Bruce BassiArticle written by John Riley, PA-C
Original: October 6, 2020, Updates: February 9, 2023
Mental health disorders are the largest cause of disability in the world. The costs associated with mental health conditions surpass diseases such as diabetes and cardiovascular disease. According to a U.S. Department of Health and Human Services survey, in 2011 the number of adults in the United States who had a mental illness was 45.6 million, or 19.6% of all adults in the country; and recent data suggests little has changed in recent years as there were 43.8 million adults in 2015 and 44.7 million in 2016 with a mental illness (Substance Abuse and Mental Health Services Administration, 2012; National Institute of Behavioral Health, 2017; National Alliance on Mental Illness, 2018). Likewise, the lifetime prevalence of psychiatric disorders has been estimated at between 24-50%. Estimates indicate that only half of this population receives proper psychiatric treatment (Roberts et. Al, 2013, Watanabe-Galloway, 2015).
One of the greatest foreseeable future challenges to mental healthcare is the growing number of elderly patients due to the aging Baby Boomer generation. The Health and Medicine Division (HMD) of the National Academies of Sciences Engineering and Medicine, formerly the Institute of Medicine, predicts that by the year 2030 there will be between 10.1 and 14.4 million Americans ages 65 and older who will require treatment for a mental health or substance abuse disorder. That prediction is double the current number of older Americans requiring mental health care (Bartels, 2014). Finally, a 2017 report from the National Council Medical Director Institute reports that the demand for psychiatrists may surpass supply by 6,090 to 15,600 (National Council Medical Director Institute, 2017).
This paper endeavors to provide evidence from the existing literature to illustrate the efficacy of a particular model of psychiatric services provision, Telepsychiatry. There are various methods and technologies used in the practice of telepsychiatry, but for the purpose of this article, telepsychiatry will be defined as psychiatric care, which includes psychotherapy, pharmacotherapy, and consultations, provided via live and interactive videoconferencing between a healthcare provider who is licensed to practice psychiatry (i.e. physician, PA, NP), and their respective patients. Although other modes of technology such as telephone or text-message-based care, which are part of the broader array of telemental health, have been mentioned, these modalities have not been reviewed or covered in detail. Furthermore, this paper has a focus on professions/providers who practice in the field of psychiatry which can include Physician Assistants (PAs) and Nurse Practitioners (NPs), as well as physicians. The broader term “psychiatric practitioner” will be used to refer to these professionals interchangeably, unless the specific profession’s title is used instead.
Traditional Practice of Psychiatry
Psychiatry is the branch of medicine that specializes in the prevention, diagnosis, and treatment of mental health and behavioral disorders. Psychiatric practitioners utilize various diagnostic tests (e.g. Mental Status Examination, Depression Scales etc.), provide limited psychotherapy (e.g. supportive), and prescribe and manage psychiatric medications. The effective practice of psychiatry is thought to rely partially on the clinically intimate relationship between patient and psychiatrist, also known as the patient-provider alliance or therapeutic alliance. Face-to-face, private and discrete interactions (whether individual, family, or group-based therapy) have long been the standard for mental health care as many patients who require psychiatric care often need more personalized care, which involves the establishment of a strong patient-provider alliance in order to optimally benefit from treatment (Zilcha-Mano, 2014). This alliance is an important component of the doctor-patient relationship in psychiatry. The patient-provider alliance contributes to agreement on the goals of the treatment and on what will be necessary to achieve those goals, as well as a mutual belief that the specified treatments will produce the desired outcomes. One meta-analysis examining this alliance and how it relates to psychiatric treatment outcomes demonstrated a consistently moderate association between positive therapeutic alliance and successful outcomes of treatment (Ardito & Rabellino, 2011).
Psychiatry relies on the patient-provider alliance in order to effectively communicate with mental health patients, which enhances the ability to properly identify, diagnose, and treat behavioral disorders. Signs and symptoms of mental health changes can be less apparent and less identifiable via typical diagnostic tools (e.g. blood analysis, imaging, etc.) than somatic symptoms, and often present differently within the same diagnosis. For these reasons, psychiatric practitioners strive to maintain high levels of familiarity with their patients, which facilitates their ability to recognize any changes in behavior or signs of mental health distress. An effective psychiatric appointment consists of the clinician identifying a patient’s mental health problems or concerns through detailed patient questioning and history taking, diagnosing a disorder when appropriate and establishing a treatment plan, all while forming and maintaining a therapeutic relationship (Lakdawala, 2015).
Shortage of Psychiatrists
The National Council for Behavioral Health has stated that there is a shortage of psychiatric clinicians in the United States, while at the same time the number of patients requiring psychiatric services grows (2017). Reasons for this shortage include the smaller number of medical doctors, physician assistants, and nurse practitioners working in Psychiatry compared to other medical specialties. An additional factor is the aging psychiatry workforce, which is third in medicine in employing the most practicing physicians over the age of 55, behind only Preventive Medicine and Clinical Pathology (National Committee on Certification of Physician Assistants, 2017; American Association of Nurse Practitioners, 2018; Moran, 2017). As much as 60% of patients receiving treatment for psychiatric issues are treated solely by primary care providers. For many patients, these services may be the only option for psychiatric treatment, however studies have found that primary care providers routinely fail to recognize and diagnose psychiatric disorders, prescribe the proper psychotropic medication, or refer patients for further mental health services (Butler, et al, 2018).
Nursing homes are one of the many areas experiencing the effects of the current shortage of psychiatric practitioners. The prevalence of mental disorders in nursing home residents is higher than same-aged individuals living in the community. Psychiatric services are important in these facilities because of the potentially aggressive behavior, psychosis, depression, and other psychiatric symptoms these patients exhibit, or that may arise from the neurological declines associated with dementias (Volicer, 2015; Ballard et al, 2015). Furthermore, neuropsychiatric disorders (e.g. movement disorders, neurological disorders stemming from psychiatric medications, disorders affecting mental function without a psychiatric basis) as well as severe mental illness can be present and often co-exist in residents who are admitted to nursing homes (Sachdev and Mohan, 2013). Although nursing home resident populations are increasing and are expected to reach 3.2 million people by 2030, the number of geriatric psychiatry fellows is steadily declining, and in 2010 was one half of the number of fellows in 2005 (Lee, 2013). Therefore, many nursing homes will not have available on-site services of a geriatric psychiatric provider.
Rural and medically underserved areas are also experiencing a shortage of psychiatric practitioners. Medically underserved areas are defined by the Health Resources and Services Administration by their population-to-provider ratio, percent of population living below federal poverty level, and other criteria, with mental health medically underserved areas being especially prevalent in the U.S. (Health Professional Shortage Areas, 2016). In 2014, 85% of federally designated health professional shortage areas were rural (Watanabe-Galloway et al., 2015). Rural adults face many obstacles to receiving adequate psychiatric services as evidenced by one survey of older rural adults which identified the following as potential difficulties to receiving psychiatric healthcare: availability of psychiatric practitioners, healthcare affordability, transportation, stigma, and long-distances between patients and providers (Brenes et al, 2015).
Marginalized populations such as veterans and prisoners face greater difficulties concerning access to adequate psychiatric care. By some estimates, 40% of veterans reside in rural communities. These veterans can face difficulties traveling to receive care due to poor public transportation, disabling medical conditions, time constraints, and fear of mental health stigma secondary to reduced privacy in rural settings. Furthermore, veterans residing in rural areas may be less open to technology that could be used to support their healthcare. One study of 201 veterans in rural Alabama found that about 50% were regular Web users, which is substantially lower than the percentage (71%) in nationally representative veterans assessed during the same time period. It is presumed that low use of technology is due to lack of access or experience using technology. There is research to suggest that individuals who reside in rural locations believe that using technology is inconsistent with their rustic lifestyle (Whealin, King, Shore & Spira, 2017). Another population lacking sufficient psychiatric healthcare is prisoners. Over 20% of both federal and state prisoners have psychiatric profiles. One striking example of this discrepancy is the Los Angeles County Jail, where more than 800 psychiatrically ill prisoners are housed, giving rise to the prison’s moniker of the largest single “psychiatric institution” in the country. In 2012 it was estimated that there were over 350,000 inmates with severe mental illness in prisons and jails, and 35,000 patients with severe mental illness in state psychiatric hospitals (Bashshur, Shannon, Bashshur, & Yellowlees, (2016).
