One of the great use cases for telemedicine has proven to be mental health. It does not require physical contact between caregiver and patient (though seeing a patient's affect in person can be better than via video). Rarely does mental health require in-person tests. Taking vitals is not necessary. Overall, it's a great fit – and one that soared during the pandemic and beyond.

So, what's the outlook for telepsychiatry this year? Dr. Zoe Martinez has three predictions.

She is a member of the clinical leadership at Done, a platform that connects patients with psychiatric board-certified medical professionals for services including online video consultations, diagnosis, care team support and prescription delivery. She has more than 20 years of experience working with a wide range of patients. She’s board certified in child and adolescent psychiatry as well as adult psychiatry.

Regarding telepsychiatry, she says in 2024:

1. Telehealth will continue to grow because it fills a void in the mental health space by creating improved access for many individuals who lacked this access previously.

2. Individuals and insurance companies will see the value of telehealth as, in some ways, replacing the house call of olden days, which was an important aspect of medicine.

3. Despite the end of the public health emergency, individuals and informed political leaders will continue to work with pharmacies to continue access to vital care for individuals in need of medication for mental health because mental health is part of overall health.

We sat down with Martinez to get her to expand upon her outlook for the year.

Q. The first of your three predictions for telepsychiatry in 2024 concerns access. You contend telepsychiatry will continue to grow because it enables access to mental healthcare – which is a big challenge today.

A. Patients with mental health issues frequently must wait many months before getting seen by a licensed clinician who can prescribe psychotropic medication. During this waiting period, in addition to suffering negative consequences in their jobs, at school and in personal relationships, they run the risk of being hospitalized, which can be traumatic and costly.

Estimates for the mental health shortage indicate approximately 47% of the population (or 158 million people) live in a mental health shortage area.

This is particularly true in rural or economically distressed areas. The lack of a sufficient number of clinicians to support these underserved communities can be reduced by the use of telepsychiatry services that permit clinicians who do not live in those areas to provide remote care from wherever they live, provided they are licensed in the state of the patient’s residence.

In addition to a shortage of clinicians to provide care, there often are other barriers to access, which include cost and transportation issues. It is well known that individuals with untreated mental health issues are more likely to be in lower income brackets.

Telepsychiatry services often are more affordable as they do not require the investment in physical infrastructure a traditional office setting does. In terms of the transportation issues, the cost of owning a personal vehicle may be prohibitive for individuals in lower socioeconomic groups – and there often is a lack of reliable public transportation in rural and economically depressed areas.

In addition, if someone must travel from an underserved area to an area with more provider availability, the commute time may be a barrier to access.

If patients have to wait until they deteriorate before accessing care, their symptoms will likely be more severe, their personal losses will be greater and they are likely to feel more disenfranchised with the mental healthcare system.

Telepsychiatry addresses all of these access issues and provides an affordable option that increases the availability of services without requiring a significant infrastructure investment in physical locations and nonclinical staff to support those physical locations.

However, depending on the state and its regulations, patients may need to, at times, be seen in person. As the public health emergency of COVID is ending, state regulations are changing and fortunately telepsychiatry will still exist as part of a hybrid model.

Therefore, telepsychiatry will continue to provide a significant component of care as, even in states where, for example, initial appointments need to be in person, follow-up appointments may help to provide more frequent care for patients and therefore expand the ability of in-person clinicians to care for more patients.

Q. The second of your predictions concerns acceptance. You say payers and patients will more greatly embrace telepsychiatry as a form of healthcare delivery. What does this mean for mental healthcare this year?

A. When telepsychiatry was first in higher demand due to COVID, it is estimated in February 2019, 4% of survey respondents indicated using telehealth services. Two years later, during the pandemic, this percentage increased to 45%.

A study by the AMA in 2021 indicated more physicians had "enthusiastically embraced" telehealth, with more than 85% of physicians indicating they were comfortable using telehealth and frequently incorporated it. Telepsychiatry is a useful tool that is cost-effective and efficacious when provided by an experienced clinician.

