Mental Health Startup Uses Voice ‘Biomarkers’ To Detect Signs Of Depression And Anxiety

Young female character having a panic attack, an imaginary monster shadow silhouette, mental health issues, psychology

The quick brown fox jumps over the lazy dog,” Rima Seiilova-Olson says slowly and emphatically over Zoom.

The simple sentence holds enormous value for mental health care, she explains, smiling as if to acknowledge that it might be less than obvious how a silly phrase could be so meaningful to a computer programmer and leader of an artificial intelligence startup.

The short saying contains every letter of the alphabet and phoneme in the English language, says Seiilova-Olson, an immigrant from Kazakhstan who is cofounder and chief scientist of Kintsugi Mindful Wellness. Kintsugi believes these sounds offer invaluable insight that can help mental health providers better support people with depression and anxiety.

The Bay Area-based company is building AI software that analyzes short clips of speech to detect depression and anxiety. This so-called voice biomarker software is being integrated into clinical call centers, telehealth services and remote monitoring apps to screen and triage patients reaching out for support, helping providers more quickly and easily assess their needs and respond.

“There’s just not a lot of visibility as to who is severely depressed or anxious.”

Kintsugi CEO and co-founder Grace Chang

Seiilova-Olson, 36, first met co-founder and CEO Grace Chang, 40, a Taiwanese immigrant now based in Berkeley, in 2019 at an open AI hackathon in San Francisco. Surprised to cross paths at a male-dominated event, the women began comparing notes about their respective personal challenges trying to access mental health care:

Seiilova-Olson had struggled to secure a therapist during postpartum depression with her first child, and when Chang had needed her own support, she said it had taken months for anyone from Kaiser to call her back.

“Living in the Bay Area, you can push a button and a car can come to you or food can come to you,” Chang says. “But this was really a challenge.” As engineers, they viewed the dilemma differently than clinicians might.

“We saw this as an infrastructure problem, where you have so many people trying to jam through that front door,” Chang explains. “But there’s just not a lot of visibility as to who is severely depressed or anxious, who is low-to-moderate. And if we could provide this information to those frontline practitioners, then we’d maybe have an opportunity to greatly alleviate that bottleneck.”

Kintsugi was born out of that idea in 2019. It sits in a competitive space of health tech startups like Ellipsis Health and Winter Light Labs that are using voice biomarkers to detect mental health or cognitive issues, built on research showing that certain linguistic patterns and characteristics of a person’s voice can be correlated with psychiatric or neurological conditions.

Kintsugi last year raised $8 million in seed funding led by Acrew Capital, and in February, announced it had closed a $20 million Series A round led by Insight Partners, which valued the company at nearly $85 million, according to PitchBook.

In-person mental health facilities typically use questionnaires to gauge the severity of patients’ anxiety or depression, measures known as PHQ-9 and GAD-7 scores. But during telehealth visits or phone consults — where face-to-face interaction is lost, making it harder to pick up on symptoms — Kintsugi’s technology helps to fill that gap.

Nicha Cumberbatch, assistant director of public health at Spora Health, a provider focused on health equity and people of color, uses Kintsugi’s software to assess women in its all-virtual, doula-led maternal health program, Spora Mommas.

The voice analysis tool, which Spora began using for patient consultations a few weeks ago, has helped Cumberbatch identify women who are, or may be at risk of, experiencing anxiety and depression before, during or after their pregnancies. When a patient starts speaking to a Spora clinician or doula on Zoom, Kintsugi’s AI begins listening to and analyzing her voice.

After processing 20 seconds of speech, the AI will then spit out the patient’s PHQ-9 and GAD-7. The employee can then use that mental health score to decide what additional testing may be needed and how best to advise or direct the patient to resources — like a psychiatrist, cognitive behavioral therapist or obstetrician.

Cumberbatch says Kintsugi’s technology is allowing her to “​​keep a more watchful eye” on her patients “and then move forward with proactive recommendations around mitigating their symptoms.” And while it’s not meant to replace clinicians or formal medical evaluations, she adds, it can be used as a screening tool to “allow us to have a more well-rounded, 360-view of the patient when we don’t have them in front of our face.”

“That technology… [allows] us to have a more well-rounded, 360-view of the patient when we don’t have them in front of our face.”