The mentally ill are overrepresented in correctional settings at estimated rates ranging from two to four times the general population, and so there are now ten times more individuals with a serious mental illness in prisons and jails than there are in state mental hospitals. This overrepresentation of mental health patients in the prison system has not yet been adequately compensated for by a sufficient number of mental health professionals (Al-Rousan, Rubenstein, Sieleni, Deol, & Wallace, 2017). One systemic review found that one in seven prisoners have major depression or psychosis, and that these rates have stayed consistent for the previous three decades. Higher than average rates of drug and alcohol dependence comorbidities in prisoner populations further exacerbate and complicate effective treatment, as well as worsen prognoses. Additionally, suicide, suicidal ideation, and self-harm are more prevalent in prison populations, with the average risk of male suicide being 3-6 times higher and female suicide being more than 6 times higher than the general population. Victimization secondary to having a psychiatric disorder is also higher in prison populations. A regional survey of state prisons in the U.S. found that 1 in 12 male prisoners with a mental disorder were sexually victimized by another prisoner within a 6-month period, compared with 1 in 33 male prisoners without a mental disorder. Sexual victimization was also found to be 3 times higher in female prison populations than in males. Similar data was found concerning physical victimization. (Fazel, Hayes, Bartellas, Clerici & Trestman, 2016).
Barriers to Receiving Psychiatric Care
Barriers to mental health care can occur at different levels including organizations, providers and patients. At the organizational level, a shortage of psychiatric practitioners can limit reach, especially in rural and low-income areas. Individuals with either private or public health insurance often find it difficult to locate or receive quality mental health care due to provider network restrictions or long waiting lists. In most Medicaid and uninsured populations, the need for psychiatric services far exceeds the capacity of in-network providers. At the provider level, barriers can include biases and stigmatizing beliefs, discomfort with assessing and treating particular mental health conditions, beliefs about treatment efficacy, resource and time constraints, and burnout. At the patient level, barriers include cost, health insurance coverage, distance to providers, cultural and language discrepancies, personal stigma, and privacy concerns (Clarke & Yarborough, 2013).
Stigma concerns negative stereotypes, social status loss, and discrimination related to a particular perception of difference. Stigma is based on assumptions and stereotypes about identity that are shared among a wide population as well as understood by the person being stigmatized. The stigma attached to mental health disorders is a more personal and less tangible barrier to mental health access. Whether it is a lack of information, individual belief, mistrust, or a traditional cultural concept, patients may feel uncomfortable seeing a mental health professional or acknowledging a mental health issue. (Chen et al., 2016; Lau et al., 2017). The desire to avoid being stigmatized can result in the refusal to acknowledge a psychiatric issue, pursue mental health treatment, or adhere to established treatments (Stotzer, Whealin & Darden, 2012). Furthermore, the negative feelings of self-worth stemming from stigmatization can exacerbate existing psychiatric symptoms.
Barriers associated with geography including travel distance from patients to providers, lack of transportation, and scheduling conflicts (work, family, school) are another impediments to psychiatric care, and can result in delayed treatment, as well as nonadherence to appointments and noncompliance with treatments (Lingley-Pottie, Mcgrath, & Andreou, 2013). In one study involving patients receiving mental health services for posttraumatic stress disorder (PTSD), the Veteran Affairs health system found that geographical barriers such as patient distance from clinics led to a decreased rate of initiating and continuing treatments when compared to the federal recommendation (Hilty, 2013). Telepsychiatry has the potential to increase patient comfort by connecting them with culturally similar or culturally familiar psychiatric providers who may not be geographically local enough to see the patient otherwise.
When patients present to the emergency departments (ED) in crisis there is often no psychiatry specialists immediately available for assessment and treatment, and this dearth of psychiatric practitioners can be even larger during night-shifts, weekends, or in underserved populations including rural areas. The result can be unnecessary hospitalizations, inappropriate discharges or other inadequate treatment that is disruptive to people’s lives and expensive for the healthcare system (Seidel & Kilgus, 2014). Clinic capacity, the logistical relationship between patient volume and healthcare provider availability, is yet another issue affecting access to psychiatric health care. With the expansion of Medicaid through the Affordable Care Act, the financial encumbrance of mental health care has been lessened and more Americans have access to mental health care than ever before (Cummings, 2017). In addition to lack of providers effecting a clinics capacity to manage those with psychiatric illness, psychiatric practitioners are reimbursed less for services provided to Medicaid and Medicare patients, which further decreases the number of psychiatric practitioners who will accept these patients (Vo et al., 2015).
Diagnoses of depression, anxiety, PTSD, substance abuse, and schizophrenia have all been shown to have higher prevalence in impoverished, lower socioeconomic status (SES) areas. These patients also tend to receive less specialty care for mental health, and instead rely on acute hospital care for medical and psychiatric needs. Multiple obstacles prevent those with low SES from engaging in specialty care including long wait times for services, limited health insurance benefits, limited clinicians willing or able to provide services at lower rates of reimbursement, and multicultural barriers such as perceived bias and cultural mistrust (Devine, DeCaporale-Ryan, Lim & Berenyi, 2017).
Cost of Psychiatric Care
US health-care spending has been increasing at an annual rate of over 3% per year to a total of $2.9 trillion dollars spent in 2013. For over a decade before this, health-care expenditures have accounted for over 17% of the nation’s gross domestic product (Centers for Medicare and Medicaid, 2014). In 2015 the National Institute of Mental Health estimated the total costs associated with mental illness to be in excess of $300 billion per year. The global cost of mental health disorders alone was estimated at $2.5 trillion in 2010, with a projected increase to over $6 trillion in 2020. Furthermore, the care of patients with comorbid medical and behavioral conditions accounts for up to one-half of all healthcare spending. (Bashshur, Shannon, Bashshur, & Yellowlees, (2016).
The view that behavioral and physical wellness are interdependent and that individuals with the highest health care costs are often those with co-morbid physical and behavioral health diagnoses is becoming more prevalent. National health care cost containment efforts of the late 1970s that seemed successful were eventually shown to have been limiting patient access to services and reducing payment to providers, as well as creating an inverse relationship between administrative expenditures and quality of patient care (Mendelberg, 2014). In one economic analysis of individuals enrolled in commercial, Medicare, and Medicaid health insurance plans, individuals with a behavioral health condition were found to cost 2–3 times as much as those without a behavioral health condition in both behavioral and physical cost categories (Melek et al., 2014; Waugh, Voyles, & Thomas, 2015).
Telemedicine
The aforementioned barriers to care, along with the increasing number of individuals needing psychiatric services, has necessitated the creation and implementation of new and innovative methods of providing psychiatric care. One method of providing access to specialized psychiatric care at a time of increasing demand with fewer psychiatric clinicians is the use of Telepsychiatry. Telepsychiatry, also known as Telemental health, is the area of telemedicine that comprises Psychiatry (medical specialty concerning mental, emotional, and behavioral disorders) and behavioral health (mental wellness healthcare including substance abuse, as well as psychological, emotional, and behavioral issues; American Psychiatric Association, 2018a; Insight, 2018). Telemedicine is broadly defined by the American Telemedicine Association as “The remote delivery of healthcare services and clinical information using telecommunications technology” (American Telemedicine Association, 2018). Telemedicine can provide contact between a healthcare professional and a patient via various telecommunication media including, but not limited to, text and email messaging, telephone, and live videoconferencing. Telemedicine is able to connect healthcare providers and patients quickly and easily, while overcoming many of the barriers to receiving quality healthcare such as stigma, geographic location of patient, provider shortage, clinic capacity, and financial considerations (Shore, 2015).
