Clinicians' Perceptions of Rapid Scale-up of Telehealth Services in Outpatient Mental Health Treatment

Introduction

Telehealth videoconferencing has increased exponentially during the COVID-19 pandemic. ^1,2 With the onset of the pandemic, clinicians quickly adopted telehealth in an effort to maintain continuity of care for patients, aided by a series of changes among federal and state laws, and health plan payment policies lifted prior restrictions and barriers to telehealth use. ^{3 –5} Before the pandemic, telehealth had been increasing over the past decade particularly for the care of mental health or substance use disorders, largely driven by clinician shortages, but it still had not been widely adopted. ^{6 –9} Early evidence suggests that the transition to telehealth during the pandemic, in lieu of in-person care, has been relatively easier for specialty mental health and/or substance use disorder (MH/SUD) clinicians than other health care specialties. ^2,10 This is perhaps not surprising given that behavioral health care is often less reliant on physical examination of patients than other medical specialties; additionally, there is considerable evidence demonstrating the feasibility and acceptability of telehealth, and similar effectiveness/efficacy compared with in-person care—particularly for depressive and anxiety disorders. ^{11 –15}

However, the experiences of usual care for MH/SUD clinicians who were in quick need of implementing telehealth during the pandemic across their patient populations may differ substantially from the prepandemic literature for several reasons. First, patients and clinicians who engaged in telehealth before the pandemic generally did so by choice; whereas during the COVID-19 pandemic, telehealth is often the only method of treatment available. Second, patients who participate in clinical trials are often not generalizable to those in usual care settings, ^{16 –19} and the clinicians may not be as well. ²⁰ Additionally, the telehealth evidence base for certain populations in behavioral health settings is more limited (such as for those with substance use disorders or schizophrenia). ^21,22 There are also questions about whether the working alliance between a patient and therapist is lower in telehealth compared with in-person psychotherapy. ²³

There have been some early qualitative reports published about the experience of outpatient MH/SUD clinicians in transitioning to provide telehealth as part of their routine care as the pandemic emergency started in the United States. ^24,25 But this early qualitative literature has been limited, either due to its focus on physicians (psychiatrists) ²⁵ or in having an anecdotal approach to describing the experience of clinicians in an organization. ²⁴ To our knowledge, there has not been a quantitative evaluation of the experiences of specialty MH/SUD clinicians in their sudden transition to telehealth care. Nor has there been an evaluation that includes the full spectrum of MH/SUD clinicians and the services they deliver. Outpatient specialty MH/SUD care is delivered by a range of clinicians (physicians, nurse practitioners, psychologists, clinical social workers), and they deliver a range of services (initial evaluations; medical evaluation and management; neuropsychological assessments; and individual, group, and family psychotherapy). The aim of this study is to assess the experiences of MH/SUD clinicians, across multiple disciplines in providing a range of telehealth services to patients, following a 2-week transition from in-person to nearly entirely virtual care using telehealth video visits during the COVID-19 pandemic.

Methods

This project was undertaken as a Quality Assessment and Improvement Initiative at McLean Hospital, and as such was not formally supervised by the Institutional Review Board as per their policies.

Setting

McLean Hospital is a free-standing psychiatric hospital near Boston that is part of the Mass General Brigham (formerly Partners Health Care), which is a large, academic nonprofit health care system. The hospital includes 6 clinical divisions: (1) child and adolescent psychiatry, (2) women's mental health, (3) depression and anxiety, (4) psychotic disorders, (5) alcohol, drugs, and addiction, and (6) geriatric psychiatry. The outpatient department typically has ∼42,000 patient visits per year.

