Overcoming telemental health disparities during the COVID-19 pandemic

Sociodemographic Differences in the Impacts of Video-Enabled Tablets on Psychotherapy Usage Among Veterans

OBJECTIVE

To examine potential health disparities due to a broad reliance on telehealth during the COVID-19 pandemic, the authors studied the impact of video-enabled tablets provided by the U.S. Department of Veterans Affairs (VA) on psychotherapy usage among rural versus urban, Black versus White, and female versus male veterans.

METHODS

Psychotherapy usage trends before and after onset of the COVID-19 pandemic were examined among veterans with at least one mental health visit in 2019 (63,764 tablet recipients and 1,414,636 nonrecipients). Adjusted difference-in-differences and event study analyses were conducted to compare psychotherapy usage among tablet recipients and nonrecipients (March 15, 2020-December 31, 2021) 10 months before and after tablet issuance. Analyses were stratified by rurality, sex, and race.

RESULTS

Adjusted analyses demonstrated that tablet receipt was associated with increases in psychotherapy visit frequency in every patient group studied (rural, 27.4%; urban, 24.6%; women, 30.5%; men, 24.4%; Black, 20.8%; White, 28.1%), compared with visits before tablet receipt. Compared with men, women had statistically significant tablet-associated psychotherapy visit increases (video visits, 1.2 per year; all modalities, 1.0 per year).

CONCLUSIONS

VA-issued tablets led to increased psychotherapy usage for all groups examined, with similar increases found for rural versus urban and Black versus White veterans and higher increases for women versus men. Eliminating barriers to Internet access or device ownership may improve mental health care access among underserved or historically disadvantaged populations. VA's tablet program offers insights to inform policy makers' and health systems' efforts to bridge the digital divide.

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

A State Profile of Disparities in Telehealth Utilization Among Medicare Beneficiaries: An Intersection Between Race/Ethnicity, Rurality, and Chronic Conditions-Arkansas, 2019

Introduction: The COVID-19 pandemic brought about renewed interest and investment in telehealth, while also highlighting persistent health disparities in the Southern states. Little is known about the characteristics of those utilizing telehealth services in Arkansas, a rural Southern state. We sought to compare the characteristics of telehealth utilizers and nonutilizers among Medicare beneficiaries in Arkansas before the COVID-19 public health emergency to provide a baseline for future research investigating disparities in telehealth utilization. Methods: We used Arkansas Medicare beneficiary data (2018-2019) to model telehealth use. We included interactions to assess how the association between the number of chronic conditions and telehealth was moderated by race/ethnicity and rurality, adjusted for covariates. Results: Overall telehealth utilization in 2019 was low (n = 4,463; 1.1%). The adjusted odds of utilizing telehealth was higher for non-Hispanic Black/African Americans (vs. white, adjusted odds ratio [aOR] = 1.34, 95% confidence interval [CI] = 1.17-1.52), rural beneficiaries (aOR = 1.99, 95% CI = 1.79-2.21), and those with more chronic conditions (aOR = 1.23, 95% CI = 1.21-1.25). Race/ethnicity and rurality were significant moderators, such that the association between the number of chronic conditions and telehealth was strongest among white and among rural beneficiaries. Discussion: Among the 2019 Arkansas Medicare beneficiaries, having more chronic conditions was most strongly associated with telehealth use among white and rural individuals, while the effect was not as pronounced for Black/African American and urban individuals. Our findings suggest that advances in telehealth are not benefiting all Americans equally, with aging minoritized communities continuing to engage with more strained and underresourced health systems. Future research should investigate how upstream factors such as structural racism perpetuate poor health outcomes.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity

Importance

The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed.

Objective

To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity.

Design, Setting, and Participants

This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023.

Exposures

Self-reported race and ethnicity.

Main Outcomes and Measures

Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment.

Results

The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions.

Conclusions and Relevance

During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.

Using Community-Based Participatory Research to Conduct a Collaborative Needs Assessment of Mental Health Service Users: Identifying Research Questions and Building Academic-Community Trust

Attempts to meaningfully engage people with serious mental illnesses (SMI) as allies in conducting research have often failed because researchers tend to decide on the research topic without including community members. Academic researchers can avoid this pitfall by collaborating with community members to conduct a needs assessment to identify relevant research topics and build trust. Here, we report on the results of a psychosocial needs assessment for adult mental health service users in Massachusetts conducted by an academic-peer research team. The project was initiated as part of an academic mental health center's efforts to conduct community-based participatory research (CBPR) with a group of people with SMI. People with SMI were hired and trained to co-lead research projects and the development of the listening group guide, and they conducted 18 listening groups with 159 adults with mental health conditions. The data were transcribed, and rapid analysis employing qualitative and matrix classification methods was used to identify service need themes. Six themes emerged from qualitative analysis: reduce community and provider stigma, improve access to services, focus on the whole person, include peers in recovery care, have respectful and understanding clinicians, and recruit diverse staff. The policy and practice implications of these findings include creating a stronger culture of innovation within provider organizations, developing specific plans for improving recruitment and retention of peer workers and a multicultural workforce, enhancing training and supervision in cultural humility, communicating respectfully with clients, and including peers in quality improvement activities.