Nicha Cumberbatch, assistant director of public health at Spora Health

Dr. ​​Jaskanwal Deep Singh Sara, a Mayo Clinic cardiologist who has collaborated with Ellipsis and led research on potential uses of voice biomarkers for cardiology, cautions that while the technology is promising for health care, the field has a long way to go to ensure that it’s accurate, safe and beneficial for patients and clinicians alike.

“It’s not ready for primetime by any stretch of the imagination yet,” Dr. Sara says. Studies in psychiatry, neurology, cardiology and other areas have shown an association between voice biomarkers and various conditions or diseases, but they haven’t shown how this relationship can be used to improve clinical outcomes, he says.

Such research is “not the same as saying, ‘How can we instrumentalize it in clinical practice, and how feasible is it? How effective is it in gauging an individual’s medical trajectory?’” he explains. “If it doesn’t provide any benefits in terms of how we manage them, then the question is: why would you do it?”

He says addressing those questions is “one of many next steps that we have to undertake on this” and that larger clinical trials are needed to answer them. “If it makes health care delivery cheaper or more efficient, or if it improves outcomes for patients, then that’s great,” he adds. “But I think we need to demonstrate that first with clinical trials, and that hasn’t been done.”

To address these issues and validate its software, Kintsugi is conducting clinical studies, including with the University of Arkansas for Medical Sciences, and the National Science Foundation has awarded Kintsugi multiple grants to ramp up its research. The company is also pursuing FDA “de novo” clearance and continuing to build its own dataset to improve its machine learning models.

(Data and insights from Kintsugi’s voice journaling app, as well as conversations with call centers or telehealth providers and clinical collaborations with various hospitals, all become part of an enormous dataset that feeds Kintsugi’s AI.) Seiilova-Olson says this self-generated, unfettered proprietary dataset is what sets Kintsugi apart in the AI health care space — where many technologies are reliant on outside data from electronic health records.

That collection of troves of data on individuals’ speech can be concerning — particularly in the mental health and wellness space, which is widely considered a regulatory Wild West. (These products and services are often not subject to the same laws and stringent standards that govern how licensed clinicians provide formal medical care to patients.)

But Kintsugi’s founders say that patient privacy is protected because what matters for its technology is not what people are saying, but how they are saying it. Patients are also asked for their consent to be recorded and care is not affected by their decision to opt in or opt out, according to the founders.

Kintsugi says it has served an estimated 34,000 patients. The company is currently working with a large health system with 90 hospitals and clinics across 22 states, and they are active in a care management call center that services roughly 20 million calls per year. It is also partnering with Pegasystems, which offers customer service tools for health care and other industries, to help payers and providers handle inbound calls.

Chang says other customers include Fortune 10 enterprise payers, pharmaceutical organizations and digital health applications focused on remote patient monitoring, but that she could not yet share their names. Kintsugi’s clinical partners include Children’s Hospital Colorado, Joe DiMaggio Children’s Hospital in Florida, Chelsea and Westminster Hospital in London and SJD Barcelona Children’s Hospital in Spain, Chang said.

Prentice Tom, Kintsugi’s chief medical officer, adds that it’s working with the University of Arkansas to explore how the tool can be used to possibly identify patients with suicidal ideation, or increased or severe suicide risk, as well as with Loma Linda University, to look at how the technology can be used to spot burnout amongst clinicians.

The team is also looking for ways to expand availability and uses for younger and elderly patients, as well as for maternal and postpartum populations. And beyond patients themselves, it’s perhaps nurses who are benefiting most from Kintsugi’s work, according to the founding team: having a triage tool that helps reduce administrative work or the time spent asking generic questions enables nurses to more seamlessly move patients in their journey.

But Tom, a Harvard-trained emergency medicine physician and former faculty member at Stanford University’s Department of Emergency Medicine, says Kintsugi is now doing far more than addressing infrastructure issues alone. It’s democratizing access to mental health care, Tom said, moving away from a physician-centric paradigm that caters more to people with significant enough depression that they require medical evaluation.

“This tool actually creates a view of mental health in terms of mental wellness,” Tom said, “where everyone has the opportunity to understand where they sit on the spectrum and that actually stratifies treatment options well beyond the current infrastructure.”