On March 11, 2020 the governor of Massachusetts declared a state of emergency due to COVID-19 and by March 16, 2020, McLean Hospital discontinued in-person outpatient visits. Clinicians were initially told to maintain phone contact with patients, as the hospital quickly set up the capacity to conduct telehealth video visits. Within 2 weeks, the hospital provisioned its outpatient clinicians with telehealth video capacity, including education and training about policies, procedures, and technical expertise needed to protect the privacy and security of the patient encounters (particularly, for group therapy, which has additional patient/privacy security risks and considerations). In the first week of the transition, there were performance difficulties with the initial vendor selected for “1:1” visits (i.e., individual sessions between a clinician and patient, not group or family therapy), and the clinicians were instructed to discontinue using that vendor product and switch 1:1 patient encounters to the product being used for family or group therapy sessions. This transition was complete by March 25, 2020. With the exception of the month of March, when there was the initial transition to telehealth, outpatient visit counts were similar or higher April through June 2020 when compared with similar months in 2019 (Fig. 1); 83.4% of these visits were conducted using synchronous video visits and nearly all the remainder (16.2%) were telephone visits.

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Fig. 1.

Monthly counts of outpatient visits, January–June 2019 and 2020. March 2020 is the month that the hospital discontinued outpatient in-person visits for mental health or substance use disorder care and switched to telehealth visits. From March–June 2020, 83.4% of visits were telehealth-synchronous video visits and 16.4% were telephone visits.

Results

A total of 107 clinicians (78.7%) completed the survey. Demographic and background characteristics for the sample are provided in Table 1. Very few participants (25%) had experience delivering care through telehealth before COVID-19; however, during the time period of the survey, nearly two-thirds (65.4%) were delivering telehealth services several times a day. Participants reported delivering a variety of clinical services through telehealth with the most common being individual (71%) and group (57%) therapy.

Approximately half of clinicians (49.5%) reported that they experienced technical issues. However, only a small minority of those that had technical issues (n = 7, 13%) reported that it affected their ability to provide treatment “moderately” or “a lot.” Of those that reported technical issues (n = 53), the most common issues were video (70%) and sound (66%) issues, and patient difficulty logging on (60%). A minority of clinicians reported having difficulty logging on (23%).

Satisfaction with delivering treatment through telehealth was examined across service types: therapy (individual, group, or family), initial assessments, evaluation and management (E&M) visits, and neuropsychological assessment (Fig. 2a–d). Across all services, a majority of clinicians agreed or strongly agreed that telehealth gives them an opportunity to build rapport with patients (67–88%) and they are able to treat their patients' needs well through telehealth (71–88%). Responses to whether clinicians would like to continue to deliver care through telehealth when the hospital returns to in-person visits varied by visit type. Approximately half of clinicians reported wanting to continue with group therapy and initial assessments through telehealth when the hospital returns to in-person visits (51% and 50%, respectively). Ratings for continuing individual therapy, E&M visits, family therapy, and neuropsychological assessment were higher, ranging from 58% to 71%.

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Fig. 2.

Clinician satisfaction with telehealth by type of services delivered. (a) Telehealth Gives Me a Chance to Build Rapport with Each of My Patients. (b) I am Able to Treat My Patients' Needs Well Through Telehealth. (c) Compared to in-person visits, how well do you feel that telehealth visits meet your patients' needs? (d) I would like to continue to deliver treatment via telehealth when the hospital returns to in-person visits.

Thematic analysis of the qualitative data (292 free text responses) from the 4 open-ended questions yielded 70 initial codes, which were then categorized into 6 themes: (1) Access, (2) Patient characteristics, (3) Clinician, (4) Psychiatric characteristics, (5) Technology, and (6) Therapy process (see Supplementary Table S1 for coding scheme). Ninety-four participants (88%) provided comments for at least one of the open-ended questions. A summary of the themes and coding counts for each of the four questions is provided in Table 2.

