Virtual mental health care visits: Making them work for you
Before the pandemic, talking to a therapist or psychiatrist on a video call was novel. Now it’s fairly common. One recent analysis, for example, found that video appointments within the massive Veterans Affairs Health Care System jumped from about 2% of all mental health care encounters in January 2019 to 35% of these encounters in August 2023.
What are some advantages and disadvantages of virtual mental health care visits? Does seeing a therapist or psychiatrist by video instead of in person affect your response to treatment? If you haven’t yet used virtual mental health counseling, what do you need to know? Below, Stephanie Collier, MD, MPH, a psychiatrist at Harvard-affiliated McLean Hospital, shares her expertise and insights.
What are some advantages of virtual mental health visits?
Virtual visits are convenient for many people, including those who might have trouble getting to an office or who live in areas where it’s not easy to find mental health care providers.
“You can chat with your mental health care clinician in the setting of your choice, which might make you feel more comfortable,” says Dr. Collier. “You don’t have to worry about getting to and from an appointment. And you can be confident that your outcome will be similar to receiving in-person treatment. For example, in a 2022 study of about 1,500 people, participants being treated for anxiety or depression reported the same level of symptom improvement on standardized scales, whether they received virtual or in-person treatment.”
How do virtual visits work?
A virtual visit with a mental health care clinician works in much the same way as a virtual visit with your doctor.
You make an appointment to speak with an expert, typically a licensed therapist, psychologist, or psychiatrist. They may be in a private practice or work with your insurance plan or a hospital system. Or they might be affiliated with an online mental health care platform. Often, you can read a bit about their professional background, expertise, and other information to help you decide if they are a good fit for your needs.
Shortly before your appointment, you’ll log on to a specified video platform, and then find yourself in a virtual waiting room. When it’s time for your session, the expert will appear on the screen and conduct a 30- to 50-minute session, depending on what you’ve agreed on, just as they would during an office visit.
Will your insurance pay for virtual visits?
Not necessarily. Make sure your sessions will be covered. Medicare and Medicaid cover virtual mental health care visits, but not all private insurers cover the service. Even if you think you’re covered, double-check in advance.
What should you check on ahead of time?
Getting ready for a virtual visit involves prepping for both a mental health appointment and a video meeting.
- Go over the instructions. The mental health care clinician should give you instructions for accessing the platform where the virtual visit will take place. If you don’t have instructions, contact the clinician’s office or the online service to get them.
- Look for compliance. The platform your clinician specifies for your session should clearly state if it’s HIPAA-compliant, ensuring the privacy and security of your information. If you don’t see any evidence of HIPAA compliance, ask your clinician about it or consider choosing another mental health provider.
- Do an equipment inventory. You’ll need a smartphone, tablet, desktop computer, or laptop to take part in a virtual mental health care visit.The device needs a camera, a microphone, and an internet connection.You’ll also need a quiet space (so you and the expert can hear each other) and decent lighting (so the expert will be able to see you).
- Do a practice run. Well before your appointment, log on to the platform your clinician has specified. Check to see if you need to upgrade your software in order to use the platform. You don’t want any surprises just before appointment time. Try out the volume and your camera angle.
How can you help make video sessions work well for you?
When you have an in-person visit, it may be easier to see body language and express yourself. But many people –– especially younger people –– feel very comfortable online. And others might find the technology and apps easier to navigate with a little guidance.
Here are some tips to ensure that you’re seen and heard.
- Set a reminder to charge your equipment. The device you use should be well charged or plugged in to an electrical outlet for the appointment.
- Gather some supplies. You might want to have a drink of water, a box of tissues, and a pad and pen handy for taking notes.
- Make a list of questions or topics on your mind. “Think of a few topics you want to discuss in advance, so you can get through them during your session,” Dr. Collier says. “If you keep a journal or sleep log, and the information will be important, have it with you at appointment time.”
- Be willing to share your thoughts and emotions. You won’t have to carry the whole conversation. Your therapist will ask you questions and prompts to guide the session and help you open up about your feelings and experiences. For instance, they might ask, “How has your mood been since our last session?” or “What are some challenges you faced this week?”