I’m a Senior Writer at Forbes covering the intersection of technology and society. Before joining Forbes, I spent three years as a tech reporter at Politico, where I covered

Source: Mental Health Startup Uses Voice ‘Biomarkers’ To Detect Signs Of Depression And Anxiety

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How To Build Digital Tools That Health Plan Members Will Use

According to recent Cognizant-sponsored research, to boost digital usage and member loyalty, healthcare payers need to prioritize investments in analytics, awareness, strategy and design, say Bill Shea and Jagan Ramachandran, leaders in Cognizant’s Healthcare practice.  

From our perspective, these lagging adoption rates are a result of payers underinvesting in awareness campaigns, analytics, strategy and design. Here are the steps payers can take to address these critical components of successful digital adoption.

1. Aggressively promote awareness of digital capabilities.

Our research over the last six years has shown increasing enthusiasm among members for conducting health plan transactions digitally. Yet even when health plans build desired digital features, members don’t use them. Our current survey shows that in 2020, when telehealth use was growing by 24%, 39% of plan members used telehealth capabilities — but from third-party service providers, not their health plans. At least one reason why is that 40% of members said they didn’t know their plans offered a telehealth option.

Payers must close these awareness gaps. Many do a poor job of promoting the tools they have and/or bury them several layers deep on their websites and don’t push them out to members when/where they need them most.

While payers often tell us, members don’t interact with them frequently enough to learn about their digital capabilities, the experience in the property and casualty insurance industry negates that excuse. The average consumer has far fewer property and auto claims in a year than they do healthcare claims. Yet P&C insurers enjoy much higher digital adoption rates than healthcare payers do, according to our research.

Why? P&C companies continually promote their apps and digital capabilities in their advertisements, websites, social feeds, etc. While they may use the apps infrequently, P&C customers do download them. Health insurers should similarly tout their digital capabilities in their marketing campaigns.

2. Make foundational investments in analytics.

Payers won’t get the value they expect from digital initiatives without strong analytics. Analytics and intelligence are prerequisites to anticipating member needs and prompting them to use a digital feature or other next best action in an app or on a website.

Analytics are also invaluable for learning about member needs. For example, most payers view call center deflection as a win. Analytics can help achieve that goal by learning from data about why and when members call for help so that payers can anticipate and proactively address those issues. If the data shows nine out of 10 members contacting the call center for updated deductible data after an emergency department visit, that function can be built into an app or website and advertised.

3. Adopt business-led strategy and design for each digital initiative.

Consumers today expect great digital experiences that payer tools don’t seem to deliver. However, health plan members reported unsatisfying experiences with payer tools, even when these tools offer self-service and other functions, they want most, such as provider search and cost estimation.

To avoid delivering disappointing member experiences, payers need to ensure the business, not IT, is leading these initiatives. In turn, the business must lead with in-depth strategy and design activities to ensure the digital capability meets actual member needs while creating business value.

Whereas business-led digital development follows a rigorous methodology that includes creating personas and journey maps and using outside-in analysis for examples of how other industries deliver similar solutions, IT-led development often starts with technology selection, and then fits processes to the technology’s capabilities. The business-led approach fully scopes out member needs first. These needs then drive the technology architecture design and technology selections so that the technology serves the business vision vs. defining it.

A large health plan we worked with took this approach to create new experiences for how brokers interact with members. We developed and designed personas, user journeys and eight future-state business processes before developing technology requirements.

4. Change funding mechanisms.

It’s accepted practice today to spend heavily on implementation while strategy and design efforts receive limited funds despite being prerequisites to successful outcomes. One organization we worked with was trying to build an industry-leading artificial intelligence model but lacked adequate budget to estimate ROI. Organizations must reallocate more budget to strategy and design efforts.

Advances in platform solutions that minimize customization needs support this funding shift. Organizations also must redefine how they identify OpEx and CapEx spend because many strategy and design efforts (e.g., journey maps, process models, business architecture, etc.) are critical to building required future capabilities and may be capitalized.

Our study revealed a number of immediate investment priorities for payers, including tools for estimating procedure costs, looking up benefits, searching for providers, finding plan options, reviews and features, checking on claims status, and calculating out-of-pocket expenses. But to realize high adoption and commensurate returns, payers must build these capabilities on a foundation of analytics and business-led strategy and design, followed by strong awareness campaigns.

