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I’m a primary care internist and health services researcher in Portland, Oregon; a large proportion of my patients have mental health conditions that I manage along with behavioral health specialists.

During the COVID-19 pandemic, many of my patients with mental health conditions began scheduling regular telehealth visits to discuss psychotherapy. I often feel like a virtual mental health provider.

In this month’s issue of Health Affairs, my coauthors and I analyzed more than 100 million outpatient mental health encounters to compare service utilization before and during the COVID-19 pandemic. We found that in-person mental health encounters were reduced by half in the early months of the pandemic, as others have similarly reported for a variety of health conditions.

But as early as April 2020, outpatient mental health encounter volume actually started to exceed prepandemic levels, an observation largely attributable to telehealth uptake.

While telehealth volumes for mental health were negligible in the preceding study years, nearly half of monthly average mental health encounters were telehealth visits from March to December 2020.

State lockdowns, temporary regulatory waivers, and expanded reimbursement for telehealth coverage, among other factors, all facilitated this massive shift in care delivery.

Policies on telehealth continue to evolve.

Medicare telehealth flexibilities that the Centers for Medicare and Medicaid Services (CMS) implemented during COVID-19 were extended for five months in the just-passed FY2022 omnibus spending bill.

In the 2022 Consolidated Appropriations Act (CAA), there’s a requirement that an in-person service must take place every 12 months after a telehealth service, rather than within the 6-month window that the 2021 CAA required.

Many states are also reviewing coverage and/or payment parity policies and have made these permanent.

There are several pieces of legislation winding their way through Congress.

• The highly anticipated Cures 2.0 Bill, introduced in the House in November 2021, includes provisions that aim to expand telehealth in Medicaid and CHIP and eliminate Medicare’s geographic site restrictions to access telehealth services.

• Last month, Senators Catherine Cortez Masto (D-NV) and Todd Young (R-IN) introduced the bipartisan Telemedicine Extension and Evaluation Act to establish a two-year extension for certain COVID-19 emergency waivers, expand the list of permissible telehealth providers, and increase the availability of audio-only telehealth services.

• The Telehealth Extension Act, introduced by members of the House Ways and Means Health Subcommittee in December 2021, aims to lift geographic and site restrictions to allow Medicare beneficiaries to access telehealth services regardless of where they live.

By and large, policy makers at all levels of government have embraced telehealth, which is set to become a permanent fixture in care delivery postpandemic.

Given my research interests in mental health, I’m hopeful that telehealth applications can address some existing gaps in mental health care delivery.

Even before the pandemic, a robust evidence base supported the use of telehealth to address gaps in access to mental health care, with high acceptability and satisfaction among both providers and patients.

Mental health care may also be particularly suited to telehealth modalities, with early research on telehealth use among rural Medicare beneficiaries finding that nearly 80% of these visits were for mental health conditions.

Telemental health has been shown to be as effective as in-person care in diagnostic accuracy, medication and symptom monitoring, treatment effectiveness, and quality of care, even for those with serious mental illnesses.

But important questions remain, including how this technology can best be applied to address different mental health context–and for whom.

An oft-repeated goal of telehealth is to improve access to care, particularly for those patients who live in areas without sufficient supply of mental health specialists.

However, disparities in telehealth use grew during the COVID-19 pandemic, with inequitable broadband access disproportionately affecting rural communities, communities of color, and older adults.

Likewise, in our analysis, those with bipolar disorder and schizophrenia had a lower composition of telehealth encounters as a proportion of total outpatient encounters compared to people with other mental health conditions.

While many patients find telehealth to be an acceptable alternative to in-person care, there are some clinical characteristics for which hybrid models of care could be more appropriate.

A recent randomized clinical trial of patients with posttraumatic stress disorder and bipolar disorder found that those with sustained in-person outreach at their local clinic were more likely to remain engaged with psychotherapy than those assigned to connect solely with a psychologist via video chat.

More evidence is needed, and many experts are working on studying these clinical questions. But our findings suggest we should view telehealth as a tool, not as a panacea, for addressing gaps in the mental health system.

For patients in need of additional support, telehealth may be a useful complement to in-person care, rather than an alternative mode of care delivery.

As telemental health models are expanded, flexibilities that account for clinical context, continued in-person outreach, care continuity, and patient needs and preferences are warranted.

Something Fun

Apart from clinical care delivery, another thing that has shifted for me during the COVID-19 pandemic has been my work-life balance. In January I gave birth to my second pandemic child (my first was born in April 2020, as the first wave of shutdowns happened).

Between child care, pet care, dinner prep, and laundry, I’m finding myself a bit frazzled these days.

To decompress and clear my mind, I’ve started protecting time each day to step away, walk the dog in the Portland drizzle, and listen to a rotating array of podcasts.

A few episodes I have enjoyed recently: “This Conversation Will Change the Way You Think About Thinking,” The Ezra Klein Show (if you’re in a contemplative mood); “Conan O’Brien,” - Smartless (for some humorous entertainment); and, fittingly, “All the Help We Can Get,” - HBR Women At Work.

About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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