The Case for Telemental Health for Improving the Accessibility and Quality of Children's Mental Health Services

Abstract

Objective:

Children's mental health problems collectively impose a staggering public health burden. However, the quality of regionally accessible children's mental healthcare varies greatly, with youth in rural and other remote communities particularly underserved. Promoting knowledge and skill in telemental health (TMH) is critical to meaningfully overcoming traditional geographic barriers to children's mental healthcare.

Methods:

To introduce this special section, we review the increasing need for child and adolescent mental health services, the decreasing child mental health workforce, and the role that TMH can play in new models of care.

Results:

Authors in this special edition are experienced TMH innovators and providers, and offer expert perspectives on the current and evolving status of TMH practice in child and adolescent mental health. The articles in this collection draw on leading TMH examples, using a range of interventions implemented across diverse TMH settings, to systematically address the critical technical, ethical, regulatory, clinical, and service delivery aspects of TMH care. These articles strategically outline the key considerations requisite for effectively incorporating TMH into children's mental healthcare

Conclusions:

TMH is a rapidly developing service delivery model that is already beginning to innovate systems of care to meet the expanding mental healthcare needs of the nation's children.

Overview: Increasing Demand and Decreasing Supply

Child and adolescent mental health specialists are practicing in inspiring and challenging times. The past two decades have brought considerable insights into the early onset of psychopathology, new approaches to pharmacologic treatment, and the development of effective psychotherapies for youth. More people in need of treatment are seeking care (Kessler et al. 2005) and the Patient Protection and Affordable Care Act (ACA) (Public Law 111-148; United States Department of Health and Human Services 2010) has broadened eligibility for mental health services.

Disparities in access and quality of child mental healthcare

Despite recent progress, some vexing problems persist. Most youth with mental health conditions still do not receive needed interventions, largely because of the insufficient numbers of child mental health specialists and their concentration in urban/suburban areas and academic hubs (Thomas and Holzer 2006). Therefore, children and adolescents living outside of major metropolitan and surrounding areas are particularly underserved in access to needed services (Holzer et al. 1998; Muskie School of Public Service 2009; American Psychological Association 2011). Moreover, when providers are available locally, they may not have access to evidence-based interventions (Sandler et al. 2005; Comer and Barlow 2013). Insufficient funding of public mental health programs often compromises the sustainability of innovative programs and a stable workforce (Glisson et al. 2008; Stirman et al. 2012). These disparities in access to and quality of care have been noted most prominently for child and adolescent psychiatrists (Thomas and Holzer 2006; Flaum 2013), but are relevant to other child and adolescent mental health specialists as well (American Psychological Association 2008, 2011; Kazdin and Blase 2011).

Challenges to rectifying disparities

Planning to address the need for more—and more equitable distribution of—child mental health specialists will be difficult because of an “aging-out effect” of the current supply of psychiatrists, and an inadequate supply of new psychiatrists. Reportedly, 55% of practicing psychiatrists in the United States are >55 years of age, compared with 30–40% for other specialties (Insel 2011; American Association of Medical Colleges 2012; American Medical Association Graduate Medical Education Database 2015). Further, over the past two decades, there was a nearly 20% increase in the number of all physicians, but a <6% increase in the number of psychiatrists (American Medical Association 2010). Although there are variations year to year (American Psychiatric Association News Release 2012; Moran 2014), a relatively smaller proportion of medical students have chosen careers in psychiatry, and the number of psychiatry residents has been essentially flat during this time (American Psychiatric Association News Release 2012; American Psychiatric Association Resident Census 2014). A similar “aging out” effect has been noted for other mental health professionals (American Psychological Association 2008; Michalski and Kohout 2011). Simply put, the supply of child-trained mental health specialists is not going to meet the demand in the foreseeable future, and non-metropolitan communities are likely to be disproportionately affected.

The current disparities and the projected decreasing supply of child mental health specialists is occurring at the same time as the broadening implementation of federal and state mental health parity laws that will likely further increase the demand for child specialty mental healthcare. New approaches to meeting this demand are needed (Comer et al. 2014a).

