in large institutions such as the Department of Veterans Affairs, Department of Defense, prisons, and large academic institutions. The 2000s saw further telepsychiatry expansion with the arrival of web-based videoconferencing, leading to widespread but sporadic adoption. Other technologies including smartphone-based apps, electronic health records (EHRs), and virtual therapies have matured to be used in conjunction with telepsychiatry.

Today, telepsychiatry can rightfully be called an evidence-based practice with decades of research supporting its effectiveness equal to that of in-person treatments across diagnoses, settings, and populations. Other digital psychiatric applications described in the literature are in various stages of maturity with a range of evidence supporting both specific applications (for example, a single mobile app) and treatments (for example, virtual reality–based exposure therapy). But while digital tools like videoconferencing platforms and mobile apps were already beginning to transform the practice of psychiatry before the pandemic, their evolution was a few steps behind the use of digital technology in society.

Rather than surging into the information age, psychiatry (and arguably medicine as a whole) remained stuck at the peak of 20th-century, industrial-age medicine, relying on technology to reinforce the existing systems of care, rather than to change and improve them. An example of this mismatch is how the modern EHR has enhanced billing, coding, and symptom tracking but has not reduced provider burnout or improved patient-provider interactions. It’s as if a 2021 McLaren sports car frame has been placed on a 1950 Ford truck chassis. Underneath the shiny hood, little has changed.

Over the past several years, however, telepsychiatry has moved to create and implement new models of psychiatric care by blending videoconferencing with other technologies such as EHRs, patient portals, and passive data-collection tools on smartphones. Examples of these include virtual models of integrated care, residential psychiatric care, and asynchronous psychiatry such as store and forward telepsychiatry e-consults. This evolution led psychiatrists, as well as other medical professionals, into a new epoch of “hybrid doctor-patient relationships.” This term describes relationships that are managed through a variety of mediums including in person, videoconferencing, patient portals, telephone, texts, and email. The psychiatrist works to match the most appropriate communication medium based on the patient’s diagnosis and needs as well as social and personal circumstances. Psychiatrists have had to learn the strengths, weaknesses, clinical adaptations, regulations, and parameters for each of these technologies as these hybrid-relationship models have been radically and rapidly advanced during the pandemic out of necessity.

Digital psychiatry before the era of COVID-19 was shaped by larger trends in psychiatry and medicine. These included workforce needs and a growing demand for services in the face of an aging workforce at a time of increasing burnout among physicians, including psychiatrists. Psychiatry was, and is, facing a number of interlocking funding issues; these include the rollout of value-based payment reforms, the uncertain future of the Affordable Care Act, and increased consolidation that is leading more physicians to become employees of large health care organizations. Interestingly, psychiatrists have had greater protection from health care consolidation due to the coupling of lower reimbursements for psychiatric care and unmet demand. This has led to many psychiatrists opting out of employee-based practice for private practice, further increasing the overall workforce shortage in psychiatry, especially in the public sector.

The two noteworthy issues impacting patients before the pandemic were generational attitudes toward technology and digital disparities. The first issue involved the conflict of the “digital natives” who have grown up in a digitally interconnected world vs. “digital immigrants” who did not encounter widespread digital technologies until adulthood. There exist significant differences between these groups in their use of and comfort with technologies, with recent data suggesting that early use of technology may even impact the development of the brain. As digital natives have become adults, they have increasingly accepted and demanded to be able to access health care through digital means.

The second issue is the challenge of the “digital divide”—obstacles that patients encounter in accessing health care. The digital divide has often focused on broadband availability, especially in rural areas, but can include a wider range of issues from the availability of technology, technology literacy, and access to insurance that covers digital health services. “Digital deserts” caused by these problems can be framed within the larger context of a wide range of social determinants of health. The digital divide significantly impacts underserved populations such as those who live in poverty, homeless people, non-native English speakers, and communities of color. These groups experience a disproportionate burden of problems that impact their mental health, and the lack of digital health resources is another factor fueling health inequities. These inequities and the previously discussed trends impacting psychiatry have greatly accelerated during the pandemic.

March 2020 witnessed the initial surge of COVID-19 cases and the subsequent shutdowns of schools, businesses, restaurants, churches, and more while many people were on lockdown at home. The implementation of videoconferencing and associated technologies occurred at a supersonic speed from March 2020 onward. Out of necessity, psychiatrists and psychiatric organizations adapted videoconferencing and telephony for clinical purposes, in many cases overnight. They also had to virtualize entire business operations, a decidedly separate set of tasks with complications beyond the implementation of any single technology. This often occurred with minimal staff and provider training, scant planning, and limited transition support. The telepsychiatry implementation adage of “Most of the work occurs before the first patient is seen” was atypical of the adaptations started in March 2020.

