Telepsychiatry Substantially Improves Outcomes for Patients With Complex Psychiatric Disorders

The interventions are especially helpful for patients in rural and underserved populations.

Telepsychiatry collaborative care and telepsychiatry-enhanced referral significantly and substantially improve outcomes of patients with complex psychiatric disorders.

The findings suggested health system leaders should implement the most sustainable approach.

John C. Fortney, Ph.D., and a team of investigators compared two clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. For telepsychiatry/telepsychology-enhanced referral, telepsychiatrists and telepsychologists assumed responsibility for treatment. Telepsychiatry collaborative care was where telepsychiatrists provided consultation to the primary care team.

There were 24 clinics from 12 federally qualified health centers in three states included. Eligible clinics had no psychiatrists or licensed clinical psychologists practicing on site. Participants received up to 12 months of treatment and went to the clinic for interactive video visits. Patients who screened positive for bipolar disorder and/or post-traumatic stress disorder (PTSD) were enrolled. The team randomized participants to telepsychiatry collaborative care and telepsychiatry-enhanced referral using blocking and stratification by health center and screening status. Those who screened positive for both bipolar disorder and PTSD were categorized as having bipolar disorder. At the six-month mark of the study, patients assigned to telepsychiatry-enhanced referral with two or less interactive video encounters were randomized a second time.

In the collaborative care group, on-site behavioral health care managers and off-site telepsychiatrist consultants supported primary care providers who prescribed all psychotropic medications. Care managers have psychoeducation, conducted outreach and treatment engagement activities, and delivered behavioral activation psychotherapy. They used a web-based registry to monitor engagement and symptom severity. Telepsychiatrists met weekly with care managers for case reviews to identify those who were not engaging in or responding to care and suggested treatment recommendations.

Those in the telepsychiatry-enhanced referral group had an encounter to establish diagnosis and develop a treatment plan. If referred, telepsychologists gave either cognitive processing therapy for PTSD or cognitive behavioral therapy for bipolar disorder. Symptoms were monitored and treatment was documented.

The telepsychiatry-enhanced referral group also included phone-enhanced referral for those not engaging in treatment. Phone referral involved telephone outreach and motivational interviewing.

Telephone or web-based surveys were given at baseline and six and 12 months later. Treatment group assignment was masked. Mental health functioning at 12 months was the primary outcome.

Of the 508 patients randomized to the telepsychiatry collaborative care group, 91.3% had at least one care manager encounter. The mean number of encounters was 10.3. Nearly 80% had at least one behavioral action psychotherapy encounter, with a mean of 9.6 encounters. More than 76% had a telepsychiatry consultation, with a mean of 1.4 encounters.

Participants in both groups had large and clinically meaningful improvements from baseline to 12 months. Those not engaging in telepsychiatry-enhanced referral at six months had no significant difference in 12-month mental health scores. Implementing both interventions in primary clinics in rural and underserved areas increased access to and engagement in effective treatments.

The findings emphasized the benefits of telehealth to improve patient outcomes.

The study, “Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care,” was published online in JAMA Psychiatry.