The Rise and Fall of Telepsychiatry

Lucas Evergreen

Alright folks, let’s dive into the story of telepsychiatry on our fourth episode of the virtual psychiatrist . I welcome our founding cohost Dr. Muhamad Aly Rifai So, we're talking about a practice that’s been around longer than you might think—since 1959, right, Dr. Rifai?

Muhamad Aly Rifai, MD

That’s correct, Lucas. It started at the Nebraska Psychiatric Institute, using a two-way television setup for group therapy and other psychiatric services. At the time, it was groundbreaking—imagine delivering care through a screen in the late '50s. Welcome folks to our fourth episode of the virtual psychiatrist we are still going strong. Do you know that most podcasts never go beyond their 2nd or third episode but we are still going strong and we have a lot of wonderful content coming.

Lucas Evergreen

Whoa, 1959? That’s like when my parents were toddlers. So, it took off from there, or did it, you know, hit some bumps along the way?

Muhamad Aly Rifai, MD

Oh, there were definitely bumps. 1959 I was not even born then Lucas, but Telepsychiatry remained a niche option for decades, mostly used in underserved or academic settings. But by the early 2000s, enough evidence had been gathered to show it was just as effective as in-person care. That’s when things slowly started to shift.

Lucas Evergreen

And The Commonwealth of Pennsylvania—your stomping ground—played a big role in this, right? I mean, wasn’t it one of the earlier states to jump on board the telepsychiatry train?

Muhamad Aly Rifai, MD

Yes, Pennsylvania was pivotal. In 2006, the state approved reimbursement for telepsychiatry services, particularly to help those in rural areas where psychiatric care was scarce. I was part of that early movement, and in 2007, I even helped establish telepsychiatry systems for hospital emergency departments to evaluate patients more efficiently.

Lucas Evergreen

Hold up. Emergency departments using telepsychiatry—that seems like a game changer. Wasn’t that, like, a tough sell back then?

Muhamad Aly Rifai, MD

Oh, very much so. There was skepticism—from clinicians and even patients—about whether psychiatric care could really work remotely. But we demonstrated its impact. For instance, evaluations in the emergency room helped stabilize patients early, potentially avoiding further complications, even psychiatric admissions, patients were evaluated and if they did not need to be in hospital they were treated and sent home.

Lucas Evergreen

That’s wild. It sounds like telepsychiatry was ahead of its time but just needed, well, the times to catch up. So, what convinced people it was worth it?

Muhamad Aly Rifai, MD

Persistence and results. Over time, programs like Pennsylvania’s and the Department of Veterans Affairs showed tangible benefits—improved access, better outcomes, even cost savings. It built credibility. And for me, being part of those early systems gave me firsthand insight into its potential.

Lucas Evergreen

Geez, Dr. Rifai. No wonder you’re such a champion for this. It sounds like you were in the thick of it, shaping how telepsychiatry actually works today.

Muhamad Aly Rifai, MD

So, with all that persistence and those results paving the way, telepsychiatry must have some pretty undeniable perks now, right? I mean, what are the biggest wins in its corner?

Lucas Evergreen

I also heard that you helped with with Tele ICU program at a local health network in Pennsylvania, and oooh boy that program proved very necessary during COVID.

Muhamad Aly Rifai, MD

Absolutely Lucas I am proud of this program that morphed out of Telepsychiatry. But telepsychiatry proved its worth also for starters, studies have shown significant reductions in psychiatric hospitalizations, especially among veterans. The VA found that incorporating telepsychiatry cut hospitalization rates by 25%. That’s a huge deal in terms of both patient health and healthcare system efficiency.

Lucas Evergreen

Twenty-five percent? That’s not just a win; that’s a slam dunk. So, veterans benefit. What about folks in, you know, middle-of-nowhere towns?

Muhamad Aly Rifai, MD

Those are often the people who gain the most. Telepsychiatry has expanded access to therapy and medication management for underserved populations. Rural areas, in particular, benefit greatly. Patients who might otherwise have driven hours for care can now receive treatment without leaving home.