Telepsychiatry
Telemedicine has its origins in psychiatry, being first developed and utilized at the Nebraska Psychiatric Institute in 1959, and eventually being used to provide mental healthcare services to airport employees and then the local community in Boston in 1968 (Deslich, 2013). Telepsychiatry, now over sixty years old, is a well-recognized and established method of providing mental health care and is in use in all areas of the United States and in many other countries worldwide. The American Psychiatric Association (APA) fully endorses videoconferencing as an effective means of psychiatric healthcare delivery, and even provides and continually updates a resource known as the Telepsychiatry Toolkit to further educate providers about the many aspects of telepsychiatry practice (American Psychiatric Association, 2018b). The American Telemedicine Association (ATA) is another organization that has created and regularly updates guidelines for telemental health practice.
The Centers for Medicaid and Medicare services (CMS) recognize telepsychiatry by reimbursing for its services – if real-time communications, including audio and video, are utilized (CMS Telehealth Services, 2018). Federal law now requires Medicare to reimburse for telepsychiatry services if the patient is in a clinical facility located in a county outside of a metropolitan area. These clinical facilities include offices of physicians or practitioners, hospitals, critical access hospitals, rural health clinics, Federally Qualified Health Centers, renal dialysis centers affiliated with hospitals or critical access hospitals, skilled nursing facilities, and community mental health centers. Patients’ homes are not considered clinical sites and will not be reimbursed by Medicare for telepsychiatry services originating from a patient’s home. Private insurance carriers are able to provide coverage for in-home telepsychiatry services, yet this represents a smaller number of patients utilizing telepsychiatry. While progress is being made, the current Medicare reimbursement system fails to address challenges in providing psychiatric care in urban areas or to homebound patients (Amirsadri, Burns, Pizzuti, & Arfken, 2017).
Benefits of Telepsychiatry
One benefit of telepsychiatry-with numerous clinical applications-is its ability to reduce or eliminate the distance between patient and provider, and thus increase access to care. Telepsychiatry’s ability to increase access opportunities for patients, providers, and payers is partly due to the elimination of costs associated with patient and provider travel time and expense. More than 70% of the cost of time and travel for a patient and provider for a standard in-patient visit can be saved through the use of telemedicine visits in rural and remote areas (Harley, 2006, Spaulding et al., 2010). Research has shown that telepsychiatry is associated with local economic benefits beyond those directly linked to increased care access. Potential benefits – especially for rural areas – include increased job productivity for both patients and providers who are able to participate in treatment with less costs associated with travel and missed work, and patients who may otherwise not be treated effectively, whose symptom alleviation allows more productive work days. Furthermore, other local services such as lab and pharmacies that may have previously lost work to labs and pharmacies near the distant providers might benefit from telepsychiatry. Hospitals that outsource for mental health services via telepsychiatry instead of maintaining an on-site, salaried psychiatrist may also experience cost savings as well as better meeting the cultural and specialty needs of their specific patient population (Whitacre et al., 2009; Waugh, Voyles, & Thomas, 2015).
One study found that telepsychiatry was a far more cost-effective alternative to face-to-face behavioral health within a rural population of Native Americans. Over $12,000 in potential savings from reduced psychiatrist time needed to conduct clinical interviews was realized. Furthermore, it was noted that these costs had dropped substantially during the 2-year study period and were expected to drop even further in coming years. It is likely that a current replication would find even larger cost savings associated with telepsychiatry versus face-to-face psychiatry, given increasing salaries and decreasing technology costs since 2005 (Shore et al. (2007). Another study examining travel costs for 278 consultations for rural nursing home residents found savings ranged from $33,000 to $67,000 for most providers, but up to $84,000 to $253,000 for some physicians, when using telepsychiatry instead of traveling (Bashshur, Shannon, Bashshur, & Yellowlees, (2016).
Applications of Telepsychiatry
At this time, controlled trials involving telepsychiatry have been conducted with almost all prevalent psychiatric disorders including depression, anxiety disorders, eating disorders, substance abuse, psychosis, dementia, and suicide prevention. Traumatic disorders, including Post Traumatic Stress Disorder (PTSD), and the use of telepsychiatry in treating these disorders, has also been studied and the results have often been mixed. Veterans who have engaged in combat have high rates of mental health disorders. It has been estimated that 13% to 21% of U.S. veterans suffer from PTSD. The symptoms of PTSD—intrusive memories, hyperarousal, negative mood, difficulty concentrating, and a need to avoid stimuli associated with their trauma—negatively impact veterans’ ability to engage in life events. PTSD can increase risk for family conflict, interpersonal violence, suicide, and homelessness. However, the negative consequence of PTSD may be prevented by veterans’ participating in mental health treatment. Telepsychiatry services provided to the patient’s home have potential to improve access to clinical care, minimize costs, and improve veterans’ quality of life. Recent trials have indicated that evidence-based interventions for PTSD delivered via videoconferencing may be feasible and effectively equivalent in many measures to those delivered face-to-face in a clinic, including levels of participant satisfaction with treatment and symptom improvement (Whealin, King, Shore & Spira, 2017).
Opioid addiction is a relatively new epidemic which psychiatry is responding to. Jones et al, reports that 96% of states in the United States cannot adequately provide medication-based treatment for opioid addiction (2015). In West Virginia, where the opioid crisis is at its worse, patient waitlists for treatment programs can exceed 600. Telepsychiatry is beginning to be utilized to expand treatment coverage for opioid addiction. Similarly, emergency departments are another area where telepsychiatry is expanding specialty psychiatric patient care. The Centers for Disease Control and Prevention has reported that ED visits by patients requiring mental health services are increasing more rapidly than general ED visits (Letvak & Rhew, 2015). EDs are often one of the first places patients with psychiatric disorders present, yet the psychiatric services that are routinely available in these departments varies based on location, time of day, and staff availability.
Telepsychiatry and Face-to-face Psychiatry
The PA profession-originally created to help offset the shortage of medical providers and expand the reach of primary care medicine-is now represented in every field of medicine, including psychiatry. The culmination of new technologies such as telepsychiatry, and PAs increasing their presence within Psychiatry, can help to address the shortage of psychiatric practitioners and further expands and enhances mental healthcare for underserved populations. It is beneficial for PAs, who are traditionally employed in Primary Care and who are able to move between fields of medicine without formal retraining, to be aware of a modality such as telepsychiatry, both for their own practice and for patients they may encounter who participate in it.
In order to establish telepsychiatry as an effective model of psychiatric treatment, it is necessary to compare its accuracy in recognizing and diagnosing psychiatric disorders, as well as how it directly compares to face-to-face psychiatry in other areas of importance, including clinical outcome. Some of the differences between Telepsychiatry and face-to-face psychiatry that have been studied include therapeutic outcomes, treatment compliance, patient-provider alliance, healthcare access, cost-effectiveness, and patient and provider satisfaction. The studies used for these analyses differ significantly in their methodologies, including differences in study designs, populations, sample sizes, psychiatric disorder, therapeutic intervention, clinical site, and to some extent the specifics of the telepsychiatry modality itself (e.g. internet connection, hardware-to-software interface, etc.). Methodological differences and specific statistical analyses used in cited studies will not be explored but instead statistical significances of results in standard p values will be reported. The aim of the overview is to provide a glimpse of where psychiatry currently stands in terms of its use of telepsychiatry: 1) its acceptance and impact on the doctor patient alliance; 2) assessment and treatment outcomes; 3) its effect on access and utilization of care and 4) cost of care.
