Motivation and emotion/Book/2022/Telemental health

Telemental health:
What are the pros and cons of TMH and what are the key ingredients for effective TMH practices?

Multimedia presentation (3 min)

Overview

Telemental health (TMH) is a form of delivering mental health services via telecommunications, videoconferencing, or asynchronous contact methods. Since the COVID-19 pandemic, the everyday lives of people have been disrupted (see Figure 1), leading to unexpected change and the possible aggravation of negative emotions such as fear, confusion, and isolation (Reay et al., 2020 & Perle, 2022). During this time, many countries adopted the increased use of Telemental health as a way of combating social distancing restrictions while still maintaining mental health service delivery. The effectiveness and proper utilization of this method of delivery are relatively new in its research, however early findings have shown that its use has its own strengths and weaknesses, with key components being apparent to provide effective mental health care (Hoffnung et al., 2021; Molfenter et al., 2021; Yellowlees et al., 2018).

Types of telemental health are best displayed along a continuum, each requiring its own level of resource depending on where they sit. See the figure released by SG2 displaying an easy-to-read and understandable figure of the continuum.

Focus questions What are the types of Telemental Health? What are their pros and cons? What is key to their effectiveness?

History

Telehealth has been discussed in science since the late 1800s, however, the idea of telemental health specifically was used first during the 1950s (Lustig, 2012). The Nebraska Psychiatric Institute in the US was the first to note their use of videoconferencing in 1959 to provide group therapy, long-term therapy, consultation-liaison psychiatry, and training to their medical students (Lustig, 2012). It was slowly adapted by other hospitals during the 1960s and became commonplace in most hospitals during the 1980s (Lustig, 2012). During the 2000s it became clear that telepsychiatry (a branch of telemental health) was equivalent to in-person care when it comes to diagnostic accuracy, treatment effectiveness, and patient satisfaction; while saving time, money, and resources and expanding accessibility (Lustig, 2012).

The use of telemental health was growing steadily until the requirement for social distancing due to the COVID-19 pandemic forced it to grow to encompass a much higher number of patients and clinicians (Jayawardana & Gannon, 2021; Molfenter et al., 2021; Yellowlees, 2021). The challenge for administrators and clinicians to rapidly change their safety protocols and health deployment strategies became a priority for businesses to survive and for the general public to be cared for.

Types of Telemental Health

There are two main categories of mental health delivery, those being synchronous and asynchronous. As the name suggests, synchronous means to have interactive communication in real time, whereas asynchronous treatments involve treatments that do not require specific time constraints or real-time interactions (Barak et al., 2008 & Moorman, 2021). According to a report by Osenbach et al. (2013) that includes a 12- and 24-month follow-up, asynchronous and synchronous treatment styles were found to not be significantly different from each other in terms of outcomes for patients that were experiencing mild to moderate anxiety and depression symptoms. Whether or not this finding is repeatable when it comes treating to other mental health issues is unknown, however, given current information, we can consider that neither synchronous nor asynchronous telemental health treatments are superior to each other.

Overall, clinicians have been found to be largely satisfied with both types of telemental health, with a particularly high level of satisfaction when using videoconferencing (Barak et al., 2008; Osenbach et al., 2013; Perle 2022). Observing the use of telemental health across various different locations, populations, and specific medical services, participants who received telemental health services reported that they were very satisfied, especially when considering the advantages of telemental health (Hoffnung et al., 2021; Molfenter et al., 2021; Yellowlees et al., 2018). An obvious pro when it comes to both types of telemental health is the decrease of public interaction during the COVID-19 pandemic and therefore decreasing transmission rates. As this may be a temporary situation, this will not be investigated in the following lists.

Synchronous

Figure 2: Doctor using telehealth to communicate during the COVID-19 Pandemic

Synchronous telemental health includes telephone (see Figure 2) and video conferencing (such as Skype, Zoom, etc) and attempts to replicate interactions that would normally occur in a face-to-face treatment (Barak et al., 2008 & Reay et al., 2020). It has been slowly adopted by most medical practitioners over time, however, this adoption increased dramatically over the period of the COVID-19 pandemic height.

Pros

High Efficacy

Recent research has shown that synchronous telemental health treatments are reported to be just as effective in treating adults with common mental health disorders as those receiving the standard in-person treatment (Hoffnung et al., 2021 & Reay et al., 2020).

