By Linda Beattie
The COVID-19 pandemic has created a tsunami of problems across the United States, affecting the public’s mental health in addition to the numerous physical casualties. Fears of the disease, grief for those lost, social separation and economic hardships have created new cases of anxiety and depression, while exacerbating existing mental illnesses.
A new poll by the American Psychiatric Association (APA), conducted March 26 to April 5, 2021 among a sample of 1,000 adults, found that:
• 41% are more anxious than last year when the pandemic began
• 43% said the pandemic has had a serious impact on their mental health (up from 37% in September 2020)
• 53% of parents are concerned about the mental state of their children
• 48% of parents reported the pandemic has caused mental health problems for one or more of their children, with 26% seeking professional help
During this same period when Americans have developed a greater need for mental health services, psychiatrists have had to make drastic cuts to in-person visits and dive into telepsychiatry.
“There is a huge global shortage of behavioral health physicians, and the market is unfortunately dictating a greater need. Then with the pandemic shutting down some services, we saw a major transition to telehealth platforms,” said Gabriel Bishop, director of recruiting for the diversified specialties group at Merritt Hawkins.
What is telepsychiatry?
The APA defines telepsychiatry as a subset of telemedicine, which is “the process of providing health care from a distance through technology, often using videoconferencing.” They add that telepsychiatry “can involve providing a range of services including psychiatric evaluations, therapy (individual therapy, group therapy, family therapy), patient education and medication management.”
While telepsychiatry usually involves direct psychiatrist and patient interaction, it may also include psychiatrists supporting primary care providers through professional consultations. It can be delivered via live, interactive communication or involve recorded information.
Rumbles of change before COVID
“In the three or four years before COVID hit, psychiatrists had been asking about telepsychiatry,” said Mike Belkin, divisional vice president for Merritt Hawkins. “They were interested in doing virtual visits, asking about working from home, but the market was very slow to respond. Some clients agreed to allow some of these visits, but most did not. They were worried that patient care would be sacrificed. Reimbursement was also an issue.”
“Some areas that found recruitment challenging decided to try it,” he continued. “We had some clients that were starting to incorporate one to two days of telepsychiatry visits to help attract those candidates who wanted greater flexibility.”
“Now with the pandemic creating the need for so many virtual visits, candidates are seeing that they can serve the patient population digitally, but many clients are still slow to engage.”
The overall demand for psychiatrists has increased during the pandemic, noted Belkin. “We are receiving a number of requests for psychiatrists, which reflects the reports of more behavioral health issues during this crisis. The needs have spanned adult as well as child and adolescent psychiatry.”
“But the hospitals and practices requesting child and adolescent practitioners are generally not looking for telepsychiatry; they are seeking psychiatrists who are willing to move,” he added. “And the nation’s limited supply of child and adolescent psychiatrists makes these candidate searches even more challenging.”
The current state of uncertainty
“So many physicians would love a telepsychiatry position, but clients continue to worry about patient care, loss of continuity, reimbursements, etc,” said Belkin.
“With the current state of emergency, televisits are reimbursed for now, but we’re not sure what is going to happen in the long run. There has been a lot of lobbying to extend those or make them permanent. But healthcare clients still have their doubts,” he explained, adding that their hesitancy may also relate to questions of liability if an adverse outcome occurs following a televisit.
“Yet those working in the field are telling us that, in terms of patient care, it doesn’t seem that patients have less care or worse outcomes. Our mental health providers report their level of service is just as good,” he said.
Healthcare employers that have tried telepsychiatry have also enjoyed some success, Belkin noted, including one of the firm’s clients in Wisconsin that was having trouble filling a permanent position. Once they opened it up to telepsychiatry, it took just 45 days to secure a qualified psychiatrist. Both client and physician have become fans of the arrangement ever since.
Questions of access to mental health services
Belkin noted that the convenience of virtual visits and avoiding crowded waiting rooms has been attractive for many patients.
“One caveat to the telemedicine trend, however, is that some don’t have good internet connection, or it fades in and out, which can be a problem,” he said.
While telepsychiatry can create greater access for some clients living in remote areas, public health experts have voiced concerns about inequities that may leave some unable to receive care in a virtual environment.
“A lot of organizations are trying to meet the needs of psychiatrists and their clients, but patients may not have the technology resources to be able to see these professionals remotely because they don’t have a smartphone or laptop or reliable internet,” said Bishop.
Limitations of telepsychiatry
Despite their attraction for psychiatrists, Bishop explained that there are some limitations to telepsychiatry visits.
“Body language is very important to be able to see when visiting with a patient, and a psychiatrist or psychologist can’t necessarily see that during telehealth visit; they may not see what the person is doing with hands, feet, etc.,” she said.
Some mental health conditions are also less conducive to teletherapy.
“If you are treating depression or anxiety that needs to be addressed, a telehealth visit can work. But if a patient has schizophrenia, or other more acute cases or comorbidities, those may need to be seen in person,” said Bishop.
Even the same patient may need different support at different times, she explained. “A lot of it may be medication management, so that one-month checkup online may make sense. You can easily do that virtually.”
Another thing candidates might need to consider is the compensation rate for telepsychiatry.
“Some clients are open to offering full-time, remote positions but the compensation is going to be less,” said Bishop. “Telehealth may not be as high paying.”
Psychiatry recruiting impacted by virtual practice and workforce shortages
“Behavioral health clinicians have decided that they can practice virtually from home, making it more difficult to have people consider a traditional, onsite job,” reported Bishop. “Going forward, I think more organizations need to be open to having some flexibility in their work schedules, like three days on site and two days working remotely–some kind of nontraditional schedule.”
“I can’t think of one candidate who has had a negative experience practicing in the virtual environment; most would prefer to work from home, or not have to relocate,” Belkin added. “There are so many opportunities for behavioral health jobs, but not everyone wants to move.”
“We need to figure out a solution in psychiatry, as the workforce demographics aren’t promising. More than 80 percent of psychiatrists are over the age of 45, and 60 percent are 55 or older,” he continued. “Psychiatrists do practice longer than their medical colleagues, and their average retirement age is older since they don’t usually encounter physical limitations. But supply issues are still a challenge.”
A limited capacity to train new practitioners is part of the issue, according to Belkin, who noted that there are less than 2,000 psychiatry residency slots each year. Without a robust pipeline of new physicians, the workforce shortage is expected to become an even larger crisis.
Telemedicine and the future of psychiatry jobs
“We expect the demand for psychiatrists will continue to climb,” said Bishop. “There could be a trickle effect for years to come from the pandemic, due to people who experienced traumatic losses, extended seclusion, situational depression or social anxiety. It could take years before we know how it affected younger kids especially.”
Virtual visits are also expected to remain popular, though the percentage of mental health services provided remotely vs. in-person will vary depending on location, compensation and other factors.
“The availability of reimbursement funding will have a huge impact on whether an organization will start offering telepsychiatry as an ongoing piece of their business,” said Belkin.
“If candidates are patient, we believe there will be more dedicated telepsychiatry positions down the line,” he concluded.