The Telepsychiatry Advantage: Episode 14

Telepsychiatry for Psychotic Patients: What the Evidence Shows

Introduction & Early Misconceptions

When I first started building telepsychiatry programs in the early 2010’s, it was a challenge because people did not even know the term telemedicine. Can you imagine a word that everybody knows now, very few people knew in the year 2010. And my job was to build a telepsychiatry program for the California prison system, the statewide telepsychiatry program.

And my job was cut out for me because not only did a lot of people not know about telepsychiatry, but when I told them about it, I said, hey, there’s this thing called telepsychiatry where we don’t need to recruit psychiatrist to a rural prison, that no psychiatrist wants to work around. Psychiatrists like cities.

And when I said this, the objection was, well, telepsychiatry won’t work. And they had lots of reasons why it won’t work. And one of those reasons was that they thought that patients would get paranoid talking to their psychiatrists on camera. And mind you, they didn’t have evidence for this. I mean, a lot of them, actually, most of them were not even psychiatrists. They were psychologists and other classifications that don’t even do psychiatry.

They and others, even psychiatrists, had all of these assumptions and notions about telepsychiatry where it wouldn’t work in certain types of populations. Specifically, I would hear psychotic patients a lot. I wouldn’t hear them in my head. I’m saying I would hear the objections from chiefs of mental health that psychotic patients would not do well, and they couldn’t cite any evidence, of course.

And so I had that challenge of convincing people. And once I was able to convince a few chiefs of mental health that psychiatry could work remotely via video, it worked and it helped patients, and it helped the chiefs of mental health fulfill the needs of their patients. And so they wanted more. And then pretty soon, there was a competition for those resources.

And those ideas of telepsychiatry doesn’t work for psychotic patients. They kind of faded like that wasn’t really their focus anymore because they were getting something valuable out of it.

Overcoming Assumptions & Meeting Patient Needs

I guess the lesson here is that a lot of people will make assumptions and deprive themselves of opportunities to meet their needs over ideas that aren’t actually evidence based. And the question for today is, is it evidence based?

I mean, is there enough evidence? Is there evidence against telepsychiatry for psychotic patients? We’re going to dive into all of that.

I also want to remind you guys that sometimes telepsychiatry is the only option for somebody who needs psychiatry services. So I have gotten that historically where well, telepsychiatry doesn’t work for, you know XYZ type of population. They would just rule out complete populations and say, oh, it won’t work for this, it won’t work for that. And sometimes there’s no alternative nowadays.

In fact, there are lots of patients that are completely reliant on telepsychiatry, and they live very far from a doctor’s office, like really far remote areas, small, basically villages out there in America. And so what are we going to do about those patients who don’t have access to in-person doctors, telemedicine and telepsychiatry? And so sometimes we don’t have the choice, and we have to treat a patient even if we feel like it’s suboptimal, because at the end of the day, medicine is not about being perfect. It’s about meeting the need and in the way that you can meet the need is telepsychiatry.

So did we get that straight, guys? We need telepsychiatry for all types of patients, even psychotic patients.

Friction: In-Person vs. Virtual Care

So let’s say that you have the choice between having a patient seen via telepsychiatry, or the patient having to go to the doctor’s office. Let’s say that the patient has access to both and also that they’re psychotic. They’re delusional.

What’s harder to do to get the patient to fight traffic or long commute and go sit in a waiting room with other patients and wondering, you know, if they’re being recorded in the office, having all kinds of delusions around that experience and then sitting in front of the doctor. I mean, there are plenty of opportunities to be delusional. Okay? Even if you’re not psychotic, I mean, lots of people are delusional about lots of things. So but what’s more of a bar like a higher bar doing all of that, or having the patient turn on their camera and talk to you?

Well, I mean, obviously there are some technology issues that may be challenging for certain patients, but I think that going to a doctor’s office on a regular basis, staying compliant with that process, that’s also not always something a psychotic patient can or will do, will be willing to do. So that’s another point that telepsychiatry might be a lower bar for some of these patients.

