The ongoing trial of Lindsay Clancy, accused in the deaths of her three children, has brought renewed attention to the efficacy and limitations of telehealth in mental health treatment. Clancy reportedly had 14 virtual visits with her psychiatrist over a five-month period leading up to the January 2023 incident, with the two never meeting in person.
This case has prompted broader discussions about the increasing use of telehealth for individuals with serious mental illnesses. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly half of American adults with serious mental illness now receive some form of mental health treatment via telehealth. During cross-examination, Clancy's defense attorney questioned the reliance on virtual appointments, asking the psychiatrist if she had ever suggested an in-person visit. The psychiatrist stated that the virtual interactions did not appear to be an issue and that she felt she was not missing anything.
Psychotherapist Jonathan Alpert, who was not involved in Clancy's care, noted that while virtual care can be effective, there are situations where a screen may not suffice. "The sicker and more unstable someone becomes, the less comfortable I'd be relying exclusively on a screen," Alpert said. He emphasized that if a patient is exhibiting signs of severe instability, such as suicidal ideation, psychosis, mania, or an inability to function, clinicians must consider whether an in-person evaluation or a higher level of care is necessary.
Benefits and Drawbacks of Virtual Care
Telehealth offers significant benefits in mental healthcare, including increased accessibility. For providers, virtual sessions can allow them to see more patients daily compared to in-office treatment. For patients, it eliminates commute times, making it easier to fit appointments into busy schedules. Alpert acknowledged that telehealth "has helped a lot of people get care who otherwise might not."
However, limitations exist, particularly for those with severe psychiatric disorders. Alpert pointed out that certain patient indicators, such as hygiene, agitation, intoxication, or general behavior, can be less apparent on video calls. A patient might present as composed during a 30-minute virtual session while experiencing significant distress outside of it.
Identifying When In-Person Care is Necessary
Alpert identified worsening patient condition despite frequent appointments as a critical warning sign. "More appointments aren't necessarily more treatment," he stated. "If someone is becoming more suicidal, paranoid, manic, disorganized, aggressive or simply unable to function, you can't just keep scheduling another video call and assume that's enough."
He advised that treatment plans must adapt, potentially including in-person visits, emergency evaluations, or transfers to higher levels of care. When concerns about suicide or violence arise, Alpert stressed the importance of direct questioning.
Key questions for clinicians include assessing whether the patient has thoughts of harming themselves or others, has a specific plan, has access to lethal means, and if recent actions indicate escalating risk. Alpert explained that while suicidal ideation is concerning, the presence of a plan and access to means would necessitate intervention, possibly involving law enforcement or emergency services.
Knowing a patient's location during appointments is also crucial for emergency response. Alpert also highlighted the value of information from family members or others in the patient's life, as patients may not always provide a complete picture.
Distinguishing Between Conditions
Alpert also drew a distinction between postpartum depression and postpartum psychosis. He noted that symptoms of postpartum psychosis, such as delusions, disorganized thinking, or hallucinations, definitively warrant inpatient treatment.
Ultimately, Alpert concluded that telehealth itself is not the issue. The primary concern is whether clinicians are conducting thorough assessments and if the level of care provided remains appropriate for the patient's condition. He added that while skilled clinicians can assess risk effectively via video, the same level of risk can also be missed in person. "The sicker and more unstable someone becomes, the less comfortable I'd be relying exclusively on a screen," he reiterated.