The evolving landscape of behavioral telehealth

As the need for mental health services continues to grow in the United States, physicians and healthcare facilities are increasingly leveraging technology to enhance access to care to patients.

A growing body of evidence supports the effectiveness of telepsychiatry when applied to provide high quality care utilizing a patient-centered approach. While technological capabilities have continued to expand, so have the mental health needs of the American population. Although the number of people seeking mental health treatment in the US increased during the first decade of the 2000s, the number of people reporting distress or negative effects from mental health conditions did not correspondingly decrease 1. Major depression continues to be the most widely reported mental health issue among adults with a lifetime morbidity risk of 29.9% 2. Moreover, in 2015, the National Institute of Mental Health estimated that 43.4 million Americans aged 18 or older had experienced mental illness during the previous 12 months, equivalent to 17.9% of the adult population 3.

Unrealized burden of mental illness
The societal burden of mental illness is significant and measureable. Between 2005-2010, costs related to major depressive disorder increased from $173.2 billion to $210.5 billion, with roughly half of this cost occurring as a result of reduced productivity and workplace absenteeism 4. The remaining cost is broken down in categories corresponding to direct costs, suicide-related costs, and costs associated with comorbid medical disorders 4. Considering these trends, finding a way to increase accessibility to care is not only desirable, but also economically sound.

Barriers to care
A staggering number of people with mental health conditions report that their needs are not being met. A study from 2015 provides updated estimates of the unmet mental health needs among adults in the US. It found that 62% of adults with any mental illness, and 41% with serious mental illness, were not receiving appropriate treatment 5. Many barriers to care are cited in the literature. In one survey, 72% of respondents cited one or more barriers, most prevalently cost and insufficient or lack of insurance coverage, as their biggest hurdles to treatment 13. Other barriers include time and cost of travel, unequal geographic distribution of psychiatrists, patient mobility issues, and the shortage of mental health workers in general 6.

Disruptive innovation
Historically, psychiatry was among the first specialties to use technology to communicate with patients remotely 6-8. There is now over six decades worth of evidence demonstrating the acceptability and feasibility of telepsychiatry in the provision of mental health services. Assessments performed via videoconferencing are reliable, and telepsychiatric interventions lead to clinical outcomes that are comparable to in-person treatment 9. A growing number of controlled trials are providing more insight into the potential of telepsychiatry to deliver quality care while lowering costs. The greatest reductions in cost are associated with diminished travel time, better coordination of care, and early intervention 8. A wide range of cost reductions have been achieved by entities utilizing telepsychiatry, ranging from 40% to as much as 70% in various scenarios 6. Therefore, telehealth, as a ‘disruptive innovation’, has the potential to change the way healthcare is delivered and it is likely to gain greater momentum in the coming years 10.

Effectiveness of telepsychiatry
Evaluations of the effectiveness of telepsychiatry have also been encouraging. Telepsychiatry has demonstrated viability across many settings, various psychiatric treatments, among different populations, and across age groups from child and adolescent mental health to geriatric psychiatry 8. A randomized control study conducted in 2012 found that low-income patients receiving mental health services for depression improved faster than the control group receiving face-to-face treatment, with little difference in the number of missed working days between the two groups 11. A review article cited numerous examples in the literature demonstrating the efficacy of telepsychiatric assessments. One such study found extremely high diagnostic validity for assessments conducted via videoconferencing at rates comparable to face-to-face care 6. Telepsychiatry has also been successfully implemented on a large-scale for a population encompassing many age groups. The U.S. Department of Veterans Affairs (VA) studied the rate of psychiatric hospitalizations of over 98,000 VA patients both before and after enrolling in telemental health services. Between 2006-2010, the total rates of psychiatric admissions and number of inpatient days decreased by 24.2% and 26.6% respectively 12. Evidence also shows that patients with certain conditions, such as autism spectrum disorders or Post Traumatic Stress Disorder (PTSD) may prefer receiving services via telepsychiatry rather than in-person. The distance between themselves and the clinician contributes to feeling increased control and safety during sessions 8. With evidence supporting the use of telepsychiatry in a number of contexts, it is important to consider potential limitations and the best methods of implementation to achieve optimal patient outcomes.

Integrated care model
The American College of Physicians highlights the importance of an ongoing relationship between patient and physician in the successful implementation of telemedicine 13. In the absence of face-to-face encounters with their patients, telepsychiatry clinicians should consult with clinicians that do see the patient in person on a regular basis 13. A consistent theme in the literature is that most limitations, including the potential for fragmentation of care, can be addressed by integrating telehealth with more traditional in-person care 7. Regroup’s integrated model adheres to this principle; with a strong belief that telepsychiatry should mirror in-person practice and that embedding clinicians within patients’ existing healthcare team is essential in achieving optimal patient outcomes.