Accessibility

Aside from being the only form of health care available for certain health concerns during the COVID-19 pandemic, accessibility for people experiencing various mental health conditions limiting their ability go to out and/or socialize has risen. Synchronous telehealth appointments may be anonymous for some services and have the option to limit to only vocal interaction, limiting many of the barriers for people suffering from socially debilitating mental health conditions. By removing distance and transport as a factor when providing telemental health problems, it has decreased patient no-shows (Raey et al., 2020).

Time

Less time commitment is required for patients to attend their appointments as no transport time is needed to be factored in anymore. This has been the case for some clinicians choosing to work from home as well.

Cost

Due to the lack of need for transport, costs may come down for some patients and clinicians. Telemental health appointment subsidy payments by the Australian government were made during the peak of the COVID-19 outbreak to support those looking for mental health assistance (Reay et al., 2020). This payment is being considered to be continued, however, its future is not yet decided.

Privacy

As telemental health can be attended to from any location, clients can choose locations where they feel comfortable, safe, and private, while being able to remain anonymous when using some services.

Cons

Client Relationship

Clinicians have expressed concerns about rapport building in both new and continuing patients (Perle, 2022). The reduced amount of nonverbal communication causes concern for miscommunication to occur and can therefore be a deterrent for a lot of users.

Technologically Reliant

Clinicians must become comfortable with new technology and use technical support when there are issues (Jayawardana & Gannon, 2021 & Perle 2022). The patients of services have to adapt to this expectation too, regardless of the possible extra hassle, frustration, and technical limitations that may occur.

Age

Verbal communication may become more difficult as we age and while it may be a workable situation on its own when it's coupled with technical difficulties, inability to communicate with body language, and doubt in technology it became a hindrance as we get older.

Treatment Type

There is no clear evidence that synchronous telemental health is equally beneficial to in-person therapy when it comes to using Cognitive Based Therapy (CBT) when treating anxiety disorders (Barak et al., 2008; Hoffnung et al., 2021; Yellowlees et al, 2018). Treatment types in regard to telemental health require further research to provide optimal outcomes in patients.

Asynchronous

Figure 3: Doctor using a computer to communicate with patients and other clinicians

Asynchronous telemental health treatments include various forms of communication that are generally not constrained by time. It has been the main type of telemental health used since the 1950s in various different forms including phone calls, emails, video monitoring, faxes, apps, and various online programs (Lustig 2012). It attempts to communicate a type of therapy where users are able to engage at their own pace, inviting a much more flexible, inviting treatment method. Although many of the pros and cons may be similar to that of synchronous treatments, there are some key differences among some of the categories.

Pros

Time

Time becomes flexible for both the clinicians and the patients using the service, allowing for both to be able to work by their own schedules and for the patients, their own moods, and mental states.

A 54-year-old man, Brian, was referred for alcohol abuse and depression. In the interview, Brian stated that he had a long history of alcohol use and that since he stopped drinking 2 months previously, despite regular attendance at Alcoholics Anonymous, his depression had increased. Brian’s consultation occurred within a few days of referral, and the psychiatrist was able to send his recommendations of sertraline for depression and naltrexone for alcohol use disorder to the primary care physician (PCP) within 3 days. The PCP agreed with the recommendations and was able follow-up with Brian a few days later to implement them.This case demonstrates that Asynchronous telemental health consultations can be completed in a fraction of the time that a patient would typically wait to see a psychiatrist where average wait times for a first time psychiatry visit were reported to be 25 days in 2014 (Maloway et al., 2014).

Accessibility

As with synchronous, the requirement to travel to appointments is taken away altogether, leaving the door wide open for movement/social impaired individuals to attend with ease. However, when it comes to asynchronous treatment type the accessibility is increased for those who are not able to attend sessions during regular hours or waking hours. It also leaves the door open for using a hybrid approach with people, using both a synchronous telehealth session and/or in-person session in conjunction with each other.

Growth

Continuous growth is being made in what is called "second-generation" treatments with advanced engagement features and self-guided treatments that make seeking help more accessible (Yellowlees et al., 2021). This field is continuing to see more money from the government given to organizations to develop more of these online platforms to make seeking help easier and more obtainable.