With regard to patient populations for which clinicians thought telehealth is best suited, the most prominent themes that emerged were Access (52%) and Patient Characteristics (20%). Clinicians reported that telehealth enabled continuity of care, and supports improved access to care for some patients, including those with: logistical barriers to treatment (traveling long distance, taking public transit, relying on others for transportation), competing demands such as work schedules and caregiving responsibilities to children or elderly relatives, mobility difficulties and medical concerns (including risk of COVID-19), and vulnerabilities due to the nature of their psychiatric illness (e.g., social anxiety or difficulty leaving the house due to anxiety). As one clinician stated, “Telehealth is very helpful for anyone with childcare, transportation, scheduling type issues, or children who are too anxious to come into the office.”

Conversely, the top themes for patient populations for whom telehealth is more challenging were Psychiatric Characteristics (47%) and Therapy Process (18%). Psychosis, paranoia, and catatonia were the most frequently reported diagnoses that were difficult to treat through telehealth. Some examples provided were: “Some patients have never had internet because of paranoia,” and “Patients with psychosis and or at risk of catatonia are difficult to assess via telehealth.” Other characteristics that clinicians reported are not well suited for telehealth were patients who are highly distractible, avoidant, or who need to improve social skills, as well as those with high symptom severity. Initial visits were described as more difficult through telehealth, and clinicians identified challenges related to difficulty in visualizing patients' psychomotor symptoms, taking vital signs, and other activities that are done seamlessly in person. As one clinician commented, “I don't think we can manage crisis adequately via telehealth. I would also prefer in-person visit to address certain medication side effects particularly with neurological changes.”

There were some factors that were described as both facilitators and barriers for telehealth, such as age and exposure therapy. Older patients were described as a good population for telehealth because they often have difficulties getting to the clinic, mobility concerns, and are at a higher risk for COVID-19. However, older adults were also more likely to need support using the telehealth technology. Some clinicians indicated that younger patients were more suited to telehealth because they are more tech savvy, but younger patients were also more likely to have difficulties focusing their attention, which was a challenge for telehealth visits. Diagnostic factors, such as depression, also varied as a facilitator or barrier depending on the severity of the diagnosis. For patients with exposure targets that are addressable within the home, clinicians expressed that conducting the exposure therapy through telehealth improves generalizability. However, telehealth was not ideal for “patients with anxiety disorders and/or OCD [obsessive compulsive disorder] whose exposure targets are primarily outside of the home; especially patients with agoraphobia, school avoidance, and social anxiety.”

The theme of Access was prominent in clinicians' responses to what aspects of telehealth are working well. Several clinicians described a noticeable decrease in no-shows and cancellations. Clinicians attribute this to “flexibility in scheduling” and one clinician commented that “if a patient forgets about an appointment, it's easier to ‘catch them.’” Convenience of remote work was also reported as a benefit as it reduces commuting time and supports personal safety concerns, including COVID-19 risk. Some clinicians also indicated that they are able to see more patients in total, and to see patients more frequently. The therapy process through telehealth enabled some clinicians a clinical opportunity to see family dynamics in the home. Clinicians perceived patients as feeling more at ease at home, which increased the therapeutic alliance: “There is an intimacy to the screen that some patients actually like. There is a bond that gets created when we are each in our homes. Many patients share more than they did before and the therapy is going deeper and covering previously unexplored territory.”

Forty percent (40%) of clinician comments about challenges they overcame were related to technology. In particular, they noted the ease of use with the telehealth platform, appreciation for the features (e.g., breakout sessions, Whiteboard, ability to share videos, and screen share), and equipment recommendations for web cameras and angles. In addition, they demonstrated taking the initiative to innovate not just the telehealth platform features, but also what happens before and after the session. For example, they described strategies to orient patients and set expectations about technology and privacy, scheduling appointments in advance, and discussing differences between in-person and virtual visits with patients: “It's very important to encourage patients to talk about what it feels like to be on the screen (or phone), and to explore the meaning of it for them.” Clinicians also described sending an email to group participants after the session to reinforce the concepts covered in session. Notably, a few clinicians reflected on changes they have made to their own demeanor and presence to adjust to the new delivery method. Clinicians also discussed the importance of self-care to manage “Zoom fatigue,” from not just the increased volume of video visits, but also the effort involved in conducting sessions virtually, which they described as more physically and emotionally taxing than in-person.