METHODS
The databases used to locate articles included PubMed, Google Scholar, and Web of Science for the years 2010 to 2018 and were exclusive to articles using adult populations and written in English. Search keywords included telepsychiatry, telemental health, telemedicine, videoconferencing, effectiveness, efficacy, access, therapeutic outcomes, patient satisfaction, provider satisfaction, cost, in-person, face-face, psychiatry, and concerns/limitations. Relevant articles were selected and reviewed. This paper is a literature overview in that the most relevant and impactful articles, as determined by the author, were selected to be reviewed.
RESULTS
Acceptance and Therapeutic Alliance
Campbell, O’Gorman and Cernovsky (2015) examined a randomly selected group of 84 psychiatric patients who were provided telepsychiatry videoconferencing equipment for their psychiatry sessions and then given a survey regarding their impressions of their telepsychiatry sessions. The patients in this study had psychiatric illnesses including schizophrenia, bipolar disorder, and depression. The survey included questions about the quality of the equipment and video picture, the room environment the sessions took place in, whether the telepsychiatry sessions were beneficial to their psychiatric issues, and their level of comfort speaking with their clinician over videoconferencing equipment. Nearly all (97.6%) participants rated sound quality as good to excellent, and 95.2% rated picture quality as good to excellent. The majority of participants reported positive responses concerning their comfort with the telepsychiatry service (95.2%), and answered positively regarding their ability to communicate effectively (92.9%), and finding the method to be as useful as face-to-face interventions (84.5%) and would use the method again (98.8%). Finally, only one of the 84 participants stated that using the telepsychiatry service was stressful.
A satisfaction survey was done with a geographically remote and ethnically diverse rural group of VA patients being treated for PTSD who resided on small volcanic islands in the Pacific Islands. Twenty-nine patients underwent 12 sessions of telemental health Cognitive Processing Therapy (CPT). Prior to treatment, all participants were surveyed concerning their beliefs and attitudes on telemental health. Following 12 weeks of the videoconferencing intervention, participants were asked about their attitudes regarding telemental health. Significant differences in positive survey responses between the first and second survey included the following: “Enough therapist contact in telemental health interventions” (t-test=-2.18, p=.04); “It is easy to communicate with therapist using telemental health” (t-test=-2.02, p=.05); and “Using telemental health interventions fits with my beliefs about therapy” (t-test=-2.33, p=.03). (Whealin, King, Shore, & Spira, 2017).
A survey of 600 U.S. veterans and National Guard members found that 37 (20.4%) participants with PTSD within the surveyed group (N=182) were willing to use videoconferencing telepsychiatry in a clinic and 46 (25.4%) of the participants were willing to use telepsychiatry in their homes. This was compared with the group of veterans who did not identify as having PTSD (N=418), where 191 (45.6%) participants were willing to use telepsychiatry videoconferencing in a clinic and 221 (52.7%) participants were willing to use telepsychiatry in their homes. Chi-square analyses indicated that veterans in the non-PTSD group were more willing to use telepsychiatry in both clinics (x2=33.92) and at home (x2=38.23) compared to the PTSD group (Whealin, Seibert-Hatalsky, Howell, & Tsai, 2015).
Therapeutic alliance was examined in a study of male prisoners where 50 psychiatric prison inmates receiving telepsychiatry services were compared to 50 psychiatric prison inmates receiving face-to-face psychiatric services. The two populations did not differ diagnostically (p=0.255). Working alliance was measured using the following metrics from the Working Alliance Inventory (WAI) questionnaire: development of goals, reaching their goals, and quality of relationship. There were no significant differences found between any of the measured outcomes in the telepsychiatry and face-to-face groups: development of goals had a mean of 18.96 (SD of 3.85) in the telepsychiatry group versus 19.7 (SD of 4.48) for the face-to-face group; reaching goals had a mean of 18.33 (SD of 5.3) for the telepsychiatry group versus 20.2 (SD of 5.58) for the face-to-face group; and quality of relationship had a mean of 18.18 (SD of 5.54) in the telepsychiatry group versus 19.08 (SD of 5.78) for the face-to-face group (Morgan, Patrick, & Magaletta, 2008).
Assessment and Treatment Outcomes
A study of 73 previously untreated patients who presented to an emergency room seeking psychiatric services (depressive disorder, substance abuse, bipolar disorder, psychotic disorder, and anxiety disorder) compared psychiatric evaluations done via telepsychiatry videoconferencing and face-to-face interviews. A second psychiatrist was present at each evaluation in both groups, and independently assessed each patient. The assessments included a non-standardized 10-point Disposition Rating Scale that guided hospital admittance, the Historical Clinical and Risk Management Scale (HCR-20), and the Final Risk Judgement scale rating of either low, moderate, or high. Each physician also provided a disposition recommendation to discharge or hospitalize. No significant differences were found between evaluations conducted via telepsychiatry video-conferencing or face-to-face with a psychiatric provider: p = 0.55 for disposition; p = 0.15 for Disposition Rating Scale; p = 0.43 for HCR-20 Final Risk Judgement; and p = 0.19 for Diagnosis (Seidel & Kilgus, 2014).
A study examining the role of telepsychiatry in neuropsychiatric testing using the Spanish equivalents of a standard neuropsychiatric test battery (i.e. Mini Mental Status Examination, Hopkins Verbal Learning Test, etc.) on a rural Latino population of 22 patients either monolingual in Spanish or bilingual in English and Spanish was conducted (Vahia et al. 2014) Participants either completed a face-to-face session first (n=11) with a psychiatric practitioner or a session via telepsychiatry videoconference (N=11). After the initial session, participants completed another identical session in the opposite modality. A mean composite score was calculated based on all of the administered tests and was used as an indicator of cognitive functioning. The composite scores at first and second evaluation were strongly correlated in both the telepsychiatry-first and face-to-face-first groups (r =0.870, df=10, p<0.001). First and second evaluation scores were not statistically different (F (1,37)=1.2, p=0.280). Mean change in composite score was 0.149 for face-to-face-first and 0.120 for telepsychiatry-first groups. There was no effect of group (F (1,37)=0.31, p=0.579) and there was no visit by group interaction (F (1,37)=1.95, p=0.662). The mean difference at baseline between telepsychiatry-first and face-to-face-first groups was 0.24 (95% CI: -0.47 to 0.96) and the effect sizes for this difference was Cohen’s d = 0.31 (95% CI: 0.01 to 0.65). At follow up, the mean difference was 0.03 (95% CI: -0.70 to 0.76) and the effect size for this difference was Cohen’s d = 0.04 (95% CI: -0.03 to 0.36). Scores on each of the individual cognitive tests in the battery were also compared, and no differences were found between face-to-face-first and telepsychiatry-first groups, or between visit differences.
A randomized control trial (RCT) compared the psychotherapeutic intervention known as Problem-solving Therapy (PST)-which theorizes that depression is a product of poor-problem solving skills and thus aims to improve those skills- in patients with depression via videoconferencing and face-to-face modalities. Both the telepsychiatry group (n=43) and the face-to-face group (n=42) participated in six one-hour sessions in their respective modality over twelve weeks. At 12 weeks the ratings on the Hamilton Rating Scale for Depression (HAMD) between the two groups were not significantly different: the telepsychiatry cohort’s average score was 13.92, SD=1.18 and the face-to-face group’s average score was 14.44, SD=1.19 (p=.755). At 24 weeks, the telepsychiatry group’s average HAMD score was 13.37, SD=1.18 and the face-to-face group’s average score was 14.80, SD=1.12 (p=.369) (Choi et al, 2014a).
