How Telemedicine Can Drive Change in Behavioral Health Services

AbleTo Medical Director David Whitehouse shares the potential and best practices for providing behavioral health services through telemedicine.

David Whitehouse MD, MBA, the new medical director at AbleTo, a provider of virtual behavioral health services, says telemedicine is a 'particularly good fit' for behavioral health.

Telemedicine is one of the most significant growth areas in healthcare around the world. Last year, the value of the global telemedicine market was estimated at more than $38 billion, and the market is expected to be valued at $130 billion by 2025. With a high degree of anonymity and convenience, telemedicine has gained significant traction in the provision of behavioral health services.

Whitehouse was recently picked to serve as the medical director at New York–based AbleTo Inc. He earned his medical degree from Dartmouth College's Geisel School of Medicine. His professional background includes serving as chief medical officer for Aliso Viejo, California­–based UST Global and working as CMO for strategy and innovation for Optum Behavioral Health Solutions.

HealthLeaders spoke with Whitehouse recently to get his perspectives on the potential of telepsychiatry and best practices for telepsychiatry visits. Following is a lightly edited transcript of that conversation.

HL: Why is telemedicine a good fit for providing behavioral health services?

Whitehouse: It is an especially good fit.

When the Internet was getting started, an observation that was made quickly was that among social groups and chat groups the largest number of users were people who had behavioral health issues. What they loved about the Internet was the anonymity. The other thing the Internet provides is a treatment process that can be less demanding in terms of time and energy commitment.

For example, let's take a mother with postpartum depression. Part of the stresses for her are not sleeping at night and dealing with a crying child. If you tell her that she must find baby-sitting arrangements to see a therapist on a weekly basis, you are just going to add to her stress. The ability to make treatment available conveniently to her in her home or some other private place at moments when she can best use it is incredible.

In rural situations, you have the same ability and can overcome shortages of child psychiatry, shortages of opioid addiction treatment—not just medication but also ongoing therapy. All of these services can be provided through telemedicine to people privately and conveniently.

Another thing is that stigma is a huge issue. People have been reluctant to get treatment because they do not want to be seen going into an office. People don't want to be seen going into the employee assistance program office at work because it will be presumed that they have a drinking problem or a marital problem or something else is going wrong in their life.

There is shame in admitting that your emotional life is not totally under your control. If we can do anything to reduce that stigma and tell people that seeking help when they are emotionally challenged is acceptable, it would go a long way toward helping people.

HL: Give an example where technology is driving change in the mental health field.

Whitehouse: In more serious mental illness, there are new technologies that monitor people's movements and activities. For serious and chronic conditions such as schizophrenia and psychotic depression, people become reclusive and cut themselves off from the world. Now, we can do things like use cell phones to monitor social interactions, monitor affective tone, and monitor movement. With this technology, we can have a better sense of how these people are doing.

HL: What are the best practices for conducting behavioral health visits through telemedicine?

Whitehouse: Good telepsychiatry generally should start with an excellent screening process to choose patients who are most likely to benefit from telemedicine. That first screening session is probably one of the most important things that we do.

There are some cases that should not be handled in telemedicine—certain personality disorders have a high degree of intensity in emotional and behavioral interactions. For these patients, the day-to-day flareups are not handled well at a distance.

There also is a different skill related to the way you appear when you conduct a telehealth session. Whether it is just voice-to-voice or a telehealth presence, therapists must present themselves professionally. Probably even more so than a medical doctor, a therapist is part of the therapy—the eye contact they have on the screen, the way they look interested in the patient, how they dress, how their office looks—all these factors create an ambience in which you are creating a sense of safety for the patient. It can be unconscious to the therapist, and it can be unconscious to the patient, but its power is dramatic.

HL: How are AbleTo's telemedicine visits financed?

Whitehouse: The model at AbleTo is primarily geared to health plans and insurance companies. Our telehealth visits are generally considered a payable service. In most cases, we work with patients who pay with their behavioral health insurance benefit.

In commercial insurance, there usually is a copay. Behaviorally, we like the copay because psychologically, when you make something tremendously convenient for people, you want people to have an interest in the therapy themselves. The copay is an indicator that the patient is willing to make an investment in themselves.

HL: Is it particularly challenging when you are working as a telepsychiatry provider and you have a patient who slips into crisis?

Whitehouse: There are two considerations.

One, in the screening process, you want to determine who is a high-risk patient and who is not. If a patient has a history of past suicide events or a history of psychosis, they are not going to be a good candidate for telepsychiatry. They should be handled by a team of people who can be much more readily available.

Two, everyone with a behavioral health issue can experience a crisis, and every telehealth service should have a capability that is available 24/7 for both the intake team as well as therapists out in the field.

What happens when someone has a crisis is there needs to be a way over the computer, or text message, or over the phone that you can alert someone in the organization that the patient is in crisis. The one thing you don't want to do is get off the phone or break the human contact in any way. You then start to assess the crisis; and if you are the therapist in the field, you hand over the patient to the professional crisis team, whether it's over the phone or over the computer. Then the situation is exactly the same as if the patient was connected to the national suicide hotline.

Basically, a crisis worker is trained to perform a series of protocols that will first assess and try to de-escalate the situation. Often, when psychiatric patients are in crisis, the one thing they are most afraid of is loss of autonomy. You try to maximize their autonomy and try to find out what resources are available. Is there someone else in the house? Can you get a close friend on the phone?

If someone is suicidal and they have a gun, you are going to keep them on the line, and you will generally have a text-messaging capability to text a colleague. You will text that colleague and get them to contact the crisis team in the local community. Every telehealth crisis team should have the numbers for local resources. The local crisis teams deal with these situations often, and they can determine who should go out to the patient—whether it is a mental health crisis team or the police in a highly escalated situation.

You need to have not only a series of protocols in place and access to a crisis intervention system, but you also need to make sure that every provider who is engaged internally and every provider who is engaged externally is fully aware of the crisis services and trained in how to use them. That's one of the things that we take seriously at AbleTo.