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

Pilot implementation of a telehealth safety planning group intervention for suicidal rural Veterans enhanced by lived experience veteran peer participation

Despite the Veterans Administration (VA) designating suicide prevention as the number one clinical priority, Veteran suicide rates continue to rise. One sub-population at elevated risk are Veterans living in rural communities given their heightened availability of firearms coupled with more limited access to mental health services. Telehealth delivery of treatment is a potential solution for the provision of critical services to rural areas. Despite the expansive growth of virtual treatment after the pandemic, there exist few suicide-specific telehealth health services. Our community case study aims to address this gap by piloting a manualized suicide safety planning and firearm safety group, titled Project Life Force (PLF), delivered virtually to rural Arkansas. The project's goal was to specifically enhance rural Veteran engagement with telehealth delivery through the use of community-based lived-experience rural peers. We present the rationale and details of the PLF intervention with a focus on the community Veteran peer enhancement component. This case study presents an innovative treatment design of a group led by a clinician augmented by a peer recovery leader that facilitated detailed conversations of how to limit suicide risk, encouraged disclosure about suicide symptoms, and promoted suicide related coping including encouragement of help-seeking behavior and safer storage of firearms. While the inclusion of a peer recovery leader was felt to be instrumental to the PLF-PE group's success, special attention to the peer recovery leader is essential and includes specific training, regular supervision as well as attention and support regarding the psychological impacts of self-disclosure and assuming a leadership role. This case study highlights the invaluable role that lived experience peers can play in suicide prevention treatment efforts and lethal means safety and paves the way for continued development of this effort.

Provision of Telepsychological Care Via Email during COVID-19 Confinement: An Exploratory Study

Within teletherapy, email interventions have been studied scarcely. For this reason, this exploratory study aims to characterize the assistance provided by email in a university telepsychology service and to compare the data with the assistance provided by telephone in the same service and period. For this purpose, the records of 81 users assisted via email during the COVID-19 pandemic lockdown in Spain were analyzed. The data were compared with those of the 338 users assisted by telephone in the same period. Despite its many limitations, results indicate high satisfaction with the email modality. Users express that they prefer a preference for using email when they do not feel safe in other ways. We found a lot of variation between the number of emails exchanged and the days that each case was active. Additionally, differences were found with telephone users in aspects such as age (email users being younger) and in a depression screening (email users scoring more positively). This study concludes on the high potential of this channel for the application of certain techniques (e.g., psychoeducation) or for people with certain characteristics.

Evaluation of Telepsychiatry Services Implementation in Medical and Psychiatric Inpatient Settings: A Mixed-Methods Study

Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.

School-based Mental Health Supports During COVID-19: School Professional Perspectives

Objective

The present study explored the ways school professionals adapted school-based mental health supports and services for remote delivery during the COVID-19 pandemic.

Method

We surveyed 81 school professionals (e.g., counselors, psychologists, social workers) and conducted in-depth interviews with a subsample of professionals (n=14) to explore their perceptions and experiences of supporting youth with mental health concerns and suicide-related risk during the fall and winter of the 2020-2021 school year.

Results

Commonly endorsed school-based mental health interventions (e.g., counseling services, checking in), ways of communicating (phone, email), and individuals delivering supports and services to students with suicide-related risk (e.g., counselors, teachers) were identified based on school professional survey responses. Qualitative findings point to facilitators (e.g., specific platforms for connecting with students and families) and barriers (e.g., limited communication) to successful service delivery during COVID-19.

Conclusion

Findings highlight the creative ways school support professionals adapted to provide school-based mental health supports. Implications for remote school-based mental health services during and following the pandemic are discussed.

Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic

BACKGROUND

While the COVID-19 crisis has had numerous global negative impacts, it has also presented an imperative for mental health care systems to make digital mental health interventions a part of routine care. Accordingly, through necessity, many Dialectical Behaviour Therapy (DBT) programs transitioned to telehealth, despite little information on clinical outcomes compared with face-to-face treatment delivery. This study examined differences in client engagement (i.e. attendance) of DBT: delivered face-to-face prior to the first COVID-19 lockdown in Australia and New Zealand; delivered via telehealth during the lockdown; and delivered post-lockdown. Our primary outcomes were to compare: [1] client attendance rates of DBT individual therapy delivered face-to-face with delivery via telehealth, and [2] client attendance rates of DBT skills training delivered face-to-face compared with delivery via telehealth.

METHODS

DBT programs across Australia and New Zealand provided de-identified data for a total of 143 individuals who received DBT treatment provided via telehealth or face-to-face over a six-month period in 2020. Data included attendance rates of DBT individual therapy sessions; attendance rates of DBT skills training sessions as well as drop-out rates and First Nations status of clients.

RESULTS

A mixed effects logistic regression model revealed no significant differences between attendance rates for clients attending face-to-face sessions or telehealth sessions for either group therapy or individual therapy. This result was found for clients who identified as First Nations persons and those who didn't identify as First Nations persons.

CONCLUSIONS

Clients were as likely to attend their DBT sessions over telehealth as they were face-to-face during the first year of the Covid-19 pandemic. These findings provide preliminary evidence that providing DBT over telehealth may be a viable option to increase access for clients, particularly in areas where face-to-face treatment is not available. Further, based on the data collected in this study, we can be less concerned that offering telehealth treatment will compromise attendance rates compared to face-to-face treatment. Further research is needed comparing clinical outcomes between treatments delivered face-to-face compared delivery via telehealth.

Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic

IMPORTANCE

Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown.

OBJECTIVE

To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022.

EXPOSURE

Receipt of a video-enabled tablet.

MAIN OUTCOMES AND MEASURES

Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs).

RESULTS

The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide.

