Teletherapy is finally here to stay

Mental health via telehealth.
Mental health via telehealth.
Image: Sarah Mazzetti for Quartz
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Starting around mid-March, Mary Alvord stopped seeing patients in person. The coronavirus pandemic and ensuing lockdown orders meant that she, like lots of psychologists, had to figure out how to keep their practices going when office appointments were impossible.

Alvord, who has a private practice in the suburbs of Washington, DC, had a leg up on many other psychologists: She’s been treating patients remotely for nearly a decade. “I would say 10-15% of our practice was already telehealth,” she says. “But we had to quickly pivot to it being 100% of those willing.” Her practice already had a digital platform compliant with health-related privacy laws and patient release forms that included a clause about telehealth. Many of her existing patients were able to quickly make the jump online.

She initially became interested in telehealth in part because she believes it allows more patients access to mental health services. And since mid-March, Alvord has used her experience to educate an estimated 10,000 mental health practitioners in how to maintain care from a distance.

“Telehealth has saved the day,” she says.

For decades, experts have touted the utility and efficacy of performing psychological services via telehealth. But adoption—by insurers, by healthcare practitioners, and by patients—has been slow. Now, because of the pandemic, many of the barriers to telehealth have disappeared. Telehealth may finally be able to achieve its potential.

“Telehealth was taking baby steps [before Covid-19]. Even though there’s good evidence suggesting that it could be quite effective, all kinds of regulations were forcing everyone to go slow,” says Richard Frank, a professor of health economics at Harvard Medical School. “After Covid, you won’t be able to put the genie back in the bottle.”

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A slow adoption

One of the earliest examples of telehealth (or telemedicine) in the US dates back to the 1950s, when a hospital and psychiatric facility in Nebraska were connected via closed-circuit television. Today, telehealth includes asynchronous communication, phone and video calls, and monitoring devices that allow doctors to track the health of their patents remotely.

Nearly every field, from dentistry to dermatology, has a remote corollary. But it can be especially natural to practice psychiatry this way: Talk therapy, psychological assessment and diagnosis, and medication monitoring all translate well to digital platforms. “Mental health, especially certain types of mental health like behavior therapy, rely on talk. That’s how patients are diagnosed and treated. And so if all you need to do with a patient is talk, you can use video,” says Rashid Bashshur, the executive director of eHealth at the University of Michigan Health System.

And telehealth for mental health has been shown to be just as effective or better than in-person visits. Studies show that patients who use telehealth for psychological disorders have the same or better long-term outcomes. They take their medication more consistently, too. (All that, with no commuting and no waiting room.) Being able to do psychological treatment remotely wasn’t a surprise, says Bashshur. “What did surprise many people was that it could be an effective means of reaching patients and providing care at a distance without having to come to the clinic.”

Of course, telehealth isn’t always perfect. Sometimes tech glitches or slow internet connections inhibit patients’ conversation with doctors. Doing audio-only sessions reduces the amount of information a doctor can observe, like nonverbal cues or hygiene, that may be a sign their patients aren’t doing well. Alvord has had to work hard to figure out how to engage the children she works with, who can get antsy just sitting in front of a screen. Some of her patients with autism have declined to continue sessions with her remotely during the pandemic.

Other countries have adopted telehealth—including teletherapy initiatives—on a large scale only thanks to concerted government efforts. Denmark, which started its push towards telehealth in the 1990s, has been a leader in the digital health space for a decade. The Ontario Telemedicine Network serves 13 million Canadians, making it the largest digital health network in the world.

The US has made strides to incorporate telehealth into its existing healthcare system, but regulatory hurdles (pdf) have slowed adoption.

The government only started the process of requiring health records to be digitized in 2015 (pdf). Insurers—particularly the Centers for Medicare and Medicaid Services (CMS), which covered about 144 million Americans in 2019—didn’t have plans to reimburse doctors for telehealth appointments. And state-based licensure regulations limited how patients and doctors could connect across state lines. There were open questions about how malpractice suits would be handled, and privacy issues the platforms might present.

While official channels struggled to allow telepsychology or teletherapy to become mainstream, direct-to-consumer therapy apps like Talkspace and Better Help started to become popular. But they were often not covered by insurers. Despite the seeming ease of access, teletherapy hadn’t reached as many people as it promised.

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Pandemic effect

For years, Universal Health Services, a healthcare service provider that treats millions of patients per year across 37 states, had a fairly limited telehealth platform. It was really only intended for rural patients, because that was the population the federal government would reimburse for, says Karen E. Johnson, senior vice president at UHS.

Once lockdown orders went into place to slow the spread of Covid-19, however, the company realized it needed to make telehealth available to everyone, and fast.

Within a few weeks, the company built out its telehealth platform, a version of Zoom that complies with guidelines from the medical privacy law HIPAA, Johnson says. Soon hundreds of patients started using the tools—far more than she expected. “It’s still early for us. But what we’ve seen has far surpassed how I thought people would feel comfortable talking to a clinician,” Johnson says. “That’s a sign of pent-up need, if people are willing to adapt their behavior from what was the normal way to access care.” While UHS didn’t provide specific numbers on the increase in telehealth adopters for mental health, a spokesperson says the data they are tracking is promising.

