Telehealth Treatment for Alcohol Use Disorder Associated With Patient Retention

Patients with alcohol use disorder (AUD) who receive treatment via telehealth are more likely to engage in more psychotherapy visits and have a longer duration of medication treatment compared with those who have only in-person visits, according to a study published this week in Alcohol, Clinical and Experimental Research.

“Evidence-based treatment for AUD differs from other substance use disorders in that it includes multiple psychotherapy and medication options,” wrote Ponni V. Perumalswami, M.D., of the VA Ann Arbor Healthcare System and colleagues. “Evaluating telehealth delivery of treatment to vulnerable patients, including those with AUD, is particularly important in the current context as the United States debates whether to sustain or revoke pandemic-era policies that decreased barriers to telehealth.”

Perumalswami and colleagues analyzed electronic health record data from the Veterans Health Administration (VHA) during the year following the start of the COVID-19 pandemic (between March 1, 2020, and February 28, 2021). They included 138,619 patients aged 18 or older who were diagnosed with AUD in the year prior to or during the study period and who had at least one AUD treatment visit. AUD treatment included an individual or group psychotherapy visit and/or AUD medication coverage (defined as the number of days covered by a filled prescription for AUD). The authors used VHA codes to determine whether patients received their treatments via video, telephone, or in person.

During the study period, 52.8% of participants had at least one video visit, 38.1% had at least one telephone visit but no video visits, and 9.1% had only in-person visits. Telehealth was associated with a greater number of psychotherapy visits and medication coverage days compared with in-person visits for both patients initiating and continuing treatment during the study period. Further, among those who received any treatment via telehealth, those who had video visits had a significantly greater number of psychotherapy visits compared with those who only had telephone visits.

Participants who had only in-person visits were more likely to be initiating AUD treatment and were older, male, Black, rural, homeless; they were also more likely to have an opioid and/or stimulant use disorder. Additionally, among participants who received any treatment via telehealth, those who were 45 years or older, Black, and diagnosed with a cannabis or stimulant use disorder or serious mental illness were less likely to receive video compared with telephone visits. The authors noted that this finding highlights “important disparities in AUD telehealth use.”

“Additional efforts to increase the engagement of certain VHA patient groups in telehealth use should be made, given its association with receiving more AUD treatment,” the authors concluded. “This study offers insights into patient characteristics associated with AUD treatment in an era of expanded telehealth and suggests that future policy changes in telehealth should be carefully considered given the potential to widen disparities in care.”

For related information, see the Psychiatric News article “Federal Telehealth Policy Changes After COVID-19 Public Health Emergency.”

(Image: Getty Images/iStock/brusinski)

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Patients Seeking Mental Health Care Want More Say in In-Person, Virtual Appointments

Nearly 1 in 3 adults receiving mental health treatment who were surveyed earlier this year said they don’t have much choice when it comes to whether they see their clinician in person or via telehealth. In part, this was because those surveyed reported that they did not see clinicians who offered both in-person and telehealth visits.

These were a few of the key takeaways from a report published this afternoon in Health Affairs.

“Although preferences regarding modality varied, with some preferring in-person care and others preferring telehealth for different types of behavioral health visits, the majority of interview participants wanted to have the choice,” wrote Jessica Sousa, M.S.W., M.P.H., of the RAND Corporation and colleagues.

The researchers conducted a nationally representative survey of 2,071 U.S. adults (average age 49 years, 74% White) in early 2023, including 571 who used behavioral health services in the prior year. They also completed in-depth interviews with 26 people with bipolar disorder or depression during this time. The participants were asked whether their clinicians were offering both in-person and telehealth visits for medication or individual therapy and how decisions about whether they saw the clinician in person or virtually were decided.

Recipients of individual therapy were about twice as likely to have telehealth visits (80%) as in-person visits (42%) during the prior year, the researchers found. Those seen for medication visits were about equally likely to receive telehealth visits (54%) as in-person visits (58%). About 24% of those seeking therapy said that the provider decided whether they were seen in person or via telehealth; for those seeking medication appointments, about 35% said the provider decided.

The respondents whose clinicians offered both in-person and telehealth appointments were also asked to rate their level of agreement with statements such as “When deciding whether visits would be in person or by telehealth, my provider considered my preference” and “Most of the time, I was able to get the type of visit (telehealth versus in-person) that I preferred.”

