Exploring psychotherapeutic issues and agents in clinical practice
The COVID-19 pandemic has changed psychopharmacological prescribing and management practice for advance practice RNs (APRNs) around the world. Social distancing requirements led to nearly overnight transition from face-to-face patient visits to telepsychiatry. A recent survey of psychiatric providers showed a shift from in-person to telehealth visits during this pandemic. Pre-COVID-19, 64% of providers reported not using telehealth and an additional 29% reported using it with <25% of their patients. Two months into the pandemic, this number shifted dramatically to 85% of respondents seeing more than 75% or all of their patients via telehealth (American Psychiatric Association [APA], 2020b).
Historically, studies have demonstrated that patients who use telehealth are generally satisfied, particularly in rural and underserved communities (Orlando et al., 2019). Relaxed federal reimbursement policies during the COVID-19 pandemic expanded patient awareness and access to virtual care, launching telehealth into almost every community and specialty practice (Kyruus, 2020). As a result, virtual care has become an expectation. Recent surveys by the APA (2020b) and Kyruus (2020) suggest that federal, state, and third-party payers are being urged by health care agencies and provider groups to continue the policy changes supporting access to telehealth during the COVID-19 pandemic. If reimbursement parity and relaxed geographic restrictions continue to be allowed, telepsychiatry is likely to be an option that patients will expect even after the pandemic.
For many psychiatric APRNs, the transition to telepsychiatry was intended as a temporary solution until it is possible to return to “business as usual,” with in-person patient care. We value the therapeutic alliance and connections we have historically developed with our patients face-to-face. The following case study explores the nuances of telepsychiatry with an adolescent nonbinary patient, including strengths and challenges of telemental health, and recommendations for practice.
B.J. (pseudonym) is a 17-year-old adopted gender nonbinary pansexual high school junior who prefers they/them pronouns. B.J. was 9 months old when they were foster adopted by a family with two biological children and three other adopted children. B.J. and siblings were home schooled until B.J. entered fourth grade. At that time, B.J. was diagnosed with attention-deficit/hyperactivity disorder and had responded favorably to atomoxetine until it was changed to bupropion XL when insurance authorization of Strattera® became problematic. However, bupropion was discontinued after it induced aggression and threatening of others, as well as the first suicide attempt in eighth grade.
B.J. was referred to a psychiatric–mental health nurse practitioner (PMHNP) for outpatient psychopharmacological management after being discharged from a psychiatric hospitalization, out-of-state residential treatment, partial hospitalization, and intensive outpatient (IOP) services over a period of approximately 2 years. B.J. had attempted suicide on four occasions, had made homicidal threats to family members prior to admission, and was diagnosed with major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder. Psychiatric providers affiliated with each of the treatment facilities continued the psychopharmacological treatment prescribed in the hospital: daily escitalopram 30 mg, quetiapine 400 mg, lithium 300 mg, and prazosin 2 mg. In addition, B.J. was taking over-the-counter melatonin 5 mg, 10 to 15 tablets before bed.
When B.J. arrived for initial psychiatric evaluation, the clinic was restricted to telepsychiatry due to the COVID-19 pandemic. B.J. and their mother were both interviewed from their home, 1 day after discharge from IOP treatment. Introductions were made, with a review of confidentiality and safety measures, including confirmation of parent phone number and availability during the interview. After collateral information was gained from a conjoint psychiatric interview, the parent stepped away for the patient interview, returning at the patient beckoning for treatment planning. Nonetheless, it was difficult to confirm the degree of privacy the patient had in the family home.
The previous provider had authorized 2 months of prescriptions; therefore, serum lithium level, thyroid-stimulating hormone (TSH), creatinine, chemistry panel, lipid panel, complete blood count, and urinalysis were ordered prior to any treatment change, as we began discussion of slowly “deprescribing” as a goal for outpatient management.
Psychoeducation was based on an emphasis on patient goals, including their concern about recent weight gain and fear of recurrent sleep disturbance and/or nightmares. The parent, patient, and provider were included in shared decision making to prioritize a plan to strengthen the use of nonpharmacological sleep support (e.g., attention to physical activity, electronic light exposure, sleep ritual, mindfulness, relaxation, therapeutic music and/or audio or written content). Psychoeducation addressed the evidence for much lower doses of melatonin being more effective than high doses, with dose timing being a critical aspect of successful improvement in delayed sleep–wake phase disorder (Bruni et al., 2015).
Challenges With Telepsychiatry
In contrast, for the follow-up visit, B.J. “arrived” to the Zoom session with the parent unavailable and refused to turn on the camera based on not wanting to see themselves. Lack of verbal spontaneity and minimal responses suggested that therapeutic alliance was still tenuous as the patient was interviewed using telehealth on Day 2. Discussion regarding treatment goals was difficult to advance without a visual and emotional connection to the patient. Labs had not been drawn yet; however, the patient had reduced the number of melatonin 5 mg tabs from 10 to five based on information shared by the PMHNP at the intake appointment. This was a point of engagement for listening and validating, ensuring that the patient knew the PMHNP was interested in their personal need for sound sleep, response to the medication change, and overall well-being. The goal of reducing to 5 to 10 mg was explored, and the patient agreed to consider this tapering. Because the parent was unavailable, an email was sent to remind the parent of the importance of laboratory blood draw, and a face-to-face appointment (with health screening, masks, and other COVID-19 precautions) was scheduled for the next visit.
