A Virtual Psychiatry Update

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The COVID-19 pandemic officially ended a couple of years ago and, since then, virtual psychiatric treatment has remained a widespread treatment modality in outpatient psychiatric practice. I have previously discussed why telepsychiatry is so attractive to patients and psychiatrists, and I will not repeat the reasons here.^1,2 Telemedicine in general is also now widely practiced—for follow-up internal medicine appointments, follow-up surgical appointments, routine annual evaluations of sleep apnea patients, etc.

Telepsychiatry occupies a special place within telemedicine, and as such, it demands special attention and consideration. This is because psychiatry deals directly with the psyche of the patient, in addition to the soma, making the psychiatric encounter particularly complex. Each visit entails a careful mental status assessment as well as an evaluation of the signs and symptoms of illness that brought the patient to treatment.

Psychiatric encounters require a trusting relationship in a setting of psychological intimacy that is not necessarily present to the same degree in other branches of medicine. The psychiatrist must also attempt to assess the validity of the information provided by the patient. To accomplish these goals, telehealth visits must come as close as possible to in-person appointments.

In this article, I will offer suggestions on how to optimize virtual psychiatric appointments so that they most closely approximate in person visits. These are not a set of rules or guidelines but instead ways that I have found helpful in my virtual psychiatric practice.

Equipment to Optimize Telehealth Visits

As we know, telehealth psychiatric appointments take place over the internet using a laptop or desktop computer, tablet, or cellphone, or via telephone without a visual component. I have psychoanalytic colleagues who prefer meeting with their patients by phone without patient and psychiatrist seeing one another on a screen. In my opinion, this is because, for most of their careers, these analysts sat behind their patients lying down on a couch, and almost exclusively—although not entirely—attended primarily to the sound of their patients voices. They now attempt to recreate this situation in the present. Phone therapy may also be most comfortable for patients with shame-based psychopathology who do not want to be viewed.

Adequate Wi-Fi connection is necessary for proper telepsychiatry. Virtual treatment works best when both clinicians and therapists have purchased the fastest Wi-Fi speed possible. Wi-Fi speed can be quickly evaluated free of charge by doing an internet speed test.

Virtual treatment will also be enhanced by adding a pair of relatively inexpensive high-end speakers, a stand-alone microphone, and a camera that can be placed in front and in the middle of the computer screen. These devices plug into the USB ports of the laptop or desktop computer. The combined cost of all of these devices is a few hundred dollars, but the improvement in the audio and visual quality is remarkable. It is also important to have adequate lighting in front of, and not behind, the psychiatrist.

The psychiatrist should always work from a quiet, confidential space and dress professionally for every visit. Although patients will meet with us from a variety of locations and settings, ideally they will be in a space where others cannot overhear the verbal exchange during the session and will not be visually distracting. Dogs and cats often stroll across patient screens. I refuse requests from patients to meet with them while they are driving, letting them know that if they were to have an accident, I would feel guilty about having been a contributing factor. One patient discontinued treatment with his psychotherapist who scheduled appointments when the therapist was driving in her car. The patient thought he should have been charged half price since the therapist was only half paying attention to him, echoing the importance of patient perception during telepsychiatry visits.

Improving Compliance and Making Telehealth Similar to In Person Visits

Soon after I began meeting with my patients virtually, I decided to notify each patient by email of their appointment earlier in the day. Since there are fewer cues to keep track of appointment times virtually than with in person appointments, I wanted to decrease the likelihood of no-shows. I compose these emails the night before and schedule them for delivery the next morning. I generally write something like this:

“I will be emailing you a Zoom link at 1 PM today. Best regards, Dr Perman.”

Some of my colleagues might say that this infantilizes my adult patients, but I believe that benefits outweigh potential disadvantages. Patients can never say that they were not notified of their appointment and patient compliance approaches 100%.