By taking this approach, payers will set the stage for future member interactions that are more relational vs. transactional, such as health coaching, which will build loyalty and market share.

For more, read our report “Health Consumers Want Digital; It’s Time for Health Plans to Deliver,” produced in partnership with HFS Research.

Jagan Ramachandran is an Assistant Vice President and Partner in Cognizant’s Healthcare advisory practice. He leads Cognizant’s stakeholder experience management service line with over 20 years of experience at the intersection of healthcare business and technology. Jagan has executed a wide range of management consulting projects in the health plans space in the areas of digital strategy, member experience, broker experience, provider experience, establishing new lines of business, platform selection, M&A, and automation advisory. Jagan is a speaker on emerging trends in healthcare in several industry forums. He can be reached at Jagan.Ramachandran@cognizant.com

William “Bill” Shea is a Vice-President within Cognizant Consulting’s Healthcare Practice. He has over 20 years of experience in management consulting, practice development and project management in the health industry across the payer, purchaser and provider markets. Bill has significant experience in health plan strategy and operations in the areas of digital transformation, integrated health management and product development. Bill can be reached at William.Shea@cognizant.com

Source: How To Build Digital Tools That Health Plan Members Will Use

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This Remote Patient Monitoring Startup Just Landed A $70 Million Series C

Health Recovery Solutions in action

hen Covid-19 cases began to soar around Ann Arbor in April, the University of Michigan Hospital reached 100% capacity. Like most hospitals, University of Michigan Hospital was not ready for the pandemic surge, but they did have a leg up.

That same month they’d coincidentally implemented Health Recovery Solutions’ remote patient monitoring, a patented technology system that records patient vitals via Bluetooth and connects them with their clinicians through video or instant messaging. This enabled the resource-strapped hospital to care for over 400 patients remotely throughout 2020.

Today, HRS announced it closed a $70 million series C led by LLR Partners with participation from existing investor Edison Partners, bringing the Hoboken, New Jersey-based startup’s total funding to $86 million. The news comes on the heels of a year of massive growth, which saw their head count balloon 258% to 155 employees and revenue grow by 188% to $23.5 million.

“People are choosing the proven remote-monitoring solution right now,” says Jarrett Bauer, HRS’ Forbes 30 Under 30 cofounder and CEO. “That’s one of the reasons why we’re doing so well—people are looking for the company that’s best.”

Bauer, now 34, was inspired to start by HRS by his grandma. Battling a heart condition, Bauer’s grandma was admitted to the hospital three times, resulting in over $14,000 of medical bills. While pursuing his M.B.A. at Johns Hopkins in 2012, Bauer began constructing an at-home hospital alternative that would eventually become HRS. “We didn’t know where to start,” Bauer told Forbes in 2019 when the company raised its $10 million series B. “We just knew it was a problem, and the best companies solve problems.”

With Covid-19, telehealth doctor appointments have become just doctor appointments, increasing 154% from March to October of 2020, according to the Centers for Disease Control. Rather than cut into HRS’ margins, the telehealth boom has helped HRS soar. The healthcare company has deals with over 220 U.S. healthcare systems—74 of which signed on as clients of HRS during the pandemic—with over 20,000 nurses checking HRS logs every day.

“We consider Health Recovery Solutions the Cadillac model,” says Brandy Knudson, Michigan Medicine’s Telehealth Project Manager. “It fills a huge gap for us because we want to reduce readmissions and reduce unnecessary trips to the hospital.”

The company makes money by billing clinical institutions on subscription to integrate their solutions in treatment, coming at no additional cost to patients. HRS recognizes the varying levels of sickness and technological ability of patients, so the company’s products range from a pulse oximeter for the sickest, while near-recovered patients can manually enter symptoms on HRS’ smartphone app.

All of this patient data is stored in a cloud for clinicians, making it easier to recognize prognosis patterns and health trends. By implementing HRS, major healthcare systems like Penn Medicine have reduced 30-day readmission by over 50% for all heart failure patients, while FirstHealth of the Carolinas says the technology has saved patients more than $1.9 million since its implementation in 2016.