An RCT involving patients with depression-as defined by HAMD scores greater than 24- undergoing six one-hour therapy sessions of either videoconference-based PST (n=40) or face-to-face PST (n=45) found that after 12 weeks, average HAMD scores were not significantly different between the two groups: 29.72, SD=1.25 for the videoconferencing PST group, versus 30.13, SD=1.19 for face-to-face PST group (p=.772). Similarly, at 24 weeks the average HAMD scores were not significantly different between the two groups: 12.38, SD=0.85 for the videoconferencing PST group comparted to 14.12, SD=0.80 for the face-to-face PST group (p=.138). At 36 weeks however, the average HAMD scores for the videoconferencing PST group was significantly lower than the face-to-face PST group: 11.08, SD=1.07 for the videoconferencing PST group compared to 14.16, SD=0.99 for the face-to-face PST group (p=.035) (Choi et al, 2014b).
A study involving self-identified Hispanic patients with a major depressive episode examined the effectiveness of specialized psychiatric treatment provided remotely through videoconferencing (n=74) or with face-to-face treatment as usual (n=85) at a community health center. Patients in both groups underwent six intervention sessions of their respective modality over a period of six months, consisting of an initial psychiatric evaluation and treatment along with subsequent evaluation and management, including medication management. The clinician-rated Montgomery-Asberg Depression Rating Scale (MADRS) and the self-rated Patient Health Questionnaire (PHQ-9) were used to assess baseline levels of depression as well as any changes in depression levels following treatment. Positive treatment outcomes were defined as a 50% decrease in PHQ-9 scores, with depression remission being considered a 75% decrease in PHQ-9 scores. At the end of treatment, 40 of the 85 face-to-face patients (47%) showed a positive treatment response compared to 48 of the 74 telepsychiatry patients (65%), demonstrating a significant difference in treatment groups (p=.024). Furthermore, 29 of the face-to-face patients (34%) achieved remission compared to 36 of the telepsychiatry patients (49%) with a statistical difference of p=.06 (Moreno, Chong, Dumbauld, Humke, & Byreddy, 2012).
In a study of 119 veterans being treated for depression in the VA healthcare system it was found that 73% of the telepsychiatry patients (n=59) completed their 8 sessions of treatment compared to 70% of the face-to-face psychiatry patients (n=60). The Hamilton Depression Rating Scale (HDRS) was used to measure baseline depression as well as any changes in depression levels at the end of treatment. While mean HDRS values were not given, a positive response to treatment was considered a 50% decrease in HDRS scores. 49% of the telepsychiatry group had positive responses to treatment compared to 43% of the face-to-face psychiatry group, which was not statistically significant (Ruskin et al, 2004).
A study using retrospective chart reviews comparing substance abuse patients enrolled in face-to-face (n = 54) and telepsychiatry (n = 46) interventions involving buprenorphine medication management found no statistically significant group differences on outcome variables. Some of the outcome variables that were analyzed included abstinence time and urine drug screen results. The study’s results included no significant difference in <90-day treatment retention rates between telepsychiatry (51.1%) and face-to-face (49.2%) groups (p=0.99) and >90-day treatment retention rates between telepsychiatry (50.8%) and face-to-face (49.2%) groups (p=0.99). Likewise, >365-day retention rates were not statistically significant, with the telepsychiatry group being 41.7% and the face-to-face group being 35.5% (p = .99). For those reaching 90 days of abstinence time, 43% of the telepsychiatry patients and 27% of the face-to-face patients did not use any additional substances while attending the weekly groups, as evidenced by urine drug screen results. In addition, no differences were found in the number of participants reaching 90 days of continuous abstinence between the telepsychiatry group (49%) and the face-to-face group (37%) (p = .31). (Zheng et al, 2017).
One randomized control trial focusing on alcohol use and dependence disorders compared patients receiving outpatient face-to-face substance abuse treatment (N=39) from psychiatrists and other medical professionals, to patients who received videoconferencing telepsychiatry treatment (N=19) conducted by the same mental health professionals. Socioeconomic and alcohol characteristics were similar in each group. Premature treatment dropout at the 6-month follow-up was the primary measure of the study. Secondary measures included successful treatment completion, number of days in treatment, a 12-month follow-up interview concerning alcohol use in the past month preceding the interview, and composite scores regarding alcohol use, employment, legal status, family status, medical status, and psychiatric status.
At the end of 6 months, 2 out of 32 (6%) participants of the telepsychiatry group had dropped out prematurely compared to 12 out of 39 (31%) participants in the face-to-face treatment group (p = .008). After one year, 25% of the participants in the telepsychiatry group had dropped out compared to 44% of the participants in the face-to-face treatment group (p = .02). Secondary measure outcomes included 19 of 32 (59%) telepsychiatry group participants successfully completing treatment compared to 21 of 39 (54%) participants of the face-to-face treatment group (p = .64), and 44% of the telepsychiatry group compared to 18% of the face-to-face group still being in treatment after one year (p = .03). No significant differences were found in the other secondary measure outcomes (Tarp, Bojesen, & Mejldal, 2017).
Other studies have demonstrated the effectiveness of telepsychiatry in assuring quality care for mental health patients in the ED setting. Psychiatric patient ED waiting times were studied in a rural hospital before and after implementation of a telepsychiatry system. 24 patients requiring psychiatric intervention, who presented to the ED pre-telepsychiatry implementation, were compared to 38 patients requiring psychiatric intervention who presented post-telepsychiatry implementation. Study outcomes included a reduction in ED arrival-to-consult time (10.5 hour average for telepsychiatry group versus 22.7 hour average for non-telepsychiatry group; p<0.001) , total ED length of stay (17 hour average for telepsychiatry group versus 31.7 hour average for non-telepsychiatry group; p<0.001), and consult order to actual consult time (5.4 hour average for telepsychiatry group versus 16.2 hour average for non-telepsychiatry group; p<0.001) (Southard, Neufeld, & Laws, 2014; Letvak & Rhew, 2015).
Access and Utilization
The South Carolina Department of Mental Health implemented a state-wide telepsychiatry initiative in 18 EDs (both rural and urban), and from March, 2009 until June, 2013, the program has serviced over 18,000 patients. One study based on this telepsychiatry initiative examined ED visit data from 7,261 patients who utilized the telepsychiatry videoconferencing technologies and compared it with 7,261 matched controls. Outcome data included outpatient follow-up within 30 days of initial ED visit (46% of telepsychiatry group versus 16% of control group; p<.001), outpatient follow-up within 90 days of initial ED visit (54% of the telepsychiatry group versus 20% of the control group; p<.001), and hospital admission rates (11% of telepsychiatry group versus 22% of the control group; p<.001). A separate analysis was done using regression analysis to adjust for variables including patient age, sex and race. When compared to the control group the computed odds ratio indicates that those individuals in the telepsychiatry group were more than 5 times more likely to follow up with outpatient services within 30 and 90 days of their initial ED visit (5.48 (p<.001) and 5.68 (p<.001) respectively). The telepsychiatry patients had less than half the hospital admissions and length of stay than the control group (0.41 (p=.022) and 0.43 (p=.003) respectively; (Narasimhan et al, 2015).
In a study examining 98,609 patients in the VA health system enrolled in a newly-implemented telepsychiatry service data were obtained for all patients who used mental health services by remote high-speed videoconferencing for the first time between 2006 and 2010. Patients were enrolled for an average of 182 days. Utilization was measured as the number of hospital admissions and the total number of days hospitalized in inpatient treatment on acute general psychiatry, substance abuse, and posttraumatic stress disorder units. For the patients enrolled, the total number of hospital admissions related to psychiatric symptoms fell from 3,948 before the implementation of the telepsychiatry program to 2,994 afterwards, a 24.2% decrease. Moreover, the total number of days spent hospitalized for psychiatric symptoms decreased from 35,532 before the implementation of the telepsychiatry program to 26,080 days afterwards, a 26.6% decrease (Godleski, Darkins & Peters, 2012).
