Telepsychiatry offers a tantalizing solution to the significant undertreatment of mental illness in the United States. According to the National Institutes of Health, an estimated 1 in 5 U.S. adults experience a mental illness, but despite this high prevalence, only 43% of those affected receive mental health services. The reasons for this are multifold and include stigma and access to care. A similar situation exists for mental health clinical trials; an estimated 90% of the population lacks access to traditional brick-and-mortar clinical trial sites. This impacts the diversity, recruitment, and retention of participants - all of which impedes treatment innovation.
There is already considerable evidence that moving mental health treatment into patients’ homes is effective. Clinical outcomes are similar to those obtained with face-to-face treatment (Hubley, 2016), a similarity that holds true across different mental disorders as well as different ethnicities and age groups. A variety of pediatric disorders have been successfully treated remotely, including depression, anxiety, obsessive-compulsive disorder, tics, attention deficit hyperactivity, and behavioral disorders. Satisfaction has been rated as very high by parents, teens, and referring providers. While geriatric individuals are generally less accepting of both change and technology than younger people, recent studies have identified a generational acceptance of technology and e-health (Kruse, 2017). For example, a review by Christensen (2019) found that when it comes to video consultations, the experiences and satisfaction of older people with depression were positive, and any initial skepticism quickly disappeared once the consultation was experienced.
Despite these encouraging developments, only 1 in 10 Americans have used telehealth services and 75% lack awareness or do not have access to telehealth options (JD Power, 2019). What explains this lag of telepsychiatry adoption when its utility has so clearly been demonstrated? A number of barriers have been identified that offer insight into this question (Mahmoud, 2019). The scope and quality of telepsychiatry training during residency, if offered at all, is often limited. There are also concerns about privacy as well as technology challenges (software and connectivity), licensure limitations, and unresolved impediments around reimbursement.
...And Then Came COVID-19
The implementation of widespread stay-at-home measures to restrict travel, coupled with a reduction of the number of clinics offering face-to-face mental health services, has caused demand for in-home care to skyrocket. Many influential organizations, including the CDC, WHO, American Medical Association, and the Academy of Family Physicians, have all advocated for telemedicine and released related guidelines. To accommodate this demand, a number of telemedicine-related regulations have been relaxed. For example, the Ryan Haight Online Pharmacy Consumer Protection Act, a federal law that limits the prescribing of controlled substances without an in-person evaluation, was suspended at the beginning of the pandemic. Previously, Medicare was only reimbursing for telehealth if the patient went to a healthcare facility located in a county that is either designated as a shortage county or a rural county. These restrictions on reimbursement have been lifted, at least temporarily. What happens with this in the future is uncertain, but it is possible that the positive experience will result in lasting changes. The American Journal of Managed Care (Rockwell, 2020) concluded that “although certain legal, regulatory, and reimbursement challenges remain, the COVID-19 outbreak may be the right impetus for lawmakers and regulatory agencies to promulgate further measures that facilitate more widespread adoption of telemedicine.”
What Will Stick?
One effect of our current experience, however, will be irreversible. Clinicians have been thrust into the telemedicine world regardless of their reluctance to adopt technology or their pre-existing views of interacting with patients remotely. Institutions that wanted to increase the adoption of telepsychiatry believed it would be a slow process based on previous experiences with electronic medical records and other technological innovations, where it was common to see prolonged implementation periods. For example, the Veterans Health Administration (VHA) had a modest telemedicine goal for 2019 for front line providers. Now, in the context of the pandemic, most VHA primary care and mental health clinicians have been compelled to quickly learn and implement telepsychiatry. A similar scenario has developed within the Kaiser Permanente and University of California health systems. Because these institutions are active in medical student and residency education, their trainees will have also received a crash course in telepsychiatry. With the likelihood of stay-at-home measures staying in place in some manner for the coming months, clinicians and trainees will have completed two or three months of immersion training. This preparation will leave them not only competent in the technology, but also completely comfortable using this mode of communication with patients. They will also appreciate how for many patients, telepsychiatry improves access by removing barriers to treatment, such as transportation.
