VA telemental health: suicide assessment

Assessment of suicidal ideation via telemedicine: a case report and management suggestions

BACKGROUND

Nowadays, we find ourselves in very unexpected and challenging circumstances facing the COVID-19 pandemic. The impact of the new coronavirus pandemic probably affected everyone's mental health, and people with pre-existing mental disorders may have an aggravated disease condition, leading to a suicide attempt. Pandemic also increased the use of direct-to-consumer telemedicine (TM) exponentially, and consequently, it was expected that cases of attempted suicide could be evaluated remotely. Some TM centers have adapted safety protocols from psychiatric guidelines for managing these patients. However, there is a lack of evidence of the effectiveness of follow-up by TM for patients at high risk for suicide, and there is no consensus on what action should be taken vis-à-vis the patient who requests immediate help remotely.

CASE PRESENTATION

Here, we reported a case of a TM evaluation of a patient's suicidal ideation in a direct-to-consumer telemedicine emergency center, describing the conduct taken in the face of this situation. We also discuss the importance of planning the emergency telemedicine center for situations of risk of suicide.

CONCLUSIONS

Telemedicine centers should be prepared for direct consumer assessment of suicidal ideation. Current management suggestions include recognizing the risk profile through institutional training and software skills and immediate referral for face-to-face assessment, encouraging continuous monitoring until the admission and active recruitment of family members or closest friends.

Use of Direct-to-Consumer Telemedicine to Access Mental Health Services

BACKGROUND

The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare.

OBJECTIVE

To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare.

DESIGN

Retrospective cross-sectional study.

SETTING

Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018.

PARTICIPANTS

Patients and physicians.

MAIN MEASURES

Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression.

KEY RESULTS

We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits).

CONCLUSIONS

As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.

Suicidal behavior in new patients presenting to the Telepsychiatry services in a Tertiary Care center: An exploratory study

BACKGROUND

The COVID-19 pandemic has led to expansion of telepsychiatry services and formulation of telemedicine guidelines. However, the telemedicine guidelines are not very clear about psychiatric emergencies, such as suicidal behaviour, resulting in psychiatrists facing dilemma about handling such situations.

AIM

To evaluate the prevalence of suicidal behaviour in new patients presenting to the Telepsychiatry services in a Tertiary Care centre.

METHODS

1065 new adult patients (aged > 18 years) registered with telepsychiatry services were assessed for suicidal behaviour, in the form of death wishes, suicidal ideations, plans, attempts (lifetime/recent) and non-suicidal self-injurious behaviour (NSSI) (lifetime/recent).

RESULTS

In terms of suicidal behaviour, in the last few weeks prior to assessment 14.4% of the patients had death wishes, 2.4% had thoughts of killing themselves, 0.9% had attempted suicide in the lifetime and 0.6% in the last few weeks, 1.1% had active suicidal ideations at the time of assessment, 0.6% had active suicidal plan, 1.3% had history of NSSI in the lifetime and 0.5% had NSSI behaviour in the last few weeks. Based on the current suicidal behaviour, 1.3% of the patients were asked to report to the emergency immediately, 0.5% were given an appointment within 72 h for follow-up, and 14.4% were explained high risk management.

CONCLUSIONS

Overall prevalence of suicidal behavior is relatively low in new patients seeking psychiatric help through telepsychiatry services.

Understanding Mental Health Professionals' Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study

BACKGROUND

Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices.

OBJECTIVE

This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices.

METHODS

A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed.

RESULTS

Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals.

CONCLUSIONS

The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals.

Telehealth in Rehabilitation Psychology and Neuropsychology

With the evolution of the COVID-19 pandemic in the United States in March 2020, most ambulatory care environments rapidly pivoted to extensive use to telehealth to protect patients and providers while continuing to provide care. This shift resulted in the expansion of telehealth platforms and workflows. Many behavioral health services can be provided in a telehealth format. The case example in this article illustrates that transition to telehealth is feasible and sustainable. Limitations include preoperative psychological assessments and certain neuropsychological tests requiring material manipulation. Careful consideration of risk factors should be exerted for more vulnerable patient populations.