Addressing Paranoia and Patient Preference

Okay, so for my next point here I’m going to talk about what happens if they are delusional. First of all, can you think of anyone who’s been delusional with the camera and saying, why are you recording me? Well, I don’t think that’s a major problem, at least not in my practice and not in all the people that I’ve worked with. Rarely ever have I heard that the patient was reluctant to do telepsychiatry over a fear of being recorded. Now that can happen with psychotic patients or non psychotic patients. Some people will not trust the technology. But I can tell you that from my experience, seeing thousands of patients, tens of thousands of patients and also overseeing lots of psychiatrists who they themselves have seen 10,000 patients, I don’t think that, I can’t remember a lot or even 1 or 2 times, where the doctor told me that the patient was paranoid about the camera.

Now, there have been plenty of times where they didn’t want to do telepsychiatry because they didn’t like how it felt to them or they didn’t like the doctor. I mean, most of the time it’s about the doctor. They don’t like the doctor. Okay, so let’s fix that, guys. Okay? If your patient doesn’t like you, then that’s a much bigger problem than the idea that they are paranoid about the camera. They may not like you and that’s probably the bigger, much bigger reason. In fact, I shouldn’t say probably, that’s almost always the biggest reason they don’t like talking to you because you talk down to them, or you don’t explain things in a way they can understand, or they just don’t like you for some other reason.

So hopefully your patient likes you. And sorry for that little tangent. I’m sure your patients like you. I don’t mean to offend anybody out there, but the point that I’m trying to make here, guys, is that you got to put everything in perspective, okay? The patient is much more likely to not like their doctor than not like telepsychiatry because they’re worried that they’re being recorded. So that’s the reality.

But you can still keep listening to this episode because we can still talk about this idiosyncratic and really niche idea that the patient is not going to do well over telepsychiatry because they’re psychotic.

Continuing with this conversation about psychotic patients in front of the camera, well, what if they do say that they don’t feel comfortable? Well, the fact is that they’re probably not going to show up. So you might not even know about that because they won’t show up. And so part of it is going to be whenever there is a no show, figure out why. And this is just the general good, useful thing to do to investigate why your patients don’t show up. If it’s because they don’t feel comfortable on camera, then you address that situation. You tell them that you know it’s a safe technology. Now, granted, you need to make sure that it’s safe and it’s HIPAA compliant and that all the protocols are put in place to make it a secure visit. You want to make sure that they understand that.

And also you want to tell them that if they feel uncomfortable at any point, we can always stop the telepsychiatry appointment and figure out another way to take care of them, whether it’s resuming it at another time or finding some sort of in-person solution. I think it’s important for your patient to know that. No pressure here.

And I often tell my patients, anybody who’s reluctant to do telemedicine, I tell them, just give it a try. And then if they try it, they almost always I’m not saying always because I can’t tell you every single patient experience that’s ever happened on telepsychiatry. But in my experience, every time the patient gave it a try, it was okay. And maybe the session ended for other reasons. Like the patient got upset because I wasn’t telling them what they wanted to hear. And yeah, you know, shockingly, some patients don’t like me. Most of them do, because, you know, I’m a great psychiatrist and they love me. But, you know, there are some people out there that don’t love me and that is okay too.

But anyway, getting back to it, I would say that once you get them started on telepsychiatry, they kind of forget about all the concerns that they had about it. And just like that mental health chief, those mental health chiefs that I was talking about earlier where they forget about their complaints and concerns about telepsychiatry when they’re getting what they need. The same goes for the patient. If they’re getting the treatment that they need and they’re benefiting from the appointment and they feel good about you as a doctor, they’re not going to be concerned about the technology, even psychotic patients.

Clinical Strategies for Psychotic Patients on Camera

And what do you do when you’re dealing with somebody who’s psychotic, delusional? Some of the same things that you’ll do in person. Okay. That is, you don’t confront the patient about their delusion and say you’re wrong. You know, you’re wrong about reality because the nature of psychosis and delusions and hallucinations are that the patient experiences them as real things. So it’s like, if I tell you right now that you’re not listening to a podcast. You believe that you are listening to this podcast, and I can’t say anything that’s going to convince you that you’re not. So you should know this from basic training here, but don’t confront your patient about the delusion. Validate their emotion, about their feeling about it, not the delusion itself. Like, oh, I understand that that must be a really hard experience for you, or it must, you know, make you feel scared. You can validate the emotion, but you don’t want to validate the actual psychotic belief. Like, yes, you’re right, you’re being recorded and it’s being sent to the FBI. Like, obviously, you know, in an effort to try to relate to the patient and form a bond and rapport with the patient. You don’t want to validate the delusion itself because you don’t want to reinforce that.