Discussion

The rapid shift to telehealth for outpatient treatment in March 2020 prevented sharp disruptions in care, as evidenced by monthly visit volumes in April–June 2020 that were similar or higher than the previous year. Although most of the MH/SUD clinicians in this survey were relatively inexperienced with telehealth care, a majority transitioned quickly to delivering telehealth services several times per day. When technical issues occurred, overwhelmingly clinicians reported that these issues did not significantly impact patient care.

Across the different types of services, clinicians generally agreed that that they could establish rapport with patients and treat their patients' needs well through telehealth; however, agreement with these statements was consistently lower for group therapy, family therapy, and initial assessment visits. When asked to compare telehealth to in-person treatment, with the exception of E&M and individual therapy, only a minority of clinicians felt that telehealth met their patients' needs equally well or better. This is consistent with prior research that describes that the experiences of patients and clinicians in group telehealth therapy is mixed in terms of building therapeutic alliance, when compared with in-person group therapy. ²⁸

A large proportion of the clinician comments in this study were focused on access, specifically that telehealth reduces barriers to treatment from geographical distance, or patient time-management difficulties due to work or caregiving responsibilities. This is consistent with the literature on telehealth more broadly, ^{29 –31} as well as some evidence in prior research on telehealth in behavioral health settings specifically. ³² Many clinicians also reported a decrease in no-shows and cancellations, and that they were able to see more patients, more frequently with telehealth care. These observations align with the idea that telehealth can increase access to care by allowing clinicians to see a larger volume of patients. However, the qualitative data also highlighted that the increased volume and the additional effort needed to conduct virtual visits contributed to what has become known as “Zoom fatigue.” ³³ Clinicians expressed the importance of attending to self-care due to the extensive use of virtual platforms.

Our study highlights that while clinicians view that telehealth can be an important and effective tool to deliver treatment to patients with mental health or substance use disorders, there are some patients for whom clinicians were less enthusiastic about the use of telehealth compared with in-person care (e.g., patients with psychotic disorders, high symptom severity, or who need to improve social skills). This is also consistent with findings from prior literature. ³⁴ It is also important to note that while meta-analyses describe a robust literature regarding telehealth's efficacy in behavioral health care, there are also important gaps in the literature, ^{11 –15} such as for the treatment of substance use disorders and schizophrenia or other psychotic disorders. ^21,22

Our results also show that we need to be cautious about generalizations regarding factors that seem to be a good fit for telehealth, because these same factors can also be a challenge. The most common examples in our sample were age and exposure therapy. Diagnostic factors were also shown to vary with regard to being a facilitator or barrier to telehealth, depending on the severity of the symptoms. ²⁸

There are several limitations of this study. First, this is a single-site study where the transition to telehealth went well and site-specific factors facilitating this transition may vary. Therefore, these results may be specific to our site and not generalize to other behavioral health settings especially those where information technology services are not robust. However, participants in this sample encompassed a diversity of clinical roles and services provided. These data are specific to the clinician's experiences with telehealth; patients may have different experiences. Furthermore, this survey reflects experiences of MH/SUD clinicians caring for patients through telehealth video visits. Certain patient populations face additional challenges in crossing the digital divide to participate in telehealth video visits—such as those who are elderly, poor, or racial/ethnic minorities. ^{35 –38} Such considerations are also important when considering the future role of telehealth in behavioral health care.

Conclusions

Telehealth can be an important and effective tool to deliver MH/SUD care to patients; however, this study highlights that in routine behavioral health outpatient settings, among a diverse range of clinicians and patient populations, there are some populations and types of services that warrant additional investigation to determine the appropriate role for telehealth in MH/SUD care going forward as we are able to transition to in-person care.