Psychiatrists Anticipate Mental Health Needs With COVID-19
— Telemedicine an important way to help – by Elizabeth Hlavinka, Staff Writer, MedPage Today December 31, 2020
This story was originally published on March 24, 2020. As part of MedPage Today‘s review of the past year’s top stories, we are republishing it, along with an update on COVID-19’s mental health impacts, reviewing subsequent developments in 2020.
It was contracting the COVID-19 coronavirus herself that made Maryland psychologist Myrna Frank, PhD, completely transition her practice to telehealth appointments.
On Monday, March 9, the day after Frank returned from the annual American Group Psychotherapy Association meeting in New York, she was seeing clients in her clinic, being careful to avoid touching surfaces and keeping her hands as clean as possible. But that night, the fever, chills, and nausea presented suddenly.
“I felt incapacitated for 36 hours,” Frank told MedPage Today.
Over the next week, more than a dozen meeting attendees tested positive for COVID-19 coronavirus (as of March 18, a total of 22 cases were confirmed). Concerned that she, too, may have contracted the virus and could spread it to others, Frank decided to get tested and was finally able to track down a tented testing facility the following Monday, March 16. One week later, Frank’s test came back positive.
But her symptoms have mostly subsided, meaning it was a mild case.
Like many mental health professionals in private practice, Frank had prior experience using online services with long-distance patients and was able to transition smoothly to the new medium once she started to feel better.
Psychiatric appointments across the country have been going virtual as mental health professionals try to limit potential exposures by moving to home offices and keeping outpatient visits to a minimum.
“Some people may have more difficulty with it” — because of technical access, cost, or with conditions not amenable to it — “but there are so many people we can reach with telehealth who otherwise would not get help,” Frank said.
Psych Care Goes Virtual
Teladoc Health, which offers behavioral and physical health services virtually, said it had already seen an “unprecedented” number of daily visits as of March 13 as COVID-19 was spreading across the country.
Doctors on Demand, a similar online care delivery system, reported a 50% increase in demand in the past week, with the largest spike of new patient visits in the psychiatric services department since it began in 2016, said the site’s medical director of behavioral services, Nikole Benders-Hadi, MD.
“We have a large cohort of providers who are at the ready,” Benders-Hadi told MedPage Today. “Many of our providers have added additional hours … to provide services to patients.”
Ayana Jordan, MD, PhD, an addiction psychiatrist and an associate residency program director at Yale University School of Medicine, said providers are trying to triage patients through telephone interviews before they come in.
Mobile teams are being dispatched into the community to deliver long-acting injectables and other medications, she said.
“We don’t have a blueprint, there is no precedent for this,” Jordan told MedPage Today. “We have to be creative in how we provide care. We have to rise to the occasion, and we can, but people are going to have to be flexible.”
Overall, the goal is to minimize illness among providers by limiting the number of patients who walk into the facility.
“We’re trying to preserve as much of our staff as possible by having them stay at home and do telephone or telemedicine visits because we don’t want to unnecessarily expose our clinicians right now,” Jordan said. “The reality is, we’re going to have to rotate them back in later.”
Jordan works at a state-run mental health facility that recently transitioned to electronic prescription services. Her group still uses paper charts and, although they have begun to transition to telemedicine check-ins and appointments using video platforms like Zoom, the transition has not been as widely adopted as it has for many providers in private practice.
The majority of Jordan’s patients come from socioeconomically disadvantaged backgrounds, often homeless or with unstable housing, which not only increase their susceptibility to the virus, but also make it difficult to access telemedicine.
“Telemedicine works for certain populations, but it’s more realistic to think about the use of telephone services for people who may not have access to the internet or want to use their data to talk to their psychiatrist,” Jordan said.
Last week, the Centers for Medicare & Medicaid Services (CMS) expanded reimbursements to include telehealth services retroactively starting March 6. Prior to their announcement, telehealth was only covered in designated rural areas.
The American College of Physicians (ACP) requested CMS expand coverage further to waive co-pays for all types of telemedicine services to both new and established patients in a letter sent last week.
“States should be encouraged to implement telehealth triage so that emergency departments aren’t overburdened with non-emergency cases,” wrote ACP President Robert M. McLean, MD. “Further, since some states reimburse telehealth services at lower rates than in-person services, states should be strongly encouraged to provide reimbursement parity for COVID-19-related care.”
The Drug Enforcement Administration also expanded regulations to allow controlled substances to be prescribed without an initial in-person visit.
And in the same week, the Substance Abuse and Mental Health Services Administration loosened regulations on prescribing medication-assisted treatment to include telemedicine providers and granted 28-day and 14-day supplies of take-home medication for patients in an opioid treatment program, depending on stability.
But states and clinics still have to adopt these policy changes and it remains unclear how they will be implemented in the coming months, said Ximena Levander, MD, of Oregon Health and Science University in Portland.
“The federal government can say one thing that is really badly implemented downstream,” Levander told MedPage Today. “That’s the problem with having these really restrictive policies to begin with, they create an environment in which people [are] hesitant to make necessary changes in an emergency.”
Managing the Mental Health Burden
The American Psychiatric Association (APA) also put together resources for treating patients amidst the developing pandemic and policy changes.
Joshua Morganstein, MD, chair of the APA’s Committee on the Psychiatric Dimensions of Disaster, which put together the resources, stressed the importance of normalizing concerns and understandable fear surrounding the pandemic.
“It’s important to avoid giving people the message that somehow there is something wrong with how they are feeling or it is somehow a medical diagnosis,” Morganstein told MedPage Today.
But with so much still unknown about the physical and economic toll COVID-19 will have globally, psychiatrists can expect the community’s anxieties to translate to a significant mental health burden in the coming weeks, said Jessica Gold, MD, MS, of the department of psychiatry at Washington University in St. Louis.
“It’s impossible for me to believe the burden on the mental health system is not going to increase [exponentially],” Gold told MedPage Today.
In a poll conducted March 13-16, about one-fifth of respondents said their mental health has taken a hit and 29% said their emotional well-being had worsened in the past week.
Thus far, Chinese physicians are already experiencing the psychological impact of the coronavirus. According to a survey reported in JAMA Network Open, about half of healthcare workers in Wuhan — where the COVID-19 pandemic began — reported depression and/or anxiety symptoms.
The mental health consequences for healthcare workers will continue once the physical health of the country has been taken care of, said Roy H. Perlis, MD, MSc, of Massachusetts General Hospital in Boston, in an editorial accompanying the publication in JAMA Network Open. “Sooner or later, every clinician is also a patient,” he wrote.
As the pandemic progresses, psychiatrists will likely have to treat their first-responder peers who may be experiencing trauma or acute stress disorder, Gold said.
“The workforce question is going to be huge,” Gold said, noting the longstanding shortage of mental health workers. “If our whole country has a substantial increased demand in mental health services after this,” she added, “I think you’ll see that strain.”