Management

Management of treatments may become easier for clinicians and patients due to the flexibility of being able to contact each other at all times. The ability to maintain contact with many patients at one time may be increased through the use of mass emails and/or group video sessions. However, this is depending on the clinician as it may be restricted by their information technology abilities.

Autonomy

Promotes autonomy for the individual as the treatment comes down to them putting the time aside to treat themselves rather than having to abide by session times and structure that may not work with their mental health or physical condition.

Cons

Client Relationship

Much like the synchronous type of telehealth treatment, clinicians have expressed concerns about rapport building in both new and continuing patients. The reduced amount of clear verbal information, in this case, is cause concern for miscommunication to occur and can therefore be a deterrent for a lot of users.

Technologically Reliant

Again, clinicians must become comfortable with new technology and use technical support when there are issues. The patients of services have to adapt to this expectation too, regardless of the possible extra hassle, frustration, and technical limitations that may occur.

Expectation

Clinical and patient expectations can differ when there are no clear ways to show ongoing improvement aside from simply being told in an asynchronous way (Barak et al., 2008; Hoffnung et al., 2021., Molfenter et al., 2021). A lot of clinicians who adapted to using telemental health strategies during the rise of COVID-19 have since reverted to only doing face-to-face appointments, creating an expectation that patients would also been just as keen and feel just as safe to return to face-to-face care.

Key components for successful practice

There is a large list of successful components when it comes to the successful treatment of mental health, obviously, some of these components will differ from patient to patient, however, the ones listed below generally cover most, if not all, patient situations.

Choice of approach

The choice of approach will always come down to each patient and what they are attempting to get out of the service and/or treatment. Flexibility in delivery methods and treatment options are therefore some of the most important components when building a successful practice. The more accommodating the clinicians are to each individual need, the more likely it is that the patient will return to continue using the service and receive treatment (Barak et al., 2008 & Reay 2020). This may mean the practice needs to be flexible in its delivery type, contact methods and/or work hours. The choice between synchronous and asynchronous treatment is also an important component when selecting the most appropriate treatment for both a client and a clinician. The pros and cons in the previous segment are worth considering for each individual client as well as worth considering for the clinician delivering the treatment/s.

Approaches to Telemental health at the international and national level have changed and adapted due to the need for social distancing during the COVID-19 pandemic. These changes included things like funding for clinicians to adapt their service to new ways of communicating involving extra technical assistance and access to updated technology (Jayawardana & Gannon, 2021). Changes also came from the government level in Australia, adapting Medicare (public health payments) to subsidize part of the telehealth and telemental health payments.

Technology & Technological skills

One of the main concerns that both clinicians and patients have in regards to telemental health is their confidence in the use of new technology, especially among those in older age brackets (Barak et al., 2008; Osenmbach et al., 2013). This fear, which can sometimes result in its more severe form, technophobia, becomes an added barrier that must be worked on to ensure client and clinician confidence. Having the appropriate computer hardware and software is essential in being able to maintain a seamless online and offline system of service. The Australian government supplied grants to medical organizations in order for them to transition to this mode of delivery during the COVID-19 outbreak, however, this funding has now ceased, which places the financial burden of relevant technology on the clinicians and patients (Jayawardana & Gannon, 2021). Where there are issues with technology, there are time delays, increasing stress and cost, both detrimental to providing a successful telemental health practice.

In order to be able to provide services that are available to all ages and technology skill levels, again practices must be flexible is what they are able to offer. A mix of face-to-face appointments along with online communication may work better for some, using the time in the office to communicate ways to navigate the digital space and access the required information from home. Lessons in the use of technology may be able to be delivered via videos, handouts, or in-house demonstrations, just to name a few.

Type of treatment

The type of treatment being provided over telemental health services and the particular mental issue being treated are two factors that can have large influences on the outcome (Barak et al., 2008). By aiming to use treatment types that have been shown to display very high effect sizes, like cognitive-behavioural therapy, rather than those who have shown low effect size like Behavioral and Psycho-education therapies (Barak et al., 2008). Other less commonly used therapies have showed both promising and unpromising results that may also be considered for use (Barak et al., 2008). Age also seems to be a factor on the type of treatment used and it's corresponding effect size. Those in the 25-39 year age categories showed the highest effect size among age groups, while those in the 18 and under group and 40 and over groups showed very little effect sizes (Barak et al., 2008).