Lucas Evergreen

And they probably love the convenience, right? Like, no need to get stuck in traffic or, you know, arrange a dog sitter or whatever?

Muhamad Aly Rifai, MD

Convenience is a major factor. But it’s also about privacy and reducing the stigma around seeking psychiatric care. Telepsychiatry allows people to attend sessions discretely from their own space—this has been particularly important for those hesitant to visit traditional clinics.

Lucas Evergreen

Right, because not everyone’s thrilled about running into their talk therapist in the coffee shop line. Makes sense. But—and here’s my cowboy skepticism creeping in—what about the downsides? There’s gotta be a flipside.

Muhamad Aly Rifai, MD

There is. Challenges include regulatory obstacles and the use of platforms that might not be HIPAAA-compliant, like Zoom and FaceTime during the pandemic. And let’s not discount cultural stigma. Some patients and even providers struggle with the idea of virtual care replacing in-person interactions.

Lucas Evergreen

Yeah, I can see that. Like, how’s a screen gonna replace good old face-to-face trust? Feels kinda, I dunno, impersonal maybe?

Muhamad Aly Rifai, MD

That’s a common concern, but clinical studies show telepsychiatry outcomes are comparable to in-person treatment. It’s all about finding the right approach. Even so, transitioning during COVID-19 caught many off guard, and not everyone adapted smoothly.

Lucas Evergreen

No kidding. It’s like everyone had to learn to swim while already in the deep end. But man, it sounds like patients still jumped on board—privacy, convenience, less stigma. Can’t argue with that.

Lucas Evergreen

Alright, so we’ve seen how telepsychiatry is making waves with accessibility and convenience. But now I’m curious—when it comes to the rules and systems supporting it, things seem to be shifting fast. What’s changing in that space, Dr. Rifai?

Muhamad Aly Rifai, MD

Certainly, Lucas. A lot of the current challenges revolve around outdated regulations like the Ryan Haight Act, which, since 2008, has restricted the remote prescribing of controlled substances without an in-person evaluation. During COVID-19, those restrictions were temporarily lifted, enabling psychiatrists to provide vital care virtually. But as we near 2025, there’s concern that these flexibilities might expire.

Lucas Evergreen

Wait, what? After all the success telepsychiatry has had, they might go back to the old rules?

Muhamad Aly Rifai, MD

That’s correct, and it's troubling. We’re talking about millions of people who rely on telepsychiatry—especially in rural or underserved areas—losing access because they can’t comply with in-person visit requirements. Despite strong evidence of telepsychiatry’s efficacy and safety, agencies like the DEA and CMS are cautious due to fears of fraud and misuse.

Lucas Evergreen

Man, it’s like taking two steps forward and one step back. What’s the deal with CMS? They seemed on board for a while.

Muhamad Aly Rifai, MD

Well, during the pandemic, CMS adapted quickly, allowing reimbursement for virtual and even telephonic sessions. But now, they’re set to revert their policies, requiring in-office visits for reimbursement. It's a huge setback for patients who thrived under these temporary policies—not to mention clinicians who set up virtual-only practices.

Lucas Evergreen

So basically, patients and docs are getting caught in the middle of this tug-of-war. It’s frustrating to hear. Why are these agencies so hesitant?

Muhamad Aly Rifai, MD

Much of it boils down to misunderstanding and risk aversion. The fear is that loosening regulations could lead to improper prescribing or fraud. But the data doesn’t support this skepticism—if anything, telepsychiatry has proven to be just as effective and secure as in-person care. What’s needed now are modernized policies informed by evidence, not fear.

Lucas Evergreen

Yeah, makes sense. But you’ve walked this road yourself, right? You’ve dealt with these policy hurdles firsthand. How do you stay optimistic?

