Telemental health seems to be emerging, even booming. Also referred to as telebehaviorial health, e-counseling, e-therapy, online therapy, cybercounseling, or online counseling, for purposes of this post, I will define telemental health as the provision of remote mental health care services (usually via an audio/video secure platform) by psychiatrists, psychologists, social workers, counselors, and marriage and family therapists. Most services involve assessment, therapy, and/or diagnosis. Over the last few years, I have seen a wider variety of care models—from hospitals establishing telepsychiatric assessment programs in their emergency departments to virtual networks of mental health professionals providing telemental health services to underserved areas to remote substance abuse counseling being provided to inmates in state prisons.
Even the federal government is in on the act. For example, in 2010, the Veterans Health Administration established a National Telemental Health Center. In 2013, the center provided almost 3,000 video encounters to 1,000 patients at 53 sites in 24 states. The scope of the services the center provides includes all mental health conditions with a focus on post-traumatic stress disorder, depression, compensation and pension exams, bipolar disorder, behavioral pain and evidence-based psychotherapy.
There are many reasons for the recent boom. First, telehealth is a good fit for providing mental health services because providers rarely have to lay hands on the patient in conventional face-to-face encounters. Second, telemental health is accepted by a large number of payers as a legitimate use for telehealth—more so than other telehealth disciplines. As an example, most Medicaid programs and many private insurers cover and reimburse for telemental health services. Finally, patients surveyed have consistently stated that they believe telemental health to be a credible and effective practice of medicine, and studies have found little or no difference in patient satisfaction as compared with face-to-face mental health consultations.
The Need for Telemental Health
In essence, we are stuck in a vortex of sorts with millions of Americans suffering from mental illness or substance abuse disorders combined with a shortage of qualified mental health providers to address these issues. The numbers speak for themselves.
- An estimated one in four adults (about 60 million Americans) experiences mental illness in a given year.
- About 14 million people live with a serious mental illness.
- Approximately 20 percent of youth ages 13 to 18 experience severe mental disorders in a given year.
- 7 percent of American adults live with major depression.
- An estimated 18 percent of American adults live with anxiety disorders (e.g., panic disorder, OCD, PTSD).
- About 9 million adults have co-occurring mental health and addiction disorders.
- 20 million Americans suffer from substance abuse.
In addition to the high numbers described above, there is a critical mental health provider shortage creating significant access to care issues. Here is a snapshot:
- Only 40 percent of Americans with mental illness report receiving treatment.
- One mental health provider exists for every 790 individuals.
- Approximately 4,000 Mental Health HPSA (professional shortage areas) exist which is based on a psychiatrist to population ratio of 1:30,000—meaning it would take approximately 3,000 additional psychiatrists to eliminate the current mental health HPSA designations.
- A report to Congress found that 55 percent of the nation's 3,100 counties have no practicing psychiatrists, psychologists or social workers.
You get the idea. And even with mental health parity laws, cost of care remains an issue—not to mention the social stigma and mistrust of mental health providers that exists in many communities.
Telemental health is bridging the gap. Numerous studies have shown the effectiveness of telemental health services. For example, a recent study showed that providing telemental health services to patients living in rural and underserved areas significantly reduced psychiatric hospitalization rates. Another study concluded that the effects of telemental health on low-income homebound older adults were sustained significantly longer than those of in-person mental health services. Many other studies arrive at the same conclusion. Note, however, obstacles remain, including how to properly assess non-verbal cues by video, technical difficulties, and the lack of proper training of many providers regarding telehealth.
There is also good news in that, unlike other telehealth subspecialties, there is a well-developed library of practice guidelines available regarding telemental health. The American Psychiatric Association, American Psychological Association, National Association of Social Workers, Association of Social Work Boards, TeleMental Health Institute, for example, all have guidelines or statements related to telemental health. The American Telemedicine Association has developed a series of practice guidelines over the years related to telemental health, including its latest regarding using real-time videoconferencing to provide online mental health services. There are also other resources such as the telehealth resource centers that provide guidance on telemental health.
Legal & Regulatory Issues
As with all things telehealth, however, there are a number of significant legal and regulatory issues implicated by the use of telemental health, including privacy and security, follow-up care, emergency care, treatment of minors, and reimbursement. While telemental health touches on some federal laws and regulations (e.g., HIPAA), most of the significant issues involve state law. And as you might imagine, the result is an inconsistent patchwork of laws and regulations that vary widely by state.
We recently completed a 50-state survey of laws and regulations that may be implicated by the use of telemental health services to assess a variety of issues such as privacy, follow-up care, treatment of minors, and provider scope of practice. Here are a few nuggets:
- Psychiatrists, as practicing physicians, must comply with all the obligations that apply to physicians practicing telehealth generally. Very few states exempt mental health from physician requirements despite the fact that many psychiatrists never lay hands on patients. Ironically, Texas is one of the few states that explicitly carves out mental health services from other telehealth requirements.
- In Delaware, an individual practicing “telepsychology” must conduct a risk benefit analysis and document findings specific to issues such as whether a patient’s presenting problems and apparent condition are consistent with the use of telepsychology to the patient’s benefit; and whether the patient has sufficient knowledge and skills in the use of technology involved in rendering the service or can use a personal aid or assistive device to benefit from the service.
- Kansas requires psychologists and social workers providing telemental health services to obtain the informed consent of the patient before services are provided.
- In Maryland, physicians (psychiatrists) are required to develop a procedure to prevent access to data by unauthorized persons through password protection, encryption, or other means; and develop a policy on how soon an individual can expect a response from the physician to questions or other requests included in transmission.
- Montana psychologists can initially establish a “defined professional relationship" electronically so long as the means of communication involves a two-way, real-time, interactive platform providing for both audio and visual interaction.
- To regulate marriage and family therapy therapist, South Dakota relies on the American Association for Marriage and Family Therapy’s Code of Ethics which provides that therapists evaluate whether electronic therapy is appropriate for individuals and inform them of the potential risks and benefits associated with electronic therapy.
As I look over the telehealth landscape, I predict that telemental health will continue its significant growth. Demand for mental health services will not recede, and coupled with the mental health provider shortage, telemental health will be viewed as a viable solution by more and more clinicians, payers, and policymakers. There are, however, significant legal and regulatory considerations—especially at the state level— with which stakeholders must wrestle.