Telemedicine’s Role in Improving Mental Health

The suicides of accessories designer Kate Spade and chef Anthony Bourdain brought mental health to the front pages of nearly every media outlet in the world – albeit briefly. The world has already moved on to other stories. However, in the days after those tragic, high profile suicides, calls to the National Suicide Hotline (1-800-273-8255) increased by 25 percent. The sad truth is that as much attention is paid to healthcare, little focus is on mental and behavioral health. It’s time for that to change. Telemedicine can help.

Suicide should remain on the front pages of our media for longer than a 24-hour news cycle. The extent of the suicide crisis in the United States was detailed in a recent report by the Centers for Disease Control and Prevention (CDC). It says that suicide rates increased in 49 of the 50 states (only Nevada saw a decline, though still in the top 10) between 1999 and 2016. According to the report, suicide is a leading cause of death in the U.S.:

• In 2016, nearly 45,000 people died by suicide
• Suicide rates increased more than 30 percent in at least half of the states
• Delaware saw the lowest increase at 6 percent while North Dakota saw the highest increase at 58 percent
• 54 percent of those who died by suicide didn’t have a known mental health problem
  • Women make up 16 percent of them
• Of suicide victims who did have known mental health conditions, women comprise 31 percent
• Suicide is rarely caused by a single factor
  • Issues that can contribute to suicide include relationships, substance use, physical health, job, money, legal, or housing stress

We didn’t set out to write a post on suicide. We set out to write one on the fact that telemedicine and telepsychiatry are making significant headway in providing care for those dealing with mental health issues. It closes gaps in care, improves follow up with patients who might not make or keep appointments, helps those in recovery and can reduce relapse rates. It’s also approved for reimbursement by CMS, with some caveats. The fact that events led us to open this post with information on suicide is a painful indication of how desperately help is needed. It is also an indication of the speed with which outreach and meaningful connection must reach those in pain. Telemedicine for mental health services and telepsychiatry can’t be implemented fast enough.

Not enough providers, not enough funding

First of all, it’s important to point out that the technology to extend mental health care to more people already exists. Telemedicine can be used to impact the suicide rate as well as behavioral and mental health issues in the U.S. There is no time to waste. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2014, (the latest year reported):

• 8 million adults aged 18 and older in the United States had a serious mental illness
• 7 million adults (aged 18 or older) and 2.8 million youth (aged 12 to 17) had a major depressive episode during the past year
• An estimated 22.5 million Americans aged 12 and older self-reported needing treatment for alcohol or illicit drug use
• 8 million adults self-reported needing mental health treatment or counseling in the past year
• 17 percent of teenagers report considering suicide

Despite these statistics, the number of mental health beds and the amount of funding available to treat mental health patients continues to be slashed.

According to The Pew Charitable Trusts:

• States cut $4.35 billion in public mental health spending between 2009 and 2012, though some states have made modest increases since 2012.
• The Treatment Advocacy Center recommends 40 to 60 psychiatric beds for every 100,000 people. The national average is 11.7.
• Some estimates show that the nation needs an additional 123,300 psychiatric hospital beds just to meet the current need.
• Georgia has 9.3 beds for every 100,000 people and 233 fewer beds than it did in 2010.
• One 2012 study found that 70 percent of emergency rooms had to board psychiatric patients for more than 24 hours and 10 percent had to board them for a week or more.

It is worth emphasizing SAMHSA’s conclusion: By 2020, mental and substance use disorders will surpass all physical diseases as a major cause of disability worldwide.

And yet, it’s estimated that more than 100 million people are without adequate access to mental health services in the U.S. as evidenced by 4,627 designated mental health shortage areas across the country.

 The urgent need to expand and improve access

The ability to talk to someone is a core tenant of any type of behavioral or mental health care. A patient’s ability to access providers with continuity is step one in delivering meaningful care. Lack of continuity between the provider and the patient creates risky gaps in care.

New York Presbyterian discovered that telepsychiatry could address some of those challenges. In fact, it reduced a 24-hour wait for psychiatric services to less than 1 hour through the implementation of telepsychiatry services. Now, emergency department patients don’t have to return to the ED for a follow-up visit for psychiatry services. They can visit the doctor via telepsychiatry instead.

Stanley Berman, Ph.D., Vice President for Academic Affairs at William James College in Newton, Massachusetts says that despite ongoing challenges with the delivery of telepsychiatry, it can significantly improve access for patients.

