Research roundup: Telehealth & the practice of psychology

The availability of telehealth technologies and the acceptance of their use by consumers and regulatory agencies alike have grown in recent years. Telepsychology, the delivery of psychological services via technologies such as telephones, video conferencing, the internet and/or social media — also referred to as telebehavioral health (TBH) — may be an attractive way to provide mental health care to those who might not otherwise have access or desire to access traditional mental health services. But is it easy to implement and cost effective from the psychologist perspective? And for the client, how effective are the treatments provided?

The following studies explore the efficacy of telepsychology interventions, preferences and concerns of psychologists regarding telehealth communications, and reimbursement practices of large, private insurers.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Varker, T., Brand, R.M., Ward, J., Terhaag, S., & Phelps, A. (2018). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services. Advance online publication. http://dx.doi.org/10.1037/ser0000239.

The use of telepsychology could help increase access to services and reduce barriers to treatment for a variety of mental health issues. The term telepsychology, however, encompasses a variety of different methods. Synchronous telepsychology includes mediums where the visual and/or auditory interactions between the mental health provider and client happen in real time (e.g. telephone, video teleconference). Asynchronous telepsychology involves client-provider interactions that are not in real time (e.g. email, automated internet or computer-based interventions where clients receive pre-programmed responses/direction based on what information they input). The goals of this particular review were to determine the efficacy of synchronous telepsychology for the treatment of depression, anxiety, PTSD and adjustment disorder.

After an extensive search for peer-reviewed literature from January 2005 to July 2016, 24 randomized controlled trials using adult participants with a diagnosis or cutoff score indicating an anxiety disorder, major depressive disorder, PTSD or adjustment disorder who received psychological interventions delivered by synchronous telepsychology were included in the review. Due to the relatively small number of articles in the review, studies were grouped by telepsychology modality regardless of the mental health condition addressed in the study.

The authors concluded that use of telephone-delivered psychological intervention for clients with mental health conditions demonstrates clear, consistent evidence of a beneficial effect. This conclusion was based on 10 studies demonstrating high quality strength of evidence, evidence of positive effect, moderate to high consistency and generalizability as the studies included a range of disorders and samples, and high applicability to a Western health system given the studies’ treatments and delivery formats. Video teleconference-delivered interventions also demonstrated clear, consistent evidence of a beneficial effect based on 11 studies demonstrating high quality strength of evidence, evidence of positive effect, high consistency, moderate to high generalizability and high applicability to a Western health system. Internet-delivered text-based treatment was determined to have insufficient evidence of a beneficial effect based on three studies and further research is needed.

Glueckauf, R.L., Maheu, M.M., Drude, K.P., Wells, B.A., Wang, Y., Gustafson, D.J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues and training needs. Professional Psychology: Research and Practice, 49(3), 205-219. http://dx.doi.org/10.1037/pro0000188.

The authors of this study sought to better understand how psychologists are actually using telecommunication technologies in clinical practice (telebehavioral health or TBH), what types of online services they are providing to clients, what TBH education and training they might need, and what ethical and legal concerns they have around the use of TBH services. 

A national sample of 164 professional psychologists completed a 28-item online survey. Relationships between demographic factors such as age, gender, and practice setting and participants’ responses to items on the survey regarding telehealth practices were examined. Results indicated that 48 percent of psychologists reported delivering some of their practice services online. While only 10 percent of respondents indicated that at least 10 percent of their current practice was delivered online, 51 percent reported that in the future they would like it to be at least 10 percent. The technologies psychologists reported using most frequently to deliver counseling services during the previous year were: landline telephone (63 percent), mobile telephone (51 percent), email (38 percent) and videoconferencing (26 percent). A small percentage of respondents reported using smart phone applications (7), online telephone (6) and chat room or instant messages (3). Although only 26 percent of respondents used videoconferencing, 73 percent view it as a useful means of service delivery. With respect to background characteristics of the respondents, a significantly greater proportion of psychologists 37 years of age or older provided TBH one or more hours a week than those 36 years of age or younger. Additionally, a higher proportion of male clinicians reported using online teleconference system technologies than female providers.

Despite 80 percent of psychologists considering it ethical for licensed mental health professionals to deliver TBH, only 58 percent reported an awareness of state and federal laws governing these activities. Twenty-seven percent were unsure whether it was legal to provide TBH to clients outside the state in which they were licensed.

Security, confidentiality and HIPAA compliance were primary concerns regarding the use of TBH and almost three quarters of respondents were unsure whether their malpractice carrier covered TBH services. Psychologists age 37 and over were more likely to indicate that the delivery of TBH by licensed providers was ethical than their younger counterparts and were less likely to report uncertainty about whether licensed professionals should engage in TBH practices. Additionally, a substantially higher proportion of psychologists between age 37 and 64 reported being aware of telehealth laws and regulations at the state and federal level than both psychologists age 36 or younger or those 65 and above. 

Finally, 96 percent of respondents believe that training about clinical, legal and/or ethical issues related to telehealth should be taken and 90 percent reported that practitioners should receive training on technical issues surrounding the delivery of telehealth services. Twenty-four percent reported a lack of available telehealth education or training programs and 45 percent were unaware of relevant professional association guidelines on TBH. Of those reporting concerns about the lack of education or training in TBH, a significantly higher proportion of psychologists had been practicing for 10 years or less.

Wilson, F.A., Rampa, S., Trout, K.E., & Stimpson, J.P. (2017). Telehealth delivery of mental health services: An analysis of private insurance claims data in the United States. Psychiatric Services, 68(12), 1303-1306. http://dx.doi.org/10.1176/appi.ps.201700017.

As telehealth technologies have advanced, offering new paths for expanding the services of mental health providers and reducing barriers to care access, a growing number of states have eased restrictions or clarified policies on reimbursements for telehealth clinical services (State Telehealth Laws and Medical Program Policies, 2017). In this study, the authors examined private claims data to spot trends in how mental health providers are delivering telehealth services.

Claims data from the Health Care Cost Institute which includes claims from Aetna, Humana and UnitedHealth for more than 50 million individuals per year was analyzed for the years 2009-2013. Claims were included if they used the appropriate Current Procedural Terminology code for mental health (MH) and substance abuse (SA) services along with the telehealth modifier. Dollar amounts were adjusted for inflation using the Consumer Price Index.

Of the nearly 4 million MH/SA claims, 13,480 were submitted exclusively for telehealth-related services. The most common telehealth procedure (4,485 claims) was for monitoring and prescribing psychopharmacologic agents, while the highest number of telehealth claims per provider was submitted for individual psychotherapy, 30- and 45-minute sessions. The vast majority of claims were submitted by psychiatry followed by clinical psychology, mental health professionals and social workers. Most states reported an increasing trend in telehealth claims after 2009. Average telehealth reimbursements decreased from $54.61 in 2009 to $42.04 in 2013 while there was a slight increase in charges $123.31 to $126.94. In contrast, both average reimbursements ($89.26 to $94.01) and charges ($139.09 to $256.86) for nontelehealth services increased over the same time period. Average reimbursements and charges were higher for nontelehealth claims than for telehealth claims for 90 percent of the most common telehealth procedures including monitoring and prescribing psychopharmacologic medications and individual psychotherapy (30 minute and 45 minute sessions).

Clinical implications

Taken together, the three studies above help to demonstrate the efficacy of telehealth for mental health services and the interest from psychologists to provide these services while also highlighting challenges in implementation. Given the increasingly supportive evidence for both telephone and video teleconferenced delivery of mental health services, psychologists who use these methods have the potential to overcome common treatment barriers and increase the reach of evidence-based interventions. Clinicians implementing telehealth services may wish to consider how knowledgeable they are regarding the technological, logistical, ethical and regulatory requirements of providing these services. APA’s Guidelines for the Practice of Telepsychology (PDF, 113KB) are available to assist psychologists in applying current standards of professional practice when utilizing telecommunication technologies. Psychologists hoping to utilize telehealth services to improve patient outcomes may also need to consider whether using these technologies allows them to provide their services at less expense or in greater volume given the potential for lower reimbursement rates. As new technologies are developed, it will be important to continue staying abreast of the evidence for specific methods, particularly for asynchronous telepsychology (email, automated Internet or computer-based interventions) that have yet to demonstrate sufficient efficacy.

Additional resources regarding telepsychology can be found at APA Practice Central including information regarding billing Medicare for telehealth services and a recent webinar on the main principles of providing telepsychology services and the Psychology Interjurisdictional Compact (PSYPACT).