Instead, you want to explore. So you don’t want to confront, you want to explore. Why are they feeling this way? Tell me more about that. What makes you think this? And just try to get information because this is data, okay? Like everything the patient says and does should be interpreted as data. It shouldn’t be something where you want to fix everything that they say. You want to understand your patient. And if we can understand our patient better, then that’s half the battle.

Also, when you’re dealing with a psychotic patient, you want to separate the belief from the behavior. So even if they believe something, it doesn’t mean that they’re going to behave in a way that is going to be harmful. If the camera is part of the delusion, you don’t necessarily have to like, fix that problem. You use that for information to understand how psychotic somebody is, why they believe the way they do, and just get down to the root of why they feel and think the way they do. Even just the first few moments where a patient is talking to you on camera and they’re expressing concerns, you can use that to gain information about their delusions, their hallucinations, their level of organization, the mental status examination in general. You can get a lot of information, and this is a pro tip, you can get a lot of information in a short visit.

You know, I used to work in the prison system. And one of the problems was the patient wouldn’t show. And then the custody officer would say, oh, they didn’t show up, they didn’t want to come or whatever, or maybe there was no reason given. And I would go to the patient’s cell front to get that information of why they didn’t show up. And when I did that, I got valuable information just by even if the patient didn’t talk to me at all, I would have valuable information just seeing what the patient looked like, what was their cell looking like, what was their affect, their behavior. And if they talked to me even briefly, I would get a whole lot more information as well. So if you can just get the patient on camera for a few moments, you can get a lot of information and then you can go from there. Even if they don’t want to talk to you for more than 30s, you’ll have lots of information.

So the key here to sort of net it all out for you is get the patient on camera, even if they have some reluctance to it, and try to dispel the myth or, you know, not confront them on their delusion, but just let them know that, hey, I’m not recording you. Okay? But tell me more about why you think that this is a problem.

So it’s a little bit of a balance because you don’t want to confront them, but you do want to reassure them that all of the procedures are put in place to make this appointment safe for them, and they may not believe you. And that’s okay, too.

Examining the Research Data

So now we’ve learned a little bit about what to do to get the patient to the appointment and see the patient maybe try to address their concerns. But now let’s look at the hard data okay. Not too many people want to look at data when they come to conclusions about telemedicine and about telepsychiatry. They have their own misconceptions about it. And fortunately, over time, people have less and less concerns about telemedicine. But what does the actual data show?

So generally, the data shows that telemedicine and telepsychiatry are effective. Telepsychiatry is effective in not only affecting good patient outcomes, but also patient satisfaction. There was a study done in 2014. I’m calling it a meta analysis, they didn’t call it that in the study, but they looked at 390 articles and they found 18 relevant articles. And they said that based on the data available, the use of modalities involving internet, video conferencing and telephone was feasible with patients with schizophrenia.

So that was kind of an early study, 2014, and that’s early for telemedicine standards. And I was able to find an even earlier study. This was in 2011, and it showed that the use of video conferencing with patients with psychosis, it was a review of the literature, and they found that there was little evidence that patients with psychosis had difficulty with video conferencing or experienced any exacerbation of symptoms, and that the evidence, in fact, suggested that the distance could be a positive factor.

So imagine the idea that it could actually be a positive for patients with psychosis to see their doctor on video, as opposed to going to the doctor’s office.

Okay, so now we’re going to go to a more recent article. In 2018, there was a review of the literature that showed that telehealth interventions for schizophrenia spectrum disorders and those that were clinically at risk for psychosis, it showed that video conferencing was feasible and that there was a high acceptance of this intervention modality for these patients. So that was an article in 2018.

Now, an even more recent study, this was in January of 2025, showed the effectiveness of video conference based cognitive behavioral therapy for patients with schizophrenia. So not only is it medication management that can be effective, but also cognitive behavioral therapy for patients with schizophrenia. Cognitive behavioral therapy is widely used via telemedicine, telepsychiatry, telemental health. And there was a notable study here, a total of 290 patients with paranoid schizophrenia were recruited to a 12 month study, and it used the smartphone, and it shows that these patients, after 12 months significant symptom reduction was observed in the study group, and cognitive training is was something that was successful via telepsychiatry for paranoid schizophrenic patients. So imagine that paranoid schizophrenia responded very well to a telemental health intervention for a lot of patients in that study.

