Daniel D. Storch, MD

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

The COVID-19 pandemic has brought to the fore inequalities in health care.¹ In a letter recently published in the American Journal of Psychiatry, Nadkarni et al² addressed the reality that there is not equal access to quality care (in this case, telepsychiatry). They reported challenges in converting their psychiatry ambulatory care center to a virtual platform at Brigham and Women’s Hospital, which is affiliated with Harvard Medical School.

Previously, I had reported in Current Psychiatry that patients at our small community mental health clinic outside Baltimore have much less audiovisual capability (they were able to receive telepsychiatry services via phone only, and not via video conferencing on a computer, smartphone, or tablet).³ Of 100 consecutive patients, we used telepsychiatry for 82 (18 were seen in person, including 14 who were seen for administration of long-acting injectable medications). Of the 82 patients receiving telepsychiatry from our facility, only 9 had video conferencing sessions (10.9%).

I repeated the survey approximately 3 months later. Preliminary data of these 125 total patients showed a slightly higher percentage (12.6%) had video conferencing sessions.

Factors associated with limited access to technology

Similar to what was reported by Nadkarni et al,² in our extremely vulnerable population, socioeconomic factors affect access. Our patients are low income, and often do not own computers or smart phones. Nearly all our patients receive medical assistance and/or Medicare. Our patients are more likely to be members of a racial minority group—4 times the national average. Our patients are older.⁴ Patient age varies from 16 to 83 years; the mean age is 54, and the median age is 56. Educational level is low. Nearly all of our patients who participate in video conferencing sessions are female. Approximately 15 of our patients have comorbid intellectual and developmental disabilities diagnoses, and at least that many have subsyndromal symptoms. Constantino et al⁵ commented on the multiple negative consequences of the COVID-19 pandemic on individuals with intellectual and developmental disabilities, including “frank disparities in access” to technology as well as gaps left by relying exclusively on telehealth.

Among our patients, being low income, a member of a racial minority group, older, less educated, male, and developmentally and/or intellectually disabled are risk factors for less access to video conferencing.³ Nadkarni et al² also noted less broadband access for rural residents and less access and lack of digital health literacy in patients with limited English proficiency.

As Nadkarni et al² suggested, we did contact our legislators, and emergency rules are continuing. For now, we are managing fiscally. Although that certainly is important, it does not address the issue of inequality.

Continue to: With this information...

With this information, we are strongly encouraging our patients to participate in video conferencing sessions. We suspect that for some patients, the possibility of them participating in video conferencing sessions is greater than they have acknowledged. We are stepping up education and support, both informally through the patient’s family and friends, and more formally through case managers who “lend” patients a device during home visits.

In summary, this inequality in access to the technology needed for telepsychiatry will loom even more prominently as we all move forward, both clinically and in policymaking.

I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.

1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.

The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.

2. Female patients fared better in their treatment than males.

3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.

4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.

5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.

Continue to: Support

6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.

My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.

Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.

1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.

The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.

2. Female patients fared better in their treatment than males.

3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.

4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.

5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.

Continue to: Support

6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.

My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.

Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I am a psychiatrist at a community mental health center located close to a large city. I want to report on our experience treating 100 consecutive, non-duplicative patients during the coronavirus disease 2019 (COVID-19) pandemic. Most of these patients had medical assistance or Medicare. Fifty-one were white, 46 were black, and 3 were Asian; 50 were men, and their ages ranged from 16 to 83 (mean: 54; median: 56). Using each patient as his/her own control (pre- and post–COVID-19), here I report 6 observations I made while treating these patients.

1. Telehealth worked for most patients. Of the 100 patients, 18 were seen in-person. Of the 18 seen in person, 14 received long-acting IM injections, and 2 patients presented with urgent matters that I felt required in-person evaluations. One patient needed to fill out several forms and provide consents, and 1 patient with chronic illness was treated at the clinic because he mistakenly arrived in person for his appointment.

The remaining 82 patients had telehealth sessions. Only 9 patients said they were able to use video conferencing, so the remaining 73 patients were treated by phone. These patients were mostly poor and/or older and had no access to smartphones or computers. This is especially important because the current emergency telehealth rules allow phone-only sessions, while regular telehealth rules do not. Our clinic strongly advocates for the extension of emergency telehealth rules. I have e-mailed many elected officials about this, but I have received few replies and no substantive responses. Our clinic also needs to help our patients obtain increased audiovisual capabilities.

2. Female patients fared better in their treatment than males.

3. Older patients did better than younger patients. Older patients’ experiences of living through past crises were helpful because they were able to compare how they persevered in the past with the current pandemic.

4. White patients showed more improvements compared with black patients. White patients generally had greater access to resources and support.

5. Patients with psychotic diagnoses/symptoms improved more than those with neurotic/anxiety/depressive diagnoses or symptoms. Most of our patients with psychotic diagnoses were already in a supportive, structured living environment, so the new “COVID-19 world” may be less disruptive for them. Additionally, it was more difficult for our patients to get substances of abuse because they had less mobility and access during the pandemic.

Continue to: Support

6. Support, especially from family but also institutional support, trumped other factors. The more support and structure our patients had, the better they did.

My observations may not be generalizable because I am reporting on a relatively small population size, most patients were older, and most were established patients who were likely more stable. I plan to follow up with these patients to see how the new COVID-19 world continues to affect them, and us.

Daniel D. Storch, MD
Key Point Health Services
Catonsville, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.