Telehealth Technology to Reduce Disparities and to Improve the Quality of Child and Adolescent Mental Healthcare

Synchronous and asynchronous telemental health (TMH)

Addressing the convergence of the increasing need for empirically supported child and adolescent mental health services and the noted shortages in the expert child mental health workforce will require innovative approaches to service delivery, and the ACA (United States Department of Health and Human Services 2010) has specifically called for the meaningful use of telehealth technologies to improve healthcare and population health for all citizens. The Health Resources and Services Administration (HRSA) defines telehealth as “The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration” (Health Resources and Services Administration 2015). When telehealth relies on synchronous (interactive) technologies, such as videoconferencing or telephony, to deliver treatment to patients that is consistent with treatment delivered in person, the Center for Medicare and Medicaid (CMS) uses the term “telemedicine” (Department of Health and Human Services 2014) and when that care specifically involves mental health or psychiatric services, the terms “telemental health” and “telepsychiatry,” respectively, are generally used (Yellowlees et al. 2010). Asynchronous, or delayed, telehealth technologies include viewing images or recordings, such as radiographs or telemetry, and sharing information through the use of patient portals. Asynchronous self-administered interventions provided online or through a peripheral drive have an evolving role in mental healthcare for adults with mood or anxiety disorders (Andersson and Cuijpers 2009; Christensen et al. 2009). An evidence base is gradually developing to support the feasibility, acceptability, and potential efficacy of similar programs for youth completed in various settings with staff supervision. For example, “Cool Teens” (Wuthrich et al. 2012) has shown preliminary efficacy for reducing anxiety in clinical samples of adolescents, “Mood Gymn” has demonstrated variable success in reducing depressive symptoms in high school students with low levels of depressive symptoms (O'Kearney et al. 2009), whereas Project CATCH-IT has shown potential to prevent depression in youth treated in primary care (Van Voorhees et al. 2009). A particular advantage of such asynchronous interventions is that they ensure fidelity in the delivery and dissemination of an intervention that can be difficult to achieve with traditional forms of treatment. These programs appear promising for treating youth with mild symptomatology or in augmenting in-person interventions.

Both synchronous and asynchronous technologies are being used to fill the service gap and to improve the quality of care for children and adolescents with mental health conditions. Efforts have emphasized the training of primary care physicians (PCPs) in diagnosing and treating mental health disorders and to honing their skills in providing evidence-based care for specific common disorders (Epstein et al. 2010). Members of the National Network of Child Psychiatry Access Providers (National Network for Child Psychiatry Access Providers 2015) use telephony to provide on-demand consultation to PCPs in the management of common mental health disorders (Sarvet et al. 2010; Hilt et al. 2013; Gadomski et al. 2014).

TMH to provide services to children and adolescents

TMH offers further opportunity to expand care across service sectors, include a broad range of collaborative and direct services, help redistribute the child mental health workforce, and disseminate evidence-based care. Programs using synchronous TMH to deliver services directly to youth and their families have developed rapidly across the country. Many programs operate at academic and major medical centers to deliver services to traditional clinical settings; for example, to collaborate with primary care providers (PCPs) in the management of children's mental health needs (Greenberg et al. 2006; Myers et al. 2007; Yellowlees et al. 2008; Lau et al. 2011; Kriechman and Bonner 2013; Goldstein and Myers 2014), and to provide ongoing direct care to youth and families (Nelson et al. 2003; Myers et al. 2008, 2010; Reese et al. 2012; Glueck 2013; Xie et al. 2013; Myers et al. 2015). Such services are being delivered to youth in diverse rural, non-metropolitan and urban communities in which families and teleclinicians may differ in their ethnic and cultural heritage (Alicata et al. 2006; Cain and Spaulding 2006; Savin et al. 2006; Myers et al. 2010; Reichenbacher 2014; Alicata and Lunsford 2014). With advances in technology, academic and major medical centers are no longer the only providers of TMH services. TMH has moved out of traditional clinical settings to reach youth in more ecologically valid settings such as schools (Grady et al. 2011), correctional settings (Myers et al. 2006; Kaliebe et al. 2011), day care (Spaulding et al. 2011), and the home (Comer et al. 2014a, 2014b; Comer et al., 2015). One need only to search the Internet using the term telepsychiatry to appreciate the plethora of private vendors that provide the technology, business management, and patient base for contracted telepsychiatrists to deliver care to agencies and individuals (Glueck 2011). Alternatively, enterprising clinicians with technical savvy, business skills, and an existing patient base are establishing their own TMH practices (Glueck 2013).

Barriers to establishing and conducting a TMH program

Despite this progress, barriers to establishing a TMH program persist, and the barriers may vary across states, payers, and technologies, discouraging aspiring teleclinicians from pursuing a TMH practice. Although most (47 of 50 states) states include some type of telemedicine in their coverage, many do not mandate parity in private payers' coverage of services, and most private payers that do cover telemedicine services do not compensate for the additional clinical or technical staff that may be needed at the patient site. Patients and healthcare providers may encounter a patchwork of arbitrary insurance requirements and disparate payment streams that do not allow them to fully take advantage of telemedicine (Thomas and Capistrant 2014). Some states have started to consider greater restrictions on telemedicine practice, such as the prescribing of controlled substances. The initial technology investment and subsequent maintenance must be covered by the teleclinician and participating site. Practitioners may be uncertain about the most appropriate technology for their work, and how to determine whether the technology is compliant with the Health Insurance Portability and Accountability Act (HIPAA) (United States Department of Health and Human Services 1999). These are daunting barriers for many clinicians.