“Patients are looking to stay in their homes longer, get care in their homes longer, and there’s an increasing prevalence of chronic conditions,” says Sasank Aleti, a partner at Philadelphia-based private equity firm LLR Partners. “HRS met our criteria of taking costs out of the system, driving better outcomes and a better patient experience.”

For Bauer, the future of HRS lies in universalizing hospital-from-home treatment. With the $70 million round, the company plans to more than double head count in 2021 to 250 employees with the goal of being able to treat over a million patients by adding new healthcare providers and upping their disease module count (they currently treat 90 diseases). “Why aren’t we like Google? Why aren’t we like Apple?” asks Bauer. “We’re playing to win—to be that.”

I’m the Under 30 Editorial Community Lead at Forbes. Previously, I directed marketing at a mobile app startup. I’ve also worked at The New York Times and New York Observer. I attended the University of Pennsylvania where I studied English and creative writing. Follow me on Instagram and Twitter at @iamsternlicht.

Source: This Remote Patient Monitoring Startup Just Landed A $70 Million Series C

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The coronavirus pandemic has overwhelmed hospitals, physicians and the medical community. That’s pushed telemedicine into the hands of providers and patients as the first response for primary care. Telemedicine isn’t new to the medical community, however it hasn’t been embraced due to insurance coverage, mindset and stigma. Here’s how it works and what it means for the future of health care. » Subscribe to CNBC: https://cnb.cx/SubscribeCNBC » Subscribe to CNBC TV: https://cnb.cx/SubscribeCNBCtelevision » Subscribe to CNBC Classic: https://cnb.cx/SubscribeCNBCclassic
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Online Therapy, Booming During the Coronavirus Pandemic, May Be Here to Stay

Mental health flows from the ceramic jug psychotherapist Lori Gottlieb keeps on her desk. There’s nothing special about the jug—a minor accessory in an office designed with the sort of tidy impersonality common to her field. And there’s no special elixir in it—just water. But all the same, the jug provides a certain kind of healing. When patients are struggling, crying, overcome in some way, Gottlieb, a Los Angeles based practitioner and author of the book Maybe You Should Talk to someone, will offer up a cup of water, pour it for them and hand it across.

In that small gesture is a whole constellation of meaning: concern, care, protectiveness, generosity. It’s a little grace note that’s possible only in person—only when two people are in the same room, sharing the same space, face to face across just a small physical gap. Ever since March, however, when much of the U.S. went into lockdown as a result of the COVID-19 pandemic, such in-office intimacy became impossible across nearly all professional disciplines. Psychotherapy sessions—like so very much else—have become virtual, conducted on-screen, at a remove, riding the electrons of Zoom or Skype or Google Meet. And that comes at a price.

“There’s the ritual of coming in every week, sitting in that room on the same spot on the same couch in the same office,” says Gottlieb. “It feels incredibly comforting and safe. I think the environment part of it is very important for people.”

That’s not true just of mental health, of course. Most of us aren’t getting a fraction of the person-to-person interaction we’re accustomed to, and most of us are pretty well fed up with it. Virtual birthday parties are no party at all. Virtual happy hours have everything but the happy. Call it Zoom fatigue, cabin fever, flat-out loneliness—many today are suffering from isolation to one degree or another and long for the moment that the virtual lives we’ve been forced to live can be tossed aside.

But telepsychology (or telepsychiatry or tele-mental-health, as it’s been variously called) may have a stickiness to it that other aspects of virtual living lack. In recent years there’s been more and more talk in the health care professions about the potential for telemedicine. For some kinds of care, it’s easy to see how routine “office visits” that allow doctors and patients to meet without the need for an actual office could work: the orthopedic surgeon checking a patient’s range of motion and inquiring about pain after knee replacement surgery, say. But too many other visits require hands-on contact—palpating, blood draws, suturing—to make telehealth a universal practice.

Tele-psych, though—with its talk-and-listen simplicity—is a different matter. If ever there was a caring discipline that was poised to jump aboard the telemedicine train, it’s mental health.

“In February of 2020, before COVID-19 really hit our country, telepsychiatry was beginning to be widely available but only sporadically adopted,” says Dr. Jay Shore, a professor at the University of Colorado Anschutz Medical Campus and the chair of the American Psychiatric Association’s Telepsychiatry Committee. “Now it’s been a tsunami. At the University of Colorado maybe 10% to 20% of [mental health] visits were over video before. Now, outside of inpatient stuff, we’re at like 100%.”

