Treating ADHD Through Telepsychiatry During COVID-19

In this video, psychiatrist Birgit Amann, MD, provides tips and strategies for clinicians treating attention-deficit/hyperactivity disorder (ADHD) through telepsychiatry during the COVID-19 pandemic.

Dr. Amann is medical director of the Behavioral Medical Center in Troy, Michigan. She treats ADHD in children, adolescents, and adults, and has been an investigator on numerous ADHD medication trials.

Read the transcript:

Hello, my name is Dr. Birgit Amann. I'm a child, adolescent, and adult psychiatrist in a private practice in Troy, Michigan. I treat children, adolescents, and adults, and an extensive amount of ADHD, along with other conditions. 

I'd like to thank you for spending time with me as we talk about treating our patients via telemedicine during these unprecedented times. My hope is that by sharing some of my own experiences over the last few months I can help you as we all transition into this new way of practicing medicine. 

This has been a difficult time for all of us, whether as practitioners, our staff in the office, families, patients. We all need to understand how best to move forward. I'm going to try and give you some tips and strategies along the way as we talk today.

I'm going to start with some of the initial transitions from a very busy private practice, seeing patients every day, all day long, into one of all remote visits via telemedicine. It was a very challenging transition for us, like I'm sure it was for many people. 

As I tried to turn our office, practically overnight, into one of virtual telemedicine visits it caused me a lot of overwhelmed feelings, anxiety, distractibility, fidgetiness. I felt like I was feeling like a lot of my patients with ADHD felt. 

There was a lot of uncertainty on the part of our patients, too. "How am I going to get my medicines?" "Is Dr. Amann going to be able to do my visit?" and "My medicine can't be called into the pharmacy. How am I going to get my prescription?"

Everybody was feeling very overwhelmed and anxious. It took us probably about 3 weeks to get a good footing, to understand how to make it run as smoothly as possible. 

The biggest thing that we learned in that initial few weeks is that we needed to do a good job with communicating to our patients. We initially worked very hard at sending out mass emails to everybody to try to explain to them how their appointment would happen. 

We did an email reminder, as well as a text reminder, but within that reminder we described how they would utilize the platform that we had adopted for their visit. Additionally, we called everybody. We did a manual phone call to leave a voicemail to, again, describe how the appointment would go.

It's been about 9 weeks that we've been doing this. As recently as yesterday I noticed that my patient, who has ADHD, was not in my virtual waiting room, so I gave her a call.

I said, "Go ahead and hit the link so we can get started with our appointment." She said, "Oh, Dr. Amann, I'm just a few miles away from your office. I didn't realize that we weren't going to be doing this at the office."

I asked her, "Did you get your text, and your email, and the manual call?" She said, "You know, I probably got all those things, but I was too overwhelmed and distracted to even take a look at any of the details."

Communication is key. Do your best to help explain to your patients, in particular our ADHD patients. They're going to need some redundancy in how this is going to go.

I also found that, as much as communication was critical for my patients, it was also critical for my staff. I have 14 providers. We spent a lot of time together in those first few weeks practicing using the platform on each other, so we had a better comfort level. Staff needed to understand how the office flow was going to go, because it was so different. 

It wasn't just our patients. When our patients call and they're very distracted and overwhelmed, in particular our ADHD patients, it makes everybody else feel a large degree of some of the same symptoms, like I said, even for myself. A lot of anxiety. We worked hard to communicate among one another, as well.

We spent a lot of time trying to determine which platform was best to utilize. Probably no one platform is perfect for any one office. 

For us, it was important to have a HIPAA-compliant platform. What we liked about our platform is that we knew if our patient, in particular our patient with ADHD, had to download an app and then go through multiple different steps in order to get into that virtual waiting room, that would be very difficult for them. 

We selected one where all we had to do was send a link. All they had to do was hit the link, and then it was as simple as they were in the waiting room and we could start the appointment. 

There were additional things, though, that we needed to understand and are very important. We needed to understand would their insurance be covering a telemedicine visit. Were we covered, as far as our malpractice in doing telemedicine visits? What if the patient's out of state when we did our visit? Was that OK?

