Effectiveness of Telepsychiatry

Originally published October 6, 2020. Updated February 9, 2023. Author: John Riley, PA-C.

Introduction

Mental health disorders represent the world's largest cause of disability, with costs exceeding those of diabetes and cardiovascular disease. Approximately 45.6 million American adults had a mental illness in 2011, representing 19.6% of the adult population. Despite the availability of treatment, only half of this population receives proper psychiatric treatment.

A critical future challenge involves the aging Baby Boomer generation. The Health and Medicine Division predicts that by 2030, between 10.1 and 14.4 million Americans ages 65 and older will require mental health or substance abuse treatment, double the current number. Additionally, psychiatric demand may surpass supply by 6,090 to 15,600 practitioners.

Traditional Practice of Psychiatry

Psychiatry specializes in preventing, diagnosing, and treating mental health and behavioral disorders through diagnostic testing, limited psychotherapy, and psychiatric medication management.

The patient-provider alliance, the clinically intimate relationship between psychiatrist and patient, forms a cornerstone of effective psychiatric practice. One meta-analysis demonstrated "a consistently moderate association between positive therapeutic alliance and successful outcomes of treatment."

Effective psychiatric appointments involve identifying patient concerns through detailed questioning, diagnosing disorders, and establishing treatment plans while maintaining therapeutic relationships.

Shortage of Psychiatrists

The National Council for Behavioral Health confirms a significant shortage of psychiatric clinicians despite growing patient demand. Contributing factors include:

• Fewer medical doctors, physician assistants, and nurse practitioners specializing in psychiatry compared to other fields
• An aging psychiatry workforce (third in medicine for practitioners over age 55)
• As much as 60% of psychiatric patients receive treatment solely from primary care providers, who routinely fail to recognize and diagnose psychiatric disorders

Vulnerable Populations

Nursing Homes: Mental disorder prevalence is higher in nursing home residents than same-aged community members. Though nursing home populations are expected to reach 3.2 million by 2030, geriatric psychiatry fellowship numbers are declining.

Rural Areas: In 2014, 85% of federally designated health professional shortage areas were rural. Rural adults face obstacles including provider availability, affordability, transportation, stigma, and distance barriers.

Veterans: Approximately 40% of veterans reside in rural communities, facing travel difficulties, disabling conditions, time constraints, and privacy concerns. One study found only about 50% of rural Alabama veterans were regular Web users, compared to 71% nationally.

Prisoners: Over 20% of federal and state prisoners have psychiatric profiles. The Los Angeles County Jail houses over 800 psychiatrically ill prisoners. An estimated 350,000 inmates with severe mental illness occupy prisons and jails, ten times more than state psychiatric hospitals. One in seven prisoners have major depression or psychosis. Suicide risk is 3 to 6 times higher for males and more than 6 times higher for females than the general population.

Barriers to Receiving Psychiatric Care

Barriers exist at organizational, provider, and patient levels:

Organizational: Provider shortages limit reach in rural and low-income areas. Individuals with insurance struggle to locate quality care due to network restrictions or long waiting lists.

Provider: Biases, stigmatizing beliefs, discomfort with certain conditions, resource constraints, and burnout.

Patient: Cost, insurance coverage, distance, cultural and language differences, stigma, and privacy concerns.

Stigma

Stigma concerns negative stereotypes, social status loss, and discrimination. Patients may feel uncomfortable acknowledging mental health issues or seeking treatment due to personal beliefs, mistrust, or cultural concepts.

Geographic Barriers

Travel distance, lack of transportation, and scheduling conflicts result in delayed treatment and noncompliance. In one Veterans Affairs PTSD study, geographical barriers led to a decreased rate of initiating and continuing treatments.

Emergency Department Gaps

When patients present in crisis, psychiatry specialists often are not immediately available, particularly during night shifts, weekends, or in underserved areas, resulting in unnecessary hospitalizations or inadequate treatment.

Socioeconomic Factors

Diagnoses of depression, anxiety, PTSD, substance abuse, and schizophrenia show higher prevalence in impoverished areas. Low-SES patients receive less specialty care, instead relying on acute hospital services, facing obstacles including wait times, limited benefits, and multicultural barriers.

Cost of Psychiatric Care

U.S. health-care spending exceeds 3% annually, totaling $2.9 trillion in 2013, representing over 17% of GDP. The National Institute of Mental Health estimated 2015 mental illness costs at over $300 billion annually, with global costs projected to increase from $2.5 trillion in 2010 to over $6 trillion by 2020.

