Collaborative and referral models of remote mental health care appear viable, study finds
The trial of adults with post-traumatic stress disorder and/or bipolar disorder compared having remote specialists provide direct telehealth treatment to having specialists consult with primary care teams via an onsite care manager, who also provided brief psychotherapy.
Both teleintegrated and telereferral models of psychiatric care can be used to treat patients with chronic and complex psychiatric conditions who have limited access to mental health specialists, a study found.
Researchers conducted a pragmatic trial among 1,004 adults with post-traumatic stress disorder (PTSD) and/or bipolar disorder who were randomized to receive either telepsychiatry collaborative care (TCC) or telepsychiatry/telepsychology enhanced referral (TER) for one year. TCC involved remote specialists who consulted with primary care teams via an onsite care manager, who also provided brief psychotherapy. For TER, remote specialists provided direct telehealth treatment.
The patients came from 24 primary care clinics without onsite psychiatrists or psychologists, associated with 12 federally qualified health centers across Arkansas, Michigan, and Washington State. Researchers assessed psychotherapy engagement by the number of sessions completed and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ). Results were published Feb. 2 by the Journal of General Internal Medicine.
Engagement in TCC psychotherapy visits was 60% greater compared to TER, the researchers found, with no association between PTSD symptom severity and treatment engagement. Of the TCC patients, 79.3% had at least one behavioral activation encounter and averaged 9.6 encounters. Of the TER patients, 45% had one or more telepsychology encounter and averaged 6.4 encounters. Overall, PCL-5 severity score was not significantly associated with starting psychotherapy or the overall number of sessions attended. The association did not vary by intervention group (P=0.21).
Pharmacotherapy engagement increased over time, with no differences between the groups. PCL-5 cluster-specific scores showed no differential associations with medication adherence (P=0.62). The internal state scale activation subscale, an indicator of mania, was associated with reduced odds of starting psychotherapy (odds ratio [OR], 0.70; 95% CI, 0.59 to 0.84), but not with the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10 (DAST-10) score was associated with fewer psychotherapy sessions (incidence ratio rate [IRR], 0.88; 95% CI, 0.81 to 0.95), while number of physical comorbid conditions was associated with greater engagement in psychotherapy (IRR, 1.11; 95% CI, 1.03 to 1.19) and pharmacotherapy (OR, 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group.
The authors noted that mania and substance use, but not PTSD symptom severity, may require additional intervention to support engagement in psychiatric care, while medical comorbidities may foster care-seeking behaviors. “While there was no difference in clinical characteristics predicting engagement between models, onsite care managers engaged patients in more psychotherapy sessions than remote therapists,” they wrote.