Nearly 55% of the survey respondents agreed that their clinician considered their visit preference when deciding whether to see the patient in person or by telehealth; 68% agreed that they got the type of visit they preferred most of the time.

“Expanding telehealth is a laudable goal, given that it often is more convenient, increases access to care, and is effective for treating many behavioral health conditions. However, telehealth alone might not be sufficient,” Sousa and colleagues wrote. “For telehealth to achieve its potential to increase overall access to high-quality, patient-centered care, it is important to implement it in a manner that expands, rather than contracts, behavioral health access and options for patients.”

For related information, see the Psychiatric News article “The Hybrid Model: New Normal or Unstable Transition Phase?”

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Psychiatrists Offer 5 Strategies for Integrating Videoconferencing Into OCD Treatment

People with obsessive-compulsive disorder (OCD) can benefit from medication and/or psychotherapy that teaches them to confront situations that trigger obsessive fears while refraining from performing compulsions. Yet, for many with OCD, these therapies may be out of reach due to therapists’ availability, cost, location, and more.

“Increasing evidence suggests that digital health technologies, including videoconferencing and other approaches (for example, online platforms, websites, and mobile applications) can circumvent these barriers,” wrote Reilly R. Kayser, M.D., of Columbia University’s Vagelos College of Physicians and Surgeons and colleagues in an article in Psychiatric Services in Advance.

One evidence-based treatment for OCD is exposure with response/ritual prevention (EX/RP)—a standardized treatment in which patients are encouraged to gradually approach feared stimuli through real-life and imagined exposures. Drawing from their experience at Columbia’s Center for OCD and Related Disorders, Kayser and colleagues describe five potential strategies for integrating videoconferencing into OCD treatment, including advantages and challenges of each approach:

Hybrid EX/RP: Beginning EX/RP treatment in person enables therapists to establish the therapeutic alliance with the patient, supervise patients’ successful completion of exposures before practicing them independently, and overall progress. Videoconferencing offers patients and therapists the ability to adapt when a patient moves, becomes ill, or other unexpected life events occur. When transitioning to remote treatment, it is important that therapists obtain informed consent and review with the patient the treatment model as well an overview of how the videoconferencing software works. “Licensure issues may occur with relocations, requiring clinicians to obtain limited permits or arrange local referrals,” they wrote.

Fully remote EX/RP: Patients who are homebound, live far from OCD treatment facilities, and/or feel significant shame about their symptoms may “find videoconferencing more tolerable than office-based care and may more readily seek remote treatment,” the authors continued. However, there are challenges to this approach: “A therapist might observe a patient’s engagement in safety behaviors onsite, but these may be less obvious over videoconferencing, limiting opportunities for corrective feedback. … Fully remote treatment may be inappropriate when patients struggle with adherence, have certain comorbid conditions (for example, psychosis, severe personality disorders), or face immediate safety concerns (for example, suicidality).”

Videoconferencing-assisted psychopharmacology: In some situations, medications may be the first-line therapy for patients with OCD, the authors noted. Videoconferencing can expand “expert pharmacological consultation and treatment beyond metropolitan centers (where most specialty programs are located).” Potential challenges to this approach include licensure and/or medication supply issues and the inability to perform a physical exam of the patient.

Virtual support groups: There is evidence to suggest that OCD support groups may reduce loneliness, isolation, and stigma while reinforcing cognitive-behavioral therapy techniques. Virtual support groups have the advantage of allowing patients to see each other without the logistical challenges of in-person meetings. “We recommend groups with trained moderators to ensure that treatment does not inadvertently reinforce accommodation of symptoms or avoidance,” they wrote.

Videoconferencing-assisted clinical supervision: Videoconferencing can also be used to facilitate and increase access to clinical supervision. “Similar to traditional supervision, online software allows supervisors to view trainees’ recorded treatment sessions and provide retrospective feedback. Supervisors can also passively view sessions with video or audio disabled, activating video or audio at key moments to provide real-time feedback.”

The authors concluded, “Although digital health technologies such as videoconferencing are unlikely to replace in-person OCD treatment, they are quickly becoming important tools to increase access and improve care for this debilitating, undertreated condition.”

For related information, see the Psychiatric News article “How Are OCD Patients Coping With COVID-19?”

(Image: iStock/izusek)

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