“Access to mental health services can be improved for several different types of patients,” said Berman. “They include those who live in rural areas miles away from providers. It includes those who have limited mobility due to health or disability issues. Those who are going through exhaustive medical regimens like cancer treatments don’t have the strength to physically return to the hospital one more time for a mental health visit.” Telepsychiatry can deliver services to these people and make sure they receive care that is important to their quality of life.

“Clearly it is a modality that can be used effectively, especially when care can’t be delivered face-to-face,” said Berman. For example, when a mental health provider has been working with a patient for a long time and the patient has to travel on business. The provider may realize his or her patient is in a tough place mentally and continuity of care is essential to wellbeing. Telepsychiatry bridges gaps that were previously created by the inability to be in the office in person. “Video chats that allow the patient and provider to see one another on the screen is a preferred modality,” says Berman. “However, when one has an established relationship with a provider, then a telephone meeting does not have to be a less desirable option.”

Furthermore, studies show that telepsychiatry is one of the most powerful types of telemedicine. A study conducted by Harvard and the RAND Corporation found “dramatic growth in the use of telemedicine for the diagnosis and treatment of mental health disorders in rural areas.” However, it also found inconsistent implementation. The study found that among rural patients there was an average annual increase of 45 percent in telemedicine visits between 2004 and 2014 – depending upon where they lived.

• Four states had no telemedicine visits for mental health
• Nine states had more than 25 visits per 100 patients with “serious mental illness.”

While telemedicine is being used to treat rural patients with mental health needs, implementation remains at an anemic 1.5 percent.

Harvard Medical School looked at the number of Medicare patients who were using telemedicine for mental health issues. It found “the number of telemedicine visits provided to Medicare beneficiaries increased by 28 percent per year from 2004 to 2013.” That represented a total of 107,000 visits in 2013.

• Over 40,000 rural Medicare beneficiaries received one telemedicine visit in 2013, and those patients had a mean of 2.6 visits each.
• Disabled beneficiaries with mental illness, who were relatively sicker and poorer than the average Medicare user, were the most likely to have received telemedicine services; the vast majority of those visits were for mental health conditions.
• Even with the sharp increase in visits, less than 1 percent of total rural Medicare beneficiaries received a telemedicine visit in 2013.

Veterans are benefiting from telepsychiatry

Especially relevant to the argument about the effectiveness of telemedicine is the U.S. military. The armed forces are way ahead of civilian healthcare in its implementation of telemedicine services for its personnel. The Department of Veterans Affairs started serving its patients in rural areas through telemedicine in the 1990s.

A study published in Psychiatry Online looked into the effectiveness of telemedicine services for veterans. It reviewed the clinical outcomes of 98,609 mental health patients before and after they enrolled in “telemental health services” with the VA between 2006 and 2010.

The study compared the number of “inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing”. It reviewed data for an average of six months before and after their enrollment in the ‘telemental health services’”. The results showed that psychiatric admissions decreased an average of 24.2%. Hospitalization days decreased by an average of 26.6%.

Dr. Berman witnessed a military telemedicine case study firsthand during a conference in Honolulu. The discussion centered around telemedicine services delivered by Tripler Medical Center in Honolulu;  the medical center for all military personnel in the Pacific. “The military officer was stationed in Guam and had been diagnosed with mental health issues,” said Berman. “We watched video footage showing him receiving regular telepsychiatry services from Honolulu. He never had to leave Guam to be successfully treated.”

The work at Tripler was featured in an article published by the American Psychological Association in 2011.

Even though it was ahead of the curve already, delivery of telemedicine for veterans just took another step forward. The VA Mission Act (VAMA) was recently passed and allows telemedicine to be delivered to veterans across state lines. That removes one looming barrier to the delivery of care. It allows “VA healthcare professionals to practice telemedicine regardless of the location of the provider or patient during the treatment.” That change needs to be implemented for the delivery of civilian telemedicine as well.

VAMA also requires that VA health professionals adhere to quality and efficiency standards that are consistent across the country. The VA will have to submit a report to that effect at the end of the first year of the act’s implementation. Among the metrics, they will have to document provider and patient satisfaction with care delivered via telemedicine. They will also have to report statistics showing the impact of telemedicine services on patient wait times.