Regroup’s model
Regroup Therapy ensures the delivery of high quality healthcare through a clinically-integrated model, ensuring that our telehealth clinicians are fully engaged with their patients’ care team. In contrast to the “per click” or “just in time” models where physicians are randomly assigned to patients based on availability, our clinicians are “virtually staffed” and fully integrated within the healthcare facilities they are assigned to. This model means that our clinicians are embedded within the healthcare treatment team, becoming an integral part of the team, and utilizing a collaborative care approach. Accordingly, our clinicians are assigned to the same facility every week, utilize that facility's electronic medical record (EHR) and electronic prescribing system when available. Regroup’s integrated care model is in sharp contrast with on-demand models. When patients consult specialists independently, or “on demand,” it creates “silos” or “orphan events” in their medical histories which are especially problematic where no electronic health records exist 9. The integrated approach and collaborative model ensures continuity of care, higher patient engagement and better mirrors ideal in-person care. Regular interaction with patients’ care teams allow Regroup clinicians to practice in a manner that reflects more traditional face-to-face care while leveraging the increased flexibility and access that technology provides.

Conclusion
As the need for mental health services in the United States continues to increase, telemental health has emerged as an effective and accepted method of healthcare delivery, significantly enhancing access to mental healthcare across the country and overcoming multiple barriers. It is our responsibility to continue to develop telepsychiatry, in a manner that maintains and enhances the delivery of high quality mental health services. Regroup’s mission and priority remains “to ensure that anyone in need of mental healthcare can access a clinically-appropriate, high quality behavioral health provider, regardless of where they live.” 14. Regroup’s integrated model of virtual staffing ensures patient engagement, clinician collaboration and continuity of care, and continues to represent best practice and the standard of care to strive for everyday.

Authors’ Bios:

David Cohn
David Cohn is the Founder and CEO of Regroup Therapy. David holds an MBA from IE Business School in Madrid, Spain and a Bachelor’s Degree in Economics from Colorado College. He served in the US Peace Corps in Guatemala and advised global CIOs as Director for Latin America, and Southern Europe with CEB.

Hossam Mahmoud, MD MPH
Dr. Hossam Mahmoud is the Medical Director at Regroup Therapy. He is a board certified psychiatrist, licensed in Illinois and Massachusetts. He is a Clinical Assistant Professor at Tufts University School of Medicine, and holds a Masters of Public Health from the American University of Beirut, Lebanon.

References

1. Mojtabai, R., & Jorm, A. F. (2015). Trends in psychological distress, depressive episodes and mental health treatment-seeking in the United States: 2001–2012. Journal of affective disorders, 174, 556-561.

2. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International journal of methods in psychiatric research, 21(3), 169-184.

3. National Institute of Mental Health. (2015). Any Mental Illness (AMI) Among U.S. Adults.

4. Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of clinical psychiatry, 76(2), 155-162.

5. Walker, E. R., Cummings, J. R., Hockenberry, J. M., & Druss, B. G. (2015). Insurance status, use of mental health services, and unmet need for mental health care in the United States. Psychiatric Services, 66(6), 578-584.

6. Deslich, S., Stec, B., Tomblin, S., & Coustasse, A. (2013). Telepsychiatry in the 21st century: transforming healthcare with technology. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 10(Summer): 1f.

7. Dorsey, E. R., & Topol, E. J. (2016). State of telehealth. New England Journal of Medicine, 375(2), 154-161.

8. Shore, J. H. (2013). Telepsychiatry: videoconferencing in the delivery of psychiatric care. American Journal of Psychiatry, 170(3), 256-262.

9. Chakrabarti, S. (2015). Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches. World journal of psychiatry, 5(3), 286-304.

10. Schwamm LH. Telehealth: seven strategies to successfully implement disruptive technology and transform health care. Health Aff (Millwood) 2014; 33: 200-6.

11. Chong, J., & Moreno, F. (2012). Feasibility and acceptability of clinic-based telepsychiatry for low-income Hispanic primary care patients. Telemedicine and e-Health, 18(4), 297-304.

12. Mojtabai, R., & Jorm, A. F. (2015). Trends in psychological distress, depressive episodes and mental health treatment-seeking in the United States: 2001–2012. Journal of affective disorders, 174, 556-561.

13. Daniel, H., & Sulmasy, L. S. (2015). Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper Recommendations for the Use of Telemedicine in Primary Care Settings. Annals of internal medicine, 163(10), 787-789.

14. Regroup Therapy. (2017). About Us: Our Mission.

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