CONCLUSIONS AND RELEVANCE

This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

Comparing efficacy of telehealth to in-person mental health care in intensive-treatment-seeking adults

The heightened acuity in anxiety and depressive symptoms catalyzed by the COVID-19 pandemic presents an urgent need for effective, feasible alternatives to in-person mental health treatment. While tele-mental healthcare has been investigated for practicability and accessibility, its efficacy as a successful mode for delivering high-quality, high-intensity treatment remains unclear. This study compares the clinical outcomes of a matched sample of patients in a private, nation-wide behavioral health treatment system who received in-person, intensive psychological treatment prior to the COVID-19 pandemic (N = 1,192) to the outcomes of a distinctive group of patients who received telehealth treatment during the pandemic (N = 1,192). Outcomes are measured with respect to depressive symptoms (Quick Inventory of Depressive Symptomatology-Self-Report; QIDS-SR) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire; Q-LES-Q). There were no significant differences in admission score on either assessment comparing in-person and telehealth groups. Patients in the partial hospitalization level of care stayed longer when treatment was remote. Results suggest telehealth as a viable care alternative with no significant differences between in-person and telehealth groups in depressive symptom reduction, and significant increases in self-reported quality of life across both groups. Future research is needed to replicate these findings in other healthcare organizations in other geographical locations and diverse patient populations.

Patient satisfaction with partial hospital telehealth treatment during the COVID-19 pandemic: Comparison to in-person treatment

Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of ambulatory behavioral health treatment has transitioned to a telehealth, or virtual, format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared patient satisfaction of partial hospital services delivered via telehealth to in-person treatment provided to patients treated prior to the COVID-19 outbreak. The sample included 240 patients who were treated virtually from May, 2020 to October, 2020, and a comparison group of 240 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction after the initial evaluation and at the end of treatment. For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with the initial diagnostic evaluation and were optimistic at admission that treatment would be helpful. At the completion of treatment, both groups were highly satisfied with all components of the treatment program and almost all would recommend treatment to a friend or family member. Thus, patient satisfaction was as high with telehealth partial hospital treatment as with in-person treatment.

Telehealth During COVID-19: Suicide Prevention and American Indian Communities in Montana

Background:

Public health measures that prevent the spread of COVID-19, such as social distancing, may increase the risk for suicide among American Indians due to decreased social connectedness that is crucial to wellbeing. Telehealth represents a potential solution, but barriers to effective suicide prevention may exist.

Materials and Methods:

In collaboration with Tribal and Urban Indian Health Center providers, this study measured suicide prevention practices during COVID-19. A 44-item Likert-type, web-based survey was distributed to Montana-based professionals who directly provide suicide prevention services to American Indians at risk for suicide. Descriptive statistics were calculated for survey items, and Mann–Whitney U tests examined the differences in telehealth use, training, skills among Montana geographic areas, and barriers between providers and their clients/patients.

Results:

Among the 80 respondents, two-thirds agreed or strongly agreed that American Indians experienced greater social disconnection since the COVID-19 pandemic began. Almost 98% agreed that telehealth was needed, and 93% were willing to use telehealth for suicide prevention services. Among current users, 75% agreed telehealth was effective for suicide prevention. Over one-third of respondents reported using telehealth for the first time during COVID-19 pandemic, and 30% use telehealth at least “usually” since the COVID-19 pandemic began, up from 6.3%. Compared with their own experiences, providers perceive their American Indian client/patients as experiencing greater barriers to telehealth.

Discussion:

Telehealth was increasingly utilized for suicide prevention during the COVID-19 pandemic. Opportunities to improve telehealth access should be explored, including investments in telehealth technologies for American Indians at risk for suicide.

Responding to the Psychological Needs of Health-Care Workers During the COVID-19 Pandemic: Case Study from the Medical College of Wisconsin

With the advent of the novel coronavirus (COVID-19) pandemic, health-care workers have been faced with an inordinately high level of trauma as frontline providers. The Medical College of Wisconsin (MCW) partnered with affiliate hospitals and community partners to mobilize a matrix of available support and interventions to deliver psychological services to reach all levels of health-care providers in timely, accessible formats. While virtual peer support groups were the most utilized resource among the support group options, other opportunities also provided unique benefits to learners whose education had been disrupted by the pandemic. Mental health must be prioritized for health-care workers in the event of future public health crises. Lessons learned from this pandemic indicate that it is critical to involve learners early on in the process in order to meet their educational needs and to increase access to evidence-based care.

An examination of suicidal behaviour among veterans receiving mental-health appointments in person versus clinical video telehealth

INTRODUCTION

The US Department of Veterans Affairs (VA) is a national leader in the implementation of clinical video telehealth (CVT) services. Despite the growth of mental-health services offered via CVT, it is unclear to what extent these services are offered and accessed by veterans with previous suicidal behaviour.

METHODS

The current quality improvement project examined this question within a local VA health-care system using data from suicide behaviour reports (SBRs), the Veteran Health Administration's official reporting and surveillance system. The frequency of SBRs was compared during two different time points among veterans who received individual mental-health appointments in person only or via CVT during the 2017 calendar year. Among veterans with a SBR, time in days elapsed from their first mental-health appointment to a SBR was examined as a function of treatment modality.

RESULTS

Results indicated veterans who received in-person treatment only were more likely to present with a SBR six months prior to their first mental-health appointment compared to those who received CVT during the observation period. There were no differences in SBRs during the 12 months after the first appointment or the time from the first appointment to the SBR as a function of treatment modality used.

DISCUSSION

Although veterans who received in-person mental-health services were more likely to have had a SBR six months prior to treatment, suicide risk throughout the observation period did not differ between groups. Clinical implications that arise from these findings are described in the discussion.