It was at least fortunate that technology use in mental health had reached a sustainable level when the pandemic hit. Had COVID-19 emerged a decade or two earlier, the available technology would have been unable to support the provision of reliable virtual care at the needed scale. Even with today’s widespread use of videoconferencing, many psychiatrists have had to rely on other tools to support patients. An APA survey of pandemic telepsychiatry in June 2020 found widespread use with high levels of patient and provider satisfaction, but respondents indicated that they were using the telephone to connect with up to 25% of their patients.

In response to the need to virtualize medical care during the pandemic, there occurred almost overnight a host of policy and regulatory changes favorable to telemedicine and telepsychiatry. These included relaxation of regulations around licensure, prescribing, billing, and reimbursement. Although many are temporary and tied to COVID emergency declarations, they have been critical in supporting the current levels of virtual care.

The virtualization of psychiatry has brought with it a number of challenges and concerns. Will COVID-19 regulatory changes and funding chains remain after the emergency declarations end or will their pre-COVID-19 status be reinstated? If so, what will be the timeline of the transition periods? What do we make of the newly minted pandemic phenomenon of “Zoom fatigue” and concerns of physician burnout associated with excessive videoconferencing and screen time. There are also the issues of stress, burnout, and fatigue driven by the concentration of work, home, school, and/or telehealth tasks all being done under the same roof. The methodical process of developing and funding research projects was having difficulty keeping pace with rapid technological change before the pandemic, so how are we to harness the critical lessons on rapid transformation and apply them in the “new normal” after the pandemic?

The next year or so will likely be one of the more dynamic and interesting periods for psychiatry. As we begin to emerge from the pandemic, individual psychiatrists and psychiatric organizations will need to prepare for a society with greater mental health needs. Studies on the overall impact of natural disasters predict significant increases in the overall rates of mental illness in society, something we are seeing borne out during the pandemic with an increase in the number of suicides, overdoses, and stress-associated problems.

The demand for services will likely not be accompanied by a greater supply; in fact, overall resources for mental health care are at risk to decrease. How are psychiatrists and psychiatric organizations to adapt to new mental health service structures without knowing what the overall funding landscape will look like?

As psychiatrists begin to re-establish in-person care, they should take a deliberate and strategic approach in assessing the risks and benefits of virtual vs. in-person care. Solutions will arise for this driven by local COVID-19 status, resources, and demands, with many health care professionals having to shift their balance back and forth between remote and in-person care. As the pandemic winds down and associated quarantines lessen, demand for services will rise, fueled by a combination of those who had put off seeking care during the pandemic due to safety concerns and those experiencing the mental health aftershocks of the experience. The long-term direct and indirect economic impacts of the pandemic will affect systemwide resources for mental health as well as resources available to individuals seeking care in the face of mounting unemployment and gaps in insurance as people move from one job to another, lack of insurance, and inability to pay for care. These pressures could hasten psychiatrists’ moving into private practice as the increasing need for psychiatric care places additional burdens on public systems and creates a more favorable marketplace for fee-for-service practice, but also has the unintended consequence of creating a vicious cycle by further reducing access to psychiatrists in public sector services.

The COVID-19 pandemic accelerated the widespread and rapid adoption of telepsychiatry and technology in psychiatric practice. Health care professionals and organizations are now familiar with virtualized operations, and patients have experienced increased satisfaction and comfort, many intending to continue their care electronically after the pandemic. This is an optimal time to examine and refine the appropriate balance between in-person and virtual care and understand how to tailor care for each patient. Psychiatry as a field should look for opportunities to change delivery and funding structures within the mental health system before the inertia of stability sets back in.

There are a number of landmines and pitfalls of which to be cognizant as we transition to making greater use of technology, especially digital disparities and health inequities accentuated by the pandemic. These challenges can be addressed by taking more of a technology-supported public health perspective through increasing access to care, building models of team-based virtual care for population health management, better customizing care for individual patients, and facilitating networking and linkage with wider resources.

Leveraging technology to tackle these concerns needs to be done strategically and thoughtfully with care taken not to inadvertently increase disparities and aggravate existing challenges. There is a burgeoning literature focusing on unintended consequences of technology in health and mental health, especially artificial intelligence (AI). Examples include how the design, process, and use of EHRs has increased administrative workload and contributed to burnout and AI algorithms that unintentionally decrease quality of care and outcomes in specific patient populations.

We are at an extraordinary moment for transformation. Psychiatry must act boldly to seize this opportunity to facilitate system change drawing from the crucible of the COVID-19 pandemic to continue to advocate for increased access to care, health care equity, and improved quality of care for our patients and communities. ■