Cost-effectiveness
One study examining cost-effectiveness of telepsychiatry services involved eighteen hospital EDs and compared 7,261 patients who utilized telepsychiatry videoconferencing services, to 7,261 control patients. Inpatient costs for the 30 days following the initial ED visit were $2,336 lower in the telepsychiatry group ($8,290 versus $11,224; p<.001), while the total health care costs in the 30 days following the initial ED visit-which included all inpatient costs during total length of admission, as well as any other hospital charges and ED charges-were $12,634 for the telepsychiatry group versus $14,052 for the control group (p =.001). Regression analysis was also used to adjust for variables such as whether the initial ED visit was on a weekday or a weekend. This adjusted data found inpatient costs within 30 days of initial ED visit to be $2,336 lower in the telepsychiatry group (p=0.41), while total healthcare costs within 30 days of the initial ED visit were not statistically different, although they were less for the telepsychiatry group (Narasimhan et al, 2015).
DISCUSSION
This overview has helped to support other work in this area in that concerns about telemedicine, such as being inferior to face-to-face care have not been demonstrated (Raney, Bergman, Torous & Hasselberg, 2017). The results of this overview found that telepsychiatry, in the form of live videoconferencing is overall as efficacious as face-to-face psychiatry in every direct comparison. Specifically, this overview found that among the studies done, telepsychiatry has similar measurable outcomes when compared to face-to-face psychiatry in various populations and when treating various psychiatric illnesses including schizophrenia, bipolar disorder, and depression. Both patient and provider acceptance of the telepsychiatry were high when measured via surveys. One survey that assessed attitudes towards telepsychiatry before and after patients utilized the intervention illustrated that many of the negative attitudes concerning telepsychiatry do not manifest themselves in practice. No significant differences were found when measuring therapeutic alliance between patients using telepsychiatry and those using face-to-face psychiatry, indicating that a vital part of the patient-provider relationship in psychiatry can exist even over videoconferencing.
Arguably two of the most important and necessary comparisons between telepsychiatry and face-to-face psychiatry is accuracy in assessing psychiatric disorders and treatment outcomes. No significant differences were found in this overview between assessing psychiatric disorders such as depressive disorder, substance abuse, bipolar disorder, psychotic disorder, and anxiety disorder. Neuropsychiatric testing and psychotherapies such as Problem-solving Therapy were also found to be equally effective via telepsychiatry or face-to-face psychiatry. While many of the studies in this overview lacked large sample sizes, the South Carolina Department of Mental Health study from 2009-2013 and the VA health system study from 2006-2010 demonstrated with large sample sizes the efficacy of telepsychiatry compared to face-to-face psychiatry when comparing psychiatric readmission rates, lengths of hospital stays, and cost-effectiveness.
I expected much of the results from this overview due to the fact that telepsychiatry’s goal from its inception has been to expand quality mental healthcare, and how those who need mental healthcare would benefit from any type professional psychiatry, no matter the delivery system. I was surprised by the various populations that have been studied and am confident that with continued use and acceptance among patients and providers, telepsychiatry will only continue to expand quality access to mental healthcare. As telepsychiatry expands in its scope, more studies will be done, and further evidence will contribute to claims of it being as effective as face-to-face psychiatry. The expansion and further study of telepsychiatry will benefit those who struggle to access mental healthcare and help fill a gap in our healthcare system.
This overview found patients accepting of the use of telepsychiatry as well as showing it is efficacious in the treatment of depression and PTSD. The broader literature supports this as others have found the use of telepsychiatry an effective delivery method for mental health services. In addition, a diverse patient and provider population has reported on their experience with telepsychiatry, and their responses to surveys, interviews, and other assessments suggest that they are comfortable using this technology, appreciate its practical benefits, and are not especially concerned about potentially adverse impacts of telepsychiatry on the therapeutic alliance. In terms of intervention quality, the evidence reviewed suggest that telepsychiatry is comparable to face-to-face psychiatry in the reliability of assessment and effective treatment of a range of psychiatric disorders. There is evidence that the intervention has been effective for use with children, non-elderly adults, and elderly adults has been demonstrated via case studies, program evaluations, and controlled trials. Future research needs to demonstrate its effectiveness with other populations such as racial minorities or people living in rural areas.
The literature suggests that the use of telepsychiatry in routine clinical practice settings is increasing, while the costs associated with videoconferencing are decreasing. This was supported by this overview. Telemedicine platforms are becoming increasingly easy and affordable to implement. Hardware needs are being replaced by cloud-based platforms that operate on standard and affordable devices such as laptops, tablets, and smartphones (Shore et al., 2014). Future work should include the assessment of direct and indirect costs associated with this medium of care, including long-term cost-effectiveness and cost–benefit comparisons as well as how cost-effectiveness is affected by geography, patient sociodemographic and clinical characteristics, provider type, and organizational characteristics.
Related to costs is the willingness of insurers to reimburse for telepsychiatry services. Reimbursement for telemedicine has been a barrier to care in the past, but this is changing. While many insurers- including Medicare- as well as individual states, initially had policies and laws that were not favorable to the use of telemedicine, this is no longer the case. Nearly all states now have reimbursement policies and regulations regarding the use of telemedicine. These regulations vary concerning the technology allowed, the type of services offered, who can provide them, where the services can be provided and in some cases the amount of reimbursement allowed (Center for Connected Health Policy, 2017). Medicaid reimbursement for telepsychiatry services is available at each state’s option, and no two states are alike on how telemedicine is regulated. Regulations are constantly changing at both the state and federal level as payers and insurance companies both are realizing the potential for many forms of telemedicine, including telepsychiatry.
This review did not address issues associated with methods and study design, however there are concerns that should be addressed in future research. Of the studies that evaluate clinical efficacy, too few ensure that both the face-to-face and telepsychiatry conditions are assessed in a standardized or consistent manner. Although some studies have demonstrated an advantage for particular patient groups to benefit from telepsychiatry relative to face-to-face interventions, the specific reasons why telepsychiatry is more beneficial to the patient than face-to-face psychiatry remain undetermined. In general, efficacy studies have focused on general psychiatric services such as psychiatric evaluation and medication management rather than the delivery of psychotherapy, and many of the psychotherapy studies reviewed have failed to use standardized or replicable interventions. Large trials targeting specific populations with specific psychiatric disorders and using standardized approaches across conditions are needed to further the telepsychiatry evidence base.
Telepsychiatry research usually incorporates the hypothesis that the experimental intervention (telepsychiatry) does not differ from the control intervention (face-to-face psychiatry). The goal of much telepsychiatry research is to demonstrate that this mode of intervention is as efficacious as traditional modes of service delivery. It may be time to move beyond the traditional comparison analysis to more sophisticated designs examining the factors associated with effective telepsychiatry versus face-to-face interventions.
Additional design factors needing to be examined include: over-reliance on self-report methodologies; selection biases that over-represent patients amenable to telepsychiatry; insufficient sample sizes; and lack of direct comparison of preferences for telepsychiatry versus face-to-face psychiatry. Experimental designs that rely solely on participant self-report are enough to demonstrate a minimum standard of acceptability, but to obtain a more thorough understanding of reactions to telepsychiatry, mixed-methods and experimental designs are necessary. Since the finding that patients are satisfied with telepsychiatry services is prevalent in the literature, future studies may be able to focus less on assessing satisfaction, and more on clarifying the actual effects of telepsychiatry on therapeutic alliance and various clinical outcomes.
Future studies may benefit from shifting focus from establishing equivalent reliability between telepsychiatry and face-to-face assessments, to identifying which types of assessments are most effective with telepsychiatry, which types of assessments are most difficult to administer via telepsychiatry, and how best to improve the accuracy, efficiency, and consumer experience of telepsychiatry assessments. Also, even well-designed RCTs are subject to several sources of biases. It is becoming increasingly clear that telepsychiatry is comparable to face-to-face psychiatry and what is necessary now is more research focusing on factors that increase telepsychiatry adoption, as well as strategies for integrating telepsychiatry services within the greater context of healthcare service delivery.