This was newly possible in part because of sweeping policy changes made in response to the pandemic. In the span of just a few weeks, federal agencies did more to clear the barriers to telehealth than they had for years.

In March, the Trump administration made it easier for practitioners and patients to connect even if they weren’t in the same state. It also said it would no longer enforce some elements of HIPAA: Healthcare providers could use a greater number of nonpublic audio and video platforms, like Zoom, FaceTime, and Skype, with the understanding that they may present a privacy risk. That means that it’s easier for psychologists and therapists to meet with patients—though some of the nuance of in-person meetings is lost, video and phone are still great mediums for talk therapy.

By April, the US Food and Drug Administration had loosened regulations around digitally-administered therapy. And in May, the Drug Enforcement Administration started allowing practitioners (pdf) to prescribe medication without seeing a patient in person. In terms of mental health, this means patients could more easily access the drugs they need, such as SSRIs or antipsychotic medication.

One of the biggest changes has been that CMS agreed to reimburse medical appointments conducted via telehealth at least into 2021. “In the past few months, we have implemented an aggressive strategy to help to expand telehealth services and coverage to keep beneficiaries safe and prevent the spread of Covid-19 by getting rid of barriers to telehealth that have long existed in the Medicare program,” according to a CMS spokesperson. The plan seems to be working—1.4 million Medicare beneficiaries used telehealth services during the week ending April 25, up from 13,000 people prior to March 7, according to the spokesperson.

“For people who are not aware of digital health or telemedicine prior to this pandemic, it opens a lot of doors,” says Adam Haim, the chief of the Treatment And Preventive Intervention Research Branch at the National Institute of Mental Health. “Providers who were resistant or unaware are now using it. In some systems, that’s the dominant way of receiving treatment at this point.”

Similar efforts to expand access to telehealth—often including telepsychology—are happening around the world, in countries such as China, Canada, the UK, and Australia.

Many practitioners believe that telehealth has benefitted patients over the past few months if for no other reason that it granted them access to services when they might not have otherwise had it. But that doesn’t mean the system is perfect, for the present or for the future.

“We’re in the process right now of trying to build the boat and sail it all at once,” says Frank, the health economist. “They’ve been building one part of the boat—can you talk to people over Zoom and FaceTime, and can you do that safely and effectively? The answer is largely yes.”

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The future of telehealth

Now that many more people have experienced the benefits of telehealth, many will probably want to keep using it for their mental health care. Several experts suggested that in the future many psychologists and psychiatrists will want to go with a hybrid approach, one in which patients who prefer to use telehealth can do so, while those whose needs are best met in person can come into a doctor’s office.

In the US, it’s not yet clear that the policy changes that would help telehealth reach a large number of patients will stick around. CMS can expand how it reimburses for care, but some decisions about licensure and quality of care require federal or state legislation, says Christine Calouro, a policy associate for the Center for Connected Health Policy.

And though HIPAA protections may not be a priority now, practitioners will eventually have to evaluate platforms’ privacy concerns. Patients discuss a lot of sensitive issues with their therapists, from concerns about other facets of health to whether they are at home alone, that could prove detrimental in the hands of others. “There are issues—big, important, confidentiality and risk mitigation stuff that needs to be worked out. I don’t think we know what we’re doing there,” Frank says.

If the regulatory environment can catch up, though, there’s hope that mental health care’s rapid adoption of telehealth could speed up new standards for care.

Providers have always struggled to find the right moment to intervene if a patient is in crisis (pdf), for example. Many providers keep contact information for someone who can check up on the patient if needed, but sometimes there’s not much to do when that person isn’t answering the phone.

But with better integration of data, mental health care could go from passive (patients get in touch with services they need) to more active (those services going out and connecting with potential patients). “You’re going to have to use data to find people… You’re going to have to somehow become aware of who has challenges,” says Paul Galdys, the deputy CEO of RI International, which provides mental health services in five US states. This might mean creating special teams to check up on people, or having automatically triggered reach-outs when someone uses another service, like a homeless shelter.

This moment, then, is effectively a large-scale experiment into how to do mental telehealth the right way. “We jumped into it at this scale with minimal planning and minimal training. When you do that, you are bound to make mistakes,” Bashshur says. “We really have no clear idea what the results of this initial experience will be. But if we expect it to be perfect, I think we’re going to be disappointed.”

In the future, with state and federal policy changes, widespread practitioner adoption, and patient adaptation, telehealth might simply become woven into the fabric of the US healthcare system. “When we do our banking online, I don’t think of it as telebanking—I just think of it as banking. Similarly, I think telehealth is going to be part of healthcare. That’s where I think we’re moving,” Calouro says.

Alvord agrees. Though she says she’ll go back to seeing some patients in person when it’s safe again, “I think the increased use of telehealth is here to stay,” she says. “It would be nice if people see this as the silver lining of what’s come out of this otherwise very difficult time.”

If you or someone you know is in crisis, in the US you can call the National Suicide Prevention Lifeline, 24/7, for confidential support at 1-800-273-8255. For hotlines in other countries, click here.