Experiences of Mental Health Clinicians and Staff in Rapidly Converting to Full-Time Telemental Health and Work from Home During the COVID-19 Pandemic.

Background: The mitigation strategies for the COVID-19 pandemic pushed much of the mental health workforce to rapidly convert to full-time telemental health (TMH). For many people, this occurred in the context of working from makeshift home offices with novel distractions. We describe the results of an online survey of mental health clinicians and staff regarding their experiences in rapidly converting to full-time TMH and work from home (WFH) during COVID-19. Methods: Fourteen clinicians and 11 administrative staff from two outpatient mental health clinics in a large academic medical center completed the survey in May 2020. Results: More than 85% of participants rated the experience of providing or supporting full-time TMH care as "somewhat better" or "much better than expected." Clinicians and administrative staff reported perceptions that most clients were satisfied with TMH services. Identified TMH challenges included difficulty providing clinical forms and difficulties with technology. Identified benefits of WFH included lack of commute, time with loved ones, opportunities for self-care, and increased flexibility. Maintaining team cohesion and communication while working remotely, and setting boundaries between work and nonwork hours were identified as challenges. Nearly all respondents indicated a preference to continue some TMH from home in the future. Conclusions: Findings suggest that rapidly adopting TMH and WFH during a pandemic were well accepted. Should the progression of the pandemic require agile movement in and out of TMH and WFH, overcommunication and extra attention to supporting employee connection and morale are especially important.

Telemental Health Response to the COVID-19 Pandemic: Virtualization of Outpatient Care Now as a Pathway to the Future.

The use of telemental health (TMH) has fostered the continued provision of mental health care during the COVID-19 pandemic, and ultimately prevented the significant drop in clinical visits as experienced by other health care disciplines. Many health care providers and systems rapidly virtualized care to include visits occurring in what previously were defined as nontraditional locations such as provider and patient homes. Emerging data and reports suggest that this rapid virtualization of mental health services occurred safely and effectively. Although it is uncertain how long the full virtualization will remain, we envision a future wherein mental health services are delivered using a hybrid in-person/TMH approach. This opinion provides an overview of current lessons learned from rapid virtualization due to COVID-19 mitigation strategies and recommends that mental health providers and systems use these lessons to define and promote hybrid care delivery.

Rapid Conversion to Telemental Health Services in Response to COVID-19: Experiences of Two Outpatient Mental Health Clinics.

Background: The COVID-19 pandemic triggered changes across health care systems, with many sectors seeing significant drops in patient visits. Rapid transition to telemental health (TMH) allowed for the continued delivery of mental health care. Although several guidelines and best practices are available for the methodical development of a TMH service, there are few documented procedures on rapidly converting to fully virtualized services. We discuss how two outpatient mental health clinics at the University of Colorado Anschutz Medical Campus rapidly virtualized clinical services during the COVID-19 pandemic. Methods: All current clinical appointments were converted to virtual, and all new clinical intakes were scheduled as virtual visits starting March 16, 2020. Virtualization included a modified needs assessment, updated clinic procedures, focused patient and staff training on TMH, and increased frequency of team meetings. We conducted a retrospective evaluation of clinic log and electronic health record data to examine the number of appointments and no-shows before and after COVID-19 virtualization. Results: Virtualization was operational within two business days. Scheduled appointments decreased 10.6% immediately postvirtualization, followed by an increase of 17.8% across the 6 months postvirtualization. No-show rates dropped from 11.9% pre- to 6.8% postvirtualization, leading to a 26.2% increase in completed visits. Discussion: Rapid virtualization of mental health services can occur effectively. Wider use and acceptance of TMH, especially to patient-homes, is likely in the foreseeable future as health care providers and systems reconceptualize service delivery. Future research must include analyzing the impact such changes make on clinical outcomes and patient visit volumes.

Technology-Based Mental Health Treatment and the Impact on the Therapeutic Alliance.

PURPOSE OF REVIEW: Telemental health, which is treatment mediated by technology, is an increasingly common method of delivering mental health care. However, its impact on the therapeutic alliance is unclear. This review examines studies of telemental health and its impact on therapeutic alliance. RECENT FINDINGS: Findings indicate that a therapeutic alliance can be maintained through a variety of communication technologies, with some caveats. Considerations on maintaining a successful therapeutic alliance include using technology as an adjunct to treatment and ensuring patients and providers have back-up plans for continuing communication in the event of technical difficulties. Overall, the studies found that clinicians often have more concerns about alliance than patients do, suggesting that clinicians could make some changes to feel more comfortable. Recommendations are offered for implementing techniques into practice that will help clinicians increase their awareness of ways to support the therapeutic alliance when using telemental health.

Review of Virtual Reality Treatment in Psychiatry: Evidence Versus Current Diffusion and Use.