Finally, one issue that has received little attention in the literature is training. One survey of Psychiatric Nurse Practitioners investigating concerns over their use of telepsychiatry found that a lack of provider experience, training, and self-efficacy are some of the current challenges to implementing telepsychiatry. Education and training in telepsychiatry have lagged behind its use and are not currently a part of many psychiatry training curriculums. Telepsychiatry practice could benefit from standardized training of this delivery method in order to improve its familiarity and ease-of-use with psychiatric practitioners. A recommendation made by the study authors was to have certification in Telepsychiatry as a step to assure quality and safety in the implementation of telepsychiatry services (Baird, Whitney, & Caedo, 2018). Some clinicians continue to believe that the artificial nature of the transmission experience has the potential to negatively affect the patient-provider relationship. These beliefs remain despite the fact that studies consistently indicate that telepsychiatry sessions require minimal technical modifications on the part of the therapist, and the communication medium of videoconferencing appears to have little negative influence on clinical outcomes or satisfaction (Richardson, Frueh, Grubaugh, ede, & Elhai, 2009).
Limitations for this study include not reviewing the entirety of the available literature concerning telepsychiatry. Examples of the available literature that was excluded from this overview include studies conducted in countries outside of the United States, studies focusing on pediatric populations, and studies completed more than a decade prior to this overview. Although the articles used in this literature overview were self-selected, careful effort was taken to maintain the selection criteria outlined in the Method’s section when deciding to include a study. Another limitation of this overview concerns the various modalities of telepsychiatry other than live videoconferencing, such as asynchronous telepsychiatry, text. Furthermore, the varying methodologies and statistical analyses from the included studies were not independently reviewed, and thus the validity and generalizability of all included results are limited.
This study’s intent is to provide a general overview of telepsychiatry’s efficacy as compared to face-to-face psychiatry. While the topic of telepsychiatry may be of limited importance to those who do not practice psychiatry or incorporate telepsychiatry in their practices, or to those patients who do not participate in telepsychiatry interventions, this is an important topic for Physician Assistants. PAs benefit from being knowledgeable of telepsychiatry because of the large amount of opportunities that it presents, including clinical care, education, and research. With the increasing use of telepsychiatry, it is becoming more likely that PAs will encounter a patient who has or is currently participating in a telepsychiatry intervention. Being aware of telepsychiatry’s efficacy via a literature overview such as this serves as a relatively brief education on a medical topic that may not be adequately covered in a PAs education or clinical experience yet may be important to understand in order to better treat future patients.
References
Al-Rousan, T., Rubenstein, L., Sieleni, B., Deol, H., & Wallace, R. B. (2017). Inside the nation’s largest mental health institution: a prevalence study in a state prison system. BMC public health, 17(1), 342.
American Association of Nurse Practitioners (2018). NP fact sheet. Retrieved from https://www.aanp.org/about/all-about-nps/np-fact-sheet.
American Psychiatric Association (2018). What is psychiatry? Retrieved from https://www.psychiatry.org/patients-families/what-is-psychiatry.
American Psychiatric Association (2018). Telepsychiatry. Retrieved from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry.
American Telemedicine Association (2018). About telemedicine. Retrieved from http://www.americantelemed.org/about/telehealth-faqs-.
Amirsadri, A., Burns, J., Pizzuti, A., & Arfken, C. L. (2017). Home-based telepsychiatry in US urban area. Case reports in psychiatry, 2017.
Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology, 2, 270.
Baird, M. B., Whitney, L., & Caedo, C. E. (2018). Experiences and attitudes among psychiatric mental health advanced practice nurses in the use of telemental health: results of an online survey. Journal of the American Psychiatric Nurses Association, 24(3), 235-240.
Ballard, C., Orrell, M., YongZhong, S., Moniz-Cook, E., Stafford, J., Whittaker, R., … & Woodward-Carlton, B. (2015). Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) program. American Journal of Psychiatry, 173(3), 252-262.
Bartels, S., Pepin, R., & Gill, L. (2014). The paradox of scarcity in a land of plenty: Meeting the needs of older adults with mental health and substance use disorders. Generations, 38(3), 6-13.
Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The empirical evidence for telemedicine interventions in mental disorders. Telemedicine and e-Health, 22(2), 87-113.
Brenes, G. A., Danhauer, S. C., Lyles, M. F., Hogan, P. E., & Miller, M. E. (2015). Barriers to mental health treatment in rural older adults. The American Journal of Geriatric Psychiatry, 23(11), 1172-1178.
Butler, D. J., Fons, D., Fisher, T., Sanders, J., Bodenhamer, S., Owen, J. R., & Gunderson, M. (2018). A review of the benefits and limitations of a primary care-embedded psychiatric consultation service in a medically underserved setting. The International Journal of Psychiatry in Medicine, 53(5-6), 415-426.
Campbell, R., O’Gorman, J., & Cernovsky, Z. Z. (2015). Reactions of psychiatric patients to telepsychiatry. Mental illness, 7(2).
Center for Connected Health Policy (2017). Current state laws and reimbursement policies. Retrieved from https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies.
Centers for Medicare and Medicaid. (2014). National health expenditures 2013 highlights. Baltimore, MD: Centers for medicare & medicaid services. Retrieved from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends- and-Reports/NationalHealthExpendData/Downloads/highlights. pdf.
Centers for Medicare and Medicaid (2018). Telehealth services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf.
Chen, E. S., Chang, W. C., Hui, C. L., Chan, S. K., Lee, E. H. M., & Chen, E. Y. (2016). Self- stigma and affiliate stigma in first-episode psychosis patients and their caregivers. Social psychiatry and psychiatric epidemiology, 51(9), 1225-1231.
Choi, N. G., Hegel, M. T., Marti, C. N., Marinucci, M. L., Sirrianni, L., & Bruce, M. L. (2014). Telehealth problem-solving therapy for depressed low-income homebound older adults. The American Journal of Geriatric Psychiatry, 22(3), 263-271.
Choi, N. G., Marti, C. N., Bruce, M. L., Hegel, M. T., Wilson, N. L., & Kunik, M. E. (2014). Six‐month postintervention depression and disability outcomes of in‐home telehealth problem‐solving therapy for depressed, low‐income homebound older adults. Depression and anxiety, 31(8), 653-661.
Clarke, G., & Yarborough, B. J. (2013). Evaluating the promise of health IT to enhance/expand the reach of mental health services. General hospital psychiatry, 35(4), 339-344.
Cummings, J. R., Allen, L., Clennon, J., Ji, X., & Druss, B. G. (2017). Geographic access to specialty mental health care across high-and low-income US communities. JAMA psychiatry, 74(5), 476-484.
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).
Devine, M., DeCaporale-Ryan, L., Lim, M., & Berenyi, J. (2017). Psychological issues in medically underserved patients. Primary Care: Clinics in Office Practice, 44(1), 99-112.
Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet Psychiatry, 3(9), 871-881.
Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 US Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatric services, 63(4), 383-385.
Harley, J. (2006). Economic evaluation of a tertiary telepsychiatry service to an island. Journal of telemedicine and telecare, 12(7), 354-357.
Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: a 2013 review. Telemedicine and e- Health, 19(6), 444-454.
Insight (2018). Defining behavioral health. Retrieved from http://insighttelepsychiatry.com/defining-behavioral-health.
Jones, C. M., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American journal of public health, 105(8), e55-e63.
Lakdawala, P. D. (2015). Doctor-patient relationship in psychiatry. Mens sana monographs, 13(1), 82.
