Of all the medical specialties impacted by telemedicine during the course of the pandemic, perhaps the one with the most wholesale and lasting effects is behavioral and mental health.

Mental health appointments do not typically involve any collection of vitals or specimens, nor do they absolutely require a face-to-face meeting, although therapists can observe physical cues from the whole body in person. Just talking via video, or even just audio, is enough.

We talked with Dr. Janice Johnston, chief medical officer and cofounder of Redirect Health, a telehealth technology and services company, to get her expert observations regarding:

• The biggest ways telehealth is changing America's treatment of mental health. 
• What impact increased telehealth accessibility has had on mental health treatment. 
• The challenges telehealth presents in treating mental health.
• The improvements that can be made to telehealth for the treatment of mental health.

Q. What are the biggest ways telehealth is changing the U.S.'s treatment of mental health issues?

A. Before COVID-19 and historically in the U.S., there has been a negative stigma around receiving mental healthcare. While there have been a lot of movements and campaigns attempting to try and stamp out the stigma, many people have been deterred from seeking professional help due to a lack of coverage in healthcare plans, high copays and fear.

As telehealth widens, the availability of mental health services continues to grow and is more accessible than ever. Gone are the days of driving to appointments and sitting in a waiting room, with the feeling that all eyes are on you. Social networks also have created a platform for mental health activists and we are seeing, in real time, an increase in people looking for treatment or routine mental care.

COVID-19 accelerated the need for more access and new ways of treating mental health, such as telehealth. As a result of the COVID-19 pandemic, we also have seen many major insurance companies offer permanent or temporary plan benefits that include mental health services.

Telehealth has made it easier for insurers to include these benefits in their plans with less out-of-pocket costs for patients. In many cases, insurance providers even waived the entire cost for visits when using telehealth.

While most people don't want to be thought of or treated differently because they choose to seek mental health treatment, the stigma around it can make them feel judged, and they avoid choosing care.

Telehealth has made it possible for people to now access care from the privacy of their homes, making the decision to seek care much easier and more comfortable. Being able to speak with a mental health professional from home has provided patients the ability to choose a setting that provides the most comfort, making the process of opening up and sharing concerns with a new person much easier.

Q. What impact has increased telehealth accessibility had on mental health treatment in the U.S.?

A. The COVID-19 pandemic forced changes for Americans across the country that have affected mental wellbeing, such as working from home, quarantine enforcements, lack of spending time with friends and family, and feeling isolated.

This led to a surge in mental health issues with most non-emergency medical treatments shut down due to safety concerns and quarantine enforcements. Telehealth was a necessity we didn't see coming, and the pandemic accelerated this service due to the timely needs that were arising.

With the higher demand for mental healthcare, telehealth has been the answer for many. People living in rural communities or underserved areas, specifically, experience limited access to specialty healthcare services, especially mental health. One of the key impacts of increased telehealth accessibility is that these communities have been able to turn to telehealth as an option when they may not have had an alternative.

Different from rural or underserved communities, many urban populations see that finding in-person care isn't the difficult part, but affording it and getting to their appointment can be. Another key impact of increased accessibility is that telehealth tends to be a much more cost-effective option, as in-person care can regularly be more than double the cost.

Think of all the money and time wasted having to take off work, which can result in lost wages, needing to hire a babysitter, or paying for gas when commuting to and from appointments. With telehealth, patients are able to afford their scheduled appointment at a time that is convenient and works for them.

Additionally, while most offices provide services in standard office hours, many telemental health services provide care before and after work hours as well, so patients have more scheduling flexibility.

There also are a lot of cultural barriers and health inequities that many minority communities experience that may deter them from seeking mental healthcare.

During the pandemic, these communities experienced a rise in telemental health usage. While there are several reasons why this rise has occurred, we have seen that telehealth has been able to combat some of the barriers these groups have had to overcome.

For one, telehealth affordability has made services much more accessible to minority groups or lower income individuals, enabling them to include mental healthcare into their budgets. Additionally, minority groups have experienced higher rates of depression and anxiety, only exacerbated by the pandemic, so the demand from these communities, along with the decrease in negative stigma around mental care through telehealth, has driven them to these options.

Lastly, telehealth allows those with language barriers in the U.S. to have access to a broader group of mental health professionals who can provide a better understanding of their cultural backgrounds, partnered with the ability to speak in their preferred language.

Q. What are some of the challenges telehealth presents in treating mental health issues, and instances when in-person care must be sought?

A. While telehealth has expanded access to mental healthcare for so many across the country, there are still limitations that may lead some to favor in-person care.

First, privacy. While many patients prefer telehealth so they can have their appointment in the privacy of their homes, there are situations where people may not have that same privacy in their home.

Some people may live in multi-generational homes where others are home and in earshot, or they could share a room with others with privacy not immediately available. This may leave patients taking their calls from their car, which is not always comfortable or preferred. As a result, people in these settings may prefer care in person.

Second, safe places. While some people prefer their care virtual for a variety of reasons, others feel that virtual mental healthcare is cold and distant, and favor in-person care in order to feel more engaged with their mental health provider. Sometimes being removed from their normal home setting can help create a safe place for the patient to discuss their mental health concerns.

This is especially a factor with live support groups, which can be more engaging and easier in person than virtually. Many times, live support groups are used for people looking to overcoming addictions, and being able to separate them from their traditional setting can be helpful for pulling them out of their environment, even momentarily.

And third, technology. Some individuals may not understand the technology behind apps or websites that provide mental health services. They may not know how to access video links or use their phone to connect to a provider, which could result in a sub-par session, where they do not feel comfortable or at ease.

Patients also do not want to see time consumed or wasted during their appointment because of technical struggles and may prefer to see their providers in person to avoid the hassle of these situations.

Q. What improvements can be made to telehealth specifically for the treatment of mental health issues?

A. We can look to the current challenges of the telehealth space to find where to start with improving the telehealth experience for everyone.

For starters, creating wider access to the internet allows telehealth to reach more people who may not have any options available to them today. In fact, the Biden administration recently secured commitments from 20 leading internet service providers to either reduce prices or increase speeds to serve low-income households.

This is a great step in the right direction. Better cellular and internet speeds allow for more telemental health experiences to be held over video, and not telephonically, where mental health professionals can better assess their patient through both verbal and nonverbal cues.

With all the advancements and changes we have seen in technology in just the last few decades, there is a lot for patients and providers to keep up with. Education is key to making sure telehealth sticks around and continues to rise in its availability. Many providers are willing to learn new technology, but need to be trained by the people that thoroughly understand the ins and outs of these systems.

As new standards of care are set by technological advancements, providers and patients alike need to be provided the education to keep up with these evolving standards. It is important for those implementing new systems to deliver the proper education providers need to learn the technology, as well as assist their patients.

Another thing to consider is how to assist patients with disabilities through telehealth. There are laws in place in the U.S. to ensure equality in care for those with and without disabilities, and therefore considerations need to be made in telehealth situations as well, such as providing additional instructions or scheduling longer appointment times.

Sometimes added support or modifications need to be made to technology systems in order to support these patients as well. Telehealth systems should meet accessibility requirements and should provide resources that are available in multiple formats, like audio recordings or large text sizes.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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