With the end of the Public Health Emergency in May 2023, the DEA has set the stage for the return of the Ryan Haight Act by proposing rules, including requiring prescribers to have an in-person visit in order to write prescriptions for controlled substances.
The DEA received over 38,000 comments on the proposed rules. The overwhelming majority focused on how these new rules will ultimately be worse for mental health clinicians and their patients, primarily by reducing access to care. In response to the public comment the DEA announced its plans to temporarily extend the telehealth flexibility, though it is unclear for how long.
Still, stakeholders should also acknowledge the very real value of the in-person visit in mental health care — for those on controlled substances and beyond.
I’m certainly no Luddite. I led telehealth implementation at Columbia University’s Psychiatry Faculty Practice and served as Chief Innovation Officer at Columbia Psychiatry, where I co-led the invention of a depression treatment algorithm that clinicians can use on their phones while treating patients. I have advised, invested in, and co-founded mental health startups. That said, as a practicing psychiatrist and CMO of a mental health platform, I am keenly aware of the clear clinical benefits of in-person care, particularly improved patient-provider relationships, quality and safety controls, and access to specialized treatments.
The Clinician-Patient Relationship
In-person visits allow for enhanced relationship building between the patient and the clinician, which is critical for success. Think about online dating. People start by reviewing profiles and sending messages asynchronously. Those are reasonable ways to begin to see if there’s a match. But the goal is always to end up with an in-person date.
Mental health care is one of the most intimate forms of treatment, and at least for some patients and providers, meeting in-person increases trust, depth of experience, and the ability to be vulnerable.
Quality & Safety Controls
Controlled substances are a common component of psychiatric care. Up to 30% of outpatient mental health care may involve a controlled substance. It may be stimulants for ADHD, low-dose benzodiazepines as needed for panic attacks or other anxiety disorders, or certain sleep aids since insomnia is common among those with mental health conditions.
These medications work well, and it’s also true that they carry the risk of side effects, including addiction, misuse, and diversion. For stimulants specifically, the in-person option makes it easier to check vital signs to see if heart rate or blood pressure are out of normal ranges. We have had several patients come to our clinics and learn for the first time that their stimulants were causing hypertension in young, otherwise healthy people.
Given controlled substances have the potential for addiction as well as misuse and diversion, urine toxicology (drug screens) can be an important part of the treatment parameters. Rather than increase stigma, drug screens can in fact, help make it safer to treat people with a history of addiction and ADHD with stimulants. It allows the clinician and the patient to be confident that the treatment is working and that the patient is getting the medications prescribed and not combining them with other drugs.
In-person care also allows for physical exams. This is critical for patients on antipsychotics to ensure they do not develop tardive dyskinesia (a lifelong movement disorder), tremors, or other subtle movement disorders that can be associated with antipsychotics. It allows patients with eating disorders to be weighed in a controlled environment such that the patient and clinician alike are confident in the number on the scale.
Specialized Treatments
In-person care is not only relevant for psychiatric medication management; it helps with psychotherapy too. Some psychotherapies, like EMDR for PTSD or Exposure-Response Prevention for OCD or phobias, are best conducted in-person. Neuropsychological testing can be partially completed online, but the best neuropsychologists will tell you that some portion of the testing needs to be done in-person.
Finally, in-person care in mental health facilitates the use of evidence-based treatments that can only be provided in person – examples include ketamine, Spravato, and TMS for treatment-resistant depression. In addition, long-acting injectables, which have been shown to improve adherence for patients with schizophrenia or other chronic psychotic illness, require office visits for the injections.
Conclusion
Telehealth is here to stay, and there is every reason to be excited about its ability to increase access to care, adherence to care, and convenience of mental health care services. At the same time, we need to acknowledge that holistic mental health care requires an in-person complement. An in-person relationship goes far beyond a “check the box” and in fact, enhances our ability to provide full-spectrum, high-quality, evidence-based mental health care.
About the Author:
Ravi N. Shah is the Chief Medical Officer of Geode Health and co-founder of Mantra Health.
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