From the Editor
Just a handful of months ago, mental health work didn’t require a webcam or a lighting ring, and no one talked about Zoom fatigue. The world is different now, obviously. With COVID-19, telepsychiatry is very much part of our clinical work.
This week, we consider three papers focused on telepsychiatry and our new world.
How widespread is the adoption of telepsychiatry in this pandemic era? In the first selection, Jonathan Cantor (of the RAND Corporation) and his co-authors draw on a big American database to answer that question. In Psychiatric Services, they write: “During the COVID-19 pandemic, the percentage of outpatient mental health and substance use disorder treatment facilities offering telehealth has grown dramatically. However, our analyses also indicated that considerable proportions of mental health and substance use disorder treatment facilities still did not offer telehealth as of January 2021…”
In the second selection, John C. Fortney (of the University of Washington) and his co-authors consider two different types of care: with psychiatrists directly involved in patient care (through televideo) or indirectly, by providing support to primary care. In a JAMA Psychiatry study, they do a comparison. Spoiler alert: both approaches were effective, suggesting great potential, especially for those in rural areas.
Of course, not everyone is enthusiastic about telepsychiatry. In our third selection, Dr. J. Alexander Scott (of the University of Michigan), a resident of psychiatry, describes his ambivalence. His Academic Psychiatry paper starts memorably: “Admittedly, I’ve never liked telemedicine.” He outlines some of the problems with our digital world.
Selection 1: “Telehealth Adoption by Mental Health and Substance Use Disorder Treatment Facilities in the COVID-19 Pandemic”
Jonathan Cantor, Ryan K. McBain, Aaron Kofner et al.
Psychiatric Services, 19 August 2021 Online First
The COVID-19 pandemic has created an unprecedented need for the rapid adoption of telehealth services. Recommendations from the Centers for Disease Control and Prevention are to limit in-person, nonemergent medical consultations as a way to ensure social distancing and reduce viral spread. At the same time, depression, psychological distress, social isolation, and loneliness have markedly increased throughout the United States, and there has been a spike in substance use as well as in the number of drug overdose deaths…
Substantial evidence indicates that telehealth services for mental health conditions can be equivalent to in-person care in terms of symptom improvement and client satisfaction, although more research is needed to examine outcomes for patients with substance use disorders who receive telehealth services. Thus far, professionals, such as psychiatrists, have reported that the recent transition to telehealth has been smoother than expected and that it has reduced the no-show rate…
Despite the rapid shift to support telehealth in the health care policy landscape, no national longitudinal studies have examined changes in the availability of telehealth services for behavioral health conditions over the course of the COVID-19 pandemic. To fill the gap, we utilized a national panel data set of mental health and substance use disorder treatment facilities—updated daily—to quantify changes in their offering of telehealth services between January 20, 2020, and January 20, 2021.
So begins a paper by Cantor et al.
Here’s what they did:
- Longitudinal data on outpatient mental health treatment facilities was drawn from the Substance Abuse and Mental Health Services Administration which “collects data from nearly all mental health and substance use disorder treatment facilities in the United States.”
- Data was compared between January 20, 2020, and January 20, 2021.
- “Bivariate analyses were used to assess trends in telehealth availability in 2020 and 2021. Multivariable regression analysis was used to examine facility- and county-level characteristics associated with telehealth availability in 2021.”
Here’s what they found:
- “Telehealth availability increased by 77% from 2020 to 2021 for mental health treatment facilities and by 143% for substance use disorder treatment facilities.”
- “By January 2021, 68% of outpatient mental health facilities and 57% of substance use disorder treatment facilities in the sample were offering telehealth.”
- “Mental health and substance use disorder treatment facilities that accepted private insurance were more likely to offer telehealth in 2021, compared with facilities that did not accept private insurance.”
A few thoughts:
- This is an interesting paper.
- As we consider our digital moment, the authors do a solid job of providing data – including down to the county level.
- That said, the sample is hardly exhaustive. One big limitation of the study: “not all outpatient mental health and substance use disorder treatment facilities are in SAMHSA’s Behavioral Health Treatment Services Locator database. Although the vast majority of facilities choose to be listed in the database, it remains unclear what percentage of all facilities decline to be included in it.” It should be noted that some facilities are clearly not listed, such as those in the Veterans Affairs system. So… this is a good sample but not a definitive sample, and – obviously – very American.
- Still, they provide a nice snapshot of the moment – with many, but not all providers, moving towards virtual options.
- There is an important finding: not all providers have embraced telepsychiatry. We often speak about the need to consider equity when thinking about virtual care; that is, tens of millions of North Americans lack access to reliable broadband and efforts must be made to ensure that they aren’t left behind. But this study also shows another aspect of equity: that some will be deprived of a virtual option by their providers, and those will be disproportionately lower income (at least in the United States).
The full Psychiatric Services paper can be found here:
Selection 2: “Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial”
John C. Fortney, Amy M. Bauer, Joseph M. Cerimele
JAMA Psychiatry, 25 August 2021 Online First
Only one-third of individuals with bipolar disorder (BD) and posttraumatic stress disorder (PTSD) receive specialty mental health care during the course of a year. In primary care settings, only one-tenth of patients with BD and PTSD receive adequate care compared with more than half in specialty mental health. Managing complex psychiatric disorders is especially challenging for primary care clinicians in federally qualified health centers (FQHCs). There are nearly 1400 FQHCs with more than 13 000 clinic locations that provide services to 30 million individuals in the US. Almost half (44%) of patients treated at FQHCs live in rural areas, 91% live in poverty, and 62% are from racial or ethnic minority groups. While 97% of FQHCs offer on-site mental health services, only 12% of mental health staff are psychiatrists or licensed clinical psychologists…
The widespread adoption of telepsychiatry and telepsychology owing to the COVID-19 pandemic could potentially increase access for primary care patients with complex psychiatric disorders living in underserved areas. The Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT) trial was a pragmatic trial (PCS-1406-19295) designed to identify the best approach to delivering telemental health services to primary care clinics. Specifically, the SPIRIT trial compared the effectiveness of telepsychiatry collaborative care (TCC) and telepsychiatry/telepsychology–enhanced referral (TER) to treat BD and PTSD.