Conducting School Suicide Risk Assessment in Distance Learning Environments

The social distancing mandate, implemented in response to the coronavirus disease 2019 (COVID-19) global pandemic, has guided many schools to deliver instruction via distance learning. Among the many challenges generated by this delivery system is the need for school mental health services, including school suicide prevention and intervention, to be conducted remotely. After briefly discussing the magnitude of the problem of youth suicide and how the COVID-19 pandemic has likely increased risk for youth suicidal ideation and behaviors, this article provides guidance on how school systems can prepare for and conduct suicide risk assessments in distance learning environments.

Telepsychiatry and Outpatient Department Services

The utilization of telemedicine and telepsychiatry (TP) services in the outpatient department (OPD) has been increasing in recent years. The information about the technological, administrative, and clinical challenges is being addressed by the telemedicine and TP guidelines published by several individual nations. TP aims to address the treatment gaps, barriers for utilization, accessibility, diagnostic validity, financial implications, and individual client preferences. Utilization of TP in the OPD varies from country to country depending upon their healthcare delivery systems. It also varies in populations utilizing the TP services-urban, rural, child and adolescent, geriatric, and differently abled. TP services in the OPDs are being incorporated differentially by government organizations, insurance recognized psychiatric healthcare organizations, private psychiatric group practice deliverers, and individual, standalone psychiatric healthcare deliverers. TP may not replace the traditional in-person consultations completely. Covid-19 pandemic has hastened its utilization across several healthcare delivery systems. Healthcare organizations, clinicians, other healthcare deliverers, and end users are in the process of adapting to the new scenario. Incorporation of the big data, machine learning, artificial intelligence, virtual reality, and other technological advances in the psychiatric healthcare delivery systems into TP services in the OPDs would significantly contribute to the overall quality and efficacy of the psychiatric healthcare delivery systems in the future.

Supporting the well-being of health care providers during the COVID-19 pandemic: The CopeColumbia response

OBJECTIVE

COVID-19 is an international public health crisis, putting substantial burden on medical centers and increasing the psychological toll on health care workers (HCW).

METHODS

This paper describes CopeColumbia, a peer support program developed by faculty in a large urban medical center's Department of Psychiatry to support emotional well-being and enhance the professional resilience of HCW.

RESULTS

Grounded in evidence-based clinical practice and research, peer support was offered in three formats: groups, individual sessions, and town halls. Also, psychoeducational resources were centralized on a website. A Facilitator's Guide informed group and individual work by including: (1) emotional themes likely to arise (e.g., stress, anxiety, trauma, grief, and anger) and (2) suggested facilitator responses and interventions, drawing upon evidence-based principles from peer support, stress and coping models, and problem-solving, cognitive behavioral, and acceptance and commitment therapies. Feedback from group sessions was overwhelmingly positive. Approximately 1/3 of individual sessions led to treatment referrals.

CONCLUSIONS

Lessons learned include: (1) there is likely an ongoing need for both well-being programs and linkages to mental health services for HCW, (2) the workforce with proper support, will emerge emotionally resilient, and (3) organizational support for programs like CopeColumbia is critical for sustainability.

Recommendations for Using Clinical Video Telehealth with Patients at High Risk for Suicide

There is increasing evidence that the delivery of mental health services via clinical video telehealth (CVT) is an effective means of providing services to individuals with access barriers, such as rurality. However, many providers have concerns about working with individuals at risk for suicide via this modality, and many clinical trials have excluded individuals with suicide risk factors. The present article reviews the literature, professional guidelines, and laws that pertain to the provision of mental health services via CVT with high-risk patients and provides suggestions for adapting existing best-practice recommendations for assessing and managing suicide risk to CVT delivery.

