Mental Health Screening in the Age of Telehealth

The age of 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.