It is no secret that the United States is experiencing a mental health crisis due to aggravated conditions from the pandemic exacerbated by of a shortage of mental health professionals, especially psychiatrists.

As a result, especially because of the effects and requirements of the pandemic, telepsychiatry has been on the rise. In fact, behavioral healthcare has even received special exemptions from prepandemic reimbursement rules from the CMS and private payers.

Dr. James R. Varrell is chief medical officer and founder of Array Behavioral Care and a practicing psychiatrist. Varrell was among the first to perform telepsychiatry – back in 1999, before the Internet, via phone lines. This was through a state-sponsored grant in New Jersey. Array Behavioral Care has been at telepsychiatry for 20 years, with a large base of virtual psychiatrists.

In an interview with Healthcare IT News, Varrell talks about how healthcare organizations are coping via telepsychiatry with the mental health crisis, how tele-psychiatry has changed over the last two decades and the requisite bedside manner for tele-psychiatry.

Q. How are hospitals and primary care physicians expanding access to mental health and addressing the burden they're experiencing from the mental health crisis through telepsychiatry?

A. We have to start with why hospitals and PCPs are even needing to expand their behavioral health capabilities and access in the first place. As many as 80% of individuals seeking mental health treatment in the U.S. visit either in an emergency room or their primary care provider, rather than a psychiatrist.

At this intersection of our country's mental health crisis and the growing demand for treatment is a shrinking supply of behavioral health professionals. It's difficult for people seeking a psychiatrist, psychologist or therapist to find the right licensed professional, covered by insurance, and with availability.

Kaiser Family Foundation data from January 2021 showed that behavioral health clinicians can only meet 27% of the mental health needs across the U.S. So, when individuals' symptoms worsen, which happened across the board during the pandemic, they go to the professionals they know and can get to – EDs and PCPs.

There's a shortage of medical professionals nationwide, but in no other specialty are the gaps greater than in behavioral health. Fortunately, behavioral health is one of the specialties most easily translated to telehealth.

PCPs and EDs feeling the strain on time and resources from the growing need for behavioral care are increasingly turning to telepsychiatry to improve access to specialty care for these patients. 

Through telepsychiatry, EDs can bring in a professional within minutes or hours (instead of the days it takes on average) to evaluate a patient, determine appropriate disposition, initiate stabilizing treatment if appropriate and set up a discharge plan.

PCPs integrating telepsychiatry into their practices can work more upstream with behavioral health clinicians to identify patients who need help and develop proactive treatment plans targeted toward remission, not just reduction, of symptoms.

Improving access to behavioral healthcare through telehealth allows hospitals and PCPs to free up their staff and resources to focus on physical ailments, while still connecting the dots for patients with behavioral care needs. 

Establishing a relationship with telepsychiatry clinicians can empower providers across the care continuum with the support and information they need to fully manage the health of their patient population.

Q. How has virtual mental health care changed over the past 20 years?

A. There are two main things that have advanced tele-behavioral health over the years: the technology and widespread adoption.

Back in 1999, I was fortunate enough to perform what we know to be the first involuntary commitment via video in the U.S. I connected to a hospital screen via phone lines. And at that time, video telehealth was unheard of, a little scary, and there was very little research on it.

Since then, evidence has proven the effectiveness of virtual care in behavioral health, and now it's become quite popular – and quite feasible. Advanced technology, along with a strong cell phone signal or WiFi connection, have helped level the playing field for individuals to access – and clinicians to securely deliver – tele-behavioral care. With the appropriate state license, now a psychiatrist in California can meet with a patient in rural Iowa.

Over the years, we've seen more and more companies spring up with virtual mental health services. But the key thing we see being lost is psychiatry offerings. While patients don't always have acute challenges or need medication, it's important that the right mix of professionals are available to serve a variety of needs.

Q. What is the "webside manner" (as opposed to bedside manner) that clinicians need to provide mental healthcare online?

A. Though the in-person behavioral care skills still apply online, clinicians providing tele-behavioral care need to be more nimble and proactive in a virtual setting. They first must be mindful of the surroundings individuals are in and ensure that they can speak safely and freely.

That may mean asking questions at the top of a session that we wouldn't normally ask in person or suggesting a patient go for a walk or move to a more private place if they're discussing sensitive information. Clinicians should also consider establishing a code-word with patients that can signal if someone enters their space.

There also are technology factors to consider, such as a lag in video or audio translation through screens. Clinicians must be more attentive to some of the verbal or nonverbal cues that can be a little more challenging to pick up on in a virtual setting.

For example, they may need to pause for an extra second or two between when it seems like a patient is done speaking instead of jumping in immediately to comment. And clinicians have to be mindful of their own space, lighting, camera angles and more to be sure they are creating a comforting, professional, safe and confidential environment.

Providing behavioral care online also opens more opportunities for personal connection and building rapport. Clinicians can meet pets or family members at home who they wouldn't have met at in-person appointments, which often can provide important context to their treatment.

Clinicians also can scan the environments to see books on shelves, posters in rooms and other personal elements to talk about, which can help them find even more common ground with their patients.

Q. How do caregivers create the right environment for providing virtual care, for clinicians and patients alike?

A. For the average person, among the biggest barriers to care are affordability and accessibility. People seeking mental healthcare should not have to wait weeks for an appointment or pay out of pocket for services.

So practices or companies offering virtual behavioral care must prioritize ensuring their behavioral care services can be covered by patients' insurance as well as ensuring that their clinician availability is always one step ahead of demand. Practices or companies should also prepare clinicians with best practices to shorten the learning curve for transitioning their care to the virtual world.

For example, some providers deliver courses to show tele-psychiatry presenters – physicians, nurses, social workers or counselors – how to successfully facilitate a tele-psychiatry session. Providers also share resources with talking points to help clinicians explain to patients what they can expect out of their virtual appointment, the effectiveness of online therapy and more.

Once an individual is with a provider, the most important thing is stable, consistent care with a clinician they trust. Behavioral care outcomes often are driven by long-term relationships. And in order to foster those, practices or companies offering virtual care have to also care for their clinicians so they'll stick around and build those deep, lasting patient relationships.

Clinicians need and want an environment in which they are respected, can grow, socialize, mentor and be mentored, have the freedom to practice how and when they'd like, and truly serve their patients.

Clinicians are at the core of any virtual care service, and when we take better care of them, we'll attract and retain people who can take better care of patients. With a human-centered, relationship-focused approach to telepsychiatry and online behavioral health, we'll chip away at the mental health crisis and work toward a happier, healthier population.

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