Again, one of the key things is to make sure we understand some of those details so that we can help our patients understand, as well. 

A key message for all of us to remember is to expect glitches. Be patient. Think about our ADHD patients who get so easily distracted anyways. Know that while you're talking to them there's going to be a cat walking by in the screen, or a dog, or the system is going to disconnect. All those things for anyone causes them to feel disrupted, overwhelmed, distracted, uncomfortable, but for the ADHD patient it can be 2 or 3 times worse.

It's important on the front end of your appointment to say, "It's OK if this isn't perfect. It's OK if you get distracted because you hear the lawn cutters outside your window or if we get disconnected. We're just going to reconnect again." Flexibility is key. Expect glitches and be patient. 

Have fun with it. I now, 9 weeks into it, can say that I've had a lot of fun. I've been able to say, "Introduce me to your dog or cat" or "Show me your fresh-cut lawn that we heard the lawnmower for the last 15 minutes." Have fun with it.

I had an older lady with ADHD who I was so proud, because this is the blind leading the blind, me trying to teach her how to do this telemedicine visit. For the whole 15, 20 minutes I was staring at her feet. That was all she could get to showing me in the way of the camera, but we made the best of it.

One of the most important things is be flexible. Know that everybody's going to have distractions around them and it's OK. 

We had a lot of our ADHD patients mentioning or expressing concern about being able to come into the office to get their controlled substances. There are so many rules and regulations that are definitely different depending upon state, but a lot of our patients each month come in to pick up the paper prescription for their ADHD medications and then take it to the pharmacy. 

Prior to about 3 to 4 weeks ago our system, our electronic medical record did not offer e-prescribing of those medications. We had to communicate to our patients that it was still OK to come in and get their prescription. 

They had to wear a mask. They had to be sure they didn't have any symptoms, of course, of COVID-19. When they came in, we, in a socially distanced way, made sure to get their prescription to them.

Fortunately, about a month ago we were able to start doing e-prescribing of their federally controlled medications. Although some still choose to come in and pick up their prescription, it has offered us the ability to minimize the amount of people coming in to get their prescription.

E-prescribing has become invaluable during this time. It's very efficient and has worked out well for a lot of our ADHD patients. 

In doing my appointments with patients with ADHD it's become apparent that they have far less structure in their day. 

Whether I'm talking to the parent of a child or adolescent who's saying, "Johnny has so much less expected of him right now. He is really doing fine with not even taking his ADHD medication" or an adult who says, "My job responsibilities are very different right now, and I don't know that I need my medication as much," I try to educate them that actually during this more unstructured time you probably need your medication more than ever. It's not really the time to take a drug holiday from your ADHD medication. 

We tried to take a look at the impact of not having the same degree of structure and the potential negative ramifications of not treating their ADHD. I strongly encourage them to stay on at least the dose that they were on, if not even, if we need to, increase the dose if we need to do that. Fortunately, we're able to get an appointment in the next few weeks following that increase, reassess, and then go from there. 

It's critical for them to stay on their medications, no different than if it was summer or the weekends. We want them to maintain stability in the way of treating their ADHD.

There are strengths and weaknesses, pros and cons, to using telemedicine, but the reality is that as we move forward and have more months of uncertainty in how this is all going to look or play out, it's pretty clear that we're going to need to use telemedicine for some time moving forward. 

Not being entirely sure how it's going to look for our patients, we're trying to think about a very slow, gradual transition back safely into having a few patients in the actual office, and then working gradually to increase the amount of patients that we see here. As a result, we're going to continue to use telemedicine. 

As we've gotten more comfortable, as things have gone smoother, as we feel calmer about that, our patients feel calmer about that and they feel better about that. Then we all realize that we can do this. 

This is most definitely a work in progress. We learn new things every day about using telemedicine, about treating our ADHD patients in this format. We are definitely in this together. For our patients to know that, it provides a real comfort to them. 

I'd like to thank you for your time today. Be safe and well. 

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