Comorbid medical and behavioral conditions account for up to half of all healthcare spending. In one economic analysis, individuals with a behavioral health condition were found to cost 2 to 3 times as much as those without behavioral health conditions.

Telemedicine

Telemedicine is broadly defined as the remote delivery of healthcare services and clinical information using telecommunications technology. It can connect providers and patients via text, email, telephone, and live videoconferencing, overcoming barriers including stigma, geographic location, provider shortage, clinic capacity, and financial concerns.

Telepsychiatry

Telepsychiatry originated at the Nebraska Psychiatric Institute in 1959 and expanded to Boston airport employees in 1968. Now over sixty years old, it operates throughout the United States and many other countries.

The American Psychiatric Association fully endorses videoconferencing as an effective means of psychiatric healthcare delivery and provides the Telepsychiatry Toolkit. The American Telemedicine Association creates and updates telemental health guidelines.

The Centers for Medicaid and Medicare Services recognize telepsychiatry, reimbursing for services using real-time audio and video. Federal law requires Medicare reimbursement for telepsychiatry in counties outside metropolitan areas at clinical facilities including physician offices, hospitals, critical access hospitals, rural health clinics, Federally Qualified Health Centers, skilled nursing facilities, and community mental health centers. However, patient homes are not considered clinical sites for Medicare reimbursement.

Benefits of Telepsychiatry

Telepsychiatry reduces or eliminates distance between patient and provider, increasing care access. More than 70% of travel time and expense costs can be saved through telemedicine in rural and remote areas.

Telepsychiatry provides local economic benefits: increased job productivity for patients and providers, symptom alleviation enabling more productive work days, and potential benefits to local services like labs and pharmacies.

Cost Savings Examples

One study found telepsychiatry provided over $12,000 in potential savings in reduced psychiatrist time for a rural Native American population, with costs expected to decrease further. Another, examining 278 rural nursing home consultations, found savings ranging from $33,000 to $67,000 for most providers, up to $84,000 to $253,000 for some physicians.

Applications of Telepsychiatry

Controlled trials have evaluated telepsychiatry across prevalent psychiatric disorders including depression, anxiety disorders, eating disorders, substance abuse, psychosis, dementia, and suicide prevention.

PTSD and Veterans

An estimated 13 to 21% of U.S. veterans suffer from PTSD. Recent trials indicate evidence-based interventions for PTSD delivered via videoconferencing may be feasible and effectively equivalent to face-to-face delivery.

Opioid Addiction

96% of states cannot adequately provide medication-based opioid addiction treatment. In West Virginia, waitlists exceed 600 patients. Telepsychiatry expands treatment coverage.

Emergency Departments

ED visits by patients requiring mental health services increase more rapidly than general visits. Telepsychiatry expands specialty psychiatric care in EDs.

Telepsychiatry vs. Face-to-Face Psychiatry

Comparisons examine therapeutic outcomes, treatment compliance, patient-provider alliance, healthcare access, cost-effectiveness, and satisfaction. Studies differ in methodology, design, populations, sample sizes, disorders, interventions, and clinical sites. The analysis examines:

1. doctor-patient alliance acceptance
2. assessment and treatment outcomes
3. access and utilization effects
4. cost of care

Methods

Databases included PubMed, Google Scholar, and Web of Science (2010-2018), exclusive to adult populations and English-language articles. Search keywords included telepsychiatry, telemental health, telemedicine, videoconferencing, effectiveness, efficacy, access, therapeutic outcomes, patient satisfaction, provider satisfaction, cost, in-person, face-to-face, psychiatry, and concerns/limitations.

Results

Acceptance and Therapeutic Alliance

A study of 84 randomly selected psychiatric patients (schizophrenia, bipolar disorder, depression) receiving telepsychiatry found: 97.6% rated sound quality as good to excellent; 95.2% rated picture quality as good to excellent; 95.2% reported comfort with telepsychiatry; 92.9% found communication effective; 84.5% found telepsychiatry as useful as face-to-face interventions; 98.8% would use it again; and only one participant found it stressful.

A satisfaction survey of 29 geographically remote Pacific Islands VA patients with PTSD undergoing 12 Cognitive Processing Therapy sessions showed significant positive changes: agreement on "enough therapist contact" improved (p=.04); "easy communication with therapist" improved (p=.05); and "telemental health fits therapy beliefs" improved (p=.03).

