By Melba Newsome
Maudeb Maybin suffers from PTSD and uses a wheelchair because of cerebral palsy. Part of his overall maintenance plan includes seeing a therapist to help him cope with his depression issues. But just traveling to and from his appointment can take hours.
“It was a huge coordination effort to go anywhere, whether that was therapy or a doctor’s appointment,” says the 24-year-old. “It was doable, but a lot of the time I would end up being stuck there for hours after my appointment, waiting for transportation.”
The coronavirus pandemic has changed all that.
“Once the whole stay-at-home order thing took hold, they said, ‘Let’s see if this works’ and that’s how we ended up here,” he said.
“Here” is a regimen that has Maybin seeing his therapist online once a week.
A wide spectrum of behavioral health conditions is likely to worsen as North Carolinians struggle to cope with the psychological challenges generated by the pandemic, posing a danger especially for people like Maybin who were already in a vulnerable place before the pandemic.
In March, the Federal Disaster Distress Hotline fielded eight times the usual number of calls and text messages from those in need of help. A poll conducted in April by the Kaiser Family Foundation found that 45 percent of respondents said their mental health has been negatively impacted due to worry and stress over the virus.
But the onslaught of COVID-19 has also brought some changes that could help people like Maybin, namely easier access to behavioral health care via telepsychiatry.
Crisis changes the delivery model
Telepsychiatry or teletherapy offers an affordable, simple way to provide on-demand mental health support to individuals with a range of needs. Because it allows patients and therapists to connect from anywhere, it can make receiving counseling more convenient for patients and greatly reduce the number of no-shows for clinicians.
Virtual behavioral health care has been the last bastion of resistance in telehealth, in large part because both private and government insurance have routinely declined to cover these sessions. But the pandemic has forced a sea change for mental health providers around the state, as both federal regulators have loosened regulations and purse strings, and private insurers have done the same.
For years, proponents of telehealth have pushed for more remote access to services, but COVID-19 accomplished in weeks what they had been urging for years. Following stay-at-home orders, the promise of virtual behavioral therapy became a reality.
“[Telepsychiatry] is so accessible and mental health and telepsychiatry in particular is very well suited and our ability to increase access and reach people I think is amazing right now,” said Meltzer-Brody, who leads the Department of Psychiatry at the UNC School of Medicine.
The Mountain Area Health Education Center in Asheville was already gearing up to take its Center for Psychiatry and Mental Wellness practice into cyberspace when the stay-at-home orders hit.
“Toward the end of March, the show rates and our booking rate dipped by almost 70 percent because of COVID. People were afraid to go into the clinics and clinicians were guiding people away from the clinics to limit exposure,” says Shane Lunsford, administrative director of the Department of Psychiatry. “MAHEC went from having about 100 behavioral health televisits a month to 200 a day.”
The lockdown also spurred Winston-Salem-based Novant Health to move much faster to implement teletherapy visits.
“We were trying to avoid having patients in the office and we needed to convert to video visits as soon as possible,” explains Maripat Moore, lead clinician at the system’s psychiatric medicine site in Kernersville.
Novant did a trial run over the weekend of March 15. Three days later, Moore was seeing patients online from home and two days later, her entire schedule was converted to video visits.
“The majority of patients were very hesitant at first but there was a lot of fear about just leaving your home,” she said. “They were actually happy that they could stay home and still be seen.”
Some adjustment needed
Providing behavioral health care through telepsychiatry is pretty straightforward. Clinicians give patients session guidelines upfront and instructions how to access the secure, video conferencing platform. When appointment time arrives, clients log on and start talking.
A year ago, Andrea Mikels of Charlotte started blogging about her mental health struggles and returned to therapy in February after a five year absence. She and the therapist clicked right away and she was making good progress addressing her anxiety and depression.
Then the pandemic hit and the in-person visits came to a screeching halt. A ruptured disc had relegated her to the house for weeks but speaking freely about her issues with her husband and three children constantly underfoot didn’t seem like a workable solution.
“I really didn’t want to do it,” says Mikels. “How would I find privacy? I feared being overheard and I just wasn’t comfortable.”
She ultimately worked out a plan where her husband scheduled his calls around her therapy time to make sure her sessions weren’t interrupted.
Valerie Krall, who leads behavioral medicine at MAHEC, notes that because therapists are also working from home, this new format requires adjustments for them, as well.
“Sometimes it feels like you’re doing air traffic control,” says Krall. “You need to make sure you’re in a room that’s private, where people aren’t coming in and out and others can’t hear the content of the session.”
Krall says this might require purchasing a sound machine so the patient’s voice isn’t projecting through the house.
Technical issues can also be a problem. Some patients struggle to log on and navigate the technology, while others are frustrated by poor or dropped calls or connections. For example, some places in mountainous Jackson County don’t have broadband, internet or cellular service in their homes.
“We’ve tried a few pilot programs like giving people devices to make the calls but that doesn’t work when there’s no cellular reception at all,” says Lunsford.
Julie Liles, Novant’s psychiatry regional manager, says patient reaction has been overwhelmingly positive so far.
“We’ve had 901 surveys for patients after their video visits, and 86.15 percent scored their visit an eight in the zero to 10 category,” she said. “Considering that everybody had a lot of technical difficulty at first and some moments of being comfortable, that’s a pretty remarkably positive response.”
After the pandemic
Teletherapy sessions risk being completely phased out as MAHEC and Novant begin returning some patients to in-person visits in the coming weeks.
For more than a decade, telehealth services have been reimbursed by Medicaid and Medicare but most insurance companies have only reimbursed for in-person behavioral health services. It’s a toss-up whether psychologists, psychiatrists and therapists will see reimbursements continue after the pandemic.
Most providers believe some of the emergency changes around telehealth reimbursements that were implemented during COVID will remain but expect insurers to reinstate the prior restrictions on teletherapy.
“I sure hope the genie’s out of the bottle and it will continue to be covered,” Meltzer-Brody said. “I think there’s likely to be an evolution of what is covered and how and when.”
“The American Psychiatric Association and the North Carolina Psychiatric Association have come together to support the continuation of telehealth and telemedicine,” says Moore. “If we can continue to cover this, I really believe that more people will be served.”
Moore says this service is especially important for underserved populations which tend to struggle to make their appointments because they lack transportation, child care and other resources. Most providers are reporting their no-show rates have declined with convenient telehealth services on the uptick.
“We are hoping to see continued legislation for permanent change to the reimbursement of telehealth and to see telehealth parity come to North Carolina,” says Lunsford. “Our elected leaders need to hear from their constituents around this issue to help ensure the changes to reimbursement not only stay but get better.”
Maybin hopes there’s a way he can continue teletherapy. “I’m really grateful for telehealth,” he says. “Just knowing that I always have a line to the people that care for me is a nice thing. It’s also kinda nice being able to go to therapy in your pajamas.”
Conversely, Mikels is eager to return to in-person visits where she feels more relaxed and comfortable sharing.
“I never would have done teletherapy if I didn’t already have a record with [my therapist],” she says.