Why Telehealth Has Become an Integral Part of the Mental Healthcare Landscape  

Two and a half years into the COVID-19 pandemic, it has become increasingly clear that telehealth has boosted access to mental healthcare and bolstered the workforce. But certain hurdles stand in the way of continued use, including resistance among some providers due to the return of in-person care and the uncertainty about the future of regulatory flexibilities.

During Telehealth Awareness Week, hosted by the American Telemedicine Association (ATA), a panel of mental healthcare physicians and program leaders discussed the benefits of telemental care for providers and patients alike and detailed trends impacting the use of virtual care modalities in the future.

Matt Mishkind, director of operations, Military and Veteran Programs, University of Colorado Anschutz Medical Campus School of Medicine, deputy director at Johnson Depression Center, and chair of the ATA Telemental Health Special Interest Group (SIG), moderated the virtual session.

BENEFITS OF TELEMENTAL CARE FOR PATIENTS

Though questions surrounding best practices for virtual mental health services remain, the benefits have become increasingly apparent as the COVID-19 pandemic has dragged on.

These benefits are varied and include greater access to care for underserved populations, such as rural communities, racial minorities, and even formerly incarcerated people.  

Lauren Conaboy, vice president of national policy at Centerstone, a nonprofit health system specializing in mental health and substance use disorder treatments, shared a story about how teletherapy has helped extend needed mental health services.

"We have a therapist that had said, 'I have a client that's been referred to therapy by his parole officer. Historically, he's not been able to keep appointments or successfully engage in therapy due to lack of transportation. Now via telehealth, we have been successfully engaging him in treatment, managing his symptoms, and he's finally compliant with the terms of his parole,'" she said during the panel. "Just an example, one of many that we have, of how [telehealth] really changes the game for how people access care — whether it's somebody within kind of the criminal justice population, other individuals, rural, low-income, et cetera, that we've been able to really break down a lot of barriers [for] and increase that access."

Another key demographic that has significantly benefitted from telemental healthcare has been adolescents and children, primarily because they can access it from their homes. This has led to more comprehensive management of behavioral health issues.

"I think there is so much value in seeing these kids and their families in their natural environment of home, where we really get to understand what their real self is and what their issues are," said Ujjwal Ramtekkar, MD, senior medical director of mental health at Teladoc Health, during the panel discussion.

Telemental care can also be extended to children and adolescents in school, which enables this population to get the care they need in a private environment that may not always be available to them in their homes.

"Sometimes, that's because they're in a small apartment. There's just really, simply no place to go," said Michelle Turner, national director of clinical talent and delivery at in-school virtual medical clinic provider Hazel Health, during the session. "…and sometimes it's because what they want to discuss with their therapist is not something they're comfortable discussing knowing that other family members might be listening."

She further noted that schools don't have to be the only access point for kids — telemental care could also be offered at a community center or church location. 

Not only can telemental care be accessed from different locations, but it can also be accessed through various modalities. Telemental care can be provided via live video as well as audio-only modalities.

"I know that some of my patients live in areas of Imperial Valley that have even spotty cell phone service, let alone broadband," said Jessica Thackaberry, MD, clinical assistant professor at the University of California, San Diego, at the event. "A lot of them live with limited access to electricity. It makes it particularly challenging to reach those [patients] even in the setting of increased access via tele[health]. So, audio-only has been a game changer."

In addition to audio-only capabilities, text messaging has skyrocketed since the COVID-19 pandemic began. As a result, mental health providers have increasingly been interacting with their patients through text message features in patient portals, including sending them test results and discussing medication changes, Thackaberry added.

USING TELEHEALTH TO SUPPORT MENTAL HEALTHCARE PROVIDERS

A shortage of mental and behavioral healthcare providers has been brewing in the US for several years, with psychiatrists practicing in less than half of US counties as of 2018. The COVID-19 pandemic has worsened the situation by driving demand for these services sky-high in the face of diminishing supply.

"Since we don't have enough providers to meet the demand, there are major challenges of inappropriate utilization of emergency rooms and inpatient hospitalizations as the fastest way of getting some kind of mental health access," said Ramtekkar.

But with the recent expansion of telehealth services, many see a new lifeline for overburdened mental healthcare providers.

For one, telehealth cuts down travel time for providers, too.