However, these barriers are weakening, and some are falling. Technological literacy is dramatically improving across both patients and providers. Technological advances have produced portable, software-based telecommunications systems that are “user-friendly,” do not require on-site technical staff, and are financially feasible for communities and agencies that could not support a TMH service only 5 years ago. Interoperability software allows connectivity between different systems. The Centers for Medicare and Medicaid Services (CMS) have established guidelines for telehealth care and policies for reimbursement, including a small care coordination fee paid to the local site on a per patient per month basis (Department of Health and Human Services 2014; Medicaid.gov 2015). On the state level, there is a national trend to allow statewide Medicaid coverage of telemedicine, instead of focusing solely on rural areas or designating a mileage requirement, and there is some movement away from a “hub-and-spoke” model to recognizing nontraditional service sites such as schools (13 states) or homes (21 states) as sites of service (Thomas and Capistrant 2014). In 2006, the Office for the Advancement of Telehealth (OAT) funded the development of Telehealth Resource Centers (TRCs) to provide assistance, education, and information to organizations and individuals who are providing, or interested in providing, healthcare at a distance (www.trc.org). The 11 regional centers are mandated to assist in expanding the availability of healthcare to underserved populations and, as federally funded programs, services are generally free of charge (Office for the Advancement of Telehealth 2011).

For practitioners who are not contracted with Medicare or Medicaid or nonprofit organizations, coverage by private insurers is also changing. The American Telemedicine Association (ATA) has captured the complex policy landscape of the 50 states with 50 different telemedicine policies, and translated this information into an easy to use format (Thomas and Capistrant 2014). The resulting report notes that 21 states have parity laws for reimbursement of telemedicine services, although the specifics of provider and technology vary. The report compares telemedicine coverage and reimbursement standards for every state, and notes that over the past 3 years, the number of states with telemedicine parity laws that require private insurers to cover telemedicine-provided services comparable to that of in-person services has doubled. Their report ultimately leaves each state with two questions: “How does my state compare regarding policies that promote telemedicine adoption?” and “What should my state do to improve policies that promote telemedicine adoption?” (Thomas and Capistrant 2014). Online resources keep teleclinicians apprised of regulatory and financial developments in telehealth care (see, for example, CTel 2015; Center for Connected Health Policy 2014). Although much remains to be done to bring telemedicine, and TMH, into mainstream practice, the trend is in the direction of reducing barriers and eliminating disparities in access to mental healthcare.

Contributing Articles in the Series

This series presents work by recognized leaders in TMH whose innovative work has sought to meaningfully close the gap in access to services and improve the quality of metal healthcare for children and adolescents. The articles predominantly focus on synchronous telehealth, but include examples of innovative and evolving asynchronous technologies that may complement direct care services or be used as stand-alone interventions. As the evidence base for TMH with children and adolescents is still evolving, the authors draw largely on their own experiences in program development and service delivery.

There are five sections. The first two articles address areas considered to be barriers to the widespread implementation of TMH. Chou and colleagues review the available technologies with an emphasis on newer online videoconferencing approaches that have made TMH economically feasible and secure for implementation in multiple sites. Kramer and Luxton then review the legal, regulatory, and risk issues involved in TMH practice. The regulatory landscape is fluid as each state legislates its own policies which may change as states become more familiar with telehealth. Readers will appreciate the authors' emphasis on staying updated on local laws and their enforcement.

The second section presents synchronous applications for the delivery of clinical care. Goldstein and Glueck describe the establishment of rapport and a therapeutic alliance during TMH. Clinicians are often concerned that it is not possible to establish a therapeutic alliance when providing care over a telemonitor and that outcomes may be compromised. The authors address these concerns and approaches to using the technology to optimize rapport building and a therapeutic alliance. Nelson and Patton describe the provision of individual therapy to clinical settings with youth experiencing comorbid medical disorders. Their work underscores the need for collaboration with local providers and the child's system of care. Pharmacotherapy is one of the most frequently requested services for youth referred to TMH. Cain and Sharp present challenges and potential solutions to effective telepharmacotherapy. These experienced telepsychiatrists include their extensive experience in prescribing across different models of care. Comer and colleagues bring TMH to the naturalistic setting of the home. They describe the delivery of family-based TMH interventions, for obsessive-compulsive disorder and for early conduct problems, using personal computers, and they address the logistical and privacy considerations required for the safe implementation of home-based TMH. This work is inspiring, as these evidence-based psychotherapies are poorly disseminated outside of major metropolitan areas, and TMH offers the potential for families in rural areas to achieve parity in access to mental health services.