- If you like, ask a friend to join you. If you’ll feel more comfortable with a friend in the room to support you or help you with the technology, arrange it in advance. During your appointment, tell the expert that someone else is there with you.
- Be patient. Sometimes experts run late. That means you might be stuck in an online waiting room, wondering if the appointment is still on. Dr. Collier advises waiting for about 10 minutes, and then leaving a voice message (if possible) or an email for your expert, explaining the situation.
Should you make another appointment?
If you feel your appointment was productive, consider scheduling another one. Again, make sure your insurance will cover it.
What if you didn’t “click” with the expert? “It’s an important consideration, since your relationship with your therapist is the best predictor of how you’ll do in therapy. So give it a few sessions. If you still don’t think your therapist is a good fit, it’s ok to change clinicians. Many telehealth platforms allow you to do that pretty easily.”
About the Author
Heidi Godman, Executive Editor, Harvard Health Letter
Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing
Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD
PTSD: How is treatment changing?
Over the course of a lifetime, as many as seven in 10 adults in the United States will directly experience or witness harrowing events. These include gun violence, car accidents, and other personal trauma; natural or human-made disasters, such as Hurricane Katrina and the 9/11 terrorist attacks; and military combat. And some — though not all — will experience post-traumatic stress disorder, or PTSD.
New guidelines released in 2024 can help guide effective treatment.
What is PTSD?
PTSD is a potentially debilitating mental health condition. It’s marked by recurrent, frightening episodes during which a person relives a traumatic event.
After a disturbing event, it’s normal to have upsetting memories, feel on edge, and have trouble sleeping. For most people, these symptoms fade over time. But when certain symptoms persist for more than a month, a person may be experiencing PTSD.
These symptoms include
- recurring nightmares or intrusive thoughts about the event
- feeling emotionally numb and disconnected
- withdrawing from people and certain situations
- being jumpy and on guard.
The National Center for PTSD offers a brief self-screening test online, which can help you decide whether to seek more information and help.
Who is more likely to experience PTSD?
Not everyone who experiences violence, disasters, and other upsetting events goes on to develop PTSD. However, military personnel exposed to combat in a war zone are especially vulnerable. About 11% to 20% of veterans who served in Iraq or Afghanistan have PTSD, according to the National Center for PTSD.
What about people who were not in the military? Within the general population, estimates suggest PTSD occurs in 4% of men and 8% of women — a difference at least partly related to the fact that women are more likely to experience sexual assault.
What are the new guidelines for PTSD treatment?
Experts from the U.S. Department of Veterans Affairs and Department of Defense collaborated on new guidelines for treating PTSD. They detailed the evidence both for and against specific therapies for PTSD.
Their findings apply to civilian and military personnel alike, says Dr. Sofia Matta, a psychiatrist at Harvard-affiliated Massachusetts General Hospital and senior director of medical services at Home Base, a nonprofit organization that provides care for veterans, service members, and their families.
The circle of care is widely drawn for good reason. “It’s important to recognize that PTSD doesn’t just affect the person who is suffering but also their families and sometimes, their entire community,” Dr. Matta says. The rise in mass shootings in public places and the aftermath of these events are a grim reminder of this reality, she adds.
Which treatment approaches are most effective for PTSD?
The new guidelines looked at psychotherapy, medications, nondrug therapies. Psychotherapy, sometimes paired with certain medicines, emerged as the most effective approach.
The experts also recommended not taking certain drugs due to lack of evidence or possible harm.
Which psychotherapies are recommended for PTSD?
The recommended treatment for PTSD, psychotherapy, is more effective than medication. It also has fewer adverse side effects and people prefer it, according to the guidelines.
Which type of psychotherapy can help? Importantly, the most effective therapies for people with PTSD differ from those for people with other mental health issues, says Dr. Matta.
Both cognitive processing therapy and prolonged exposure therapy were effective. These two therapies teach people how to evaluate and reframe the upsetting thoughts stemming from the traumatic experience. The guidelines also recommend mindfulness-based stress reduction, an eight-week program that includes meditation, body scanning, and simple yoga stretches.
