Asynchronous Telepsychiatry: An Unused Solution to the Psychiatrist Shortage

The United States is facing a severe shortage of psychiatrists. In 2018, 77% of counties in the United States reported a severe deficit of psychiatrists, while an estimated 60% of adults with mental illness were not able to receive treatment. This lack of services is even more glaring in rural areas, where there is only one psychiatrist for every 30,000 Americans. America’s psychiatrist shortage is projected to get even worse: with 60% of practicing psychiatrists in the United States over 55, a wave of retirements is poised to hit. Increasing federal funding for psychiatry departments is perhaps the clearest solution to the issue, but funding for mental health services can often be politically contentious. In order to address this concerning trend, America needs to consider policies that can compensate for these shortages.

Asynchronous telepsychiatry promises to fill this policy gap and address unmet mental health needs. With asynchronous telepsychiatry, a patient’s answers to clinical questions are electronically recorded and forwarded to a psychiatrist to be evaluated at a later time. While asynchronous telemedicine is used in other specialties, it is rarely employed in psychiatry. Instead, psychiatrists favor conventional approaches such as face-to-face visits or synchronous telepsychiatry (i.e., meeting with a psychiatrist over the phone or video chat).

Asynchronous telepsychiatry can increase the efficiency of the mental health referral process by allowing for any visit with a primary care physician to double as the data collection phase for psychiatric diagnosis and treatment planning. Instead of the patient requiring two appointments, they only need to attend one, where they can record their answers to relevant questions on video. This is especially beneficial since half of patients go to their primary care physician when seeking psychiatric assistance, and two out of three primary care physicians report difficulty in referring patients for mental health care. Asynchronous telepsychiatry helps to increase the capacity of psychiatrists to serve additional clients by cutting down on the time that individual sessions take. It also decreases the time between the initial referral and diagnosis since patients can be diagnosed using a video recording instead of having to wait weeks to see their psychiatrist. Increasing the use of asynchronous telepsychiatry would help decrease the difficulty and frustration that many patients and providers experience when navigating the mental healthcare system.

These benefits have been borne out in the research. When compared to face-to-face visits and synchronous telepsychiatry, asynchronous telepsychiatry is a more efficient use of time and money. The following table is from a study that examined the experiences of 125 patients in a UC Davis primary care clinic. Patients were randomly assigned to asynchronous telepsychiatry (ATP), synchronous telepsychiatry (STP), and in-person visits (IP).

From “Cost analysis of store-and-forward telepsychiatry as a consultation model for primary care,” by Butler, T. N., & Yellowlees, P. (2012), Telemedicine journal and e-health: the official journal of the American Telemedicine Association, 18(1).

Asynchronous telepsychiatry resulted in consultations that were half as long (30 minutes) as the other consultation types (60 minutes). Furthermore, asynchronous telepsychiatry had the lowest marginal cost, meaning that upon reaching 250 consultations, it became the cheapest of the three forms of treatment.

Other studies have also validated that quality of care does not decrease with asynchronous telepsychiatry. A randomized clinical trial of 401 primary care patients and another randomized trial of 43 participants in skilled nursing facilities found no statistical difference in clinical outcomes for study participants regardless of whether they were assigned to asynchronous or synchronous telepsychiatry. Saving money and time while delivering an equivalent product makes asynchronous telepsychiatry a seemingly perfect method for addressing the psychiatrist workforce shortage.

However, the problem is not that simple. Asynchronous telepsychiatry is rarely reimbursed by insurance providers at the same level as synchronous telepsychiatry or in-person visits. Thirty-seven states mandate coverage of synchronous telehealth by private insurance, while only 27 states mandate coverage of asynchronous telehealth. When it comes to Medicaid, 49 states reimburse healthcare providers for some sort of live video consultation, while only 15 states reimburse for asynchronous telemedicine. And finally, Medicare only permits the use of asynchronous telemedicine for “federal demonstration programs in Alaska and Hawaii.” Without payment, this cheap and effective care option will continue to be underutilized.

The reasoning behind these policy arrangements is fairly murky. There are no studies arguing that the cost of asynchronous telepsychiatry outweighs the benefits, no significant political opposition to the idea, and no practitioners arguing against it. So, what explains its lack of funding?

The most likely reason is that asynchronous telepsychiatry is rarely used beyond pilot programs; it is a novel process that requires coordination between various specialties. Research into the use of asynchronous telepsychiatry has supported recommendations for additional training in three areas: comprehensive skills in brief psychiatric interviewing; adequate general knowledge of behavioral health conditions and therapeutic techniques; and clinical documentation, integrated care and consultation practices, and e-competency skill sets. While providing this training might be an additional burden to healthcare systems and providers, these kinds of investments would improve efficiency in the long run. Furthermore, the burden of coordination and training might be reduced in managed care organizations (like Kaiser Permanente) or integrated care models, where psychiatrist referrals happen in-house. If asynchronous telepsychiatry starts being used more often in these kinds of settings, the case for reimbursement might be made stronger.

Make no mistake: if the United States is to adequately address its mental health crisis, there needs to be increased government spending on accessible psychiatric care. Asynchronous telepsychiatry can reduce costs and improve access to healthcare, especially for rural counties that lack psychiatrists. If telehealth methods continue to be under-utilized, we are voluntarily impairing our ability to meet the basic needs of our citizens.

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Butler, T. N., & Yellowlees, P. (2012). Cost analysis of store-and-forward telepsychiatry as a consultation model for primary care. Telemedicine journal and e-Health : the official journal of the American Telemedicine Association, 18(1), 74–77. https://doi.org/10.1089/tmj.2011.0086.

Parish, Michelle Burke, et al. “Asynchronous Telepsychiatry Interviewer Training Recommendations: A Model for Interdisciplinary, Integrated Behavioral Health Care.” Telemedicine and e-Health, vol. 27, no. 9, 2021, pp. 982–988., https://doi.org/10.1089/tmj.2020.0076.

Xiong, G. L., Iosif, A. M., Godwin, H. T., Khan, M., Parish, M. B., Yellowlees, P., & Kahn, D. (2018). A Pilot Randomized Trial of Asynchronous and Synchronous Telepsychiatry in Skilled Nursing Facilities. Journal of the American Medical Directors Association, 19(5), 461–462. https://doi.org/10.1016/j.jamda.2018.02.007.

Yellowlees, P. M., Parish, M. B., Gonzalez, A. D., Chan, S. R., Hilty, D. M., Yoo, B. K., Leigh, J. P., McCarron, R. M., Scher, L. M., Sciolla, A. F., Shore, J., Xiong, G., Soltero, K. M., Fisher, A., Fine, J. R., Bannister, J., & Iosif, A. M. (2021). Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial. Journal of medical Internet research, 23(7), e24047. https://doi.org/10.2196/24047.