A Review of Telemental Health as a Modality to Deliver Suicide-Specific Interventions for Rural Populations

Introduction: Despite recent advancements in the development of new suicide prevention interventions, suicide rates continue to rise in the United States. As such, suicide prevention efforts must continue to focus on expanding dissemination of suicide-specific interventions. Methods: This review explores telemental health through two-way synchronous clinical video telehealth (CVT) technologies as one approach to improving access to suicide-specific interventions. Results: Studies were reviewed if (1) the modality of interest was telemental health by CVT and (2) management, assessment, or intervention of suicidal thoughts or behaviors was discussed. A total of 22 studies were included. Conclusions: Findings from the limited existing studies are synthesized, and recommendations are provided for future research, clinical, and educational advancements.

Telemental health training in the Veterans Administration Puget Sound Health Care System

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

Cardiology electronic consultations: Efficient and safe, but consultant satisfaction is equivocal

BACKGROUND

Cardiovascular electronic consultation is a new service line in consultative medicine and enables care without in-person office visits. We aimed to evaluate accessibility and time saved as measures of efficiency, determine the safety of cardiology electronic consultations, and assess satisfaction by responding cardiologists.

METHODS

Using a mixed-methods approach and a modified time-driven, activity-based, costing framework, we retrospectively analysed cardiology electronic consultations. A random subset of 500 electronic consultations referred between 2013-2017 were reviewed. Accessibility was determined based upon increased number of patients served without the need for an in-person clinic visit. To assess safety, medical records were reviewed for emergency room visits or hospital admission at six months from the initial electronic consultation date. Responding cardiologist satisfaction was assessed by voluntary completion of an online survey.

RESULTS

The majority of electronic consultations were related to medication advice, clearance for surgery, evaluation of images, or guidance after abnormal testing. Recommendations included echo (10.8%), stress testing (5.0%), other imaging (4.0%) and other subspecialist referrals (3.8%). Electronic consultations were completed within 0.7±0.5 days of the request, with a time to completion of 5-30 min. Over a six-month follow-up, 13.9% of patients had an in-person visit and 2.2% of patients were hospitalised, but none were directly related to the electronic consultation question. Satisfaction by responding cardiologists was modest.

CONCLUSION

In conclusion, within a single-payer system, cardiology electronic consultations represent a convenient and safe alternative for providing consultative cardiovascular care, but further optimization is necessary to minimise electronic consultation fatigue experienced by cardiologists.

Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide

INTRODUCTION

Suicide is a major public health problem and its human, emotional, and economic costs are significant. Individuals in rural areas are at highest risk for suicide. However, telemedicine services are typically not rendered to individuals who are actively suicidal. The goals of the current study were to identify the risks of using telemedicine for mental healthcare from the perspective of licensed mental health providers and to determine factors associated with the use of telemedicine with patients who are at high risk for suicide.

METHODS

A total of 52 licensed mental health providers were recruited online through several professional organization listservs and targeted emails. Providers completed online questionnaires regarding demographics, caseload of suicidal patients, perceived risks for using telemedicine with patients at risk for suicide, attitudes towards telemedicine, and use of telemedicine with patients at risk for suicide.

RESULTS

Three key perceived risks associated with using telemedicine were identified, including assessment, lack of control over patient, and difficulties triaging patients if needed. It was also found that individuals who had more positive attitudes towards telemedicine, younger providers, and more experienced providers were more likely to use telemedicine with patients who are at high risk for suicide.

DISCUSSION

To our knowledge, this is the first study to examine the perceived risks and use of telemedicine with patients at high risk for suicide. It is essential to continue this line of research to develop protocols for the provision of evidence-based therapy via telemedicine for this high-risk group.

TeleMental Health: Standards, Reimbursement, and Interstate Practice [Formula: see text]

BACKGROUND

TeleMental Health (TMH) is gaining widespread acceptance in the United States.

OBJECTIVE

Summarize current evidence regarding TMH risks and benefits, standards of care, practice guidelines, reimbursement, and interstate practice issues pertinent to psychiatric nurses and consumers.