In the third section, we present two approaches to asynchronous TMH that may be unfamiliar to the readership, but are gaining attention because of their focus on relatively inexpensive and universally available interventions. Merry and colleagues have developed and tested an asynchronous, self-administered gaming intervention for adolescent depression (Merry et al. 2012). Their work is cutting edge as they integrate adolescent-friendly gaming approaches with cognitive-behavior therapy concepts. Whiteside presents the development and initial examination of an app for treating anxiety, which is based on the core evidence-based concepts of exposure and response prevention that underlie effective treatment for anxiety. The appeal of such an app is immediately obvious, as it empowers youth in their treatment. These two asynchronous interventions will stimulate readers' consideration of how such self-administered programs may help to bridge the access gap, or to complement traditional therapies.

The fourth section describes the delivery of TMH-mediated care to diverse settings. Palomares and colleagues have broad experience in providing outpatient care through TMH, and take the perspective of the clinician who is considering a TMH practice. Their pragmatic considerations will help the potential teleclinician to consider the factors in setting up a practice. Alicata and colleagues then provide the perspective of service delivery to outpatient sites. Their program serves as a model for states and academic institutions seeking to develop a local TMH workforce. Under the supervision of faculty, the child psychiatry fellows partner with teams at the mental health service sites to provide culturally competent care. This article stimulates the reader's thinking about what supports are needed at the patient site to implement an effective service. There is a long history of moving healthcare for youth out of traditional healthcare settings into the community, such as schools. Stephan and colleagues take the next step, school-based TMH, to reach youth in this ecologically valid setting with input from school personnel, and the opportunity to support classroom teachers. The authors describe school-based TMH in the context of their own work with the University of Maryland, a national leader in the study and implementation of children's mental health services in school-based settings. The inclusion of child and adolescent psychiatry fellows into the program provides a model for training in school-based telemental health. Another community setting is juvenile corrections facilities. Correctional settings are one of the most common utilizers of TMH services. Bastastini notes the challenges and benefits of locating a TMH program in juvenile correctional sites that are often located at a distance from inmates' families and other services. Privacy and confidentiality provide particular challenges to delivering TMH services in correctional settings. McWilliams then presents current thinking about the potential role for integrating TMH into the pediatric medical home to meet the “triple aim” of improving the experience of care, improving the health of populations, and containing costs. She reviews models of TMH-mediated collaborative care that are in their early stages of development and provides a look into the future of child and adolescent mental health treatment; a future that will address approaches to rectify disparities in access to evidence-based treatments, accountability of care, and workforce needs.

The final section discusses future directions for child and adolescent TMH. Program development is outpacing a supportive evidence-base (Cain et al. 2015). Although multiple studies with adults have demonstrated that interventions delivered through TMH show comparable outcomes to the same interventions delivered in person (Hilty et al. 2013), the evidence base in child and adolescent TMH is gradually developing. Most published work has demonstrated that providing TMH services to youth is feasible and highly acceptable to referring providers, parents, and youth (Elford et al. 2001; Greenberg et al. 2006; Myers et al. 2006, 2007, 2008; Boydell et al. 2010; Lau et al. 2011). Dr. Hilty and colleagues note the need to update and develop practice guidelines for child and adolescent telemental health practice. They provide some key considerations for best practices while awaiting formal guidelines.

However, outcome studies are limited. Six randomized control trials have been published: Two addressed the accuracy of diagnoses made through videoconferencing (Elford et al. 2000; Reese et al. 2013), three demonstrated the equivalency of outcomes for care provided through TMH compared with in-person care for children with tics (Himle et al. 2012) or depression (Nelson et al. 2003), and for parent management training (Xie et al. 2013). Only one study has demonstrated the superiority of care provided through TMH to that provided in primary care (Myers et al. 2015). Other outcome studies have included results of pre- to post-interventions (Yellowlees et al. 2008; Storch et al. 2011; Reese et al. 2012; Heitzman et. al. 2013; Comer et al. 2014b). Given this evolving literature, Drs. Crum and Comer address the need to develop a robust evidence base to bring TMH with children and adolescents into mainstream clinical practice and to prepare child and adolescent mental health specialists for a new approach to practice.

Footnotes

Disclosures

No competing financial interests exist.

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