Telepsychiatry: Promise, Potential, and Population Health

In this month’s column, John Fortney, Ph.D., talks about how telepsychiatry can increase access to effective mental health care if applied with careful thought and a population-health perspective in mind. —Jürgen Unützer, M.D., M.P.H.

Providers all over the globe are increasingly using telemedicine to improve access to high-quality health care. Psychiatry is arguably more suited to telemedicine than most other clinical specialties and in many ways is at the forefront of the telemedicine movement. If applied thoughtfully and with a population-health perspective in mind, telepsychiatry can help address the two primary challenges facing our mental health care delivery system: the inequitable geographic distribution of mental health providers and the overall lack of capacity.

Research has determined that the quality and outcomes of psychotherapy, pharmacotherapy, and consultation delivered via telepsychiatry are equivalent to those of services provided face to face. There are many different models of telepsychiatry that require varying degrees of resource intensity, from telepsychiatry curbside consultation, which is given to primary care providers (low-resource intensity), to telepsychiatry referral, in which an off-site mental health team takes over the care of the patient (high-resource intensity).

From a population-health perspective, it is important to realize that there is a tradeoff between resource intensity and reach into the patient population. In other words, when high levels of clinical resources are devoted to an individual patient, fewer numbers of patients can be treated. Consideration of this tradeoff is important when choosing what telepsychiatry model makes the most sense to implement. Although the telepsychiatry referral model improves geographic access to specialty mental health and can impact which patients are treated, it doesn’t address the challenge of capacity. A provider treating a patient via telepsychiatry cannot simultaneously treat another patient. It’s a zero sum game.

In contrast, telepsychiatry integrated care models that place mental health specialists in consultative and supportive roles within the context of primary care have the potential to make a much larger impact at the population level. Integrated care models can increase the reach, and thereby the population-level effectiveness, of mental health specialists. While practice-based models of integrating mental health care into primary care are effective in clinics that have mental health providers on site, they don’t necessarily work in small, rural primary care clinics that lack on-site mental health staff. However, the collaborative care model, a specific type of integrated care, has been shown to be effective regardless of whether the mental health and primary care providers are physically co-located, opening the door for adapting the model using telemedicine technologies.

In telepsychiatry collaborative care, multiple members of the care team can be located off site including the care manager, psychiatric consultant, tele-therapist (delivers evidence-based psychotherapy via virtual care technology), and telepharmacist (conducts medication histories via chart review and/or telephone calls with patient). Telepsychiatric consultations and telepsychotherapy are delivered using interactive video in the primary care clinic, but web-based or smartphone audio-video communications may be used with patients in their homes or other private location. Telephone psychiatric consultations can also be effective with patients who are otherwise difficult to engage.

Three randomized, controlled trials of telepsychiatry collaborative care have demonstrated that this approach is clinically effective and cost-effective. The first focused on pharmacotherapy for depression in VA community-based outpatient clinics. Compared with usual care, rural veterans randomized to telepsychiatry collaborative care were more likely to adhere to their medications and respond to treatment and achieve remission.

The second trial focused on pharmacotherapy and psychotherapy for PTSD, also in VA community-based outpatient clinics. Compared with rural veterans in usual care, veterans randomized to telepsychiatry collaborative care were more likely to engage in evidence-based psychotherapy and experience clinically meaningful reductions in PTSD symptom severity.

The third trial focused on pharmacotherapy and psychotherapy for depression in Federally Qualified Health Centers. Compared with practice-based collaborative care without specialty mental health involvement (for example, care manager only), rural patients randomized to telepsychiatry collaborative care had modestly higher engagement in both psychotherapy and pharmacotherapy. In addition, they were much more likely to respond to treatment and achieve remission. Implementation studies have also shown the feasibility of implementing a clinically effective telepsychiatry collaborative care program into routine care.

Other telepsychiatry models also look promising such as the telepsychiatry behavioral health consultant model (currently being evaluated through a VA-funded trial) and the telepsychiatry curbside consultation model, in particular the Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) model. In SCAN-ECHO, a team of mental health specialists guides primary care providers through clinic assessment and treatment during virtual case reviews. This creates a benefit not only to the patient whose case is being reviewed, but also to other patients who have similar conditions as the primary care provider’s knowledge and skills increase over time.

Identifying which patients are most appropriate for which model of telepsychiatry is also an important consideration. Patients with less complex, less severe, or less treatment-resistant mental health problems may do well in primary care treatment with curbside consultation, whereas patients with complex, severe, and/or treatment-resistant mental health problems may experience better outcomes with a telepsychiatry referral. The most cost-effective approach is likely to be a stepped-care model in which patients receive the least resource-intensive telepsychiatry care initially and then are “stepped up” to a more resource intensive care model if they do not respond to treatment. A reasonable sequence of care may be (1) primary care with telepsychiatry curbside consultation, (2) primary care with telepsychiatry consultation-liaison, (3) telepsychiatry integrated care, and (4) telepsychiatry referral. Alternatively, complex, severe, and/or treatment-resistant patients could be stepped up immediately to more intensive care.

In the age of health care reform and accountable care organizations, the specialty mental health sector needs to reframe its mission of health care delivery to focus on the care of populations in need rather than the health of the relatively few patients who overcome the many barriers to care and present for treatment in a mental health specialist’s office. Telepsychiatry can help, and both payment reform and more research are desperately needed to incentivize and inform this growing field. ■