Exploring Tools for Virtual Behavioral Healthcare

August 07, 2023 - Though the COVID-19 public health emergency (PHE) has been officially declared over, people worldwide are still dealing with the life-changing repercussions of the pandemic. This includes grappling with an ongoing mental health epidemic.

Across the globe, mental health issues have grown at alarming rates. In the first year of the pandemic, the global prevalence of anxiety and depression increased by a whopping 25 percent, according to data from the World Health Organization. Numerous factors drove anxiety and depression, including fear of infection, financial uncertainty, political upheaval, social isolation, and grief.

Americans were not immune to these stressors. Nationwide, the share of Unites States adults reporting anxiety and depression symptoms rose from 35.9 percent in April 2020 to 39.3 percent in February 2021, a report from KFF shows. This figure fell, though only slightly, to 32.3 percent in February 2023.

The mental health crisis is most prevalent among the youth. In 2021, US Surgeon General Vivek Murthy, MD, issued an advisory calling for action to address the issue. KFF data shows that the largest share of adults (49.9 percent) reporting anxiety or depression symptoms in February 2023 were between 18 and 24 years.

As Americans' mental health worsened, virtual care grew in popularity, prompted in part by in-person healthcare restrictions tied to the COVID-19 pandemic. Telehealth was used to deliver various types of care, but behavioral healthcare quickly became one of the most common clinical use cases.

One estimate shows that telehealth-delivered behavioral health services have spiked 45-fold since the onset of the COVID-19 pandemic. The data from market research firm Trilliant Health shows that only 1 percent of all behavioral health visits were performed via telehealth prior to the pandemic, but that figure increased to 32.8 percent of all visits by the second quarter of 2022.

Research has also shown that telehealth maintained behavioral healthcare quality during the pandemic and increased access to mental healthcare.

As a result, virtual mental health-related solutions have proliferated in recent years. According to one report, there may be between 10,000 and 20,000 mental health-related applications in the market today. Here, mHealthIntelligence explores various types of virtual mental healthcare tools:

VIDEO-BASED PLATFORMS

Video-based therapy is a type of virtual behavioral healthcare that involves a provider and patient connecting via synchronous audio-visual teleconferencing tools, including smartphones, laptops, and tablets. The tools must be HIPAA-compliant.

According to a Substance Abuse and Mental Health Services Administration (SAMHSA) advisory, synchronous telehealth enables healthcare providers to deliver several behavioral therapies, such as cognitive behavioral therapy (CBT) and psychoanalytic therapy, similar to therapy delivered in an office setting.

There are numerous benefits of video-based behavioral healthcare. These include expanding access to care for people in rural communities or in areas where specialists are scarce, addressing the stigma associated with seeking mental health services by increasing privacy, and enabling clinicians to provide more availability to patients with complex conditions, SAMHSA stated in its advisory.

Video-based therapy became immensely popular during the pandemic, but research shows this modality was associated with high patient satisfaction even before the COVID-19 PHE. A study that analyzed 19,270 mental health encounters on a direct-to-consumer telehealth platform between 2016 and 2018 found that patients rated their satisfaction as 4.9 out of 5. 

During the pandemic, as the use of virtual therapy grew, research emerged that supported the efficacy of behavioral healthcare delivered via video. A meta-analysis published in 2021 shows that therapy delivered via videoconferencing was as effective as in-person therapy. The research analyzed more than 100 studies comparing in-person and video-delivered psychotherapy.

"Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence," the study authors concluded.

But there are numerous barriers to video-based care, including the lack of Internet connectivity in certain areas of the country. According to a Pew Research report, 30 percent of American adults have problems connecting to the Internet.

Further, digital health literacy issues can hinder patient access to video-based care. Patients with lower health literacy levels are more likely to use other telehealth modalities, like audio-only services.

AUDIO-ONLY SERVICES

Audio-only telemental healthcare encompasses behavioral health services delivered through audio-only platforms without any video component. These platforms include the telephone, smartphones, and audio-only applications on computers or tablets. These services are synchronous, with providers and patients connecting in real time.  

During the COVID-19 pandemic, the government enacted numerous telehealth-related regulatory flexibilities. Among these was allowing Medicare coverage of behavioral and mental healthcare services delivered using audio-only communication platforms. This flexibility was eventually made permanent.

This move followed growing evidence that audio-only telehealth services can help reach vulnerable populations with extensive behavioral healthcare needs.

For instance, a study published in April 2023 revealed that audio-only telehealth continues to be used at higher rates than video visits in federally qualified health centers (FQHCs) based in California. Researchers found that between February 2020 and August 2022, behavioral visits increased by 23 percent across 30 multisite FQHCs in the state. FQHCs typically care for lower-income people and have fewer resources than their healthcare facility peers.