Due to the prevalence of telepsychiatry as a useful model, more and more patients and clinicians will gain more experience using this modality.

An additional benefit of telepsychiatry is it may provide the benefit of old fashioned "house calls," which can be enormously useful in quickly learning about how a patient’s social environment impacts their mental health in both positive and negative ways. Seeing a patient in their home environment often helps with rapport-building, as one can physically see things such as a pet, hat collection, art collection, etc.

This helps not only to establish rapport in an initial visit but also during follow-up as the clinician and the patient can discuss any changes. Seeing a patient in their home environment can also be very useful if the patient wants their in-home support network to participate in their treatment plan. This can be both impromptu and planned and generally also helps to both improve rapport with the clinician and support for the patient.

All of these things provide an easy way that patients can share their lives and feel like a cared-for individual and not just a diagnosis.

When telehealth services began to be used, there was a great deal of confusion as to whether services would even be billable. As telehealth in general, including telepsychiatry, has become more commonly used, there has been pressure on Medicaid, Medicare and private insurance companies to develop standards for coding and billing for telehealth services. There continue to be updated guidelines to help clinicians use appropriate codes for billing.

Now that it is clear telehealth is here to stay, creating standards in coding and billing for telehealth services is a constantly evolving field. The more both government and private insurance companies can continue to create standards, the more this legitimizes telehealth as a model of clinical service provision that is not a temporary fix for surviving the public health emergency due to COVID-19 but as a valid clinical model that will persist and expand into more areas of medicine.

Q. Your third prediction concerns medication. You suggest organizations and informed political leaders will continue to work with pharmacies to continue telemedical access to medications for mental health because mental health is part of overall health.

A. There have been numerous stories in the media regarding shortages of stimulants, with particular focus on Adderall. I, myself, have been asked to address this issue for both video and written media. Telepsychiatry has been "blamed" by some entities for the shortage with the implied message being that telepsychiatry clinicians are more likely to inappropriately prescribe stimulant medications for adults, which is the reason for the increased demand for stimulant prescriptions.

As mentioned, the explanation for increased demand for stimulant prescriptions is not inappropriate prescribing, but rather increased access to care by previously unserved individuals. There is a misconception that in-person appointments somehow prevent the concerning issues such as misdiagnosis or diversion, in which stimulant prescribing would be inappropriate, which in fact, is not true.

The measures used by in-person clinicians to prevent these issues also are available to telepsychiatry clinicians. In addition to increased demand for stimulant prescriptions leading to shortages, there are other reasons for an inadequate supply, including issues with production and supply quotas in pharmacies.

The media focus on the issue of medication shortages could be extremely helpful as it provides opportunities for highly educated and experienced clinicians such as myself to accurately describe the actual process of assessment, diagnosis and treatment of patients seen via telepsychiatry versus office visits.

This includes in both cases one of the required safeguards – reviewing PDMPs to look for any possible indications of misuse of prescribed controlled substances. I have been interviewed a number of times, using different platforms, some of which provide opportunities for lay persons to ask questions. I feel this is important as it provides opportunities not only for policymakers but patients, families, friends and loved ones to receive free and timely education.

I am hopeful there will be more widely available guidelines about prescribing via telepsychiatry that are acceptable to regulatory agencies such as the DEA and FDA so prescribing clinicians can know, in advance, how to avoid sending a prescription that isn't filled.

As mentioned, this is due to multiple reasons, some of which, like production, are not easy to solve. However, at times pharmacies set limits on prescriptions of controlled substances due to uncertainty and wanting to be cautious to avoid any future problems or sanctions.

As lack of timely access to prescribed medications is not an uncommon occurrence, part of this problem could be alleviated if regulatory agencies provide clear guidelines. If this occurs, we as clinicians will follow them to ensure our patients quality and timely care.

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Email him: bsiwicki@himss.org
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