When Covid started demolishing pillars of communal life, many Americans found themselves hovering close to an emotional edge. The demand for mental health treatment spiked sharply, reflecting an increased need from current patients and a new call for services from first time sufferers. In January 2021, 41% of adults reported symptoms of anxiety and/or depressive disorder, a number that has been stable since spring 2020. Early 2020 data showed that drug overdose deaths were particularly pronounced from March–May 2020, coinciding with the start of pandemic-related lockdowns. Access to treatment was, and continues to be, a life or death issue. At the same time, something else was happening: with no magic bullet in sight, Americans started weighing the relative merits of the old versus new. Change had come overnight and in some areas of life, it felt like an improvement.
Residents of states observing federal and state restrictions expressed satisfaction with fewer hours spent working from the office. The Economist cites data showing pre-pandemic Americans spent only 5% of their working time at home. By Spring 2020 the figure was 60% and the transition was going more smoothly than expected.
No profession was more impacted by this shift than psychotherapy. The standard practice has always been for treatment to take place in an office setting, doctor and patient seated across from one another in close proximity, Covid’s restrictions forced therapy out of the office and into the virtual sphere, thrusting the whole field into uncharted territory.
State of emergency laws were passed to accommodate new challenges, and they ushered in a wave of crucial changes, including the suspension of confusing, restrictive state licensing laws that prevented clinicians from treating patients in different states, marking a significant shift in the landscape of medical state licensing requirements. Psychiatrists had been treated like lawyers under the former legislation, permitted to practice only in states where they had passed a regional exam. The regulation makes sense for lawyers, given the variance of state laws, but not for doctors, who treat the same psychiatric symptoms regardless of geography. Clinical depression looks no different in California than it does in New York. With restrictions lifted, access to treatment grew exponentially. Residents of rural areas, historically underserved because of clinician shortages, got care. People sheltering in place out of state did not experience any harmful interruptions to their therapeutic work. Without the increased flexibility, millions of people would have been left to navigate the distress of isolation, economic uncertainty, and grief, all alone.
As a new resident of Pennsylvania, I benefited personally from these adjustments. My treatment was in flux, while looking for a local doctor, I continued working with my long-time psychiatrist, licensed to practice in New York State. The policy overhaul kept me and countless other vulnerable patients from reaching a crisis stage.
With ample time to observe the effects of virtual treatment, the merits of teletherapy, an already vastly successful modality from the perspectives of app enthusiasts, gained mainstream acceptance from clinicians and patients alike. A branch of medicine slow to move towards telehealth flourished and grew. Anyone observing or participating in this phenomenon witnessed a beautiful thing; not only did many more people get treated, studies collecting feedback from patients and doctors showed absolutely no compromise in the quality of care. Patients reported feelings of deeper intimacy towards therapists and additional comforts unique to the modality, like the presence of pets during sessions and an increased openness connected to sharing from relaxed spaces.
With respect to the life-saving impact remote care has had on Americans who struggled before and during Covid, along with the sizable projections for emerging needs from formerly untreated groups, the temporarily relaxed laws need to be made permanent. Legislative action from both federal and state authorities will prevent widespread tragedy. We should all be asking our lawmakers, ‘If not now, when?’.
The American Psychiatric Association put forth an informed and well-organised list of policy suggestions. If implemented, the modifications will eliminate crippling barriers to care going forward. Each proposal concerns one of the four problematic areas of former legislation: reimbursement, HIPPA/privacy standards, licensing, and prescribing power. The continued improvements in treatment outcomes and access to care rely on their passage.
- Extend the telehealth waiver authority under COVID-19 beyond the emergency deceleration to study its impact.
- Remove geographic restrictions for mental health and allowing the patients to be seen in the home.
- The Drug Enforcement Agency should finalize regulations for Ryan Haight Act to allow for the prescribing of controlled substances via telehealth without a prior in-person exam.
- Continue to pay telehealth services on par with in person visits.
- Allow for the use of telephone (audio) only communications for evaluation and management and behavioural health services to patients with mental health and substance use disorders when it is in the patient’s best interest, and should be paid at no less than an in person visit.
- Maintain coverage and increased payment for the telephone evaluation and management services.
- Remove frequency limitations for existing telehealth services in inpatient settings and nursing facilities.
- Include all services on the expanded Medicare-approved telehealth list including group psychotherapy.
- Allow teaching physicians to provide direct supervision of medical residents remotely through telehealth.
There is no middle ground when it comes to reimagining the framework denying the necessity of easily accessible care for a traumatised country. Failure to act will leave us all vulnerable.
Elsie Ramsey was born in California and moved all around the country growing up. She runs the website, What’s Your Story?
