Could Telehealth be the Answer to Stigma Removal for Behavioral Health?

While Telehealth is a great tool for filling in treatment gaps, it won’t be the only solution

UH Clinical Update | June 2020

Early indications point to “yes" this may very well be the case; however, the consensus is while it's a great offering to have in our toolkit, it's not a replacement for in-person care. And although there may be some sacrifices to quality, it has allowed us to see more patients during this time of need.

Pre-COVID19, the UH Cleveland Medical Center Behavioral Health team saw approximately 4,000 outpatients every month. And from mid-March to mid-April after the team established telehealth to care for its patients, the number increased to over 4,800 and then climbed to nearly 5,600 during the four weeks from mid-April to mid-May. In fact, last week the team hit their highest percentage of new patients at 14 percent.

“While current patients have for the most part overcome any stigma associated with seeking behavioral healthcare, we know barriers may still exist for new patients," explained Jeanne Lackamp, MD, Director, Division of Psychiatry & Medicine at UH Cleveland Medical Center and Director, UH Pain Management Institute. “New patient volume could stem from an increase in stress-induced issues related to lockdown and physical distancing, but it could also be that we have one more option for meeting patients where they are," said Lackamp.

Certainly it appears though that both patients and providers are embracing this technology as UH has also experienced a much lower “no-show" rate using the virtual visits. “Patients and providers alike have been somewhat surprised at how good the quality of the interaction can be and that we are probably less dependent on being 'up close and personal' than we have tended to believe," said Robert Ronis, MD, Chairman, Department of Psychiatry, UHCMC; Co-Director, Behavioral Health Service Line and Psychiatrist-in-Chief, University Hospitals Health System. “We've also noticed fewer concerns coming out of their psychiatric conditions. For example, we used to worry that psychotic patients would be paranoid about who might be watching them on the screen and be unwilling to talk or interact with the video-monitor. In fact, in many cases, it seems that our patients suffering from paranoia are less anxious interacting with the computer than they are with a person in the same room."

Virtual behavioral health enhances access in numerous ways, which can also alleviate concern over seeking care. “Prior to full access to telehealth, patients had to take a large chunk of their day to travel to my office," noted Patrick Runnels, MD, Chief Medical Officer, Population Health for Behavioral Health and Director, Adult Clinical Psychiatry at UH Cleveland Medical Center. “Now, they can go about the rest of their daily business and simply take off the amount of time the appointment itself takes. That flexibility has actually resulted in many of our providers connecting with patients who had previously been difficult to reach." And, as Jennifer Brandstetter, MD, Assistant Professor, Division of Medicine and Psychiatry, UH Cleveland Medical Center, adds “It also takes out a barrier to care with transportation considerations, time of travel, and expense of parking." And in one example, the telehealth option actually facilitated a more preferable treatment protocol for a child with ADHD who also lived in a very remote area explained John Hertzer, MD, Division Chief, Child and Adolescent Psychiatry, UH Cleveland Medical Center. “Due to the distance and child's disruptive behavior in the office, the parents felt it was unattainable to continue with a psychologist and they didn't have a suitable therapist close to home, but the telehealth opportunity allowed them to resume an integral part of child's care."

And for those who do not have access to computers or internet capabilities, UH also provided a telehealth room the patients could access to receive their care.

An unexpected perk of the virtual care environment was gaining a deeper understanding of each other in terms of the patient-provider relationship. “We also find that we can learn a lot about how a patient lives at home based on what we see on the screen," Ronis continued. “I know in some cases patients have literally taken us 'on tour' of their homes, and we have that additional information to incorporate into our thinking. I can imagine not only are we learning things about how our patients live, but patients are learning some things about how we live."

Jeffrey W. Janata, PhD, Director, Division of Psychology, UH Cleveland Medical Center, shared that one UH provider was working with a patient on weight loss and the behavior changes he needed to make in order to successfully lose weight. The patient was using a smart phone for the session and walked into a grocery store, continuing the discussion as he shopped for food. “He was blissfully unaware that as he was talking about modifying his food choices he slowly was filling his cart with exactly the kinds of foods that he was swearing off. The telehealth connection allows the psychologist to address the gap between behavior and intention, between words and action. That inadvertent glimpse into the patient's behavior proved helpful in fostering more rapid behavior change than might have occurred in an office visit."

This isn't to say telehealth doesn't have its issues. Some providers have reported problems with poor connection quality, time spent trouble shooting during appointment and limitations on physical examination. “We are possibly 'missing' important information – being able to see whether someone has a hand tremor while they are talking about other things might be a sign of lithium intoxication, or of a neuromuscular reaction to an antipsychotic or just of anxiety – that is being 'masked' by someone's efforts to appear relaxed and happy," Ronis said. And those concerns are echoed by Janata. “Privacy can be an issue for patients who sometimes have to resort to keeping appointments from their cars, their garages or other remote areas of the house in order to avoid being overheard."

Additionally, not everyone has the same comfort level and access with regards to the technology and the medium leaves some patients feeling more distant and less emotionally supported, which can be difficult for patients engaging in addiction treatment where live group support is very beneficial in helping to prevent relapse. Charles Luther, MD, Medical Director and Chair, Southwest General Medical Center, Department of Psychiatry noted that for patients who live in close quarters with family or peers, it can be difficult for them to attend telehealth visits in private but said “one of the COVID-19 silver linings is that we learned the value and safety of this technology in well-chosen settings." Although he also shared a piece of advice for those considering a visit: “please don't drive and conduct your telehealth visit at the same time! Hang up and reconnect when you are in park or we can find an alternate time. Safety first.”

Telehealth is surely a tool for optimizing engagement in treatment that can fill a lot of treatment gaps, but it will definitely not be the only solution for engaging patients concluded Runnels. “Live visits are still really important when possible because patients in acute distress benefit from in person care and attention, and patients who are unknown can be difficult at times to read. That said - virtual visits as a major modality for conducting visits is here to stay.”