Among 600 surveyed veterans and National Guard members, 20.4% with PTSD were willing to use clinic-based telepsychiatry and 25.4% home-based. Non-PTSD participants showed greater willingness (45.6% clinic, 52.7% home).

In a prison study comparing 50 telepsychiatry and 50 face-to-face psychiatric inmates, no significant differences emerged in Working Alliance Inventory metrics: goal development, goal achievement, or relationship quality.

Assessment and Treatment Outcomes

An emergency room study of 73 patients (depressive, substance abuse, bipolar, psychotic, anxiety disorders) comparing telepsychiatry and face-to-face psychiatric evaluations found no significant differences: disposition (p=0.55), Disposition Rating Scale (p=0.15), HCR-20 Final Risk Judgement (p=0.43), and diagnosis (p=0.19).

A neuropsychiatric testing study on 22 rural Latino patients using standard test batteries (Mini Mental Status Examination, Hopkins Verbal Learning Test) found strong first/second evaluation correlations in both modalities (r=0.870, p<0.001) with no statistically significant differences.

Two Problem-Solving Therapy (PST) randomized control trials for depression showed comparable outcomes:

Trial 1 (depression, 43 telepsychiatry, 42 face-to-face): 12-week Hamilton Rating Scale for Depression scores were not significantly different (p=.755). 24-week scores remained non-significant (p=.369).

Trial 2 (severe depression, 40 videoconference PST, 45 face-to-face): 12-week (p=.772) and 24-week (p=.138) scores remained non-significant. At 36 weeks, videoconference PST showed significantly lower scores (p=.035).

A Hispanic depression study (74 telepsychiatry, 85 face-to-face) found superior telepsychiatry outcomes: 65% showed a positive treatment response versus 47% face-to-face (p=.024); remission rates were 49% telepsychiatry versus 34% face-to-face (p=.06).

A veteran depression study (59 telepsychiatry, 60 face-to-face) found 73% versus 70% treatment completion rates and 49% versus 43% positive response rates (not statistically significant).

A substance abuse study (46 telepsychiatry, 54 face-to-face buprenorphine patients) found no significant differences in retention rates or abstinence outcomes.

An alcohol dependence trial (19 telepsychiatry, 39 face-to-face) found lower premature dropout: 6% telepsychiatry versus 31% face-to-face at 6 months (p=.008); 25% versus 44% at one year (p=.02).

ED Performance Metrics

A rural hospital study comparing psychiatric ED performance pre/post-telepsychiatry implementation found significant improvements: arrival-to-consult time reduced from 22.7 to 10.5 hours (p<0.001); total ED length of stay reduced from 31.7 to 17 hours (p<0.001); and consult order-to-actual time reduced from 16.2 to 5.4 hours (p<0.001).

Access and Utilization

The South Carolina Department of Mental Health implemented statewide ED telepsychiatry (18 EDs, 2009-2013, 18,000+ patients). Comparing 7,261 telepsychiatry users with 7,261 matched controls:

• 30-day outpatient follow-up: 46% telepsychiatry versus 16% control (p<.001)
• 90-day outpatient follow-up: 54% telepsychiatry versus 20% control (p<.001)
• Hospital admissions: 11% telepsychiatry versus 22% control (p<.001)

Adjusted odds ratios showed telepsychiatry patients were more than 5 times more likely to follow up within 30 and 90 days.

A VA health system study of 98,609 telepsychiatry patients (average 182-day enrollment) showed psychiatric hospitalizations decreased 24.2% (3,948 to 2,994 admissions) and hospitalized days decreased 26.6% (35,532 to 26,080 days).

Cost-Effectiveness

The South Carolina ED study found 30-day inpatient costs $2,336 lower in telepsychiatry ($8,290 vs. $11,224; p<.001). Total healthcare costs were $12,634 telepsychiatry versus $14,052 control (p=.001).

Discussion

The overview supports findings that telepsychiatry concerns about inferiority to face-to-face care have not been demonstrated. Results found telepsychiatry overall as efficacious as face-to-face psychiatry in every direct comparison.

Telepsychiatry showed similar outcomes across populations treating schizophrenia, bipolar disorder, and depression. Both patient and provider acceptance measured high. Negative attitudes about telepsychiatry did not manifest in practice. No significant therapeutic alliance differences emerged between modalities.

