Telehealth is Gaining Traction, but do Mental Health Providers Like It?

It is hard to ignore the growing interest in telemental health care provided via videoconferencing (TMH-V). Similar to Skype or Facetime, TMH-V allows providers to deliver psychotherapy, medication management, or assessment to clinics without on-site mental health services or directly to patients’ homes. TMH-V can increase access to mental health care for a wide variety of patients, including those who:

  • Have long commutes to their closest mental health clinic due to distance, traffic, and/or weather
  • Prefer not to attend an in-person clinic because of stigma or shame
  • Have difficulty leaving their home due to mental health symptoms, physical limitations, lack of transportation, or child/elder care responsibilities

The potential benefits of TMH-V are clear, and patients report being satisfied with this mode of care delivery overall (Kruse et al., 2017).

Yet the question remains: what do mental health providers think of this new technology?

This represents a critical gap in the literature, given that providers are often the gatekeepers of healthcare innovations. If providers do not support the use of TMH-V, patients will be unable to access TMH-V care. To help answer this question, we published a systematic review of providers’ attitudes towards TMH-V in Clinical Psychology: Science and Practice (Connolly, Miller, Lindsay, & Bauer, 2019). 38 articles were included. Most involved delivering care to patients at remote hospitals and clinics, five provided care directly to patients’ homes, and four involved alternate locations, such as schools and community centers.

Most of the included studies reported that providers had positive attitudes towards TMH-V overall. Benefits included:

  • Increasing access and efficiency
  • Giving the provider a window into the patient’s living environment
  • Serving as stepping stone into care for anxious and avoidant patients

Despite these positive overall opinions, providers also noted multiple drawbacks to TMH-V.  These included:

  • Technological difficulties, such as poor audio and video quality
  • Interfering with the therapeutic relationship by seeming impersonal and making it more difficult to detect nonverbal cues
  • Equipment set-up and scheduling hassles
  • Concerns regarding licensure, patient safety, and provider liability

Importantly, providers’ attitudes towards TMH-V improved with experience, suggesting that the initial growing pains of adjusting to a new technology decreased over time. Providers described developing strategies to improve TMH-V sessions, including adjusting camera placement to best see and be seen by the patient, and maintaining a low threshold to inquire about recent substance use, given the greater difficulty of detecting intoxication from behind a screen.

The balance between perceived benefits and drawbacks of TMH-V will likely continue to shift in response to ongoing advancements, including:

  • Improvements in TMH-V technologies, internet connectivity, and access to devices
  • More streamlined training processes
  • Legislation allowing for telehealth to be practiced across state lines and to be reimbursed at the same rate as in-person care (see Adler-Milstein, Kvedar, & Bates, 2014; Brooks et al., 2013; U.S. Department of Veterans Affairs, 2018; Wicklund, 2019)

Arguably the greatest strength of TMH-V is its ability to provide services directly to patients’ homes versus to remote clinics. Only five of the included studies delivered TMH-V to the home and four of those studies were published in the past three years, highlighting the novelty of this modality. As the current review included studies published between 2000 and 2019, it is likely that many of the TMH-V technologies being reviewed have since been surpassed by more sophisticated platforms. Continued research is needed to capture potential changes in attitudes towards TMH-V as technologies improve.

Our review found that patients tended to report higher TMH-V satisfaction than providers, and that providers preferred in-person appointments when given the choice. As such, TMH-V can be viewed as one of several effective modes of treatment whose pros and cons will vary depending on the circumstances. For patients with significant barriers to receiving in-person care, TMH-V may be the first and only way in which they can undergo treatment. Even if a provider may generally prefer seeing their patients in person, the benefit of providing therapy via TMH-V to a patient who otherwise would receive no treatment is clear. A hybrid model of care may be ideal in other cases, such that patients receive a combination of in-person and TMH-V sessions.

In sum, our review found that providers’ attitudes toward TMH-V are positive overall, despite there being drawbacks to its use. This suggests that the relative advantages of TMH-V in certain cases, such as increasing access to care where services are limited, may outweigh its disadvantages from the provider perspective. Gaining TMH-V experience may lessen perceived drawbacks and foster the development of strategies to improve care delivery. As healthcare systems increasingly prioritize TMH-V, it is crucial to consider providers’ perspectives, as they will play a key role in the successful uptake of this innovation.

Reference Article

Connolly, S.L., Miller, C.J., Lindsay, J.A., & Bauer, M.S. (2019). A systematic review of providers’ attitudes toward telemental health via videoconferencing. Clinical Psychology: Science and Practice.

Discussion Questions

  1. What are the biggest barriers to TMH-V uptake at the provider level? At the patient level?
  2. What steps can healthcare systems take to help providers gain experience using TMH-V?
  3. Given the length of time required to publish peer-reviewed articles, do we need to be evaluating mental health technologies via other, faster means?

About the Author

Samantha Connolly, PhD received an AB in Psychology from Harvard University and a PhD in Clinical Psychology from Temple University. She is currently an Investigator at the VA Boston Center for Healthcare Organization and Implementation Research (CHOIR), an Instructor at Harvard Medical School, and a practicing clinical psychologist within the VA Boston General Mental Health Clinic. Dr. Connolly’s research involves the implementation of novel technologies within mental health care, including telehealth, smartphone apps, and patient portals. She has experienced both the benefits and challenges of attempting to integrate these tools into treatment firsthand, and these clinical insights continually inform her research.

References

Adler-Milstein, J., Kvedar, J., & Bates, D. W. (2014). Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Health Affairs, 33(2), 207-215.

Brooks, E., Turvey, C., & Augusterfer, E. F. (2013). Provider barriers to telemental health: obstacles overcome, obstacles remaining. Telemedicine and e-Health, 19(6), 433-437.

Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2017). Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open, 7(8), e016242.

U.S. Department of Veterans Affairs (2018). VA expands telehealth by allowing health care providers to treat patients across state lines [Press release]. Retrieved from https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4054.

Wicklund, E. (2019, June 25). Telehealth Licensure Compact for Psychologists Is Ready to Go Live. mHealth Intelligence. Retrieved from https://mhealthintelligence.com/news/telehealth-licensure-compact-for-psychologists-is-ready-to-go-live.