Lau, Y. W., Picco, L., Pang, S., Jeyagurunathan, A., Satghare, P., Chong, S. A., & Subramaniam, M. (2017). Stigma resistance and its association with internalised stigma and psychosocial outcomes among psychiatric outpatients. Psychiatry research, 257, 72-78.
Lee, W. C., & Sumaya, C. V. (2013). Geriatric workforce capacity: a pending crisis for nursing home residents. Frontiers in public health, 1, 24.
Letvak, S., & Rhew, D. (2015, August). Assuring quality health care in the emergency department. In Healthcare (Vol. 3, No. 3, pp. 726-732). Multidisciplinary Digital Publishing Institute.
Lingley-Pottie, P., McGrath, P. J., & Andreou, P. (2013). Barriers to mental health care: Perceived delivery system differences. Advances in Nursing Science, 36(1), 51-61.
Moran, M. (2017). No. of seniors matching into psychiatry takes large leap. Psychiatric News. Retrieved from https://doi.org/10.1176/appi.pn.2017.4b8.
Melek, S. P., Norris, D. T., & Paulus, J. (2014). Economic impact of integrated medical- behavioral healthcare. Milliman Am Psychiatr Assoc Rep, 7, 7.
Mendelberg, H. E. (2014). The integration of professional values and market demands: A practice model. The Psychologist-Manager Journal, 17(3), 159.
Moreno, F. A., Chong, J., Dumbauld, J., Humke, M., & Byreddy, S. (2012). Use of standard Webcam and Internet equipment for telepsychiatry treatment of depression among underserved Hispanics. Psychiatric Services, 63(12), 1213-1217.
Morgan, R. D., Patrick, A. R., & Magaletta, P. R. (2008). Does the use of telemental health alter the treatment experience? Inmates’ perceptions of telemental health versus face-to-face treatment modalities. Journal of Consulting and Clinical Psychology, 76(1), 158.
Narasimhan, M., Druss, B. G., Hockenberry, J. M., Royer, J., Weiss, P., Glick, G., & Magill, J. (2015). Impact of a telepsychiatry program at emergency departments statewide on the quality, utilization, and costs of mental health services. Psychiatric Services, 66(11), 1167-1172.
National Alliance on Mental Illness (2018). Mental health by the numbers. Retrieved from https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers.
National Council Medical Director Institute (2017). The psychiatric shortage: causes and solutions. Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf.
National Institute of Behavioral Health (2017). Mental illness. Retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml.
Raney, L., Bergman, D., Torous, J., & Hasselberg, M. (2017). Digitally driven integrated primary care and behavioral health: how technology can expand access to effective treatment. Current psychiatry reports, 19(11), 86.
Richardson, L. K., Christopher Frueh, B., Grubaugh, A. L., Egede, L., & Elhai, J. D. (2009). Current directions in videoconferencing tele‐mental health research. Clinical Psychology: Science and Practice, 16(3), 323-338.
Roberts, L. W., Ohayon, M., Coverdale, J., Goldsmith, M., Beresin, E. V., Louie, A. K., … & Balon, R. (2013). Strengthening psychiatry’s numbers.
Ruskin, P. E., Silver-Aylaian, M., Kling, M. A., Reed, S. A., Bradham, D. D., Hebel, J. R., … & Hauser, P. (2004). Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. American Journal of Psychiatry, 161(8), 1471-1476.
Sachdev, P. S., & Mohan, A. (2013). Neuropsychiatry: Where are we and where do we go from here?. Mens sana monographs, 11(1), 4.
Seidel, R. W., & Kilgus, M. D. (2014). Agreement between telepsychiatry assessment and face-to-face assessment for emergency department psychiatry patients. Journal of telemedicine and telecare, 20(2), 59-62.
Shore, J. H., Aldag, M., McVeigh, F. L., Hoover, R. L., Ciulla, R., & Fisher, A. (2014). Review of mobile health technology for military mental health. Military medicine, 179(8), 865-878.
Shore, J. H., Brooks, E., Savin, D. M., Manson, S. M., & Libby, A. M. (2007). An economic evaluation of telehealth data collection with rural populations. Psychiatric Services, 58(6), 830-835.
Southard, E. P., Neufeld, J. D., & Laws, S. (2014). Telemental health evaluations enhance access and efficiency in a critical access hospital emergency department. Telemedicine and e- Health, 20(7), 664-668.
Spaulding, R., Belz, N., DeLurgio, S., & Williams, A. R. (2010). Cost savings of telemedicine utilization for child psychiatry in a rural Kansas community. Telemedicine and e-Health, 16(8), 867-871.
Stotzer, R. L., Whealin, J. M., & Darden, D. (2012). Social work with veterans in rural communities: Perceptions of stigma as a barrier to accessing mental health care. Advances in Social Work, 13(1), 1-16.
Substance Abuse and Mental Health Services Administration (2012). Results from the 2011 national survey on drug use and health: mental health findings. Retrieved from https://www.samhsa.gov/data/sites/default/files/2011MHFDT/2k11MHFR/Web/NSDUH mhfr2011.htm.
Tarp, K., Bojesen, A. B., Mejldal, A., & Nielsen, A. S. (2017). Effectiveness of optional videoconferencing-based treatment of alcohol use disorders: randomized controlled trial. JMIR mental health, 4(3).
The Center for Medicaid and CHIP Services (2018). Telemedicine. Retrieved from https://www.medicaid.gov/medicaid/benefits/telemed/index.html.
Vahia, I. V., Ng, B., Camacho, A., Cardenas, V., Cherner, M., Depp, C. A., … & Agha, Z. (2015). Telepsychiatry for neurocognitive testing in older rural Latino adults. The American Journal of Geriatric Psychiatry, 23(7), 666-670.
Vo, A., Shore, J., Waugh, M., Doarn, C. R., Richardson, J., Hathaway, O., … & Thomas, M. (2015). Meaningful use: a national framework for integrated telemedicine. Telemedicine and e-Health, 21(5), 355-363.
Volicer, L. (2015). Nursing home telepsychiatry. Journal of the American Medical Directors Association, 16(1), 7-8.
Watanabe-Galloway, S., Madison, L., Watkins, K. L., Nguyen, A. T., & Chen, L. W. (2015). Recruitment and retention of mental health care providers in rural Nebraska: perceptions of providers and administrators. Rural & Remote Health, 15(4).
Waugh, M., Voyles, D., & Thomas, M. R. (2015). Telepsychiatry: Benefits and costs in a changing health-care environment. International Review of Psychiatry, 27(6), 558-568.
Whealin, J. M., Seibert-Hatalsky, L. A., Willett Howell, J., & Tsai, J. (2015). E-mental health preferences of Veterans with and without probable posttraumatic stress disorder. Journal of Rehabilitation Research & Development, 52(6).
Whealin, J. M., King, L., Shore, P., & Spira, J. L. (2017). Diverse veterans’ pre-and post- intervention perceptions of home telemental health for posttraumatic stress disorder delivered via tablet. The International Journal of Psychiatry in Medicine, 52(1), 3-20.
Whitacre, B. E., Hartman, P. S., Boggs, S. A., & Schott, V. (2009). A community perspective on quantifying the economic impact of teleradiology and telepsychiatry. The Journal of Rural Health, 25(2), 194-197.
Zheng, W., Nickasch, M., Lander, L., Wen, S., Xiao, M., Marshalek, P., … & Sullivan, C. (2017). Treatment outcome comparison between telepsychiatry and face-to-face buprenorphine Medication-Assisted Treatment (MAT) for opioid use disorder: A 2-Year Retrospective Data Analysis. Journal of addiction medicine, 11(2), 138.
Zilcha-Mano, S., Dinger, U., McCarthy, K. S., & Barber, J. P. (2014). Does alliance predict symptoms throughout treatment, or is it the other way around?. Journal of Consulting and Clinical Psychology, 82(6), 931.
