Telepsychiatry Sessions Sufficient for Managing Schizophrenia

NEW ORLEANS — The COVID-19 pandemic spurred healthcare providers to get creative in their shift to telepsychiatry for patients with schizophrenia, a subanalysis of the OASIS study showed.

Across all types of visits — from routine to crisis visits — the percentage conducted via telepsychiatry increased more than threefold during the pandemic among 35 sites across the country, said Dawn Velligan, PhD, of the University of Texas Health Science Center at San Antonio, during the American Psychiatric Association annual meeting:

• Routine visits: 15% pre-pandemic to 69% during the pandemic
• Monitoring visits (not injection): 14% to 59%
• Treatment initiation visits: 12% to 56%
• New patient visits: 15% to 56%
• Crisis visits: 12% to 45%

Of the 35 sites surveyed, 15 said they were already utilizing telepsychiatry prior to the start of the pandemic and the other 20 were prompted to implement telepsychiatry sessions after COVID hit. Of the 15 that were already using telepsychiatry, 87% expanded their services during the pandemic.

“People were scrambling in doing what they had to do and they all found their unique solution,” Velligan told MedPage Today. “I think it’s also important that people seem to navigate the situation pretty well and patients were still being seen and taken care of.”

Along with greater adoption of telepsychiatry, clinics saw around a 33% drop in the amount of “no-show” patients or visit cancellations.

The majority of clinicians (57% to 80%) said telepsychiatry visits were sufficient to detect and manage side effects from long-acting injectables (LAIs), prescribe and start new antipsychotics, and establish therapeutic relationships.

The pandemic also appeared to influence prescribing patterns for patients with schizophrenia. Specifically, 31% of sites said they switched some of their patients who were originally treated with LAIs to a longer injection-interval LAI in order to stretch out the time between injections. On top of that, 34% of sites said they switched some patients on LAIs to an oral antipsychotic.

“I was surprised that some of the clinics actually took people off long-acting injectables,” said Velligan. “Some of the clinics were very creative and came up with ideas like having the injections be outside or transporting people in who couldn’t get transportation because their relative was sick or whatever the case, so they did some creative things.”

“I would’ve liked to see more of that because I don’t think taking people off an injection when they’re stable is almost ever a good idea,” she added. “I worried far less about my particular patients who were on long-acting injectables than the ones who were on oral antipsychotics during the pandemic.”

As for medication adherence, 60% of sites said their patients on LAIs remained adherent. However, among clinics that saw a change in adherence — eight seeing decreases and one reporting an increase — the most common reason cited was an unwillingness to leave their homes. Other reasons included a reduction in clinic hours, difficulty in communicating with patients, and patients’ lack of transportation or financial woes.

Several barriers still persist that limit an even greater adoption of telepsychiatry. Among the sites surveyed, the top barrier that providers said moderately or extremely limited implementation of telepsychiatry was a lower reimbursement rate (31%), followed by cost of implementation (29%) and insufficient staffing (26%). Other issues included no EMR telemedicine functionality, insufficient resources to train staff, lack of access to technology or equipment, unwillingness of staff to use telepsychiatry, lack of IT support, and privacy or security concerns.

In ameliorating some of these barriers to care, policy is the next step, Velligan said. “I really think that our patients need access to high-speed internet and good technology if we’re going to keep going with telemedicine, and some people just don’t have it.”

It would be beneficial to have a designated person at practices to aid patients through the telepsychiatry process, such as logging into Zoom, she added.

Barriers to greater telepsychiatry adoption aren’t just site-specific, either; patients might also face difficulties. Almost three-quarters of sites said that patients’ lack of access to technology or internet is a substantial barrier to telepsychiatry use, and 60% said that patients have a lack of training on said technology. Furthermore, 46% of sites listed homelessness as another substantial patient-related barrier, in addition to comprehension or attention issues, distrust of technology, and cultural or linguistic issues.

But even with these barriers to care, Velligan said telepsychiatry is “absolutely” here to stay and will take the form of “individualized approaches.” This sentiment was reflected in the study too, with 69% of sites saying that their telepsychiatry visits — in combination with in-person visits — would likely continue after the pandemic ends.

The survey included responses from 35 of 50 Observational Study of LAI Medications in Schizophrenia (OASIS) sites. OASIS is an ongoing observational study of patients with schizophrenia newly initiated on one of the following FDA-approved atypical LAIs: aripiprazole (Abilify Maintena), aripiprazole lauroxil (Aristada), paliperidone palmitate (Invega Sustenna), or risperidone (Risperdal Consta).

The online, cross-sectional surveys were completed from October to November 2020. Nearly half of sites were independent or private practices, followed by community mental health clinics (37%), hospital networks (14%), and academic sites (3%). Most were located in the South (43%), followed by the Midwest (23%), West (20%), and Northeast (14%). Most were in urban areas, 34% were in suburban areas, and only two sites were located in rural areas.

The responding healthcare providers spent an average of 23 years practicing, and an average of 16.2 years prescribing LAIs. They also spent an average of 13.1 years working at their current clinic.