Combining Telepsychiatry With In-Person Visits
When the patient and parent arrived for the in-office visit 2 weeks later, they were both greeted warmly with acknowledgement of this first “three-dimensional” meeting. The PMHNP took the vital signs and observed as B.J. ambulated the hallway, sat, and responded to Abnormal Involuntary Movement Scale testing. The PMHNP acknowledged B.J.'s reticence to share video screen and discussed this in light of social anxiety; self-esteem issues; their struggles with online school requirements, including break-out groups; and “seeing yourself all day” on a video screen. This improved therapeutic alliance, as the PMHNP could acknowledge the patient's concerns, clarify their understanding of what is needed to reach their personal treatment goals, include them in problem solving, and set shared objectives for moving forward. The rationale for labs was framed around the patient's desire to taper off Seroquel®, which would be started once a baseline lithium level, TSH, creatinine, chemistry panel, lipid panel, complete blood count, and urinalysis were obtained (Los Angeles Department of Mental Health, 2020).
Deprescribing requires a structured approach to obtaining a comprehensive medication history, considering overall and individual medication risks, priori-tizing, implementing, and monitoring response to tapering. In the outpatient setting, it is important to provide education about medications, options for change, potential risks and benefits, as well as alternative therapeutic options (Bellonci et al., 2016). In the case of B.J., this process was enhanced by the timely use of one in-person session. Telepsychiatry follow-up visits have improved since the face-to-face visit. B.J. has gained understanding about the medication risks versus benefits. Seroquel is being tapered with the goal of deprescribing this medication while monitoring mood symptoms using the clinical interview and Patient Health Questionnaire-Adolescent rating scale (APA, 2013). Sleep hygiene is improving as parent and patient gain insight into the relationship between behavioral choices and sleep cycle. As the patient engaged in their own treatment goals, cognitive-behavioral therapy was offered, using 7-session Creating Opportunities for Personal Empowerment (Lusk & Melnyk, 2011). Once the patient secured the manual, the content was delivered by the PMHNP using Zoom “share screen” as an adjunct to psychopharmacological treatment. In addition, B.J. was referred to a therapist for weekly telepsychotherapy sessions to support them and their family during the transition back home after approximately 1 year of residential treatment.
Therapeutic Alliance with Youth
The impact of COVID-19 on socialization and emotional support of youth adds complexity to the decision regarding use of telehealth versus in-person visits with adolescents (Fegert et al., 2020). The opportunity to meet once for a “live” session facilitated therapeutic alliance that may have taken longer to develop in the virtual environment. Although there is evidence to suggest that telemental health is an effective option for psychopharmaco-logical prescribing with youth, multiple challenges warrant problem-solving considerations (Myers et al., 2017). In addition to establishing a relationship with the patient, the APRN must adapt the diagnostic evaluation to the virtual environment without scale or manometer, and without the natural flow of an office and waiting room to separate patient and collateral informants. Cain and Sharp (2016) suggest that other difficulties may include (a) determining the technology and connectivity needed; (b) coordinating pharmacotherapy with other providers; (c) determining the infrastructure needed at the site where the patient will be receiving the telepsychiatry services; (d) preparing documentation and maintaining records; (e) managing the logistics of medication prescribing and maintaining compliance with professional practice standards and state and federal regulations; (f) managing urgent and interim care; (g) providing patient education regarding pharmacotherapy; and (h) monitoring the response to medication. The APA's (2020a) Child and Adolescent Telepsychiatry Toolkit can help with planning, implementing, evaluating, and continuing successful telepsychiatry with youth.
Since the onset of the COVID-19 pandemic, rapid and successful adoption of telepsychiatry has expanded possibilities for access to psychiatric care. The demand for continued telehealth is likely to result in hybrid telehealth/in-person practice models that adapt to patient and provider needs. The current case illustrates the challenges of establishing a therapeutic relationship, particularly with youth and their parents, as well as the importance of clearly outlining expectations for engagement in a “two-dimensional” virtual environment. Discussing confidentiality, space, and camera requirements, as well as a plan for parent participation, can help mitigate some of the challenges of adolescent telehealth, supporting patient engagement and treatment adherence. Building therapeutic alliance in the virtual environment can be supplemented with in-person visits when appropriate.
As in the case of B.J., therapeutic alliance, patient engagement, psycho-pharmacological adherence, physical assessment, and psychiatric evaluation may be addressed using telepsychiatry, collaboration with the patient's primary care provider, and/or initial or intermittent office visits. Determining whether to see an adolescent patient in-person or virtually should be based on a holistic assessment of the patient's response to prolonged periods on-camera with school, patient needs, expectations, and treatment goals.
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