ROCHESTER, Minn. -- Sharon Bastin had gone months without her biweekly therapy sessions and knew she needed help. As her depression spiraled, she became consumed with dark thoughts.
“You don't have enough effort inside yourself to say, ‘You're just thinking wrong.’ It doesn't allow you to do that,” said Bastin, who works as a data specialist for the Minnesota branch of the National Alliance on Mental Illness. “When you’re suffering from severe depression, you can talk yourself into all kinds of things.”
In the early months of the pandemic, Bastin’s therapist was not offering in-person sessions in her Minneapolis office, where Bastin is also based. During that time, Bastin’s mental health deteriorated greatly. Finally, she was able to see her therapist remotely, using a video telehealth system — a resource she counts as potentially lifesaving.
Behavioral and mental health treatment was ahead of other specialties in terms of telemedicine use before the pandemic, but patients have still increasingly turned to those services over the past year.
One study found that telemedical care for mental health or substance abuse disorders increased from 1% of visits before the pandemic to 41% in October 2020.
For most people providing and receiving medical care, the escalated adoption of telemedicine is one of the silver linings amid the devastation of the pandemic. The funds funneled into the technology reflect its increased use. Investment in telehealth technologies in the first half of 2021 was greater than all of 2020, according to an analysis from management consulting firm McKinsey & Company.
While the benefits of telemedicine have been especially appreciated among people who live with physical disability or mental illness, telehealth has also created new barriers for users during a time when medical support was vital.
A stress-saving lifeline
For over a year, Alexis’ anxiety kept her from driving. The Rochester resident, who asked that only her first name be used, felt relieved when she could start receiving care for her mental illnesses remotely during the pandemic.
“It saved me the extra stress of having to get to an appointment on time in person,” she said. “I could just sit in the comfort of my own home and just click on my computer.”
The accessibility benefits for those living with mental illness are enormous, said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness.
“It was much more convenient to access than before,” she said.
A NAMI survey found that telehealth visits provided connection in a time when people were starved for it, especially while grappling with mental illness.
“Great to be able to connect with services right from my home. Being able to continue to be in visual connection with my therapist during the most isolated days/weeks of this pandemic was crucial. Nice to see people without masks on!” one respondent wrote.
Several respondents stated that they appreciated the relief of not having to figure out transportation for in-person appointments. Others wrote that they thought it was the safest option for themselves and their families during the pandemic, and it allowed them to stay in a comfortable environment on days they weren't feeling well.
“Love it! Days I would cancel because I am not feeling up to an appointment I would keep (the) appointment because I can use telehealth,” wrote another respondent.
Providers across specialties have noted fewer missed appointments during the pandemic for those receiving care via telehealth, Abderholden said.
For one distressing week in May 2021, Alexis lost her telemedicine access when her computer stopped working.
“I noticed I was getting a little bit more keyed up, a little more nervous,” she said after missing several appointments, which could have impeded her ability to have prescriptions refilled.
Feeling helpless, Alexis turned to Southeastern Minnesota Center for Independent Living. The SEMCIL team offered a repository of 20 iPads and 50 Chromebooks to those in need during the pandemic, fueled largely by CARES Act dollars.
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“The intention would be to help with social isolation,” said Chanell Calhoun, SEMCIL’s independent living program supervisor and assistive technology specialist. She added that while some used the tablets to connect with family members or attend virtual workshops, many used them to access medical care.
When Alexis used her iPad to fill in the gaps when her computer was down, it provided a sense of support in a time when she felt very alone.
“You're more isolated; you feel like you're on your own and you're kind of spinning,” she said.
While some patients were able to find solutions to their technological woes, others were left stranded.
“The elderly and kids are the ones who probably lost the most ground in terms of the pandemic and having to move to telehealth,” Abderholden said.
A survey conducted by the Minnesota Department of Health also found that these were the groups most affected by barriers with technology.
Older patients seeking treatment for mental illness often encountered technological issues, sometimes only accessing their telehealth services after a provider walked them through how to download the software. Some users stuck with audio-only services, a lifeline for those living in areas with poor internet access.
Even for technology savants, telehealth posed a different problem: screen-time burnout.
School-age children who spent all day in front of their computers engaging in remote schooling would often not feel like diving into emotional issues in the same setting.
“The technology worked fine, but my child was burnt out on doing everything via video and started ending the sessions early. I'm not sure how to make the engagement better though,” wrote one respondent to the NAMI survey.
There were also privacy concerns for people who shared spaces with family members and couldn’t find a discreet area to candidly express their struggles with a mental health professional. Bastin found herself moderating what she said and when, even as she logged into her therapy sessions in the privacy of her room, because she worried family members might hear through the walls.
“It's not soundproof. So if you talk too loud, then they're going to hear you. But I still would rather have that and be able to talk to my therapist than have sat there with my own depression talking me into stupid things,” she said.
Minnesota has had a telehealth law since 2015, passed after much discourse between patients and providers about cost, fraud and quality.
“We've had the law on the books saying health plans, you must cover telehealth if it's medically appropriate, and you must pay the same as you would have paid if this service was in person,” said Dave Renner, advocacy director for the Minnesota Medical Association.
For years, advocates have tried to loosen restrictions surrounding telemedicine access. When the pandemic prompted widespread use of telehealth services, legislative changes finally followed.
The location where patients are eligible to receive telehealth services broadened in spring 2020 under emergency power authorization, enabling in-home care, and not solely in-hospital or clinic care. A second change allowed for audio-only care, a shift from previous regulations that restricted telehealth visits to video.
Legislation passed in June 2021 as part of the Health and Human Services bill made these changes part of law, not just part of the emergency powers declaration. The coverage of audio-only services is still in question due to concerns regarding quality of care, Renner said, but it is protected for at least the next two years.
Area physicians hope telemedicine will remain a fixture of medical care even after the emergency provisions created under the pandemic ease. There are always populations who can benefit from having it as an option, particularly those with physical disabilities, said Dr. Steve Ommen, a cardiologist and the medical director for experience products for Mayo Clinic's Center for Digital Health.
“It doesn't matter where you live if getting out of your house is a challenge. Then, being able to connect with your doctor or your nurse manager who manages care, to be able to do that from the comfort of your own home is just so much easier for those individuals,” he said.
Regardless of its benefits, Ommen emphasized that telemedicine is likely best used in combination with in-person care.
“We believe that telemedicine virtual care will be integrated with on-site care, and will smoothly move in between those based on the needs of the patient at that time,” he said.