Telehealth referral, collaborative care improve outcomes in PTSD, bipolar disorder

Patients with PTSD or bipolar disorder reported significant improvement with consultation of primary care physicians or treatment by telepsychiatrists, according to a JAMA Psychiatry study.

“The study was motivated by the inequitable geographic distribution of mental health specialists in the United States,” John C. Fortney, PhD, of the University of Washington’s department of psychiatry and behavioral sciences and Seattle’s Center of Innovation for Veteran-Centered and Value-Driven Care, told Healio Psychiatry. “This inequity results in substantial unmet need in rural counties and a significant rural-urban disparity in access to and receipt of specialty mental health care.”

Fortney and colleagues randomly assigned 1,004 participants (70.1% women, 66.4% white) with bipolar disorder and/or PTSD across 12 federally qualified health centers in Arkansas, Michigan and Washington to 1 year of telepsychiatry/telepsychology-enhanced referral (TER) or telepsychiatry collaborative care (TCC) between Nov. 16, 2016, and June 30, 2019.

TER involved treatment by telepsychiatrists and telepsychologists, while telepsychiatrists consulted primary care physicians in TCC. Non-engagement in TER at 6 months prompted random assignment to phone-engaged referral (PER) as intervention. Patients self-reported mental health outcomes and adverse psychotropic medication events through surveys at baseline, 6 months and 12 months.

A total of 50.1% of participants lived in a rural area, 65.5% reported household income below the 2016 poverty level, and 83% were publicly insured or uninsured (83%).

Further, 97.4% of participants had moderate PTSD, and 78.1% reported a traumatic event. Bipolar disorder occurred among 36.6% of participants, 9.3% of whom were euthymic at enrollment.

At baseline, participants’ mean score was 30.8 (range, 0-100) on the Veterans RAND 12-item Health Survey Mental Component Summary (MCS), two standard deviations below the U.S. average. With TCC, average MCS score increased from 30.4 to 39.7 at 12 months (Cohen d = 0.81; 95% CI, 0.67-0.95); with TER, average MCS score increased from 31.3 to 41.2 (Cohen d = 0.9; 95% CI, 0.76-1.04). Both groups had significant and clinical improvement, with no significant difference in 12-month outcomes.

For patients randomly assigned to PER, there was no significant difference between TER and PER.

“We did not expect that so many patients would engage in care in the [TER] group,” Fortney said. “In the past, we have observed that referrals to non-integrated mental health specialists are usually not successful due to stigma, long wait times, high cost and travel barriers.”

Researchers determined that cognitive processing therapy and/or cognitive behavioral therapy in TER correlated with MCS improvement, but behavioral activation therapy in TCC did not.

While the study was strengthened by its large sample population, it was limited by low survey follow-up rates, non-inclusion of a usual care group and use of research funds to help provide some clinical services and state medical school telepsychiatrists and telepsychologists.

“During start-up, the clinics preferred that the state medical school telepsychiatrists and telepsychologists be credentialed and privileged to practice at the primary care clinic,” Fortney said. “Thus, patients did not have to enroll as patients in the academic medical center, and this helped mitigate the impact of many of the other barriers to referral.”

Fortney and colleagues suggested the most sustainable practice should be used in clinics, and that TCC should be incentivized in public policy to help with telepsychiatrist shortages. They are conducting further research to help support telepsychiatry services in rural areas.

“We are currently trying to identify implementation strategies to help rural clinics adopt these evidence-based practices,” Fortney said.