That has been true pretty much everywhere else in the country, where therapy sessions have been happening either online or not at all. In mid-May, the American Psychiatric Association surveyed its members on how frequently they held tele-psych sessions both before and after the onset of the pandemic. The results were striking: Prior to COVID-19, 63.6% of respondents did not use virtual sessions at all. After the onset of the pandemic that figure plunged to just 1.9%. Conversely, before COVID-19 hit, only 2.1% reported using tele-psych 76-100% of the time. During the pandemic that figure has soared to 84.7%.

It was a change made by necessity, not by choice, but there are plenty of people who like what they’re experiencing. There’s convenience for one thing: a 50-minute session is a 50-minute session, not two or three times that as the patient wastes part of the day just getting to and from the appointment. That’s especially important in rural communities that might have been mental health deserts before—with the nearest caregivers requiring a long drive to the closest big city.

Patients are able to have their appointments pretty much anywhere. “If you were going to go drop your kids off at soccer practice, you could sit in the car and have a relatively private session with your therapist while you’re waiting for the soccer match to be over,” says psychologist Jared Skillings, chief of professional practice for the American Psychological Association. “This provides a significant increase in access and quality of life.”

Tele-psych also allows for more enduring doctor-patient relationships. If your job transfers you to another city, you can always find another doctor to tend to your physical ills, but you didn’t spend years confiding your most intimate secrets to your cardiologist or ophthalmologist and now have to start over with an entirely different person. Your psychologist is another matter entirely. “The advantage is clearly that you get to have continuity of care,” says Gottlieb.

All of those plusses have some in the community convinced that not only are tele-sessions the future of mental health, but that that future is now. “I think that anyone who tries to prognosticate comes across as a fool,” says Shore. “But what I can say is that we will never be the same, we won’t go back to where we were.”

And yet, what about that water jug? What about the sense that a therapist’s office is a third place, a safe space, neither work nor home but a place that, for those 50 minutes at least, feels like the patient’s own? Not every patient is the same and for many there is a comforting ritual in the opening of the doctor’s door and the gathering in that follows. Shore may indeed be right that the forced experiment with tele-psych that the quarantine months have necessitated has dramatically changed the game. Just how much and how enduringly it’s been changed is the real question.

Teletherapy may seem very much of the moment, but it’s not a new idea. As long ago as 1959, the University of Nebraska began a pilot project using mid-century video technology to allow patients and doctors to meet remotely. But the system was expensive and impractical and it lent itself poorly to the Freudian era of lying on couches and free-associating to a silent therapist whose face you didn’t even see. It wasn’t until the late 1990s, with the Internet fully entrenched and two-way video platforms coming online that the telehealth gained any traction. Even then though, it was used in a limited way.

“We started to see big systems like the Department of Defense and the Veteran’s Administration and jails develop sustainable larger scale telepsychology services to serve their populations,” Shore says.

Still, that was enough to prove the technology’s potential—if not its immediate appeal—and practitioners adopted it unevenly. While Shore reports that well before the pandemic he already had patients he’d worked with for 12 to 15 years and had never met in person, Gottlieb wanted no part—or at least very little part—of telehealth.

“I didn’t do telehealth at all unless there was a circumstance like I already had an established patient and that person was going to be on a work assignment for a few months,” she says. “But I would never meet somebody doing telehealth.”

Then the pandemic forced the profession’s hand and even doubters like Gottlieb have seen some of its advantages. She concedes that she likes the leveling effect of both patient and doctor getting background glimpses into each other’s homes—a sort of intimate equality of behind-the-scenes access. She likes the insight she gets when a patient Zooms from a bedroom and she catches sight of what’s on the nightstand.

“Usually what people keep on their nightstand tends to be the most personal of things, what means the most to them,” she says.

And she likes, too, the spontaneity and humor that a tele-session can provide. A surprising number of people, Gottlieb says, will have a session in the bathroom, sitting on a closed toilet—looking for a private spot in their homes. During one session, a patient was crying because her mother was in a nursing home where COVID-19 had been detected, and she was worried. She sat back and accidentally hit the handle of the toilet causing it to flush loudly.