TCC is an integrated population-based model of care. By integrating BD and PTSD treatment into primary care and taking a population-based care management approach, TCC is expected to engage a higher proportion of patients in treatment than TER, which is a traditional referral model of care that focuses exclusively on patients attending scheduled appointments.
So begins a paper by Fortney et al.
Here’s what they did:
- They conducted a pragmatic comparative effectiveness trial using a sequential, multiple-assignment, randomized trial design with patient-level randomization.
- Who was treated? “Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.”
- “Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.”
- The primary outcome: The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score.
Here’s what they found:
- 1004 participants were included.
- Demographics. 70.1% were female and 66.4% were White; the mean age was 39.4; roughly half (50.1%) lived in a rural area; 65.5% lived in poverty.
- There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0…). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81… TER: Cohen d = 0.90…). See figures below.
- “Treatment effects measured by MCS were not significantly different across age, sex, race or ethnicity, screening results, or baseline MCS scores.”
A few thoughts:
- This is a good study.
- To summarize: both approaches worked, and worked well.
- “Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care.” The need is great. This paper suggests ways of addressing the access gap. Nice.
- Both approaches worked but they weren’t equivalent in the use of resources. The authors conclude by writing: “By leveraging scarce telepsychiatrist capacity, TCC is able to serve more patients than TER.”
- Like all studies, there are limitations. The authors note: “Survey follow-up rates at 6 months and 12 months were relatively low. However, there were only slight differences between survey completers and noncompleters, and results were not sensitive to alternative assumptions about missing data.”
The full JAMA Psychiatry paper can be found here:
Selection 3: “I’m Virtually a Psychiatrist: Problems with Telepsychiatry in Training”
- Alexander Scott
Academic Psychiatry, 9 September 2021 Online First
Admittedly, I’ve never liked telemedicine. When I first observed it in medical school, I found it impersonal and artificial. But with the COVID-19 pandemic, what was once an alternative became the only game in town. Although optimists have noted the virtues of virtual visits (e.g., improved access to care, our better understanding of patients’ environments), practicing nearly exclusively in this way for a year has frustrated me. In telepsychiatry, that interaction between patient and psychiatrist which is so fundamental to the therapeutic process is altered in many ways. I worry that these alterations have a negative impact on my learning.
So begins a short paper by Dr. J. Alexander Scott.
Dr. Scott describes several concerns; we highlight three here:
Telepsychiatry changes communication, most readily evident in technical limitations.
“Camera positioning gives the impression that, while looking directly at the screen, we are not quite looking the patient in the eye.” He continues: “The two-dimensional image lacks depth and impairs facial observation.”
Trust is more difficult to develop, amid the usual difficulties experienced by the constantly rotating resident.
He lists several problems: “Delays in data transmission interrupt speech and expressions, damaging the flow of the interview. Some of my patients with paranoid ideations have feared for their privacy because the session is conducted over the Internet. The omission of peripheral body language (e.g., being unable to empathically interrupt the talkative patient with one’s hands) has been cited as a threat to the therapeutic relationship and may impair our ability to practice rapport building…”
In conducting virtual visits, my physical wellness has also suffered, having sat alone at the office for extended periods of time.
Focusing on himself and his wellbeing, he writes: “Practicing telepsychiatry approximates a workday spent almost entirely on the computer, as seeing patients, documenting clinical encounters, and administrative work all become electronic tasks. The discussion around ‘Zoom fatigue’ is ongoing, but the hypothesized negative effects on attention and communication threaten our ability to care for patients optimally, and to learn from didactic sessions and supervision.”
He goes on to write:
“As telepsychiatry is adopted nationally, it will become prudent for us to gain more experience in a hybrid model of virtual and in-person visits. Yet, the virtual setting and its effects on training must be examined more closely, as clinical successes do not necessarily ensure educational ones.”
A few thoughts:
- This is a well written paper.
- Though Dr. Scott is cool to some aspects of telepsychiatry, his ultimate recommendation – a hybrid model – isn’t controversial. Indeed, many have argued for this. Last year, Dr. Jay Shore (of the University of Colorado) co-authored a paper for JAMA Psychiatry; Dr. Shore has been working in the telepsychiatry space for more than two decades. Despite his enthusiasm, he and his co-authors ask important questions: “What will the lessons of the COVID-19 pandemic be, in terms of what can vs should be done in person or through telepsychiatry or other technologies? How much virtual care is too much? Is there a virtual saturation point, at which the benefits of a virtual relationship decrease or patients request more in-person interactions?” We considered the Editorial in a past Reading, which can be found here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-what-now-cjp-on-mental-health-of-communities-also-telepsychiatry-post-covid-jama-psych-and-gold-on-stigma-time/
Dr. Shore also joined me for a Quick Takes podcast; you can read highlights: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-rurality-and-suicide-cjp-also-covid-and-digital-practice-quick-takes-and-haughton-bromberg-on-policing-tor-star/
- University of Toronto psychiatry resident Dr. Erene Stergiopoulos comments on her own clinical work in a virtual world. Like Dr. Scott, she has some concerns, but offers a more balanced assessment – including: “I’ve gotten to meet so many of my patients’ pets over video in the last 16 months!” Her comments can be found here: https://torontolife.com/city/the-e-health-revolution-medical-pros-have-pivoted-their-practices-online/
The full Academic Psychiatry paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.