PURPOSE OF REVIEW: This review provides an overview of the current evidence base for and clinical applications of the use of virtual reality (VR) in psychiatric practice, in context of recent technological developments. RECENT FINDINGS: The use of VR in psychiatric practice shows promise with much of the research demonstrating clinical effectiveness for conditions including post-traumatic stress disorder, anxiety and phobias, chronic pain, rehabilitation, and addictions. However, more research is needed before the use of VR is considered a clinical standard of practice in some areas. The recent release of first generation consumer VR products signals a change in the viability of further developing VR systems and applications. As applications increase so will the need for good quality research to best understand what makes VR effective, and when VR is not appropriate for clinical services. As the field progresses, it is hopeful that the flexibility afforded by this technology will yield superior outcomes and a better understanding of the underlying mechanisms impacting those outcomes.

The use of collaboration science to define consensus outcome measures: a telemental health case study.

The purpose of this document is to provide an overview of a collaboration science process used to develop recommendations for the field of telemental health (TMH) in the selection of outcome measures that best reflect programmatic impacts. A common use of group development techniques in medicine is the development of clinical guidelines, which typically occurs using one of two methods: the nominal group or the Delphi method. Both processes have been faulted for limited transparency, reliability, and sustainability. Recommendations to improve the traditional process include making goals explicit, making disagreements transparent, and publicly displaying levels of agreement. A group of 26 TMH experts convened during the American Telemedicine Association's 2012 Fall Forum in New Orleans, LA to participate in a 1-day, interactive, consensus-building workshop to initiate the development of a shared lexicon of outcomes. The workshop method was designed to improve on traditional methods of guideline development by focusing on clarity of expectations, transparency, and timeliness of group development work. Results suggest that, compared with other traditional methods, the current process involved more people, occurred more rapidly, was more transparent, and resulted in a comparable deliverable. Recommendations for further process development, both within and external to TMH, as well as an initial overview of defined outcome measures are discussed.

Virtual Versus In-Person Suicide Prevention Training in the Workplace: Evaluation of the VitalCog Program.

Most suicides occur among adults of working age and workplace suicide prevention is a public health priority. Workplace suicide prevention efforts, however, remain limited. This paper describes and evaluates a workplace-based suicide prevention gatekeeper training delivered in-person and virtually. VitalCog is a 2-h suicide prevention program designed specifically for the workplace and based on best practices for gatekeeper training. It is designed to be practical and interactive, with four modules (why prevention matters, what to do if someone is suicidal, conversations about suicide, and postvention), each containing related video, group discussion, and role play exercise components. It was delivered live by experienced trainers either in-person or using synchronous technologies between 2018 and 2021. A mixed methods pre- and post-training design with no control group was used to evaluate in-person vs. virtual delivery to determine knowledge gain, confidence identifying warning signs, and comfort levels talking about suicide. One thousand two-hundred and forty-four (1244) pre- and post-training responses were analyzed, with no significant (p > .05) socio-economic differences between the pre-training and post-training respondent samples. Both in-person (n = 841) and virtual (n = 403) training groups demonstrated statistically significant increases in knowledge about suicide prevention and seeking help, confidence to identify suicide warning signs, and comfort levels talking to someone about getting help. Interestingly, the virtual group showed higher post-training outcome scores than the in-person group. While COVID-19 significantly reduced in-person training opportunities, these results suggest that offering VitalCog virtually is as effective as in-person, and potentially has advantages over in-person training.

mHealth data security: the need for HIPAA-compliant standardization.

The rise in the use of mobile devices, such as smartphones, tablet personal computers, and wireless medical devices, as well as the wireless networks that enable their use, has raised new concerns for data security and integrity. Standardized Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant electronic data security that will allow ubiquitous use of mobile health technologies is needed. The lack of standardized data security to assure privacy, to allow interoperability, and to maximize the full capabilities of mobile devices presents a significant barrier to care. The purpose of this article is to provide an overview of the issue and to encourage discussion of this important topic. Current security needs, standards, limitations, and recommendations for how to address this barrier to care are discussed.

The use of deployable telehealth centers by military beneficiaries to access behavioral healthcare: an exploratory evaluation in American Samoa.

Some U.S. Military Health System (MHS) beneficiaries face unique challenges accessing available behavioral healthcare because of the nature of their occupations, deployments to and permanent duty stations in isolated geographies, and discontinuity of services. The use of deployable telehealth centers such as modified shipping containers offers promise as an innovative solution to increase access to behavioral healthcare in remote and otherwise austere environments. The first telehealth modified 20-foot shipping container, known as a relocatable telehealth center (RTeC), was deployed to increase access to care for MHS beneficiaries on American Samoa. The goal of this study was to conduct an exploratory evaluation of patient satisfaction with and usability perceptions of this solution as a place to receive behavioral healthcare services. Twenty-eight beneficiaries participated in this evaluation. Results suggest that the RTeC is safe and private and ultimately an appropriate telebehavioral-originating site. These data provide insight into usability considerations and inform future research and deployable telehealth center development. Additionally, a brief discussion about potential cost offset is provided as cost efficiencies impact RTeC viability.

