Research published by the journal JAMA Psychiatry in late August found that telepsychiatry in undeserved rural areas was “a resounding success” among people with bipolar disorder and/or post-traumatic stress disorder (PTSD). The results provide more evidence for the effectiveness of virtual therapy, which has become an increasingly important way for people across the country to receive support during the pandemic, and offers insights on how to reduce disparities in mental health.
The Study
For this study, which began in November 2016, researchers recruited 1,004 people from 24 primary care clinics in 12 federally qualified health centers in rural parts of Washington, Arkansas, and Michigan. Federally qualified health centers offer primary care services in underserved areas and adhere to a strict set of requirements, such as providing a sliding fee scale to patients, to receive funding from the Health Resources & Services Administration’s Health Center Program. All participants screened positive for PTSD or bipolar disorder, but were not yet receiving treatment with prescription medication from a mental health specialist at the time they were recruited. Just over 70% of the participants were women, 66% were White, and the average participant was 39 years old. Most of these participants were unlikely to receive care from a mental health specialist without telepsychiatry, the researchers said. The researchers randomly assigned participants to receive telepsychiatry/telepsychology–enhanced referral care, in which they met one-on-one with a psychiatrist or psychologist via video or telephone, or telepsychiatry collaborative care, which involved a telepsychiatrist consulting with the participants’ primary care team. The participants completed surveys at the beginning of the study, as well as 6 and 12 months later. The results showed that telepsychiatry led to meaningful improvements in participants’ conditions and helped reduce the rates of side effects from psychiatric medications. Researchers also found that participants in both groups experienced a significant increase in their perceived access to mental health support and overall quality of life. “It is a well-established fact that individuals are often initially identified as having signs of mental illness in primary care settings, and often primary care healthcare providers are not skilled in diagnosing, treating, and managing serious mental illnesses, such as bipolar-related disorders and PTSD,” Desreen N. Dudley, PsyD, a clinical psychologist and mental health quality consultant at Teladoc and a full-time staff clinical psychologist at Cornell Scott-Hill Health Center, a federally qualified health center in an urban setting in Connecticut. She continues: “Approaches such as the [ones in this study] appear to indeed support improved clinical outcomes for those with serious mental illness, and healthcare facilities interested in offering mental healthcare services should consider adopting either approach.”
Telepsychiatry May Help Reduce Disparities
Telepsychiatry is more than just an effective way to treat certain conditions—it may also help reduce mental health disparities by easing barriers to care, especially in rural communities. “People in rural communities face a number of challenges in accessing mental health services, among them lack of access to any mental health practitioners at all, long wait times to be seen, and limited availability of follow-up care,” explains Elisabeth Netherton, MD, a psychiatrist with MindPath Care Centers, a Community Psychiatry practice. In fact, a Perspective essay published in the New England Journal of Medicine in 2016 noted that there were fewer than one psychiatrist for every 30,000 people in much of rural America. That means a person in need of care may have no choice of a provider—if they can find one at all. “Mental health care is intensely personal, and without the availability of multiple providers to choose from, people might be rapidly turned off from receiving care that they need because they don’t ‘click’ with a particular provider,” says Dr. Netherton. “For example, many of the patients I care for are women with histories of sexual assault. They will often tell me that when only male providers are available, they forgo care rather than receive the services that they need.” Telepsychiatry could offer people in underserved areas not only access to someone who can help, but possibly the choice of multiple psychiatrists, one of whom may be a better fit than the others. “Virtual care allows for a wider range of mental health specialists from out-of-state to treat those in rural areas without requiring providers nor patients to be in-person,” says Dr. Dudley. “The wider range of mental health specialists allows for more inclusion of professionals with cultural competence in treating diverse populations.” Furthermore, telepsychiatry and other virtual mental health services could help protect the privacy of people living in tight-knit communities, which may make it feel more comfortable for them to seek care. Receiving this support from home may also be logistically easier for those with limited access to transportation and childcare, adds Dr. Dudley.
Virtual Care Alone May Not Be Enough
Despite the advantages of telepsychiatry, it’s not a perfect way to provide and receive mental health support. “A major downside of virtual mental health care can be patients’ concern about the ability to connect with us as their providers,” says Dr. Netherton. “It can be hard to read people through a screen.” People may have limited or unreliable access to the technology needed for telepsychiatry, which could disrupt their treatment. Plus, telepsychiatry alone may not provide as robust an array of services for certain conditions as more conventional treatment centers, says Dr. Dudley. “Individuals diagnosed with PTSD and bipolar disorder can have multiple needs to address in order to improve their mental health. Brick-and-mortar in-person facilities are more apt to offer wrap-around services, such as case management, in-home visiting nurse services, and mobile crisis services,” she explains. While telepsychiatry is uniquely positioned to expand access to care in underserved communities, it’s just one of many things that need to be done to ease mental health disparities, experts say. “It would be naïve to assume that tele-mental health care will solve all of the access to care challenges faced by rural communities. Challenges with accessing emergency and inpatient hospitalization services remain, along with disparities in financial resources that impede all forms of medical visits and the ability to consistently fill medications once a provider is seen,” says Dr. Netherton. “However, the availability of these services is certainly a benefit and continued research will support remote providers as we continue working to improve the care that we provide.” While helpful, virtual therapy comes with its own downsides. People may have trouble connecting with a therapist behind a screen, accessing reliable technology, or paying for the service. Still, experts say it can play an important role in reducing mental health disparities in many areas.
