A Comparison of Mental Health Diagnoses Treated via Interactive Video and Face to Face in the Veterans Healthcare Administration

Introduction

Forty-one percent of veterans enrolled in the Veterans Health Administration (VHA) reside in rural communities. ¹ To address the geographical barriers to VHA care, community-based outpatient clinics (CBOCs) were established to provide primary care services within communities located far away from Veterans Administration Medical Centers. In 2008, the Uniform Health Services Package recommended that clinically indicated services must be available to CBOC patients on-site or by interactive video connection to a provider at the parent Veterans Administration Medical Center. ² As a result, most CBOCs were outfitted with interactive video equipment. Improving digital access via interactive video can help veterans living in rural communities overcome long travel distances associated with seeking mental healthcare. ³ In Fiscal Year 2012 (FY12), 12% of all interactive video encounters in VHA were for mental health. ⁴

Interactive video has traditionally been used by telepsychiatrists to provide medication management; however, utilization is expanding. ⁵ Across a range of diagnoses, there is ample evidence documenting the clinical equivalency of psychiatric ^6,7 and psychological ⁸ treatments delivered via interactive video. Interactive video is associated with comparable attendance, retention, adherence, satisfaction, treatment expectancy, and symptom reduction, ^9,10 suggesting that care delivered via interactive video is a high-quality and effective alternative.

Interactive video has not been adopted uniformly across diagnoses. One study found that mood (48%), adjustment (20.5%), and anxiety (17%) disorders were common diagnoses treated using interactive video, whereas substance use (4.0%), psychotic disorders (3.0%), and posttraumatic stress disorder (PTSD) (2.2%) were less common. ¹¹ It is unknown whether this variation across diagnoses is due to differences in prevalence or differences in the appropriateness of using interactive video across disorders. Interactive video continues to be used predominantly for medication management, and this type of treatment may lend itself more toward certain disorders. ⁵

Little is known about which diagnoses are most commonly treated using interactive video in the VHA. Capitalizing on large administrative datasets available to researchers, this study will compare the mental health diagnoses treated face to face with those treated via interactive video in the VHA healthcare system.

Materials and Methods

We identified all interactive video-delivered mental health encounters (n=11,906,114) available in VHA administrative data for FY12 (October 1, 2011–September 30, 2012). Encounters assigned a primary Mental Health Stop Code (500–599), a Telehealth Secondary Stop Code (690, 692, 693), and a Mental Health Diagnosis (International Classification of Diseases, 9th edition [ICD-9]: 290–319) were included in our sample. Primary and secondary Stop Codes are used to define which clinical group within the VHA is responsible for providing care associated with the encounter. For each interactive video consult, there are two encounters entered in the medical record: one for the patient site and one for the provider site. All duplicate encounters were removed to ensure an accurate count. Each interactive video encounter was categorized into one of eight mutually exclusive diagnostic categories based on the ICD-9 primary diagnosis for the encounter. Categories included PTSD, depression, anxiety disorders, bipolar disorder, psychotic disorders, substance use disorder, alcohol use disorders, and other. Information about diagnoses was analyzed at the encounter level. Because the sample includes the universe of all mental health encounters in the VHA in FY12, no descriptive or inferential statistics were used to interpret the data. Institutional Review Board approval was obtained from the Central Arkansas Veterans' Healthcare System.

Results

Overall, 1.5% of general mental health encounters (179,156/11,906,114) were delivered via interactive video. The percentage of mental health encounters that were delivered via interactive video varied somewhat across diagnosis (Table 1): 1.8% of PTSD encounters (65,210/3,604,182), 2.2% of depression encounters (51,927/2,384,869), 2.4% of anxiety disorder encounters (13,894/586,033), 1.7% of bipolar disorder encounters (10,867/622,814), 0.7% of alcohol use disorders encounters (9,054/1,379,607), 0.6% of drug use disorders encounters (9,598/1,710,799), 0.7% of psychosis encounters (7,413/1,086,292), and 1.6% of other encounters (8,283/531,518). As illustrated in Figure 1, a larger percentage of interactive video-delivered mental health encounters were for PTSD, anxiety, and depression compared with face-to-face mental health encounters for each diagnosis. In contrast, a smaller percentage of interactive video-delivered mental health encounters were for alcohol abuse, drug abuse, and psychotic disorders compared with face-to-face mental health encounters for each diagnosis.

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Fig. 1.

Percentages by diagnosis of interactive video-delivered and face-to-face mental health encounters for Fiscal Year 2012. PTSD, posttraumatic stress disorder.

Discussion

Compared with face-to-face encounters, interactive video encounters are more likely to address PTSD, depression, and anxiety and less likely to address alcohol abuse, drug abuse, and psychotic disorders. Several factors may contribute to this pattern. The Uniform Mental Health Services Package recommended that specialty PTSD treatment, delivered either face-to-face or via interactive video, must be available in all CBOCs. ² Empirical support for PTSD and depression treatment delivered via interactive video is well established, whereas there have been relatively few studies of interactive video treatment of substance use disorders and psychosis. ^10,12 Drug abuse and alcohol abuse are more likely to be treated in groups, and group treatment continues to be infrequently available via interactive video. ⁵ Many substance use services are traditionally delivered face to face (opioid agonist treatment, withdrawal management, and partial hospital/residential programs). Two interventions for veterans with psychosis—the Mental Health Intensive Case Management, which focuses on community-based support, and the Psychosocial Rehabilitation and Recovery Center, a therapeutic learning environment combined with social skills training ² —may be more likely to be delivered face to face. Providers may also consider alcohol abuse, drug abuse, and psychosis to be too complex to treat via interactive video. Lastly, patients with substance use disorders or psychosis may prefer face-to-face encounters over interactive video encounters.

A few limitations of these data include our inability to determine whether patient or provider factors influenced the diagnosis addressed via interactive video encounters.

Conclusions

As telemedicine capacity expands in the VHA, it will be necessary to monitor the diagnostic composition of encounters delivered via interactive video to ensure that a range of services are available. Data support the use of interactive video for group psychotherapies, finding them safe and effective for veterans, ^13,14 and evidence suggests that interactive video is effective for patients with psychotic disorders seeking medication management, even among those patients with delusions related to technology. ¹⁵ As support for psychotherapy delivered via telemedicine expands, so does the potential for addressing a broader range of psychiatric disorders. ¹³