Which medications are recommended for PTSD?
Some people with severe symptoms need medication to feel well enough to participate in therapy. “People with PTSD often don’t sleep well due to insomnia and nightmares, and the resulting fatigue makes it hard to pay attention and concentrate,” says Dr. Matta.
Three medicines commonly prescribed for depression and anxiety — paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor) — are recommended. Prazosin (Minipress) may help people with nightmares, but the evidence is weak.
Which medications are not recommended for PTSD?
The guidelines strongly recommended not taking benzodiazepines (anti-anxiety drugs often taken for sleep). Benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) offer no proven benefits for people with PTSD. They have several potential harms, including negative cognitive changes and decreased effectiveness of PTSD psychotherapies.
What about cannabis, psychedelics, and brain stimulation therapies?
Right now, evidence doesn’t support the idea that cannabis helps ease PTSD symptoms. And there are possible serious side effects from the drug, such as cannabis hyperemesis syndrome (severe vomiting related to long-term cannabis use).
There isn’t enough evidence to recommend for or against psychedelic-assisted therapies such as psilocybin (magic mushrooms) and MDMA (ecstasy). “Because these potential therapies are illegal under federal law, the barriers for conducting research on them are very high,” says Dr. Matta. However, recent legislative reforms may make such studies more feasible.
Likewise, the evidence is mixed for a wide range of other nondrug therapies, such as brain stimulation therapies like repetitive transcranial magnetic stimulation or transcranial direct current stimulation.
About the Author
Julie Corliss, Executive Editor, Harvard Heart Letter
Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing
Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD
Harvard Health Ad Watch: New drug, old song, clever tagline
It’s not often that a new drug comes along that could help nearly a quarter of the adult population. But when it does, you can bet you’ll see ads for it on TV and the Internet.
That’s the case with Veozah (fezolinetant), a medicine for hot flashes and night sweats due to menopause that was approved by the FDA in May 2023. One ad has this inventive tagline: “You can have fewer hot flashes and more not flashes.”
So, what is a not flash and what does the ad tell us about this new drug?
The ad: This is a not flash
The ad begins with an upbeat song, “Good Feeling,” a hit by Flo Rida released in 2011. A woman in a crowded elevator is clearly distressed and soaked in sweat as the voiceover declares, “This is a hot flash.” A second woman appears, awakening in her bedroom covered in sweat. Again, the narrator declares “This is a hot flash.” Cut to two smiling women on a dock taking selfies as boats sway behind them: “But this is a not flash.”
The voiceover tells us that Veozah is a prescription treatment for women with moderate to severe hot flashes and night sweats — or vasomotor symptoms, as medical experts say. (Hot flashes may or may not prompt sweating, while night sweats are exactly as billed.)
When the voiceover tells us the drug is “hormone free,” the words “100% hormone-free” appear on the screen. Got it? Apparently, this drug contains no hormones.
Does Veozah work?
But is it effective? The ad voiceover says, “Veozah has been proven to reduce the number and severity of hot flashes day and night. For some women, it can start working in as early as one week.”
The details are easy to miss. They appear in fine print briefly at the bottom of the screen: “At 12 weeks, women taking Veozah experienced 63% fewer hot flashes vs. 42% on placebo.” Sounds good, right? More on what this actually means below.
What does the ad tell us about risks?
The FDA requires drug manufacturers to review the most common or serious risks of taking the drug. So while the catchy song continues, images appear of women peacefully sleeping, teaching a classroom full of students, or working in a hectic office. The voiceover warns that some people shouldn’t take Veozah: anyone with cirrhosis (a form of liver disease) or severe kidney problems, and anyone who takes a medicine known as a CYP1A2 inhibitor.
Next comes the litany of possible side effects, including:
- the need for repeated liver blood tests before and during treatment
- stomach pain
- diarrhea
- difficulty sleeping
- back pain.
What does the ad get right?