"Telehealth is also another strategy to recruit and retain our workforce," Conaboy said. "I know we have many staff [members] that reported that prior to having the telehealth option [they] had to commute 45 minutes to an hour to work at some of our rural locations. And so, [telehealth] has given them so much time back in their day, whether that's to be with their families, to serve patients, [or] to create more of that work/life balance that's so critical to maintain staff today."

Further, virtual care modalities can help triage patients and connect them to the right level of care, Thackaberry said. Not every mental health need requires a consultation with a behavioral health specialist. Nurse practitioners, physician assistants, and social workers can help meet patient demand, thereby taking on some of the burden that falls on specialists.  

Then there is the quality of the care that mental health clinicians can provide through telehealth. Telemental care strategies support continuity of care, which is vital to improving clinical outcomes.

Turner experienced this firsthand when her family moved from North Carolina to Virginia.

"…[it was] just a couple hours away, but of course, because we moved over state lines, our children were going to lose their therapist," she said. "And she, on her own, got licensed in the state of Virginia so that she could continue seeing our children through teletherapy... And so, personally, one of my favorite things about teletherapy is it allowed that continuity of care for our kids."

Ramtekkar echoed this point, adding that since teletherapy isn't confined to homes and can be accessed from anywhere that might be convenient for the patient, including schools, it enables therapists to ensure that patients are sticking to their treatment plan.

KEY TRENDS IN TELEMENTAL CARE

Telemental care skyrocketed in the wake of the March 2020 lockdown amid surging COVID-19 cases in the US. This urgent need for virtual therapy options resulted in rapidly growing provider acceptance of telehealth.

"I remember actually sitting at the ATA conference in Chicago, four or five years ago… And it was this new concept that telehealth doesn't have to be your last option, telehealth could actually be first-line care, and we need to start approaching it as such," Turner said. "And without the pandemic, I don't think that would've happened as quickly as it has, especially in a lot of specialties, mental health being one of the main ones."

In her current role, Turner interviews therapists weekly. She has noticed a sense of excitement when they discuss how telehealth has changed their practice and impacted patient care.

But the eagerness to use telehealth must be supported by adequate training, noted Regan Stewart, PhD, associate professor and clinical psychologist in the Mental Health Disparities and Diversity Program and director of the Telehealth Outreach Program at the Medical University of South Carolina.

Stewart conducts training on providing telemental care to children, and pre-pandemic, she had to convince mental healthcare providers to use telehealth.

"Now I have to go in and convince folks that they might not know everything about telehealth best practices and how to make it engaging for kids because I think folks were just thrown in there in the pandemic, and it was sink-or-swim," she said during the panel. "But we can all still benefit some from a little bit more instruction."

In addition, now that in-person care is widely available once again, telehealth use has leveled off. Some behavioral health providers no longer feel the need to offer virtual care options, Stewart said.

"I hear a lot of providers saying, 'I just want to go back to in person. I don't want to do this telehealth stuff anymore,'" she said. "And that's great for your patients who can come to you, and your clients who can come to you in person, but you're going to have those kids and those adults who aren't going to be able to come to you in person. They live too far away, they have transportation barriers, work schedule barriers, whatever it might be, and telehealth is still going to be beneficial long term."

But to ensure the long-term use of telemental care services, the regulatory flexibilities enacted during the pandemic must be made permanent. Several bills are currently winding their way through Congress to solidify telehealth access, including one passed by the House in July. Titled the Advancing Telehealth Beyond COVID-19 Act, the legislation would allow virtual mental health services to be provided for up to six months without an in-person visit through 2024.

In addition, many in the mental healthcare arena, including Conaboy, hope to see public and private payers continue to reimburse modalities that extend telemental healthcare's reach, like audio-only services.

"Audio only, as we've talked about, also really weighs into the equity piece for individuals that don't have broadband, that don't have the technological literacy," she said. "It just creates more access."

Telehealth's ability to expand access and advance health equity is ultimately why it is becoming an indispensable care delivery method within the mental healthcare landscape. 

"We can bring all patients who have mental health needs, regardless of their income, regardless of their education level, regardless of their culture, regardless of where they're coming from, they can be brought to the table [through telehealth]," Thackaberry said. "They can have a voice. They can be seen by mental health clinicians and feel better regardless of where they're coming from."