Alongside moves to expand access to audio-only services for behavioral healthcare at the federal level, state Medicaid programs also expanded their coverage of these services. A KFF report published earlier this year shows that 40 states took at least one policy action to expand Medicaid coverage of behavioral healthcare provided via telehealth, and all 40 allowed or expanded Medicaid coverage of audio-only behavioral health services.

The American Medical Association has also created a CPT code for "synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system." The code became effective on April 1, 2022.

ASYNCHRONOUS TELEHEALTH SOLUTIONS

Also known as store-and-forward telehealth, asynchronous telehealth connects patients and providers, but not in real time. Instead, patients communicate with providers using secure messaging or sending previously recorded information, such as videos or documents, that providers review at a later time.

According to SAMHSA, various types of technologies support asynchronous telemental healthcare. These include mobile apps and computer programs that provide patients with medication reminders and self-assessments, remote patient monitoring (RPM) technology that can record and transmit data regarding a patient's mental and physical health, and messaging platforms that can connect patients with providers through email, chats, mailing lists, or EHR portals.

These technologies support different aspects of the behavioral healthcare continuum. In a paper published this year by University of California, San Francisco, researchers noted that asynchronous telepsychiatry can be integrated into three components of a traditional provider-patient interaction: the history and physical exam, assessment and diagnosis, and creation of a treatment plan.

The researchers further stated, "Patients have been more satisfied with the delivery of care in addition to the ATP [asynchronous telepsychiatry] workflow, which allows for more flexible scheduling than STP [synchronous telepsychiatry] for both patients and providers. If ATP were to become a regular clinical service, clinician recommendations could go from a 2-week to a 24-h turn-around time."

Other clinical evidence also backs the use of asynchronous telehealth tools for behavioral healthcare delivery. According to research published in 2021, patients using either asynchronous or synchronous telemedicine technology to meet with psychiatrists saw no significant difference in clinical improvements. The study included data from around 400 people seeking treatment for depression or anxiety across five years.

DIRECT-TO-CONSUMER SELF-GUIDED APPS

From Talkspace to Calm, the market for direct-to-consumer apps that provide self-guided mental healthcare interventions has grown significantly in recent years.

These apps provide a wide range of exercises and interventions, including guided meditations, breathing exercises, mindfulness activities, and mood tracking. An analysis of 98 self-guided CBT-based apps available in the Google Play and Apple App stores revealed that the apps offered at least four evidence-based CBT techniques, especially those targeting depression. Cognitive restructuring was the most common technique offered, and one-third of the apps provided suicide risk management resources.

Another study published in January 2023 shows that the most common types of conditions that smartphone-based mental health apps claim to help treat are substance abuse related to smoking or tobacco, stress and anxiety, and nonserious mood disorders.

However, research evaluating the clinical efficacy of these tools is mixed.

In a study published in 2022, researchers conducted a meta-review of meta-analyses of mobile phone-based interventions for mental health conditions tested in randomized clinical trials. The meta-review included 14 meta-analyses comprised of 145 primary studies representing 47,940 participants. The researchers stated that they "failed to find convincing evidence in support of any mobile phone-based intervention on any outcome."

But another study published last year found that mobile mental health apps had a positive impact on depression and anxiety. The study recruited participants who indicated they were unemployed because of COVID-19 or were designated essential workers during the pandemic. The participants were divided into four groups, and each group received a free commercial mobile app for managing distress, which they used for one month.

While app use positively impacted depression and anxiety, researchers also noted that it did not have the same impact on emotional regulation or suicide risk.   

VIRTUAL REALITY TECHNOLOGIES

As the use of virtual reality (VR) in healthcare grows, the technology is increasingly being employed to address mental health issues.

VR technology can support mindfulness, provide exposure therapies, teach coping skills to manage stress, and offer cognitive training, according to an American Psychiatric Association blog post.

Though still an emerging therapy, research shows that VR can effectively support mental healthcare services.

A literature review published in 2019 concluded that "VR environments show the possibility of changing [patients'] anxiety, depression, cognition, and social functions by effectively exposing them [to] sources of fear, presenting interactive virtual environments of cognitive-behavioral approaches, and contributing to other rehabilitation applications."

Another study published in 2021 revealed that VR is effective in supporting the treatment of anxiety or depression, including CBT delivery. The study analyzed 34 studies sourced from the Google Scholar database.

Further, there is evidence showing that VR could help support cognitive rehabilitation for neuropsychiatric illnesses.