Where mental health help is scarce, telehealth makes a big difference

When the nearest psychiatrist's office is dozens or even hundreds of miles away, a virtual connection may be enough to help people living with serious mental health conditions get effective care through their local primary care clinic, a new study shows.

The randomized study of just over 1,000 people with post-traumatic stress disorder, bipolar disorder or both conditions shows that most patients engaged with either of two types of telehealth. The study also gives insights into which patients might need additional support when getting such care.

Half of the patients connected directly with a far-away psychiatrist and psychologist, while the other half mostly engaged with team members at the local primary care clinic who received guidance from distant psychiatrist.

Either way, most patients responded well to medication and/or psychotherapy (sometimes called 'talk therapy') for their condition.

One major difference emerged: Those patients who were assigned to get a form of psychotherapy from a specially trained nurse or social worker on staff at their local clinic ended up completing 60% more of these types of sessions than those who were assigned to connect with a psychologist via video. The ongoing in-person contact with their nurses or social workers checking on their other health needs may have been a contributing factor.

The findings, published in the Journal of General Internal Medicine, come from the Study to Promote Innovation in Rural Integrated Telepsychiatry, or SPIRIT trial, which involved patients from 24 safety-net clinics in Michigan, Washington and Arkansas.

Jennifer Severe, M.D., of the Department of Psychiatry at Michigan Medicine, the University of Michigan's academic medical center, led this secondary analysis of the SPIRIT data along with fellow U-M psychiatrist Paul Pfeiffer, M.D., M.S., and John Fortney, Ph.D. of the Department of Psychiatry and Behavioral Sciences at the University of Washington. The study was conducted before the COVID-19 pandemic.

"The study started at a time where clinicians had reservations about treating psychiatrically complex patients with telehealth or integrated care models. Understandably, engagement in care was one of the many concerns," said Severe. "This study showed that patients with multiple psychiatric conditions and who also struggle with several chronic physical health problems can engage well in mental health treatment with their primary care doctors or remote mental health specialists."

The two approaches used in the study were:

• Telepsychiatry Collaborative Care, in which a psychiatrist makes the initial diagnosis via video and the local clinic team provides brief psychotherapy while the local primary care physician handles medication prescriptions with consultation from the telepsychiatrist
• Telepsychiatry/Telepsychology Enhanced Referral, in which a psychiatrist makes the initial diagnosis and handles medication prescriptions, and a psychologist provides psychotherapy by telehealth

Last summer, another study using data from the SPIRIT trial showed that patients in both groups reported substantially and statistically significant improvements in perceived access to care, decreases in their mental health symptoms and medication side effects, and improvements in their quality of life. There was no difference between the groups, and there were no differences in outcomes regarding age, gender, race or ethnicity.

The new study dives deeper into how patients' own clinical characteristics affected their experience with telehealth, and how well they stuck with the treatment course. Two-thirds of the patients in the study had incomes or disabilities that made them eligible for Medicaid, and 50% were unemployed.

The analysis shows that patients who have issues with drugs, as well as those experiencing manic symptoms from their bipolar disorder, may need additional support to get started on psychotherapy or to stay with it.

It also shows that those who have multiple physical health conditions may be most likely to keep pace with their mental health medications and talk therapy programs, likely because they are already coming to the primary care clinic for other types of care.

Severe, Pfeiffer and co-author Rebecca Sripada, Ph.D., also of the U-M Department of Psychiatry, are members of the U-M Institute for Healthcare Policy and Innovation.