DESIGN

A targeted review of literature, current practice, and TMH websites was generated using the following key search words: clinical outcomes, practice guidelines, regulations, interstate practice, and reimbursement for TMH. A search of government and professional organization websites and a literature review of PubMed and PsychINFO databases was limited to the past 15 years.

RESULTS

Studies demonstrate TMH services are equal in efficacy to that provided in face-to-face encounters and preferred by some populations. Current TMH practice guidelines, reimbursement, and regulatory issues are reviewed.

CONCLUSIONS

Providers, including psychiatric advanced practice registered nurses, can use TMH to effectively address the growing need for mental health services, although regulatory, licensure, and clinical issues must be addressed prior to offering TMH services.

Telemental Health for Children and Adolescents: An Overview of Legal, Regulatory, and Risk Management Issues

OBJECTIVE

The use of technology to provide telemental healthcare continues to increase; however, little has been written about the legal and regulatory issues involved in providing this form of care to children and adolescents.

METHODS

This article reviews existing laws and regulations to summarize the risk management issues relevant to providing telemental healthcare to children and adolescents.

RESULTS

There are several legal and regulatory areas in which telemental health clinicians need to have awareness. These areas include: 1) Licensure, 2) malpractice liability, 3) credentialing and privileging, 4) informed consent, 5) security and privacy, and 6) emergency management.

CONCLUSIONS

Although legal and regulatory challenges remain in providing telemental healthcare to children and adolescents, it is possible to overcome these challenges with knowledge of the issues and appropriate risk management strategies. We provide general knowledge of these key legal and regulatory issues, along with some risk management recommendations.

Telemental Health: Digital Disruption and the Opportunity to Expand Care

Telemental health, which involves clinicians connecting remotely to patients via teleconferencing, has seen growing interest. In addition to providing in-home treatment, this technology allows specialists to provide care in remote and underserved areas. Current research suggests that both patients and clinicians are satisfied with telemental health services and that it is comparable in terms of quality to in-person care. Nonetheless, concerns still exist regarding its effects on the role of clinicians and the care they provide.

Telepsychiatry for Inpatient Consultations at a Separate Campus of an Academic Medical Center

BACKGROUND

Many hospitals do not have regular access to psychiatry consult services. This is well understood as a common shortage at nonacademic community hospitals (especially in rural environments, and may also be a problem at noncontiguously located smaller hospitals that are affiliated with academic medical centers in urban settings. The authors sought to deliver timely inpatient psychiatric consultation-liaison services via telemedicine to a local but physically separated hospital affiliated with an academic medical center.

MATERIALS AND METHODS

The authors collaborated with an office dedicated to the advancement of telemedicine technology at their academic medical center. They developed a telemedicine-based care model to deliver inpatient consultation-liaison psychiatry consultations to an affiliated (but physically separate) small academic hospital that did not have its own on-site consultation-liaison psychiatry team.

RESULTS

The authors were able to successfully complete 30 consultations, each within 24 h. Only 1 patient was ultimately unwilling to participate in the telemedicine interview. As consultations were accomplished on same day as request, patient length of stay was unaffected.

CONCLUSIONS

This pilot study suggests that telemedicine is a viable model for inpatient consultation-liaison psychiatry services to hospitals without on-site psychiatry resources and represents a viable alternative model of service delivery.

Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches

Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencing-based telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

Suicide risk management during clinical telepractice

The effective assessment and management of suicidal patients is an essential component of telehealth-based care. With this article, we describe how we have implemented procedures for the ongoing assessment and management of suicide risk in a clinical trial that compares in-office treatment to home-based treatment delivered via web-cam to U.S. military service members and veterans with depression. We describe our safety protocol and how it was adapted from current recommended best practices, published guidelines, and local requirements for managing patient safety during home-based telepractice. We conclude with discussion of other key safety issues associated with telepractice. The topics discussed are relevant to all mental health practitioners who are interested in clinical telepractice services.