Muhamad Aly Rifai, MD

I stay optimistic because of what I see in my patients and colleagues. The demand is undeniable, and the benefits are clear. But advocacy is key—physicians, patients, and allied organizations need to push for permanent, sensible policies that reflect the reality of how mental health care can and should be delivered.

Lucas Evergreen

Right, so it’s like a battle worth fighting, huh? And it’s not just about laws; it’s about real people getting the help they need.

Muhamad Aly Rifai, MD

Exactly. Telepsychiatry isn’t just a convenience—it’s a lifeline. We’ve seen its impact during the pandemic, and it’d be a mistake to ignore that now.

Lucas Evergreen

Dr. Rifai, after everything we’ve discussed—the history, the challenges, and the stakes—what’s next for telepsychiatry? With all this back-and-forth over policies, where do you see it heading from here?

Muhamad Aly Rifai, MD

The future, Lucas, is undeniably tied to how Congress and agencies like CMS and the DEA respond to the growing mental health crisis. They need to recognize the evidence and adapt. But there’s friction—different governmental bodies often have conflicting priorities, and that creates a very uncertain landscape for telepsychiatry.

Lucas Evergreen

Conflicting priorities? Sounds like a polite way of saying they’re all arguing while patients are the ones losing out.

Muhamad Aly Rifai, MD

In many ways, that's accurate. For instance, while Congress mandated the DEA to create telehealth-specific prescriptions mechanisms in 2008, they’ve yet to fully implement that framework. It’s been 16 years of stalling, Lucas, and that's a problem when we’re facing a mental health crisis that’s grown by 30% in just over a decade.

Lucas Evergreen

Thirty percent? That’s like adding an entire new city’s worth of people needing help. What do you think’s holding them back from, I dunno, catching up to reality?

Muhamad Aly Rifai, MD

Fear of misuse and fraud. Agencies worry about risks tied to prescribing controlled substances without face-to-face evaluations. But the data counters this fear. Numerous studies show telepsychiatry is comparable to in-person care in safety and effectiveness. It’s this tension between evidence and outdated perceptions that needs resolving.

Lucas Evergreen

Okay, but here’s the thing—while they’re stuck in their boardrooms debating, real people are out there struggling. So, what gives? What's the way forward?

Muhamad Aly Rifai, MD

The solution involves modernizing regulations. For example, embracing asynchronous care—like secure messaging or recorded consultations—and integrating AI for routine tasks. Even holographic technology could enhance the experience, offering near in-person interaction remotely. But the first step is legislative action that supports these advancements without unnecessary barriers.

Lucas Evergreen

Whoa, holograms? Now you’re talking sci-fi! But hey, it seems legit if it gets people the care they need. Do you think patients are ready for that kind of leap?

Muhamad Aly Rifai, MD

Many already are, Lucas. They’ve adapted to telehealth faster than some policymakers expected. Technology like AI and holograms might sound futuristic, but for patients who’ve experienced the convenience of telepsychiatry, it could be a natural next step—as long as it’s implemented with care and equity in mind.

Lucas Evergreen

Right, because it’s not just about shiny tech; it’s gotta actually work for people, right? You’ve seen it firsthand—does all this really stand a chance?

Muhamad Aly Rifai, MD

It does. Patients are demanding it. Clinicians are advocating for it. The challenge is mobilizing that momentum into meaningful policy changes. Telepsychiatry has proven itself as a viable, effective model; now it’s about lawmakers catching up to the reality that millions rely on it as more than a convenience. It’s their lifeline.

Lucas Evergreen

Yeah, and it’s hard to argue with that, Dr. Rifai. This has been, well, eye-opening, to say the least. Thanks for sharing your story and, honestly, giving us all a lot to think about.

Muhamad Aly Rifai, MD

The pleasure’s been mine, Lucas. These conversations are essential—telepsychiatry’s future depends on all of us staying engaged and advocating for what’s right. and remember folks as our friend Norm said you are within the norms, until next time stay safe and be well, peace out.