A Retrospective Longitudinal Analysis of Mental Health Admissions: Measuring the Fallout of the Pandemic

BACKGROUND

In this research article, we review the infrequently considered long-term impact of the pandemic on inpatient mental health, by reviewing the clinical parameters of all psychiatric admissions to Mount Carmel Hospital, our region's main psychiatric healthcare facility, from 2019-2021.

METHODS

4292 patients were admitted during the research period of this retrospective longitudinal analysis. Taking 2019 as the pre-COVID reference year, we compared mean monthly admissions from 2020 and 2021, looking at patient demographics, status under the Mental Health Act, diagnosis, and self-injurious behaviour.

RESULTS

While the pandemic was reflected in a moderate increase in mean monthly presentations with suicidal ideation and suicidal self-injury, presentations in 2020 otherwise remained largely stable. This contrasted with a surge in presentations in 2021 with mood disorders, schizophrenia, anxiety, personality disorders, and autism spectrum disorders. Furthermore, presentations involving self-injurious behaviour continued to grow. Involuntary admissions also increased significantly in 2021.

CONCLUSIONS

This paper highlights the pernicious long-term impact of the pandemic on mental health presentations, demonstrated by an increase in hospital admissions and more serious presentations. These findings should be considered in the guidance for responses to any future pandemic, giving attention to the evidence of the impact of restrictive measures on mental health.

Exploring the Digital Divide among the Bhutanese Refugee Community during COVID-19: Engaged Research in Action

The digital divide proved a critical barrier to accessing information and healthcare during the COVID-19 pandemic and negatively impacted the Bhutanese refugee community. Moving beyond a technological model of the digital divide that highlights a lack of access to computers and the internet, we engaged the community to co-produce a dynamic approach that identifies the impact of socio-cultural and socio-environmental factors as well. Our paper reports on our community-academic research partnership and explores how the digital divide exacerbates health disparities in a midwestern Bhutanese refugee community. Combining the efforts of the community, anthropologists and social workers, this paper reports on the health disparities that confront the community as well as interventions designed to mitigate social inequities.

Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review

Remote, or tele-, consultations became a necessary form of mental healthcare provision during the COVID-19 pandemic. As the prevalence of mental health problems rises, they may have a role in future mental health services. We aimed to review the literature on patient and provider perspectives on factors influencing the implementation of remote consultations for community-dwelling people with mental health conditions. We searched five electronic databases (PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO) for empirical research up to July 13th, 2022. Only studies of synchronous, interactive remote consultations conducted via video, phone, or live-messaging between patients and providers were included. Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool. We integrated qualitative and quantitative data from 39 studies into a single mixed-methods synthesis. We mapped reported factors to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers. This review highlights the importance of patient preferences and provider buy-in to the future of remote consultations.

COVID-19, Rural Communities, and Implications of Telebehavioral Health Services: Addressing the Benefits and Challenges of Behavioral Health Services via Telehealth in Nebraska

Telehealth has been in use, in various forms, for over a century and is growing increasingly more popular. The current research sought to examine the prevalence, benefits, and challenges of telehealth for behavioral and mental health services in the state of Nebraska with a particular focus on rural communities. The COVID-19 pandemic coincided with the research endeavors and impacted the questions that were asked related to the use of telebehavioral health. Specifically, the research included an investigation of the rates of use of telebehavioral health across agencies and whether/how the pandemic impacted the use of telehealth services. The research included an initial examination of more than 50 behavioral health agencies to assess overall utilization of telehealth. Researchers then conducted interviews with 15 practitioners to discuss the challenges and benefits associated with telehealth services. Key results suggest that implementation of telehealth in Nebraska has resulted in increased access to services among rural residents and has deeply impacted clinical practice. Additionally, clinicians identified specific benefits and challenges of telebehavioral health. It was also noted that the majority of clinicians plan to continue providing services via telehealth if the policies and regulations remain as they are post-COVID-19. Implications of this research highlight the efficiency and effectiveness of using telehealth to increase access.