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Telemedicine, or telehealth, is the process of providing health care from a distance through technology, often using videoconferencing. Telepsychiatry, a subset of telemedicine, can involve providing a range of services including psychiatric evaluations, therapy (individual therapy, group therapy, family therapy), patient education and medication management. The intention of telehealth across all types of health care is to provide additional access to care by reducing barriers including needing transportation, child or care, or time off work in order to meet with your doctor.

Telepsychiatry can involve direct interaction between a psychiatrist and the patient. It also encompasses psychiatrists supporting other clinicians, including primary care providers, with mental health care consultation and expertise. Mental health care can be delivered through live, interactive communication, including video or audio-only care. It can also involve recording medical information (such as images and videos) and sending this securely to a psychaitrist or other clinician.

More and more people are turning to mobile health technologies (mHealth) for aspects of their care. This can include smartphone apps, smart watches, and other sensor technologies. Mobile health technologies can offer additional opportunities for assessment and treatment in coordination with a psychiatrist.

Video- and audio-based telepsychiatry helps meet patients’ needs for convenient, affordable and accessible mental health services. It can benefit patients in a number of ways, such as:

• Improve access to mental health specialty care that might not otherwise be available (such as pediatric care or care in rural areas).
• Bring care to the patient’s location.
• Help integrate behavioral health care and primary care, leading to better outcomes.
• Reduce the need for trips to the emergency room.
• Reduce delays in care.
• Improve continuity of care and follow-up.
• Reduce the need for time off work, child and family care services, etc. to access appointments far away.
• Reduce potential transportation barriers, such as lack of transportation or the need for long drives.
• Reduce the barrier of stigma in accessing mental health care.
• Enhance feelings of safety, security and priavcy for many.

While some people may be reluctant or feel awkward talking to a person on a screen, experience shows most people are comfortable with it. Some people may be more relaxed and willing to open up from the comfort of their home or a convenient local facility. With the expansion of telepsychiatry over the course of the COVID-19 public health emergency, opportunities to use hybrid treatment options (combinations of telepsychiatry and in-person care) are on the rise.

Telepsychiatry allows psychiatrists to treat more patients in distant locations. Psychiatrists and other clinicians need to be licensed in the state(s) where the patient they are working with is located. State licensing boards and legislatures view the location of the patient as the place where “the practice of medicine” occurs.

Evidence for Effectiveness

There is substantial evidence of the effectiveness of telepsychiatry and research has found satisfaction to be high among patients, psychiatrists and other professionals. Telepsychiatry is equivalent to in-person care in diagnostic accuracy, treatment effectiveness, quality of care and patient satisfaction. Patient privacy and confidentiality are equivalent to in-person care.

Research has also found that overall experiences among all age groups have been good. There are even people for which telepsychiatry may be preferable to in-person care, for example people with autism or severe anxiety disorders and patients with physical limitations may find the remote treatment particularly useful.

Telepsychiatry has been found especially effective with respect to the treatment of PTSD, depression, and ADHD. See more on the evidence base for telepsychiatry.

Telepsychiatry is used in a variety of different settings, including patients' homes, private practice, outpatient clinics, hospitals, correctional facilities, schools, nursing homes, and military treatment facilities.

Patients can schedule appointments individually with a psychiatrist or therapist for a live video appointment. Patients should plan ahead and prepare just as for an in-person appointment. Have any relevant records and information, including prescriptions, and have a list of questions to address.

Telepsychiatry is helping bring more timely psychiatric care to emergency rooms. An estimated one in eight emergency room visits involves a mental health and/or substance use condition, according to the Agency for Healthcare Research and Quality. Many emergency rooms do not have psychiatrists on-site to support people with serious mental health issues in person, and the ability to access psychiatric care through technology enhances the ability for emergency departments to provide appropriate care and treatment to these individuals.

Telepsychiatry is being used in nursing homes to provide both ongoing and emergency psychiatric evaluation and care. Many states use telepsychiatry in correctional facilities where people that are incarcerated require ongoing mental health care. In all of these examples, telepsychiatry can be helpful alongside or instead of in-person care to make sure that people who need it have access to high-quality care.

Currently, 43 states and the District of Columbia have laws that govern private payer reimbursement for telehealth (The Public Health Institute/The Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policy Spring 2020 Report (.pdf) Federation of State Medical Boards). More recently, states have been adding payment parity for telehealth services, but creating carveouts for certain specialties, including mental health in a limited number.

Fifty states and Washington, D.C. reimburse for some form of live video telehealth in Medicaid fee-for-service. Comparatively, only 16 state Medicaid programs reimburse for store-and-forward services (“asynchronous telemedicine”).

That said, state Medicaid policies, rules, and laws are continuing to evolve. Medicare policy has evolved throughout the COVID-19 public health emergency. Medicare will reimburse for the following permanent changes in telepsychiatry services: Federally Qualified Health Centers and Rural Health Clinics can serve as a distant site provider for behavioral and mental telehealth services; Medicare patients can receive telehealth services for behavioral/mental health care in their home; there are no geographic restrictions for originating sites for behavioral/mental telehealth services; and telemental health services can be delivered using audio-only communication platforms.

• Asynchronous or "Store and Forward"
  Capture and then transfer of data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.
• Distant Site
  Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system. eHealth: Health care practice supported by electronic processes and communication.
• Electronic Health Record (EHR)
  A systematic collection of electronic health information about individual patients or populations that is recorded in digital format and capable of being shared across health care settings via information networks or exchanges. EHRs generally include patient demographics, medical history, medication, allergies, immunization status, laboratory test results, radiology and other medical images, vital signs, characteristics such as age and weight, and billing information.
• e-Prescribing
  The electronic generation, transmission and filling of medical prescriptions, as opposed to traditional paper and faxed prescriptions. E-prescribing allows qualified health care personnel to send new prescriptions or renewals to community or mail-order pharmacies.
• HIPAA
  Acronym for Health Information Portability and Accountability Act. HIPAA protects the privacy of individually identifiable health information, sets national standards for the security of electronic protected health information, and protects identifiable information being used to analyze patient safety events and improve patient safety. More about HIPAA.
• mHealth
  Generally asynchronous mobile technologies, including smartphone apps, text messaging, email, and online forums. The goals of mHealth are to improve health outcomes through convenient, patient-driven access to mental health support and self-management tools.
• Originating Site
  Location of the patient at the time the service is provided via a telecommunications system.
• Synchronous
  Interactive video connections that transmit information in both directions during the same time period.
• Teleconferencing
  Interactive electronic communication (voice, video, and/or data transmission) between multiple users at two or more sites.
• Teleconsultation
  Consultation between a provider and specialist located at a distance using either store and forward telemedicine or real time videoconferencing.
• Telehealth and Telemedicine
  Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote health care that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs and nursing call centers are all considered part of telemedicine and telehealth. Telemedicine is not a separate medical specialty. Telemedicine encompasses different types of programs and services provided for the patient.
• Videoconferencing
  Real-time transmission of digital video images between multiple locations.

(Glossary sources: American Telemedicine Association, Centers for Medicare and Medicaid Services – Telemedicine, National Center for Telehealth and Technology)

Physician Review

Shabana Khan, M.D.
Chair, APA Committee on Telepsychiatry

April 2023

  References