This ad highlights significant suffering caused by hot flashes and night sweats, which affect about 80% of women during menopause. Currently, treatment options (and, truth be told, actual research on those dealing with these problems) are quite limited. Hormone replacement with estrogen and related medicines was often prescribed in past years. But concerns about risks associated with estrogen use led many physicians to stop prescribing hormone replacement, and many women decline it when it’s offered.
But Veozah works without hormones: it blocks a protein in the brain that helps regulate body temperature. That’s why the “hormone free” message is emphasized in the ad.
Just how effective is Veozah for hot flashes and night sweats??
Unfortunately, digging more closely into the data shows the difference between Veozah and placebo in reducing hot flashes and night sweats is relatively small. And some important information is missing or incomplete in the ad. I filled in gaps by looking at two pivotal trials of Veozah (called SKYLIGHT 1 and SKYLIGHT 2).
What exactly are “moderate” and “severe” symptoms?
For this study, women had to have at least seven moderate to severe hot flashes per day, although the average was 10 to 12. A moderate hot flash was defined as a sensation of heat with sweating that did not interfere with activities. A severe hot flash was a sensation of heat with sweating that did interfere with activities. So, the number of moderate or severe hot flashes tallied by the researchers in this study included sweats, regardless of what time of day they occurred.
How many hot flashes or night sweats were prevented?
The ad provides data on effectiveness as a percent reduction: 63% fewer hot flashes. Importantly, that doesn’t tell you the actual number of hot flashes prevented. During 12 weeks of treatment, women given the medicine went from experiencing an average of about 11 hot flashes a day at the start to about four a day. By comparison, the group taking a placebo (an inactive pill) dropped from 11 hot flashes a day to 6.5 a day. So, that’s about 2.5 fewer hot flashes a day in total for women taking the drug.
- What about effectiveness after 12 weeks? Based on the published studies (including SKYLIGHT 4), effectiveness persists for at least a year with continued treatment. While that’s good news, it would be helpful to know whether effectiveness wanes or persists beyond one year, because menopausal hot flashes and night sweats can come and go for many years. The average is about seven years, and it’s not rare for them to last a decade or more.
- How diverse were the study participants in the clinical trials that led to FDA approval? More than 80% of study participants identified as Caucasian, 17% as African American, 24% as Hispanic/Latina, and 1% as Asian. Studies of a more diverse population are needed.
What else should you know about possible downsides of Veozah?
The ad covers the most common side effects reported during trials of this drug. Yet advising people to avoid Veozah if they take a CYP1A2 inhibitor is likely to perplex most viewers. This warning relates to an enzyme that helps the body metabolize many medicines, including Veozah.
If you’re already taking a medicine that inhibits the action of this enzyme and you start taking Veozah, the blood levels of Veozah may rise higher than intended and increase the risk of side effects. Many common medicines can cause this interaction (including ciprofloxacin, some oral contraceptives, and cimetidine). Ask your doctor about this before starting Veozah.
Finally, the ad provides no information about cost. According to the drug maker’s website, the list price is $550 a month. That’s the amount you’d be charged if you have no health insurance.
But the average price for people with commercial health insurance is $41 a month. It’s about $77 a month for people covered by Medicare Part D, and $12 a month for people with Medicaid. The drugmaker’s Patient Assistance Program may provide the drug at no cost for some people who are eligible — though eligibility criteria aren’t easy to find and aren’t included in the ad.
The bottom line
A newly approved, nonhormonal drug for hot flashes and night sweats during menopause is big news. But it remains to be seen whether this is a small step forward or a major advance. Either way, the ad mostly does its job: it introduces us to a new medication for a common and burdensome condition that currently has limited treatment options.
Of course, this one-minute ad for Veozah isn’t intended to cover everything a viewer might want to know about it; it’s intended to get people with significant hot flashes and night sweats to ask their doctor about the advertised drug. Keep that in mind when you see ads for this drug — or any drug ad, for that matter.
While I’m not sure whether Veozah will prove to be a wonder drug, one thing’s for sure: that song sure holds up well.
About the Author
Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD