Research roundup: Telehealth applications in psychology practice
by Practice Research and Policy Staff
February 14, 2011 — Telehealth involves delivery of health or mental health services by a health care professional that are not provided in-person. The technology most often utilized by psychologists is occasional or frequent use of the telephone. Some providers deliver telehealth services via video teleconferencing (VTC). Research is beginning to emerge that can help psychologists determine when or if a telehealth application is likely to be beneficial in a given treatment situation.
Interest in Behavioral and Psychological Treatments Delivered Face-to-Face, by Telephone, and by Internet
Mohr, D. C., Siddique, J., Ho, J., Duffecy, J., Jin, L., & Fokuo, J. (2010). Interest in behavioral and psychological treatments delivered face-to-face, by telephone, and by Internet. Annals of Behavioral Medicine, 40(1), 89-98.
A survey of 658 primary care patients to assess level of interest in face-to-face, telephone and internet treatment—as well as factors that might influence that interest—suggests some openeness to alternative channels for delivering care, but no high demand at this time. Among patients interested in behavioral treatment to address mental health concerns, pain, or to change lifestyle and behaviors, 91.9 percent were interested or would consider face-to-face care compared to 62.4 percent for telephone and 48.0 percent for internet care. However, of those not interested in face-to-face care, approximately 15 percent expressed interest in telephone care and 15 percent in internet care, so these alternative channels may actual facilitate some individuals receiving care they might not otherwise seek. Respondents who indicated that time constraints were a barrier to care were more likely to express interest in telephone and internet treatments compared to face-to-face care.
The Effectiveness of Telemental Health Applications: A Review
Hailey, D., Roine, R., & Ohinmaa, A. (2008). The effectiveness of telemental health applications: A review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 53(11), 769-778.
A review of the literature identified 72 publications on telemental health (TMH) that reported clinical or administrative outcomes. Of these, 65 papers described clinical studies and 32 (49 percent) were judged to be of high or good quality. Quality of the evidence was assessed with an approach that considers both study performance and study design. Quality of evidence was higher for internet- and telephone-based interventions than for video conferencing approaches. There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorder, substance abuse, eating disorders and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. The majority of the papers (82 percent) were judged to warrant further study indicating a continued need for good-quality studies on the use of TMH in routine care.
Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults
Tutty, S., Spangler, D. L., Poppleton, L. E., Ludman, E. J., & Simon, G. E. (2010). Evaluating the effectiveness of cognitive-behavioral teletherapy in depressed adults. Behavior Therapy, 41(2), 229-236.
While the utility and efficacy of telephone psychotherapy for adult depression as an adjunct to antidepressant treatment has been demonstrated in studies in primary care, less is known about telephone psychotherapy as stand-alone treatment. In a study of adults seeking psychotherapy for depression at a mental health clinic, 30 participants received cognitive behavioral therapy treatment by telephone (CBT-TT) as a stand-alone treatment for eight sessions. The majority of participants (69 percent) were very satisfied with the CBT-TT, experienced a significant reduction in depression severity over three and six months, and nearly half (42 percent) participants were considered recovered at termination. These outcomes are very similar to studies conducted in primary care settings, even though these participants began treatment with more severe depression and did not recieve adjunctive antidepressant medication.
How Does Tele-Mental Health Affect Group Therapy Process? Secondary Analysis of a Noninferiority Trial
Greene, C. J., Morland, L. A., Macdonald, A., Frueh, B., Grubbs, K. M., & Rosen, C. S. (2010). How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. Journal of Consulting and Clinical Psychology, 78(5), 746-750.
Video teleconferencing (VTC) was used to deliver treatment to 112 male veterans with posttraumatic stress disorder and moderate to severe anger problems. The primary analyses found that VTC delivery was noninferior to in-person delivery. (“Noninferior” methodology is a rigorous analysis used to determine whether a novel treatment is as good as a standard treatment.) Secondary analyses were used to compare process variables such as therapeutic alliance and attrition among participants receiving anger management group therapy either through traditional face-to-face delivery or by VTC. The present study examined potential differences in process variables, including therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion and attrition. No significant differences were found between the two modalities on most process variables. However, individuals in the VTC condition exhibited lower alliance with the group leader than those in the in-person condition, but average self-leader alliance scores for both groups still were in the range that suggested participants experienced a reasonably strong alliance. Individuals who had stronger alliances tended to have better anger outcomes, yet the effect was not strong enough to result in the VTC condition producing inferior aggregate outcomes.
Telehealth and the Deaf: A Comparison Study
Wilson, J. A., & Wells, M. (2009). Telehealth and the deaf: A comparison study. Journal of Deaf Studies and Deaf Education, 14(3), 386-402.
Several groups within the U.S. population, including the deaf population, are underserved by traditional mental health providers and service delivery methods. Telehealth provides the opportunity to bring more specialized services to specific populations but research is needed to understand what kinds of services and what technologies are likely to be most useful with specific populations. Fifty-five deaf and hard-of-hearing community members received either a video lecture in American Sign Language on depression or read the same material in printed format. Knowledge of the subject was then tested and participants indicated their degree of satisfaction with the information format. Participants demonstrated increased knowledge with both formats of receiving information and both formats received average-to-high ratings of satisfaction. Participants’ dissatisfaction stemmed from technical difficulties, such as “bad connections” or “frozen pictures.” The study also suggested that telehealth reducing costs to both recipients and providers because travel costs and time are reduced.
Telephone-Administered Psychotherapy for Depression in MS Patients: Moderating Role of Social Support
Beckner, V., Howard, I., Vella, L., & Mohr, D. C. (2010). Telephone-administered psychotherapy for depression in MS patients: moderating role of social support. Journal of Behavioral Medicine, 33(1), 47-59.
Individuals with chronic physical health conditions may have difficulty accessing health care, particularly specialty health care. Mental health problems, such as depression, can be common in individuals with long-standing health concerns. While psychotherapy is an effective treatment, not all individuals have access to or benefit from such care. In order to increase access to care, 127 individuals with multiple sclerosis (MS) and depression were provided either telephone-administered Cognitive-Behavioral Therapy (T-CBT) or telephone-administered Emotion-Focused Therapy (T-EFT). Participants did experience a reduction in depressive symptoms, and those individuals who reported both a higher level of social support and greater satisfaction with their support showed a greater reduction in depressive symptoms in the T-CBT condition. T-CBT is characterized as a more structured and demanding treatment so those who begin treatment with a greater level of support may have more emotional resources to engage in this treatment.
Emerging research in the area of telehealth suggests that applications within psychology can be appropriate and beneficial to patients. While this body of research is still developing and “best practices” are yet to be articulated as, psychologists can be assured that research to date supports the use of technology in providing psychological services.
However, as with any intervention, the psychologist must determine the appropriate use of technology in a given situation. While the therapeutic alliance is important in all psychological interventions, particular attention to the alliance is necessary when providing care via technology. In fact, some individuals, such as those with less social support, may need the in-person interactions in order to gain some of the benefits of a supportive, therapeutic relationship. Psychologists will want to carefully assess prospective “technology clients” to determine if the lack of an in-person interaction may be a potential detriment to successful care. However, the use of technology might overcome barriers to care, ie an individual might not receive care at all without technology so providing care via technology, regardless of degree of social support, may be better than providing no care at all. Insisting on in-person care with individuals who cannot easily arrive at appointments or must travel great distances to obtain care (such as rural clients or individuals seeking specialty care) may be an unnecessary barrier if services via telehealth can be arranged.
Given these emerging technologies, psychologists will want to determine which ones are appropriate for their practice and may need to make efforts to advocate with payers and government entities for broader support of telehealth to ensure that the potential for improved access to care is not limited by unnecessary fiscal or regulatory restrictions.
Special thanks to David Mohr, PhD, Professor of Preventive Medicine, Northwestern University, who assisted with this article.