Psicoterapia pela Internet: viável ou inviável?

A psicoterapia pela internet é uma prática que, no Brasil, só é permitida aos psicólogos na forma de pesquisa. O objetivo do presente artigo foi realizar uma revisão dos estudos em psicoterapia pela internet, discorrendo sobre os recursos e os limites desse atendimento psicológico e suas implicações para a relação terapêutica e para a efetividade do tratamento. São apresentadas questões legais e éticas concernentes à prática. Os resultados apontaram similaridades entre a relação terapêutica online e a presencial, mostrando-se a psicoterapia pela internet efetiva nas mais distintas modalidades, embora a maioria dos estudos seja sobre intervenções cognitivo-comportamentais. As questões legais e éticas podem ser parcialmente solucionadas com diretrizes claras das organizações profissionais e com o treino de terapeutas na modalidade online. Concluímos que a psicoterapia pela internet, embora requeira maiores estudos, anuncia-se como uma prática viável e promissora.

Increasing suicide rates among middle-age persons and interventions to manage patients with psychiatric complaints

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to suicide rates in the United States (U.S.). Suicide is the 10th leading cause of death in U.S. adults, and rates are increasing across all geographic regions. There is a significant increase in the suicide rate among adults in the 35–64 age range. We present findings from the CDC’s Morbidity and Mortality Weekly Report (MMWR) with commentary on current resources and barriers to psychiatric care.

Future directions in the design, development, and investigation of technology as a service delivery vehicle

Treatment outcome research with children and adolescents has progressed to such an extent that numerous handbooks have been devoted to reviewing and summarizing the evidence base. Ensuring that consumers of these advancements in state-of-the-field interventions have the opportunity to access, engage in, and benefit from this evidence base, however, has been wrought with challenge. As such, much discussion exists about innovative strategies for overcoming the gap between research and practice; yet no other potential solution that has received more attention in both the popular and academic press than technology. The promise of technology is not surprising given the fast-paced evolution in development and, in turn, a seemingly endless range of possibilities for novel service delivery platforms. Yet this is precisely the most formidable challenge threatening to upset the very promise of this potential solution: The rate of emerging technologies is far outpacing the field's capacity to demonstrate the conceptual or empirical benefits of such an approach. Accordingly, this article aims to provide a series of recommendations that better situate empirical enquiry at the core of a collaborative development, testing, and deployment process that must define this line of work if the promise of mental health technologies is going to be a reality for front-line clinicians and the clients they serve.

Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study

Older men have a higher rate of suicide than the general population, but little is known about the prevalence and correlates of suicidality among older male veterans. In this study, we evaluated the prevalence, and risk and protective factors associated with current suicidal ideation (SI) and past suicide attempt (SA) in a contemporary, nationally representative sample of older male veterans. We analyzed data from 1962 male veterans aged 60 or older who participated in the National Health and Resilience Veterans Survey (NHRVS) between October and December 2011. Bivariate analyses and multivariate logistic regression were used to evaluate risk and protective factors associated with current SI and past SA in the full sample, and separately among combat and non-combat veterans. Six percent of the sample reported past 2-week SI, and combat veterans were more likely to contemplate suicide (9.2%) than non-combat (4.0%) veterans. Lifetime SA was reported by 2.6% of respondents. Major depression and physical health difficulties were the strongest risk factors for SI in combat veterans, while generalized anxiety disorder (GAD) was the strongest risk factor for SI in non-combat veterans. Posttraumatic stress disorder (PTSD) was independently associated with SI in both groups of veterans, and social connectedness was negatively related to SI in both groups. These results suggest that a significant proportion of older male veterans in the United States contemplates suicide, with higher rates of SI among combat than non-combat veterans. Interventions designed to mitigate psychological distress and physical difficulties, and to promote social connectedness may help mitigate suicidality risk in this population.