Pediatric mental health needs met with telemedicine

Pediatric mental health needs are increasing across the country. The numbers have mental health experts extremely concerned. The 2017 Youth Risk Behavior Survey (YRBS) shows a marked increase in the number of teenagers feeling sad, hopeless and having suicidal thoughts, as compared to survey results a decade ago. The YRBS is given to approximately 15,000 high school students in 39 states every two years. The 2017 results showed a disturbing picture of teenagers under crushing pressure, suffering from growing fear and despair:

• 17 percent reported considering suicide
• 31 percent said they had experienced the feelings listed above
• 28 percent reported those feelings in 2007
• 14 percent of students had made a suicide plan
• 11 percent reported doing so in 2007

In Georgia, suicide is the most common cause of death for people ages 10 to 24. It’s estimated that nearly half of the state’s counties do not have even one licensed child psychologist. The Governor’s Commission on Children’s Mental Health turned to telemedicine to try to address the problem. The fact is that schools can’t educate psychiatrists and psychologists fast enough to fill the void. Newly minted professionals might not want to practice in rural areas anyway. Therefore, telepsychiatry is a real and present solution.

The governor and the commission have requested $23 million to put “tele-mental health” in the schools. The funds will be used to purchase telemedicine services and infrastructure like cameras, computers, and training for those who will create the system. It’s hoped that the tele-mental approach will identify mental health needs in school-aged children earlier, create awareness and reduce the stigma of asking for help.

Noteworthy is the fact that suicide among children and teenagers isn’t just a problem in Georgia. The CDC says that suicide is the second most common cause of death among U.S. teens as a whole. Yet, only one-third to one-half of children have access to mental health care. There it is – that obstacle of access. It pops up over and over again. In states across the country, schools are turning to telemedicine to overcome that obstacle, fill gaps in care, and try to save children.

Utah: A bill in that state would dedicate nearly $600,000 to create a two-year telepsychiatry program for schools. It would create a telemedicine platform by which schools could schedule appointments between children and child psychiatrists.

New Jersey: A collaborative program is connecting mental health experts to urban youths via telemedicine. The New Jersey Department of Children and Families provided a $555,555 grant to Rutgers University Behavioral Health Care and New Jersey Medical School. Together they are creating a program that provides online and phone-based mental health consults to about 60 pediatricians and 100 staff in 30 primary care practices.

It’s an initiative that is badly needed. Experts at Rutgers estimate that in New Jersey:

• One in five children has a mental disorder that could be diagnosed
• One in every ten has a mental illness of some sort that impairs their ability to function

Regrettably, only one-third of these children are getting the services they need.

Obstacles and innovation

Although telemedicine can surmount obstacles of access, regulation hasn’t yet been eased to release its vast potential. That is creating yet another obstacle to the widespread adoption and implementation of telepsychiatry services. According to Dr. Berman, there are three significant obstacles to the implementation of telemedicine and telepsychiatry:

1. The lack of a national license to practice. Currently, mental health providers must be licensed in every state in which they wish to practice.
2. Ensuring that proper informed consent is obtained from the patient. Ensuring they clearly understand the security risks of any online platform.
3. Psychological testing isn’t designed for online administration.

While these impediments to telepsychiatry’s implementation are well recognized, they are being addressed slowly. VAMA is the first legislation to eliminate the requirement of individual state licenses as an obstacle to the delivery of care. As these obstacles continue to be addressed and eliminated, the world becomes an oyster for telemedicine. The possibilities for it to impact global health, substance abuse and pediatric care explode.

Berman says the impact of telepsychiatry on global mental health is just being explored. To illustrate, he points to the work of one innovator, Eugene Augusterfer, LCSW, the Director of Telemedicine for the Harvard Program in Refugee Trauma (HPRT). Augusterfer has been instrumental in developing the HPRT model. Its innovative process uses telepsychiatry to address the mental health needs of communities hit by trauma and disaster. For example, he may travel to work with traumatized populations living in refugee camps, like Cambodians refugees in Thailand. He might work with survivors of war in Bosnia-Herzegovina or survivors of natural disasters in Kobe, Japan. When he returns home to the United States, he can continue his work with people in those communities through telemedicine. It is a powerful example of how telemedicine can have a global reach and impact mental health and trauma in ways that were previously the stuff of dreams.

Fortunately, there are many more applications for telepsychiatry services; too many to cover adequately here. The good news is this: innovators, scholars, and psychiatrists are latching on to the power of telepsychiatry at growing speed. More than half of employers (56 percent) say they will cover telehealth for behavioral health needs in employee benefit plans. That rate of acceptance is doubling each year.

Just three years ago US News & World Report called telepsychiatry “The New Frontier” in mental health. It’s reassuring in a way that that statement now seems quaint. Still, we stand at the edge of a frontier where we must push hard and advocate relentlessly for the widespread implementation of telepsychiatry services. It’s time to deliver behavioral and mental health services to the millions of people who are struggling mightily without them. If we fight hard enough, we might, at the very least, be able to give our youth hope and prevent more people from resorting to suicide.