“She was embarrassed and said, ‘Am I the only person who does therapy from the toilet?’ And I said, ‘No, actually the toilet has become the new couch.’” They both laughed—which the patient later said was the best and most helpful moment in the session.

Whether all sessions will be so effective depends at least in part on the kinds of issues the patient is struggling with. Obsessive-compulsive disorder, for example, lends itself comparatively well to tele-psych sessions because the standard of care for it is what’s known as skill-based therapy—learning behavioral tools that help break the OCD cycle—which may require less intimacy than other kinds of therapy, and instead calls for rigorous practice and discipline. Post-traumatic stress disorder patients may similarly benefit from online therapy, at least at first, since the home might feel like a safer space than a doctor’s office.

But there are downsides in treating these and other disorders online—in the form of cues missed due to the limited frame of a computer screen. The jiggling foot, the knotted hands, the subtle shifting in the chair that telegraphs unease with a topic of conversation are all lost to the doctor in tele-sessions. For patients battling substance abuse it’s hard to get away with the telltale gait of intoxication or the smell of alcohol on the breath in an in-person session. Not so hard on Zoom.

Group therapy can present its own challenges. A key part of the dynamic of the group involves eye contact—who’s listening, who’s not, who’s offering an affirming nod or shifting uncomfortably at someone else’s story that may hit a raw nerve in the listener. On a Zoom screen with a dozen faces arranged in Brady Bunch tiles, all of that is missing.

Even when the group is just two people, things get lost. Gottlieb recalls counseling a couple in a telehealth session and suddenly noticing their mood going from comparatively detached to warm and compassionate. “I was trying to figure out what had shifted there and then one of them said they were holding hands,” she says. “But I didn’t see it. They were holding hands under where I could see.”

If tele-psych is going to have a wide, post-pandemic future, it depends on more than just the acceptance of patients and providers. As with so much else in the U.S. health-care system, things come down to who will pay. During the pandemic, Medicare, many state Medicaid programs and commercial insurers have loosened rules or allowed waivers to cover telehealth sessions. When the pandemic ends, however, so could the payments.

Those in the field want to stop that from happening, making sure we don’t lose the lessons we’ve learned from the experience. “We are advocating for Medicaid, Medicare, and private payers to keep telehealth turned on at least for 12 more months after the coronavirus pandemic is officially declared to be over so that we can better evaluate the impact that has had on patients,” says Skillings.

In a live June 9 event with STAT News, Seema Verma, the Administrator for the Centers for Medicare and Medicaid Services (CMS), offered support for that kind of sentiment, arguing that coverage for most forms of telemedicine, including tele-psych, should indeed continue after the pandemic ends. The dramatic increase in overall access to care—with telemedicine visits increasing 40-fold in some parts of the country during the pandemic—is, all by itself, an argument for maintaining the system, she said. In August, the CMS issued new guidelines that provide physicians nine new billing codes to cover telemedicine going forward.

The portability issue is another unsettled question that will endure beyond the pandemic. It’s true that one of the advantages of tele-psych is that patients who move from state to state can continue to work with their original doctor—but that’s only if each state’s licensing rules permit that kind of cross-border practice, and so far most don’t.

In 2011, the Association of State and Provincial Psychology Boards—one of the profession’s governing bodies—created a task force to promulgate tele-psych guidelines for practitioners. From that came a proposal for what became known as PSYPACT, a national reciprocity system under which states would accord tele-psych privileges to practitioners living in other states. Joining the group requires action by state legislatures, and currently 15 have passed the necessary laws, with approval pending in 12 more states and the District of Columbia.

“At the end of the day,” says Skillings, a vocal PSYPACT advocate, “this is actually about providing care to our community, to improve their health.”

Improving community health is, of course, what all medicine, virtual or otherwise, is about. Mental health, which lacks the clarity of other medical disciplines—the blood tests and CT scans and MRIs that can make diagnosing illnesses and prescribing treatments so straightforward—has always needed more options in its therapeutic toolkit. Tele-psych, even with its doubters and its drawbacks, is easily one of the newest. In time, it may also prove to be one of the best.

By Jeffrey Kluger

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