Using videoconferencing to provide psychological services to rural children and adolescents: a review and case example

Children and adolescents living in rural areas have difficulty accessing psychological services due to a lack of psychologists and other behavioral health professionals, especially those with expertise in treating youth. Telepsychology helps bridge this access gap. This article extends evidence supporting videoconferencing for psychological assessment and treatment in adults to support telepsychological treatment for youth. In addition, the basic components needed to begin and sustain a telepsychological practice are explored. Finally, a case example of an adolescent presenting with depression and disordered eating illustrates the practice of, and ethical standards needed for, telepsychology. Future technologies and applications around telepsychology are also discussed.

Veteran-specific suicide prevention

Suicide rates have been increasing in some subgroups of Veteran populations, such as those who have experienced combat. Several initiatives are addressing this critical need and the Department of Veterans Affairs (VA) has been recognized for its leadership. This integrative review adopts the Research Impact Framework (RIM) to address suicide-specific prevention activities targeting Veterans. The RIM is a standardized approach for developing issue narratives using four broad areas: societal-related impacts, research-related impacts, policy-related impacts, and service-related impacts. The questions addressed in this review are: (1) What are the major initiatives in Veteran-specific suicide prevention in four areas of impact-society, research, policy, and services? (2) Are there gaps related in each impact area? and (3) What are the implications of this narrative for other strategies to address suicide prevention targeting Veterans? Systematic application of the RIM identifies exemplars, milestones, gaps, and health disparity issues.

The design, implementation, and operational management of a comprehensive quality management program to support national telehealth networks

The Veterans Health Administration (VHA) is a large integrated healthcare system with a mission to care for over 5.6 million Veteran patients annually. VHA, like other healthcare organizations, is challenged with providing access to care to those it serves when they live at a distance from a physical site of care. VHA has embraced telehealth as a way of delivering care at a distance and increase access to specialty care services. Since 2003 VHA has developed large national telehealth networks that provided care to 497,342 patients in fiscal year 2012, who received 1,429,424 episodes of care, and is recognized as a national leader in this field. To ensure the safety and effectiveness of its telehealth networks in their delivery of care VHA has implemented a dedicated quality management (QM) program for telehealth. QM data for telehealth are reviewed at 3-month intervals, and the procedures and processes in place to support telehealth in VHA are assessed biannually in an internal accreditation process called "Telehealth Conditions of Participation." This collegial, nonadversarial process has ensured that all designated telehealth programs meet minimal standards and disseminate best practice. As a result of VHA's QM program, telehealth services in VHA meet consistently high clinical outcomes and have received no adverse Joint Commission citations. The Joint Commission regularly assesses patients managed via telehealth under its tracer methodology reviews.

Consumer acceptability of brief videoconference-based neuropsychological assessment in older individuals with and without cognitive impairment

Growing evidence suggests that neuropsychological assessment via videoconference shows good agreement with traditional in-person assessment. However, there are few published studies regarding patient acceptability of this methodology, particularly in individuals with cognitive impairment. In this study we sought to evaluate patient preferences and acceptability of teleneuropsychology to further shed light on the viability of this cognitive assessment medium. We examined acceptability of videoconference-based neuropsychological assessment among healthy aging individuals and in subjects with mild cognitive impairment or early stage Alzheimer disease. We found that teleneuropsychology appears to be well accepted by consumers. Our results reflected 98% satisfaction, and roughly two-thirds of participants indicated no preference between traditional face-to-face testing and examination by teleneuropsychology. Furthermore, even participants with cognitive impairment showed good acceptability of teleneuropsychological assessment. In conjunction with the preliminary data on reliability and validity from this growing literature, these results support teleneuropsychology as a viable and acceptable method for assessing cognitive functioning, and show promise for the implementation and utilization of this cognitive assessment medium in clinical and research settings.

Cognitive intervention results in web-based videophone treatment adherence and improved cognitive scores

Background

We report findings from an intervention study using telehealth modalities to determine whether provision of telehealth services can improve access to care and increase adherence to cognitive therapy in veterans with mild traumatic brain injury (TBI) while matching traditional care in terms of outcomes.