Many patients will have been similarly pushed into a telehealth experience. A significant proportion will likely perceive this approach to be a satisfactory and even preferable manner to interact with the healthcare system. A review of 36 studies, including five focused on mental health treatment, categorized satisfaction with telehealth using four dimensions:
- System experience
- Information sharing
- Consumer focus
- Overall satisfaction
There were high levels of satisfaction across all of these dimensions. Telepsychiatry brings care to rural areas where there is often a scarcity of providers. It also can reduce stigma through enhanced privacy and enable faster care delivery - all of which enhances the patient experience and ultimately results in better outcomes (Oreilly, 2007).
How Will Mental Illness Research Change?
Just as telepsychiatry is likely to have new value in the delivery of mental health care, mental health research will benefit as well. The idea of using telemedicine approaches is not new to this field. For many years, remote strategies have been commonplace for clinician-reported outcomes in clinical trials for schizophrenia and mood and anxiety disorders. For example, MedAvante-ProPhase, a company that pioneered centrally administered (remote) clinical outcome assessments, reports having completed more than 60 clinical trials using highly calibrated centralized raters. Similarly, the Veterans Health Administration’s highly successful Cooperative Studies Program is more frequently using centralized raters for primary outcome measures. A recently completed PTSD trial (CSP#591) that enrolled nearly 1,000 participants used this method for assessing PTSD symptoms. Researchers didn’t take this approach simply for convenience - it was sound underlying science. By having highly trained raters, variance is reduced, which allows for smaller sample sizes. The reduction in the number of raters also provides another key advantage over site-based ratings. The growing acceptance of using telepsychiatry for primary outcome measures is evidence that this method has the potential to transform mental health research while reaching a population that traditionally lacks access to brick-and-mortar clinical sites.
Innovative virtual trial companies are leading the way in taking telepsychiatry in mental health research to the next level – that is, bringing it to the patient’s home. For example, a recent major depressive disorder (MDD) trial completed by Science 37 was able to demonstrate effective recruitment of a diverse patient population using a digital approach, supported by social media, to attract and then engage participants. Besides all efficacy and safety data being reliably collected, 90% of participants completed the study (typical completion rates for MDD trials are 70%). This retention rate was underscored by high participant satisfaction, with 75% stating they would be “extremely likely” to recommend others participate in a Science 37 study. This approach aligns with one of the core elements of the Institute for Healthcare Innovation’s “Triple Aim” for healthcare: to bring a laser focus on improving the patient experience.
The virtual research model has become the standard in the current climate given the massive worldwide quarantine measures currently in effect due to COVID-19, and has in fact been a way to rescue a multitude of site-based trials. The coming months will likely further underscore the advantages of the distributed research model for psychiatry. At that point, the virtual model may emerge as preferable for its efficiency, data integrity, and patient-centered focus.
References
- Christensen LF, Moller AM, Hansen JP, et al. (2019) Patients' and providers' experiences with video consultations used in the treatment of older patients with unipolar depression: A systematic review. J Psychiatr Ment Health Nurs.00:1–14. DOI: 10.1111/jpm.12574
- Hubley, S., Lynch, S. B., Schenck, C., Thomas, M., & Shore, J. (2016). Review of key telepsychiatry outcomes. World Journal of Psychiatry, 6(2), 269–282.
- Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2017). Telehealth and patient satisfaction: A systematic review and narrative analysis. British Medical Journal Open, 7(8), e016242.
- Mahmoud H, Vogt EL, Sers M, Fattal O, Ballout S. Overcoming Barriers to Larger-Scale Adoption of Telepsychiatry. Psychiatr Ann. 2019;49(2):82–88
- JD Power Telehealth Survey 2019 https://www.jdpower.com/business/resource/ustelehealth-study
- Oreilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58:836–43.
- Orlando JF, Beard M, Kumar S (2019) Systematic review of patient and caregivers’ satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health. PLOS ONE 14(8): e0221848. https://doi.org/10.1371/journal.pone.0221848
- Rockwell KL, Gilroy AS. Incorporating Telemedicine as Part of COVID-19 Outbreak Response Systems. Am J Manag Care. 2020;26(4):147-148. https://doi.org/10.37765/ajmc.2020.42784