I email Zoom links to my patients about 10 minutes before the session and place them in a virtual “waiting room.” After they let me know that they have “arrived” at their appointment, I allow them to enter the session. For patients who are late, I disable the waiting room so that we can begin the session immediately when they arrive. This is equivalent to opening the door between the waiting room and the consultation room when a patient arrives late for an in-person appointment. All that a patient does in a virtual appointment (eg, arrive early, late, etc) can be grist for the therapeutic mill just as with in person treatment.

I attend to nonverbal behavior and body language during virtual, just as I would with in person, appointments. This includes paying attention to the setting in which the patient chooses to meet us, the patient’s attire and level of hygiene, the patient’s body and hand movements during the session, and especially patient affect. If we see the patient’s sclera glistening (suggesting eyes tearing up), a ruddier complexion than usual (suggesting recent alcohol intake), or a hand to the forehead (indicative of a headache), these observations should be shared with the patient making the most general inference possible, eg, “you seem to be experiencing sadness right now,” giving the patient the greatest latitude to respond.

It is also our task to let the patient know when the session is over, eg, “it is time to stop for now” and often confirm the next appointment. I increasingly send electronic prescriptions during the session itself, especially when the patient brings up the need for a refill. On one hand, the patient may be annoyed that I am taking up “their time” to fill the prescription, but on the other hand, they will also be pleased that this is being taken care of immediately so they will not have to worry about this task being forgotten. It saves the clinician administrative time, and it keeps all of the action within the boundaries of the treatment.

Sending Invoices and Getting Paid

I email an invoice to each of my patients at the end of the month and I expect payment in full by the 15th of the following month. This was my own analyst’s policy decades ago and I adopted the practice for myself. It “spreads out the pain” twice a month and allows for this aspect of treatment to be discussed twice each month. My preferred method of payment is through Zelle (that is free to me and to my patient), although some patients prefer PayPal (that includes a fee), and a few patients mail me a paper check. Many psychiatrists, of course, accept credit card payments.

About half my patients pay me soon after receiving their invoices, whereas others routinely send their payment exactly on the 15th of the month. For the rest of my patients, I send an email reminder on the 12th or 13th of the month letting them know that: “Payment is due by the 15th of the month and will be appreciated by that date.” My collection rate approaches 100% each month. I do not tolerate late payments because I cannot listen to my patients as well if I am silently angry with them about not having paid their bill on time. It also burdens the patient with the guilt of owing money. This is probably an anathema to the classic analytic model of analyzing patient’s passive aggressive behavior, rather than telling them that you want to be paid on time. I remember my analyst’s comment when I said that I was “thinking of paying late” one time. He replied: “That was not our agreement.” Given my superego and the transference, this was more than enough for me to disabuse myself of the idea of paying him late.

Concluding Thoughts

Virtual psychiatry continues to be in widespread practice since the end of the COVID-19 pandemic. Steps can be taken and procedures put in place to make the virtual treatment experience closely approximate in person treatment. Research studies have shown virtual treatment, on balance, to be as or more effective than in person psychiatric treatment.³ I predict that in person psychiatric treatment will become increasingly less frequent, to the point of becoming an antiquated treatment modality, over the next several decades.

Dr Perman is clinical professor in the Department of Psychiatry and the Behavioral Sciences at the George Washington University Medical Center in Washington, DC, and a clinical professor in the Department of Psychiatry at Creighton University Medical School in Omaha, Nebraska.

References

1. Perman GP. Virtual psychiatry is here to stay. Psychiatric Times. August 22, 2022. https://www.psychiatrictimes.com/view/virtual-psychiatry-is-here-to-stay  

2. Perman GP. Psychodynamic telepsychiatry after the pandemic. Psychiatric Times. September 13, 2023. https://www.psychiatrictimes.com/view/psychodynamic-telepsychiatry-after-the-pandemic

3. Hyler SE, Gangure DP, Batchelder ST. Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. CNS Spectr. 2005;10(5):403-413.