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  • The Carlat Psychiatry Report
  • Telepsychiatry (October)
  • Telepsychiatry: What You Need to Know

Telepsychiatry: What You Need to Know

The Carlat Psychiatry Report, Volume 13, Number 10, October 2015
https://www.thecarlatreport.com/newsletter-issue/tcprv13n10/

From The Carlat Psychiatry Report, October 2015, Telepsychiatry

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Free Articles | Practice Tools and Tips

Print Friendly, PDF & Email

Daniel Carlat, MD

Editor-in-Chief, Publisher, The Carlat Report.

Dr. Carlat has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.

The Carlat Psychiatry Report last covered telepsychiatry back in 2010. At that point, it seemed like a cool technology that some of you might want to use. Since then, telemedicine in general has taken off, with an estimated 67% of physicians using or planning to use telehealth in their practices.

The appeal of telemedicine is clear, especially for psychiatrists. We are in great demand, and there aren’t enough of us to meet the demand—especially in rural counties. Since our diagnosis and treatment usually don’t require physical contact, we should be able to be quite effective via telepsychiatry. And patients are increasingly realizing that telehealth can save them the expense and time of schlepping to and from appointments.

A recent study quantified the amount of time and money our patients waste by having to show up to appointments. Using surveys from the Bureau of Labor Statistics, the researchers found that the average amount of time patients spend per visit was 121 minutes (37 minutes in travel time and 84 minutes in clinic time—including both waiting for the doctor and time spent there). Using average wage estimates, this equated to an “opportunity” cost of $43/visit (Ray KN et al, Am J Manag Care 2015;21(8):567–574).

So, the reasons to embrace telemedicine continue to mount, and luckily the technology has improved since our last article.

Does telepsychiatry work as well as face to face?
Before getting into the details of how to set up a telepsychiatry-capable practice, let’s look at the crucial issue of whether telepsychiatry even works. We now have several studies endorsing its efficacy.

The most recent study randomly assigned 223 children with ADHD to 2 treatment groups. In the telepsychiatry group, children received 6 psychopharm visits by child psychiatrists delivered by videoconferencing. In the usual care control group, the children were treated in person by their PCPs who received telepsychiatry consultations. The kids in the telepsychiatry group did the best, significantly outperforming the PCP-treated group on all measures of ADHD (Myers K et al, J Am Acad Child Adolesc Psychiatry 2015;54(4):263–274).

Among adults, one study of depression randomly assigned 167 Hispanic patients to either webcam treatment (6 monthly video sessions) or treatment as usual at a community health center. Webcam patients were more satisfied with their treatment and had a more rapid decrease in depression severity than TAU patients (Chong J and Moreno F, J E Health 2012;18(4):297–304).
Another study, which randomly assigned 126 women with PTSD to a trial of cognitive processing therapy either in person or via videoconferencing, found comparable outcomes in both groups (Morland LA et al, Depress Anxiety 2015 Aug 3 doi: 10.1002/da.22397).

Who pays?
Will insurance companies reimburse you for these visits? The answer is that it depends on the insurance. Medicaid is the most liberal, with 47 states allowing some reimbursement for telepsychiatry visits (see the website www.securetelehealth.com/index.php for great up-to-date information on various aspects of telepsychiatry, including insurance coverage). Medicare will reimburse for services if you are located in a designated underserved area of the country. In regard to private insurance, at least 30 states have passed laws requiring private insurers to reimburse telehealth to some extent. You’ll have to contact your patient’s insurance company to find out their policy.

Table - Electronic Patient Communication: How to Keep It Private
Table – Electronic Patient Communication: How to Keep It Private
Click to view full-size PDF.

A step-by-step guide
1. Decide on your technology. Here you have two major choices: free and debatably HIPAA compatible vs. not free and pretty clearly HIPAA compatible. The major free services are Skype, Google Hangouts, and Apple’s FaceTime. In our article on HIPAA, we argue that the big three are “compatible enough” and that their convenience advantages outweigh the miniscule risks of a data breach. There are several other free or nearly free videoconferencing options now on the market that advertise themselves as being HIPAA compatible. We did some test runs of them (for more info, see our table, “Electronic Patient Communication: How to Keep It Private”).

Some of you may want to be more cautious, in which case there are many pay options out there. While we didn’t do a comprehensive survey, it appears that you can sign up for a HIPAA-compatible telepsych system for between $30–$300/month. This won’t break the bank, and they may have some advantages over Skype et al. The video quality will probably be better. Depending on the price, there will be added features, such as virtual waiting rooms, mobile access, automatic patient billing, and e-prescribing. Some reputable companies include Cloudvisit Telemedicine, evisit, Secure Telehealth.com, and Thera-link.com—listed in alphabetical order and with no implied endorsement.

By the way, if you were to do a Web search on telepsychiatry companies, as we did, you may become confused. Most of the websites listed in the search results are actually staffing companies that sell telepsychiatric services to institutions such as community clinics, nursing homes, or prisons. You have to dig deeper into the sites to figure out whether they actually offer services to private practitioners. There’s a real Wild West feel to this industry, with many companies offering different services, making different HIPAA claims, and presenting bewildering pricing schemes that vary widely for offerings that are apparently equivalent.

2. Call your malpractice carrier. Most malpractice insurance policies will cover you for telepsychiatry, but you should check with your agent to be sure.

3. Check with your state medical board. In general, you must have a medical license in the state where your patient resides. A handful of states with dire shortages of physicians extend a special telemedicine license to out-of-state physicians. Some states require an initial in-person visit before you can practice telemedicine, but those are in the minority. Some state medical boards have very little to say about telemedicine. If that is the case in your area, you can follow the guidelines established by the Federation of State Medical Boards.

4. Inform your patients. Let your patients know that they have the option of seeing you via video visits, and have them read and sign a telepsychiatry consent form. Some examples of these types of forms can be found here or here.

5. Start seeing patients. Give your patients instructions on how to download whatever software you are using. Maintain professional standards as to your appearance (no pajamas!), and like any video encounter, be cognizant of what is in the background, noise level, etc.

For 2013 practice guidelines on video-based tele-mental health services, see this page.

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Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • Race and Mental Health (May)
  • Thyroid and Mental Illness (April)
  • Living With Mental Illness (March)
  • Schizophrenia (February)
  • The Difficult Patient (January)

2021

  • Bipolar Disorder (November/December)
  • Mood Disorders (October)
  • Overdiagnosis (September)
  • Therapy (August)
  • Depression (June/July)
  • Problems with Generics (May)
  • Metabolism and Mental Health (April)
  • Stopping Psych Meds Part 2 (March)
  • Stopping Psych Meds Part 1 (February)
  • Mind-Gut Connection (January)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Chris Aiken, MD

Dr. Aiken is the director of the Mood Treatment Center in North Carolina, where he maintains a private practice combining medication and therapy along with evidence-based complementary and alternative treatments. He has worked as a research assistant at the NIMH and a sub-investigator on clinical trials, and conducts research on a shoestring budget out of his private practice.

Full Editorial Information

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