Future Tense

Telepsychiatry Is Leaving Behind the Most Seriously Mentally Ill

A doctor video chatting with nobody.
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I have broken all my promises to Katie* since I last saw her in early March. “I don’t feel like talkin’ today. I didn’t want ta come,” she snapped at me that day during the short walk to my office. Her Irish lilt never failed to make me smile. I told her she didn’t have to say anything. I knew she was angry before I even greeted her—when I paused at the door, she glared from across the waiting room. This small action only took a moment, but it is one of hundreds that stand to be lost as psychiatrists embrace telepsychiatry.

Katie is a 90-year-old woman suffering from schizophrenia, meaning she has severe disturbances in thought, communication, and perception. She also has poor insight into her illness, meaning she does not believe she is ill. Yet Katie is sick, whether she knows it or not, and she sees me once a month for both medication and therapy to keep her well. Thanks to this routine, she has been stable for nearly 30 years. She is often wary of people, but she has not tried to harm others or herself. It has taken me two years to chip away at her gruff exterior. The first chip was accidental. Two months in, I broke her silence by asking, “Did you ever leave milk out for the pixies in Ireland?”

I was rewarded with her laughter, a warm sound for the typically cranky woman. “No. No such thing as pixies. And we did all right—my mother cleaned houses. … But we couldn’t be wasting expensive milk.”

Our relationship stuttered along after that, often wordlessly. I read her body language and recognized her weighty pauses. We sat in silence, appreciating speech instead of expecting it. Sometimes she smelled terrible, which told me she was having a bad month. People with schizophrenia often have poor hygiene. When we began meeting, I silently promised her I would heed these signals, that I would respect her communication style. But now I’m not able to do any of that, because our monthly visits ceased early in the pandemic.

For many outpatients, psychiatrists have switched to remote visits. Like many psychiatrists, I resisted this change at first. I enjoy face-to-face therapy visits. Without a good alternative, I have settled into the new normal over the last few months and started seeing patients from my kitchen table. Both psychiatrists and patients report enjoying the flexibility and newfound freedom. For many of my patients, it works even better than our usual model. Recently, 34-year-old Tyler* delighted in walking me around his house to show off his artwork, actively creating quirky voices for the characters in his paintings. This may have been more therapeutic for a patient with ADHD than an office visit.

But the Katies of the world are conspicuously absent from at-home outpatient sessions.

The ever-irascible Katie was diagnosed in her 60s and has lived with the illness for 30 years since. In many ways, Katie is an anomaly—she was diagnosed older than most and has lived longer than many patients with schizophrenia. She has a landline telephone, not a smartphone or computer. She has no desire to learn new skills nor access to technology to facilitate learning. When I called her to suggest an in-person visit at the end of March, she snapped, “I’m not going! I’m not s’posed ta leave the house!” and hung up. Respecting her boundaries was difficult, but calling again risked pushing her further away. Since we couldn’t set up a follow-up appointment, I reluctantly arranged a visiting nurse who provided medications, but this could not substitute for the rapport that we spent years building.

Katie’s symptoms began 30 years ago. She stared out the window and muttered to herself. She treated family members with suspicion and obsessively checked the locks on doors. She stopped going outside. Her personal hygiene suffered. She worried that devices had been implanted in her ears so that governmental agencies could record her thoughts. Her partner finally called the police after she attacked him with an iron poker. This final symptom was the most noticeable, but it may not have reached this point had she been treated sooner.

This trajectory is common for people with schizophrenia. I can pick up on early subtleties like poor hygiene in person. Suspicion and paranoid tendencies often reveal themselves even in brief conversation. I can see a patient respond to internal voices in the office. Without face-to-face appointments, it is more difficult to know if the warning signs are there.

Telepsychiatry was developed specifically to open up new avenues of care for underserved populations: the severely depressed who struggle to get out of bed, prison populations, and those in poverty or in rural areas. Telepsychiatry differs from teletherapy in that psychiatrists offer medication management in addition to talk therapy. In the early 2010s, telepsychiatry startups promised ease and convenience via the internet and mobile apps. Telepsych has expanded since then, but the rise in the past few months has been meteoric. Psychiatrists rushed to change guidelines and adapt to caring for patients in the stark absence of in-person interaction.

However, telepsychiatry requires self-motivation and the ability to engage without the context of a structured setting. The progressive neurocognitive deficits that accompany schizophrenia make each individual task feel insurmountable. Katie, just like many patients with schizophrenia, is not motivated to attend appointments, especially since she does not believe that she is ill. Her case manager scheduled and drove her to and from all her in-person appointments. She cannot do these things herself—she would not prioritize it, she would forget, and she would not care for her own well-being until it was too late. For Katie, staying engaged with an in-person conversation is difficult enough—connecting through a screen is impossible. Because Katie does not recognize her own symptoms as part of a mental health pathology, she cannot tell me she is having them. She does not understand most technology, does not have a computer, and is not willing to learn. The benefits of telepsychiatry are numerous for those who can access them, but so far Katie cannot. Neither can the homeless, many non-English-speaking immigrants, or those with severe and persistent mental illness, for the same reasons.

As for me, I miss the moments where Katie and I would look out the window together. “So beautiful, the way the trees dance in the wind,” she said once.

Schizophrenia is one of the leading causes of disability, with 3.5 million people diagnosed in the United States. In 2013 the overall economic cost of schizophrenia was estimated to be $155.7 billion. Patients with this illness live 20 years less on average. Routine medical conditions are often missed or untreated in these patients, even when the world is not facing a pandemic. If these abrupt changes exclude the most vulnerable, they will be left behind. For now, I must work remotely—both for Katie’s safety and mine. But the longer this continues, the more likely it is to become permanent. If we forget those who cannot adjust to this system, we stand to lose a part of the population accustomed to being overlooked and forgotten, at tremendous financial and emotional cost.

“I like your hat,” I told Katie in March, at what neither of us knew would be our last appointment. I meant it. It was a black-and-white houndstooth cap. I had never seen her wear anything like it before.

“You do? I’m tryin’ ta match my clothes now because I like how you match yours.”

I was amazed. “I had no idea you noticed.”

I wonder how many of these interactions stand to be lost through screens.

*Patient names have been changed to protect their privacy.

Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.