New study raises questions about when telehealth is best used as a substitute for in-person care and when telehealth is best used to complement in-person care.
Early in the coronavirus pandemic, telehealth helped to offset a sharp drop of in-person mental health visits, but the volume of visits for several conditions such as bipolar disorder declined in part because of relatively low telehealth uptake by patients with these conditions, a new study says.
Stay-at-home orders and fear of contracting coronavirus at healthcare facilities drove down in-person visits for medical care early in the pandemic. Healthcare providers responded to the decrease in in-person visits with an unprecedented expansion of telehealth visits.
The new study was published by HealthAffairs. The study is based on an analysis of claims data from Office Ally, a claims clearinghouse for Medicare, Medicaid, and commercial payers. The researchers compared mental health service utilization from time periods before and during the pandemic: 2016 to 2018 and March to December 2020.
The claims data provided information on 101.7 million outpatient mental
health visits. Three-quarters of the visits occurred from 2016 to 2018 and one-quarter of the visits occurred from March to December 2020.
The study features several key data points.
- In March 2020, there was a 21.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
- In April 2020, there was a 49.6% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
- In May 2020, there was a 55.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
- Telehealth visits quickly led to recovery in outpatient mental health utilization. In April 2020, the combination of in-person and telehealth visits was 10.4% higher than average monthly visits in the same month in the pre-pandemic period.
- The average number of monthly mental health visits was 2.12 million in the pre-pandemic period compared to 2.11 million during the pandemic period, which was a 0.7% decrease in service volume.
- During the pandemic period, the number of average monthly visits decreased by 10.6% for bipolar disorders, 8.5% for schizophrenia and psychotic disorders, and 8.2% for depressive disorders.
- During the pandemic period, the number of average monthly visits increased by 12.1% for anxiety and fear-related disorders.
- During the pandemic period, telehealth visits compared to in-person visits varied for diagnosis groups. For schizophrenia, telehealth visits accounted for a lower proportion of total outpatient visits compared to in-person visits (1.7% versus 2.7%). For anxiety and fear-related disorders, telehealth visits accounted for a higher proportion of outpatient visits compared to in-person visits (27.5% versus 25.5%).
"We found substantial declines in in-person mental health services use in the initial lockdown phase of the COVID-19 pandemic, followed by a rapid rebound in utilization volume driven chiefly by uptake of telehealth appointments. … We also found relative reductions in encounter volume for certain groups of mental health conditions, specifically for serious mental illnesses such as bipolar and mood disorders and schizophrenia and psychotic disorders, whereas encounters for anxiety and fear-related disorders rose slightly," the study's co-authors wrote.
Interpreting the data
During the pandemic, decreases in average monthly visits for bipolar disorders, schizophrenia and psychotic disorders, and depressive disorders is a troubling, the lead author of the study told HealthLeaders.
"Evidence suggests that during the pandemic more people had mental health symptoms, and that those with mental health conditions had increased symptom acuity. So, our findings of reduced utilization for certain mental health conditions is concerning in this setting, because it suggests that some groups may have been more sensitive to care disruptions that occurred. Individuals with mental health conditions, including those with serious mental illness, are already facing challenges in accessing mental health care, due to socioeconomic factors, difficulty accessing or navigating care, clinician turnover and lack of continuity, financial barriers, and even the nature of the illness itself. It is likely that these factors were exacerbated during the pandemic," said Jane Zhu, MD, MPP, MSHP, assistant professor of medicine at Oregon Health & Science University in Portland, Oregon.
Telehealth appears to be a good care fit for anxiety and fear-related disorders, she said. "We found that telehealth encounters for anxiety and fear related disorders went up significantly during the pandemic, likely driving an increase in total outpatient volume. Many others have reported that rates of anxiety and depression increased substantially during the pandemic, particularly among younger people. So, for this population subgroup, telehealth may be a suitable and acceptable modality of care, and it helped bridge access gaps during the pandemic."
The finding that telehealth encounters for schizophrenia made up a lower proportion of total outpatient encounters relative to in-person visits in 2020 has a significant implication for telehealth and mental health care, Zhu said.
"Telehealth for mental health conditions has been shown to be as effective as in-person care for a variety of purposes, including diagnosis, psychotherapy, and medication adjustment. But it's not yet known the extent to which different groups might have different clinical needs and preferences that may change the acceptability, accessibility, and efficacy of telehealth. For example, as a primary care physician, I have patients with mental health conditions like schizophrenia who prefer in-person visits because they don't like using audio visual tools on the Internet. While our study doesn't evaluate specific reasons for this finding, it raises questions about introducing telehealth as a one-size-fits-all tech solution to mental health care," she said.
The appropriate use of telehealth relative to in-person visits has yet to be determined, Zhu said. "Telehealth is here to stay, it's certainly a critical tool to increase access to mental health care and its applications in this space are incredibly promising, but we need to understand when it's best used as a substitute for in-person care, and when it's best used as a complement, and for whom. Flexibilities may be needed to allow for hybrid models of care."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
In April and May 2020, in-person outpatient mental health visits decreased by about half compared to the same months before the pandemic.
Telehealth visits quickly led to recovery in outpatient mental health utilization. In April 2020, the combination of in-person and telehealth visits was 10.4% higher than average monthly visits in the same month before the pandemic.
From March to December 2020, the number of average monthly outpatient mental health visits decreased by 10.6% for bipolar disorders, 8.5% for schizophrenia and psychotic disorders, and 8.2% for depressive disorders.