Material/Methods

Veterans who were initially non-adherent to clinic-based cognitive therapy were offered a newly developed treatment. The control participants were selected from patient records of veterans who had completed cognitive treatment and matched to MOPS-VI participants on the basis of age, marital or relationship status, and composite memory index score. Baseline and post-treatment cognitive functioning as assessed by the Test of Memory and Learning 2^nd Edition (TOMAL-2) was obtained for all participants. The MOPS-VI modules were designed to increase understanding of TBI and elicit problem-solving skills for attention and memory impairment.

Results

Sixty-seven percent of veterans (who were assigned to the MOPS-VI treatment group because they were initially non-adherent with the clinic-based treatment) completed the MOPS-VI telemedicine treatment. Results of a two-way analysis of Variance (ANOVA) comparing baseline and follow-up scores on the TOMAL-2 in the MOPS-VI and control groups revealed there was a significant pre-post assessment effect, indicating that participant’s memory and learning improved after treatment for both MOPS-VI and standard treatment groups. There was no significant difference between clinic-based treatment and MOPS-VI therapy.

Conclusions

Preliminary evidence supports the efficacy of the treatment, defined as increased compliance in completing the treatment program, and improvements in standardized memory and learning test results comparable to those following clinic-based treatment.

Home-based telemental healthcare safety planning: what you need to know

Telemental health (TMH) care provided directly to the home is an emerging area of care delivery. TMH care involves awareness of safety issues and adequate safety planning, although detailed practical recommendations for home-based TMH safety planning are absent in the literature. With this article we aim to increase awareness of safety issues associated with home-based synchronous TMH treatment and to discuss recommendations for consistent safety planning that can inform the development of standard operating procedures, emergency protocols, and overall good TMH practice. Specific areas discussed include consideration of state and local requirements, appropriateness of TMH care, technology and infrastructure, and emergency management and monitoring procedures. The topic of safety, as it relates to TMH policy, as well as the need for additional TMH research are also discussed.

Suicidal ideation in treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support

BACKGROUND

Recent epidemiologic studies have found an increased risk of suicide among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF) with psychiatric disorders. However, little is known about whether variables other than psychiatric conditions, such as coping strategies, resilience, and social support, may be related to suicidality in this population.

METHODS

A total of 167 OEF-OIF Veterans seeking behavioral or primary care services completed a survey containing measures of combat exposure, psychopathology, pain, psychological resilience, social support, and cognitive coping strategies.

RESULTS

Thirty-six respondents (21.6%) reported contemplating suicide in the two weeks prior to completing the survey. Compared to suicide non-contemplators, suicide contemplators were older, and more likely to screen positive for depression and posttraumatic stress disorder (PTSD), and to report a deployment-related pain condition or complaint. They also scored higher on measures of worry, self-punishment, and cognitive-behavioral avoidance strategies, and lower on measures of psychological resilience and postdeployment social support. Multivariate analysis revealed that a positive depression screen, and higher scores on measures of self-punishment and cognitive-social avoidance coping were positively associated with suicidal ideation, while higher scores on measures of psychological resilience (i.e., positive acceptance of change) were negatively related to suicidal ideation. Moderator analysis revealed that a positive screen for depression or PTSD significantly diminished the protective effect of postdeployment social support on suicidal ideation.

CONCLUSIONS

1 in 5 treatment-seeking OEF-OIF Veterans may contemplate suicide. Interventions to reduce depressive symptoms, and maladaptive cognitive-behavioral coping strategies of self-punishment and cognitive social avoidance, and to bolster psychological resilience may help mitigate suicidality in this population.

Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review

The safety of telemental healthcare delivered to clinically unsupervised settings, such as a personal residence, must be established to inform policy and further the dissemination of telemental health programs. The aim of this article is to provide an overview of safety issues associated with telemental healthcare and, through a systematic literature review, evaluate the safety of telemental healthcare delivered to unsupervised settings. The review resulted in a total of nine studies that specifically evaluated the delivery of telemental healthcare to unsupervised settings. Six of the nine studies reviewed explicitly described safety plans or specific precautions that could be used if necessary. Two of the nine studies reported events that required the researchers to use safety procedures to effectively respond to concerns they had regarding participant safety. In both of these studies, the issues were resolved with prescribed safety procedures. Recommendations and future directions for the development and evaluation of safety protocols are discussed.

Psychological treatment of chronic pain

Psychological treatment has emerged as a common component of a multidimensional and interdisciplinary plan of pain care for many persons with persistent pain. Treatments are informed by a biopsychosocial model of pain and a long history of psychological research that has identified the central role of behavioral, cognitive, and emotional factors that are believed to contribute to the perpetuation, if not the development, of chronic pain and pain-related disability and emotional distress. Empirically supported self-regulatory, behavioral, cognitive-behavioral, and acceptance and commitment interventions are reviewed, and current and future interventions are highlighted. Important issues related to individual differences and disparities in the experience of pain and pain treatment are discussed. In particular, race and ethnicity are considered, and special considerations for the management of pain in children and older adults are discussed.

House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes

Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offers a significant and as yet unfulfilled promise to expand delivery of high-quality psychological therapies, regardless of clinician and patient location.

Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom

BACKGROUND

Little is known about variables associated with suicidality in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF).

METHODS

A total of 272 OEF/OIF veterans completed a survey containing measures of psychopathology, resilience, and social support. Thirty-four respondents (12.5%) reported contemplating suicide in the two weeks prior to completing the survey.

RESULTS

Suicide contemplators were more likely to screen positive for posttraumatic stress disorder (PTSD), depression, and an alcohol problem, and scored higher on measures of psychosocial difficulties, stigma, and barriers to care, and lower on measures of resilience and social support. Logistic regression analysis revealed that positive PTSD and depression screens, and increased psychosocial difficulties were associated with suicidal ideation, and that increased postdeployment social support and sense of purpose and control were negatively associated with suicidal ideation.

CONCLUSIONS

Interventions for PTSD, depression, and psychosocial difficulties, and to bolster postdeployment social support and resilience may be helpful in preventing suicidal ideation in OEF/OIF veterans.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Rationale and design: telepsychology service delivery for depressed elderly veterans

Background

Older adults who live in rural areas experience significant disparities in health status and access to mental health care. "Telepsychology," (also referred to as "telepsychiatry," or "telemental health") represents a potential strategy towards addressing this longstanding problem. Older adults may benefit from telepsychology due to its: (1) utility to address existing problematic access to care for rural residents; (2) capacity to reduce stigma associated with traditional mental health care; and (3) utility to overcome significant age-related problems in ambulation and transportation. Moreover, preliminary evidence indicates that telepsychiatry programs are often less expensive for patients, and reduce travel time, travel costs, and time off from work. Thus, telepsychology may provide a cost-efficient solution to access-to-care problems in rural areas.

Methods

We describe an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of an empirically supported treatment for major depressive disorder, Behavioral Activation, delivered either via in-home videoconferencing technology ("Telepsychology") or traditional face-to-face services ("Same-Room"). Our hypothesis is that in-homeTelepsychology service delivery will be equally effective as the traditional mode (Same-Room). Two-hundred twenty-four (224) male and female elderly participants will be administered protocol-driven individual Behavioral Activation therapy for depression over an 8-week period; and subjects will be followed for 12-months to ascertain longer-term effects of the treatment on three outcomes domains: (1) clinical outcomes (symptom severity, social functioning); (2) process variables (patient satisfaction, treatment credibility, attendance, adherence, dropout); and (3) economic outcomes (cost and resource use).

Discussion

Results from the proposed study will provide important insight into whether telepsychology service delivery is as effective as the traditional mode of service delivery, defined in terms of clinical, process, and economic outcomes, for elderly patients with depression residing in rural areas without adequate access to mental health services.

Trial registration

National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701).