May 9, 2012 (Philadelphia, Pennsylvania) — Providing telemental health (TMH) services to patients living in rural and remote areas dramatically reduces psychiatric hospitalization rates, new research shows.

The first large-scale assessment of TMH outcomes showed that patients’ psychiatric hospitalization utilization decreased by about 25%.

“This is the first really large-scale outcomes study with really positive outcomes in terms of decreased hospitalization,” principal investigator Linda Godleski, MD, director, National Telemental Health Center, US Department of Veterans Affairs (VA), and associate professor of psychiatry, Yale School of Medicine in New Haven, Connecticut, told delegates attending the American Psychiatric Association’s 2012 Annual Meeting.

Dr. Linda Godleski

Dr. Godleski pointed out that TMH has been around for more than 50 years and had its genesis in the United States at the University of Nebraska. However, she added, it is only in the last decade that technological advances have made it a viable, widely available, cost-effective treatment that has enabled the VA to undertake a major nationwide TMH initiative.

“In the past decade, the technology has become so great — the video screens are in high-definition, and the high-speed quality of the transmission allows you to see fine facial movements, tears forming in a patient’s eyes, so that within the first few minutes of the interaction, you almost forget that you’re not sitting in the same room with the patient,” said Dr. Godleski.

She noted that from 2003 to 2011, the number of TMH annual encounters in the VA increased approximately 10-fold — from 14,000 per year to over 140,000. Over the same period, there was a 6-fold increase in the number of TMH annual unique patients, the number jumping from 8000 to over 55,000. With 50 medical centers and 530 clinics receiving TMH since 2003, the VA has a database with a total of 500,000 TMH encounters.

Despite this rapid growth, research on TMH outcomes has been limited to feasibility studies and small-scale randomized control studies, which have shown that TMH is equivalent to face-to-face treatment, but there have been no national studies reporting outcomes of TMH services among large populations, said Dr. Godleski.

All Comers

The researchers hypothesized that patients with access to TMH through remote technologies would have decreased hospitalization rates, including fewer psychiatric admissions and fewer days of psychiatric hospitalization.

The prospective 4-year study included data on 98,609 mental health patients before and after enrollment in TMH services of the VA between 2006 and 2010. Of these, 91% (n = 90,175) were men. The majority (80.4%) ranged in age from 25 to 64 years.

The study used a performance improvement dashboard that was created by the VA to assess nationwide clinical outcomes.

The dashboard used aggregate administrative data for all patients who received mental health services by remote high-speed video conferencing for the first time between 2006 and 2010.

The investigators compared the number of inpatient psychiatric admissions and days of psychiatric hospitalization during a period that lasted an average of 6 months before and after enrollment in TMH services.

Newly enrolled patients did not have any TMH in the prior 12 months.

TMH services were primarily provided by clinicians at VA medical centers to patients in remote clinics; home visits were not included in the study. All types of diagnoses visits, such as individual, group, and family therapy, were included in the study.

Facilitates Earlier Treatment

Over the 4-year study period, the researchers found that psychiatric inpatient admissions of TMH patients decreased by an average of 24.2% (annual range, 16.3% – 38.7%), and the patients’ days of hospitalization decreased by an average of 26.6% (annual range, 16.5% – 43.5%).

The number of admissions and the days of hospitalization decreased for both men and women; the decreases were seen in 83.3% of the age groups.

“This study is the first to report or describe telemental health programs on a large scale, and the VA is really uniquely positioned to do this because we have 500,000 visits, and we have an incredible database because we have electronic medical records, so we can capture, collect, and analyze information on outcomes,” said Dr. Godleski.

“Our hypothesis is that the decreased hospitalization rates may be explained by increased access to services by remote care delivery, so patients aren’t waiting until they are completely decompensated before they show up in the emergency room. They can come to close-by clinics and get more routine and regular care; the services may lead to closer management, increased treatment adherence, and the need for hospitalization may ultimately be prevented,” she added.

Further, she said if there is a question of hospitalization, clinicians can see a patient remotely via TMH and determine whether remote intervention is feasible or whether they need to be hospitalized.

The investigators also compared the decreases in psychiatric hospital utilization in the VA among mental health patients receiving TMH to that of the general VA mental health population and found “that the decrease in hospitalization seemed to be unique to the telemental health population, as the overall VA population of mental health patients did not demonstrate similar decreases during this period. In fact, there were some slight increases,” said Dr. Godleski.

Although medication management was the primary paradigm for TMH, the researchers found that this is being replaced by growing rates of all types of psychotherapeutic modalities as well as diagnostic evaluations.

Preliminary findings from the 2011 data indicate decreased hospitalization rates of about 20% among TMH patients, said Dr. Godleski. However, she added, these rates increased in female patients and in patients with substance use disorders. The reason for this is unclear, but it may be that TMH is reaching groups of patients that in the past have gone undetected, she said.

Dr. Godleski noted that in its infancy, there were questions about whether TMH could match the efficacy of face-to-face physician-patient encounters. However, she added, the emerging evidence suggests that TMH may ultimately provide patients with more rapid and frequent access to mental health services.

She added that the VA is moving towards providing TMH services in a one-on-one scenario in patients’ homes.

TMH Not Without Challenges

Commenting for Medscape Medical News on TMH as a treatment modality, retired Col. Elspeth Cameron Ritchie, MD, MPH, Chief Clinical Officer, US Department of Mental Health, Government of the District of Columbia, said in her 24 years of active duty she has seen major advances in telemedicine and TMH.

However, she noted, it is not without its challenges and is dependent on, among other things, adequate bandwidth, which is not always available in countries such as Afghanistan among soldiers on active duty.

Although she agreed that rural and remote settings in the United States may be the ideal setting for TMH, she noted that the VA may be unique in its ability to provide high-quality technology and a sophisticated system of electronic medical records.

Nevertheless, said Dr. Ritchie, TMH can fill an important need in areas where there is a lack of mental health services.

However, she noted, there is some concern over the VA’s initiative to move into individual at-home TMH.

“The VA is experimenting with going directly to the homes without another provider there, and some of us are a little worried about it. For example, what happens if somebody gets suicidal or distressed and the clinician is far away?” she said.

Dr. Godleski and Dr. Ritchie have disclosed no relevant financial relationships.

The American Psychiatric Association’s 2012 Annual Meeting. Abstract SCR10-3, presented May 6, 2012.