The type of mental health issue being treated for differs in their effect size from treatments given. PTSD and Panic and Anxiety issues were shown to produce the highest of effect sizes, with Smoking Cessation just behind those, but still high (Barak et al., 2008). Other issues like Weight Loss, Physiological issues, or Depression displayed a very small effect sizes when being treatment by telemental health therapies (Barak et al., 2008).

Conclusion

The answer as to what key ingredient are necessary for telemental health is a difficult one with so many factors to consider. The pros and cons of telemental health delivery show reason for it to be implemented and grown in health services, however, not all demographics may be positively affected, although the majority of the population will be benefited. Considering the choice of approach, use of technology and development of technological skills, as well as keeping up to date on the types of treatments proving to be most beneficial for telemental health delivery are paramount in developing a successful health service. Future research and further investigation into the field of Telemental health would yield clearer directions on how to best utilize the current treatments we have in place and may help forge the way for new treatment types given the advances in technology.

See Also

Telehealth (Wikipedia)

Impact of the COVID-19 pandemic on the telehealth industry (Wikipedia)

References

Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions. Journal Of Technology In Human Services, 26(2-4), 109-160. https://doi.org/10.1080/15228830802094429

Hoffnung, G., Feigenbaum, E., Schechter, A., Guttman, D., Zemon, V., & Schechter, I. (2021). Children and Telehealth in Mental Healthcare: What We Have Learned From COVID‐19 and 40,000+ Sessions. Psychiatric Research And Clinical Practice, 3(3), 106-114. https://doi.org/10.1176/appi.prcp.20200035

Jayawardana, D., & Gannon, B. (2021). Use of telehealth mental health services during the COVID-19 pandemic. Australian Health Review, 45(4), 442. https://doi.org/10.1071/ah20325

Lustig, T. (2012). The role of telehealth in an evolving health care environment (3rd ed.). National Academies Press (US).

Molfenter, T., Heitkamp, T., Murphy, A., Tapscott, S., Behlman, S., & Cody, O. (2021). Use of Telehealth in Mental Health (MH) Services During and After COVID-19. Community Mental Health Journal, 57(7), 1244-1251. https://doi.org/10.1007/s10597-021-00861-2

Moorman, L. (2021). COVID-19 pandemic‐related transition to telehealth in child and adolescent mental health. Family Relations, 71(1), 7-17. https://doi.org/10.1111/fare.12588

Osenbach, J., O'Brien, K., Mishkind, M., & Smolenski, D. (2013). SYNCHRONOUS TELEHEALTH TECHNOLOGIES IN PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS. Depression And Anxiety, 30(11), 1058-1067. https://doi.org/10.1002/da.22165

Pauli, E., Bajjani-Gebara, J., O'Quin, C., Raps, S., & DeLeon, P. (2018). Telehealth – The Future for Advance Practice Mental Health Nursing. Archives Of Psychiatric Nursing, 32(3), 327-328. https://doi.org/10.1016/j.apnu.2018.03.018

Perle, J. (2022). Mental health providers’ telehealth education prior to and following implementation: A COVID-19 rapid response survey. Professional Psychology: Research And Practice, 53(2), 143-150. https://doi.org/10.1037/pro0000450

Reay, R., Looi, J., & Keightley, P. (2020). Telehealth mental health services during COVID-19: summary of evidence and clinical practice. Australasian Psychiatry, 28(5), 514-516. https://doi.org/10.1177/1039856220943032

Yellowlees, P., Burke Parish, M., González, Á., Chan, S., Hilty, D., & Iosif, A. et al. (2018). Asynchronous Telepsychiatry: A Component of Stepped Integrated Care. Telemedicine And E-Health, 24(5), 375-378. https://doi.org/10.1089/tmj.2017.0103

Yellowlees, P., Parish, M., Gonzalez, A., Chan, S., Hilty, D., & Yoo, B. et al. (2021). Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial. Journal Of Medical Internet Research, 23(7), e24047. https://doi.org/10.2196/24047

Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: A simulated-patient study in three US cities. Psychiatr Serv 2014;66:94–96.

External links

• The History of Telemental Health (Website)
• A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions (Journal)
• Telemental health: what works for whom? (YouTube - Talks from the Mental Health Policy Research unit (MHPRU) webinar that took place on Tuesday 22nd March 2-5pm.)
• Telemental Health Tips: Don'ts and Do's (YouTube)