Usability and feasibility of smartphone video capabilities for telehealth care in the U.S. military.

The two-way audio/visual capabilities on the latest smartphone platforms bring new possibilities for the delivery of healthcare services to users. Because this technology is so new, the feasibility and the basic usability of the technology need to be evaluated before more research is conducted on its application in the telehealth field. The purpose of this study was to conduct preliminary usability testing of smartphone two-way video capabilities for potential telehealth use for U.S. military service members. Seven service member volunteers communicated with research staff at a large military installation via Apple's (Cupertino, CA) FaceTime® app on the iPhone® 4 smartphone platform and conducted basic usability testing of the technology. Preferences for potential use of the technology were also assessed. The results showed that the technology has both limitations as well as potential for telehealth applications that warrant additional research.

Home-based telemental healthcare safety planning: what you need to know.

Telemental health (TMH) care provided directly to the home is an emerging area of care delivery. TMH care involves awareness of safety issues and adequate safety planning, although detailed practical recommendations for home-based TMH safety planning are absent in the literature. With this article we aim to increase awareness of safety issues associated with home-based synchronous TMH treatment and to discuss recommendations for consistent safety planning that can inform the development of standard operating procedures, emergency protocols, and overall good TMH practice. Specific areas discussed include consideration of state and local requirements, appropriateness of TMH care, technology and infrastructure, and emergency management and monitoring procedures. The topic of safety, as it relates to TMH policy, as well as the need for additional TMH research are also discussed.

The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment.

A retrospective cohort study was conducted to examine risk and protective factors for combat-related posttraumatic stress disorder (PTSD) symptoms reported by soldiers (n = 2,583) at postdeployment. Positive appraisals of military service related negatively, OR = 0.86, 95% CI [0.83, 0.89], to screening positive for presumed PTSD at postdeployment. Decreases in perceived intimate relationship strength from predeployment to postdeployment were positively associated with presumed PTSD at higher, but not lower, levels of combat exposure; this effect, OR = 1.91, 95% CI [1.08, 3.39], was found only for female soldiers. Overall risk for postdeployment presumed PTSD was found to be nearly 2.5 times greater for women, as compared to men. In addition, positive screening rates of anxiety, depression, hazardous alcohol use, and PTSD increased from predeployment to postdeployment, with the most prominent increase found for PTSD.

Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review.

The safety of telemental healthcare delivered to clinically unsupervised settings, such as a personal residence, must be established to inform policy and further the dissemination of telemental health programs. The aim of this article is to provide an overview of safety issues associated with telemental healthcare and, through a systematic literature review, evaluate the safety of telemental healthcare delivered to unsupervised settings. The review resulted in a total of nine studies that specifically evaluated the delivery of telemental healthcare to unsupervised settings. Six of the nine studies reviewed explicitly described safety plans or specific precautions that could be used if necessary. Two of the nine studies reported events that required the researchers to use safety procedures to effectively respond to concerns they had regarding participant safety. In both of these studies, the issues were resolved with prescribed safety procedures. Recommendations and future directions for the development and evaluation of safety protocols are discussed.

Establishing Telemental Heath Services from Conceptualization to Powering up.

Telemental health is a demonstrated and effective aspect of the overall mental health system and considered a standard of care for many treatments. Adoption has not been as robust as expected and failure to properly develop implementation plans is a significant barrier. This article provides an overview of a step-by-step planning process to more effectively implement and sustain telemental health programs.

Evaluating the benefits of a live, simulation-based telebehavioral health training for a deploying army reserve unit.

Telebehavioral health (TBH) has previously been reported as underutilized in the Afghan Theater of Operations despite efforts to expand the number of operational TBH sites. A lack of training on TBH services and equipment was identified as a probable cause. The National Center for Telehealth and Technology (T2) provided members of the 1972nd Medical Detachment (Combat Stress Control [CSC]) U.S. Army Reserve with an in-person TBH training designed to provide the unit with hands-on knowledge and skills to deliver TBH services in theater. A key training component consisted of placing unit members in live, simulated clinical and technical scenarios they were likely to encounter while deployed. Evaluations suggest that the training was successful at preparing the 1972nd CSC for its TBH mission. During its deployment, the 1972nd CSC led an approximate 40% expansion of TBH services, including the direct provision of around 700 clinical encounters. Several best practice recommendations were identified including: (1) maintain the hands-on component, (2) use lessons learned to develop scenarios, (3) incorporate training into daily activities, and (4) tailor training while ensuring that all stakeholders have the same base knowledge set. To our knowledge, this is the most comprehensive process improvement evaluation of a predeployment telehealth training available.