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The age of te
“Here you go Sally, Dr. Whittle would like you to fill out this questionnaire today.” A medical assistant in Dr. Whittle’s office hands Sally a PHQ 9 depression screening. After the Medical Assistant scores the screening it shows that Sally scores a 15 Moderately Severe Depression. She answers questions 9 in the following way:
…now what?
Because of the comorbidities between depression and many other areas of physical medicine, Primary Care and Specialists are dealing with depression almost daily. Some choose to treat depression inhouse and some refer patients out to Psychiatrists. In either scenario, these physicians see the effects of depression on their outcomes. When underlying depression is dealt with, outcomes improve. This has led to the large national push to screen for depression, from almost every major medical association.
The PHQ 9 is a powerful tool Doctors like Dr. Whittle can use to help determine whether patients like Sally are suffering from depression. It can help determine the severity of the depression, and whether to consider Major Depressive Disorder or Other Depressive Disorder. Provided that each score is charted, it is an excellent way to track results over time.
The issue with the PHQ 9 and other similar instruments, is that they are exposing the underlying depression, but they do not provide all of the information for a Physician to make a diagnostic decision. This leaves a Physician with an “open wound” of sorts. They must now spend the time to dig for more information. Information like potential bereavement, effects of drugs or alcohol, or potential physical issues that may be factor. They are also exposing a risk for suicide, but not digging deep enough to determine either plan or intent, requiring as many as 7 more questions related to potential self-harm.
Verbal questioning has the tendency to “uncork the bottle” of emotion in patients, compared to computer or even paper-based screening and testing. This can increase visit time by up to 43% over a non-mental health related visit. In an already hectic and busy clinic, this additional time can create significant issues. Studies also show that a patient tends to be less honest face to face when dealing with a sensitive issue like mental health*. It is not a wonder that so many Physicians chose to take a naïve approach to mental health in their clinics.
With the significant improvement in technology in recent years there is a solution emerging; intelligent, computer-based testing. These types of instruments use computer-based, branching logic engines to provide Physicians with the answers they need to determine next steps, prior to entering the room with a patient. These systems can dig, where appropriate, to expose suicide ideation, plan, and intent. They can ask all the necessary questions for a Physician to diagnose a patient. Unlike paper-based screenings, these tools do not need to ask questions unless they are necessary. This means that for most patients, testing is simple and short. Only patients that trigger more extensive questioning are asked for more details.
There is a way for Physicians to have their cake and eat it too, they can screen without slowing down their workflow. They can determine when patients need more care without increasing visit times. Most of all they can improve their outcomes.
*Administering an iPad questionnaire in physician waiting rooms proved an effective way for patients to report unhealthy behaviors and mental health issues, according to a study published online September 9, 2013 in the Annals of Family Medicine.
Telehealth is upon us. Telehealth, which encompasses the delivery of medical and mental health assessment and treatment, can be administered via telephone, live video conferencing, and other digital communication modalities. Although telehealth has existed for decades, its utilization has increased exponentially during the COVID-19 pandemic. Previously, it was primarily reserved for people living in rural areas and certain long-term care facilities, in no small part because insurance providers typically failed to adequately reimburse for telehealth services. With the coronavirus posing clear health risks to those receiving in-person services that could otherwise be safely and effectively delivered via telehealth, the public health emergency ushered in significant policy changes (e.g., increased reimbursement for telehealth) that dramatically accelerated the development and utilization of telehealth across wide swaths of the healthcare industry. Since these changes, some medical practices have reported conducting up to 50-175 times more telehealth visits compared to before the pandemic1.
Whereas some medical subspecialties (e.g., surgery, oncology) face significant obstacles regarding the viability of telehealth, behavioral health is particularly well suited for remote delivery. Telemental health, as it is often called, includes psychological screening, assessment, education, therapy, and medication management. Beyond the obvious safety benefits in the context of the ongoing pandemic, telemental health offers a variety of advantages over in-person care. Importantly, it substantially enhances access to mental health services for people in need of psychotherapy and psychotropic medications – addressing an ongoing problem in which most people experiencing mental illness do not receive care2. Many people find it less stigmatizing and intimidating to seek mental health care from the comfort of their own home. Telehealth also removes barriers related to transportation (e.g., cost, access, long commute, weather) and low motivation – which are among the most frequent obstacles to patients receiving mental health treatment.
Along with substantial benefits of telehealth, there are, of course, drawbacks and limitations. First, certain conditions and populations typically benefit from, or even require, a higher level of care than can be provided remotely. For example, young children may have difficulty engaging via telehealth, and individuals with serious psychotic symptoms or at high risk for suicide may require inpatient hospitalization or more frequent, high-intensity care than is practical via remote outpatient services, just as these same patients would not be appropriate for weekly outpatient in-person therapy. Second, for safety reasons, some psychotropic medications (e.g., lithium, clozapine) require therapeutic drug monitoring that requires some degree of in-person services (e.g., laboratory blood draws). There are also limitations regarding psychological testing via telehealth. Although many psychological tests can be validly administered remotely, others – particularly neuropsychological assessment instruments – require an in-person proctor. Limitations regarding access and capacity to effectively utilize technology can also present barriers. Lastly, some patients and providers simply prefer in-person care and believe that something of the human connection is lost in virtual care.
Although there will inevitably be a return to some sort of normalcy within the healthcare industry when the pandemic subsides, there will surely continue to be demand for telehealth, particularly in domains like mental health and routine primary care, which are so amenable to this modality. As such, the future of mental health assessment and treatment requires thoughtful adaptation to this new frontier. Fortunately, mounting evidence suggests that telemental health is both feasible and efficacious. A variety of psychological conditions (e.g., depression, anxiety, PTSD) can be adequately treated via remote interventions, and some research suggests people are less likely to drop out of therapy prematurely when it is delivered remotely3.
There remains a significant opportunity, however, to improve upon valid and reliable remote assessment of mental health conditions. This pertains to both comprehensive assessment batteries conducted by licensed psychologists and to more efficient and circumscribed psychological screening completed by primary care providers (PCP’s), who treat the majority of psychological conditions in the United States. Whereas many PCP’s are accustomed to working in team-based settings, alongside behavioral health consultants (BHC’s) in an integrated model of care, the expansion of telehealth changes this dynamic. It limits the availability of “curbside consults” between PCP’s and BHC’s and with them, the PCP’s opportunity to benefit from a mental health specialist’s diagnostic impressions and treatment recommendations. As a result, it is increasingly important for PCP’s to utilize effective and efficient psychological screening tools in their daily practice to enhance evidence-based clinical decision making.
Recent data from more than 4,000 individuals who used Connected Mind’s self-screening tool over six months during 2020 revealed significant levels of mental health symptoms across a variety of categories (e.g., depression, anxiety, substance use). Although the symptom levels are higher than what is typically observed, these findings align with other surveys and anecdotal reports of increased mental health symptoms during the pandemic4. Further, the relative prevalence of different symptom categories identified in this dataset corresponds with epidemiological knowledge about various mental health conditions (e.g., three to five times greater rates of unipolar than bipolar depression). These findings are encouraging as we look to the future of telehealth. They suggest the remote electronic administration of Connected Mind’s mental health screening tool is both viable and nuanced. During what may be an inflection point in the adoption of telehealth services, tools like this – that are efficient, flexible, and adept at aiding in differential diagnosis – are critically important.