Assessment accuracy for depressive, substance abuse, bipolar, psychotic, and anxiety disorders showed no significant differences. Neuropsychiatric testing and psychotherapies like Problem-solving Therapy proved equally effective. Large-sample studies (South Carolina 2009-2013, VA 2006-2010) demonstrated telepsychiatry efficacy for psychiatric readmissions, hospital stays, and cost-effectiveness.

The author expected these results given telepsychiatry's goal of expanding quality mental healthcare access. However, surprising findings included the diverse populations studied and the confidence that continued use and acceptance will expand telepsychiatry adoption.

Key Findings Summary

Patients accepted telepsychiatry and demonstrated efficacy for depression and PTSD treatment. Diverse patient and provider populations reported comfort using technology and appreciation for practical benefits, without serious therapeutic alliance concerns. Evidence suggests telepsychiatry reliability matches face-to-face psychiatry for assessing and treating various psychiatric disorders across children, non-elderly, and elderly adults.

Future research should examine effectiveness with racial minorities and rural populations, assess direct and indirect costs including long-term cost-benefit comparisons, and analyze cost-effectiveness by geography, patient characteristics, provider type, and organizational factors.

Reimbursement Landscape

Insurance reimbursement for telepsychiatry initially faced barriers but is changing. Nearly all states now have telemedicine reimbursement policies and regulations, though specifics vary regarding technology, services, providers, locations, and reimbursement amounts. Medicaid reimbursement remains state-optional with varying approaches. Regulations continuously change at state and federal levels as payers recognize telemedicine potential.

Research Design Concerns

The review noted several design limitations affecting efficacy study conclusions:

• Insufficient standardization between face-to-face and telepsychiatry conditions
• Undetermined reasons why telepsychiatry benefits particular patient groups
• Focus on general psychiatric services rather than psychotherapy delivery
• Failure to use standardized, replicable psychotherapy interventions
• Need for large trials targeting specific populations with standardized approaches

Telepsychiatry research traditionally hypothesizes that experimental (telepsychiatry) and control (face-to-face) interventions do not differ. Future research should move beyond traditional comparisons to examine factors associated with effective telepsychiatry versus face-to-face outcomes.

Additional Design Considerations

Future studies should address:

• Over-reliance on self-report methodologies
• Selection biases favoring telepsychiatry-amenable patients
• Insufficient sample sizes
• Lack of direct treatment preference comparisons
• Need for mixed-methods and experimental designs beyond self-report
• Shifting focus from equivalency to identifying assessment types most effective via telepsychiatry
• Determining which assessments prove most difficult remotely
• Improving telepsychiatry accuracy, efficiency, and user experience

Well-designed RCTs remain subject to multiple biases. Research increasingly shows telepsychiatry comparability to face-to-face psychiatry; now focusing on factors increasing telepsychiatry adoption and integration strategies is necessary.

Training Gaps

Training received minimal literature attention. A Psychiatric Nurse Practitioner survey identified lack of provider experience, training, and self-efficacy as implementation challenges. Education and training in telepsychiatry lag behind usage and are not standard psychiatry curriculum components. The field could benefit from standardized training and potential telepsychiatry certification ensuring quality and safety.

Some clinicians believe the transmission experience artificially negatively affects patient-provider relationships, though studies consistently show telepsychiatry requires minimal technical modifications and videoconferencing communication has little negative influence on clinical outcomes or satisfaction.

Study Limitations

Limitations include:

• Non-comprehensive literature review (excluded studies outside the U.S., pediatric populations, and studies over a decade old)
• Self-selected articles (though selection criteria were maintained)
• Limited coverage of telepsychiatry modalities beyond live videoconferencing (asynchronous telepsychiatry, text-based care excluded)
• Varying methodologies and statistical analyses not independently reviewed, limiting validity and generalizability

Conclusion

This overview demonstrates telepsychiatry's efficacy compared to face-to-face psychiatry. While telepsychiatry may have limited importance for non-psychiatry practitioners or patients not participating in telepsychiatry, it is important for Physician Assistants. PAs benefit from telepsychiatry knowledge given numerous opportunities in clinical care, education, and research. Increasing telepsychiatry usage makes it likely PAs will encounter patients participating in telepsychiatry interventions. Understanding telepsychiatry efficacy through literature review serves as important education for treating future patients.