When we talk about results, we’re not just talking about reduction of symptoms. We’re also looking at outcomes like hospitalization. There was an article in 2017, so that would be nine years ago, by my math, that showed a reduction of medical hospitalizations in veterans with schizophrenia using home telehealth. So I can keep citing studies. And hopefully I am convincing you that there is literature out there that shows that, generally speaking, telepsychiatry is a very valuable tool for seeing patients with schizophrenia and other psychotic conditions.

Guidance from the American Psychiatric Association

Well, what about the American Psychiatric Association? What is their stance on this subject? Well, the American Psychiatric Association has consistently promoted telepsychiatry for patients with serious mental illness, including patients with psychosis and schizophrenia. And they’ve put out statements that say that it’s a myth to say that paranoia is the biggest factor when it comes to technology. And in fact, the biggest factor in reluctance to use telepsychiatry is not paranoia. The APA cites studies that show that the concern is more about privacy issues than paranoia and delusions, and the APA consistently puts out information to suggest that psychiatrists should embrace telepsychiatry for every type of patient population. They don’t say necessarily every single patient is appropriate for telepsychiatry, but they don’t say that “hey, you cannot use telepsychiatry, telepsychiatry helpful for patients with paranoia and schizophrenia:. In fact, they see the opposite, that it’s a valuable tool that should be embraced and used. So there is lots and lots more research and articles, publications about the effectiveness of psychiatry, not only for the general patient population, but specifically for patients with schizophrenia.

So hopefully I’ve convinced you that the evidence base is supportive of doing this. And if I haven’t convinced you, I don’t think I ever will convince you until you do it for yourself and you see that it’s going to work for most patients.

Now, I do want to stick with the APA here for a moment longer and show you that all of the guidelines and recommendations that the APA has for treatment of patients with schizophrenia can be accomplished via telepsychiatry. So let’s go through some of those guidelines. I’m going to read from the guidelines that were published by the APA. November 6th, 2020 the practice guidelines for the treatment of patients with schizophrenia. And in their guidelines, they recommend that the initial assessment of a patient with a possible psychotic disorder includes several things, like the reason why they’re presenting to you, the goals and preferences for their treatment, a review of their psychiatric symptoms, their substance use, the assessment of their physical health, assessment of their psychosocial and cultural factors in mental status examination–all of these things can be done via telepsychiatry.

They also recommend that the initial evaluation includes a quantitative measure to identify and determine the severity of symptoms and impairments. Again, that can be done via telepsychiatry. They recommend that the patient with schizophrenia have documented comprehensive and person centered treatment plans that include evidence based non-pharmacological and pharmacological treatments. Again, this can be done via telepsychiatry. So they recommend all kinds of guidelines around pharmacotherapy monitoring side effects, recommending clozapine, for example in treatment resistant schizophrenia, they recommend schizophrenia be treated with long acting injectable antipsychotic medications if the patient prefers this treatment or has a history of poor outcomes. And I’m not going to bore you with the rest of these guidelines, but I can tell you that all of the pharmacological and psychosocial interventions can be accomplished using telepsychiatry as a tool.

Conclusion & Next Steps

And so the bottom line here is telepsychiatry works for patients with schizophrenia, schizophrenia spectrum disorders, psychotic patients, even if they don’t have schizophrenia. It can work with essentially any type of patient population. And you should not rule out telepsychiatry based on the type of patient that you have. Now again, the disclaimer here is that certain patients may not be a great fit for telepsychiatry. Maybe they just flat out refuse and you can’t convince them. Maybe they don’t have access to the technology, or they just hate technology in general. So there could be isolated situations where a patient refuses to participate or is just not a good fit. But those are very rare, and you should not rule out telepsychiatry based on an arbitrary, arbitrary assumption that you have or a misconception that you have that hopefully I’ve dispelled today.

In some cases, a hybrid model might be the most effective way to treat a patient. In some cases, not. So again, you look at the scenario and you decide for yourself how you can best serve the patient. And in most cases, telepsychiatry is a fantastic way to do that. So now that you have the information, go bravely forward with telepsychiatry.

I’m going to list some of the articles that we talked about in the show notes. But until next episode, thank you for joining The Telepsychiatry Advantage and keep raising the standard.