Sage Journals: Discover world-class research

Abstract

Objectives:

Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders.

Methods:

Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers.

Results:

For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments.

Conclusions:

These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

Introduction

ACCESS TO CARE

Improving access to mental health care is key to addressing our country’s mental health crisis.¹ According to the Centers for Disease Control and Prevention, less than half of individuals with mental health problems are participating in mental health treatment.² Furthermore, minority members, rural patients, and patients with serious mental health conditions have an even greater disparity between need and use.^3,4 Barriers to accessing care include a shortage of clinicians in specific areas of the country (e.g., rural, or partially rural, areas), a shortage of clinicians with expertise in treating patients with serious mental illness, the cost of travel, the cost of taking time off from work, and patient stigma.

TELEMENTAL HEALTH

Due to its ability to connect providers from across the country with individuals in remote locations, telemental health via videoconferencing (TMH-V) can overcome most of these barriers.^5,6 For more than a decade, researchers have demonstrated that TMH-V is as effective and as safe as in-person appointments.^7

–10 Furthermore, it has strong bipartisan Congressional support.¹¹

Since the onset of coronavirus disease 2019 (COVID-19), there has been a significant loosening of insurance restrictions and other financial and administrative barriers to the use of TMH-V. This has led to a dramatic increase in rates of telehealth use among those with bipolar disorders.¹² Moreover, studies during the pandemic period have demonstrated the value of telehealth care for this population. For example, telehealth has been shown to be an effective way for individuals with bipolar disorder to monitor mood and anxiety symptoms.¹³ In addition, a study of patients with serious mental illnesses found that those who received telehealth treatment during the first wave of the pandemic were significantly less likely to have subsequent emergency department visits and hospitalizations.¹⁴

THE BIPOLAR DISORDERS TELEHEALTH PROGRAM

Whereas other health care facilities began to ramp up their use of TMH-V during the COVID-19 pandemic, the U.S. Department of Veterans Affairs (VA) has been using TMH-V widely for more than two decades.^3,9,15,16 For bipolar disorder specifically, the VA’s National Bipolar Disorders TeleHealth (BDTH) Program started providing care in 2011.^17,18 The VA designed this program to make clinical expertise in bipolar disorder available to Veterans across the country using a hub and spokes model.¹⁹ That is, the VA medical centers (i.e., the spokes) refer Veterans to the BDTH Program (i.e., the hub) for diagnostic assessment, psychiatric consultation, and specialized care, which is structured around the evidence-based principles of the Collaborative Chronic Care Model (CCM).^20

–23

INITIAL EVALUATION OF THE PROGRAM

Based on the first 400 referrals, initial analysis of BDTH services suggested that program participants had positive changes in quality-of-care indices and clinical outcomes.^17,18 Specifically, Veteran receipt of BDTH services was associated with decreases in mental health symptoms, alongside significant improvements in mental health-related quality of life and guideline-concordant psychotropic prescriptions (e.g., increased lithium prescriptions, decreased antidepressant prescriptions).

PROGRAM EVALUATION GOALS

The primary goal of this article is to update these findings for more than 3,000 Veterans who have been referred to the BDTH Program during the first 10 years of its existence (i.e., 2011–2021). A secondary goal is to examine the effectiveness of BDTH services for the diagnostic subgroups: bipolar type I, bipolar type II, and others. The “others” category includes the remaining Veterans in our sample. In the year before intake, these Veterans had either (1) another bipolar diagnosis (e.g., unspecified bipolar and related disorder) or (2) a suspected bipolar diagnosis only.

Methods

OVERVIEW

This project was undertaken as a partnership between the VA Behavioral Health Quality Enhancement Research Initiative (BH QUERI) Program and the National Expert Consultation & Specialized Services (NEXCSS), which manages the BDTH Program. The VA Boston Research and Development Committee reviewed the project and determined that it constituted nonresearch;²⁴ thus, prospective IRB review and individual patient consent were not required.

PROGRAM DESCRIPTION

The general structure of the BDTH program has been described previously.¹⁷ Briefly, BDTH clinical services are guided by the CCM^22,23 with the following core components: comprehensive diagnostic assessments utilizing Diagnostic and Statistical Manual, version DSM-IV (from 2011 to 2013) and DSM-5 (from 2013 to 2021); psychopharmacological consultations; six modules from the Life Goals Program focusing on bipolar disorder; and follow-up monitoring, including administration of structured symptom and quality of life measures. In the six modules, a psychologist helps Veterans identify values, goals, symptom profiles, and coping strategies and prepare for their next provider visit using a Life Goals illness management workbook.²⁵ The overall program structure addresses four of the six CCM elements: provider decision support, self-management skill enhancement, clinical information systems, and work role redesign. Typically, a Veteran’s episode of care within BDTH lasts about 6 months.

BDTH is currently staffed by 1.35 full-time equivalent psychiatrists and 3.20 full-time equivalent psychologists, who are physically located in four U.S. states. Additionally, the BDTH Program shares 4.00 full-time equivalent scheduling and programmatic support staff with the other telehealth programs at NEXCSS.

VETERAN SAMPLE

BDTH services are intended to serve Veterans with known or suspected bipolar spectrum disorders. To participate in the program, the Veterans must be receiving mental health treatment at their local VA medical center. Referrals to BDTH care are made via a consult in the electronic medical record, which is automatically forwarded to BDTH staff. The goal of the current analyses was to evaluate the program outcomes for the Veterans referred within the first 10 years of the BDTH Program (2011–2021).

DATA ANALYSIS

For our analyses, we used clinical and administrative data from the VA Corporate Data Warehouse²⁶ and data from surveys. Our a priori program evaluation goals are detailed in Table 1; however, we provide a brief description here. We investigated three quality metrics (lithium prescriptions, antidepressant prescriptions, and prazosin prescriptions) in the year before referral versus the year following referral. Lithium and prazosin represented recommended evidence-based treatments, with the latter being limited to those with a PTSD diagnosis.^30
–32 In contrast, antidepressants were typically not recommended given the consensus that they are generally ineffective,³³ they may increase risk of recurrence of depression,³⁴ and they bring potential risk of manic switch and rapid cycling.^35,36 We also assessed mental health hospitalizations in the year before and the year following BDTH referral.

Table 1.

Program Evaluation Analyses

PROGRAM EVALUATION TARGET	SPECIFIC OUTCOME VARIABLE(S)	DATA SOURCE WITHIN VA CORPORATE DATA WAREHOUSE (CDW)	STATISTICAL TEST
Guideline-concordant psychopharmacology	Lithium prescriptions among those with bipolar spectrum diagnosis	VA pharmacy data	McNemar’s test, Cochran–Mantel–Haenszel test
	Antidepressant prescriptions among those with bipolar spectrum diagnosis	VA pharmacy data	McNemar’s test, Cochran–Mantel–Haenszel test
	Prazosin prescriptions among those with comorbid PTSD diagnosis	VA pharmacy data	Fisher's exact test, Cochran–Mantel–Haenszel test
Symptoms of bipolar disorder	Internal State Scale (ISS; Bauer et al., 2000) ²⁷	Health factors from BDTH program measures embedded in the VA medical record	Within-group prepost analysis: paired t-test
Mental health-related quality of life	Mental Component Score of the Veterans RAND SF-12 (Selim et al., 2009) ²⁸	Health factors from BDTH Program measures embedded in the VA medical record	Within-group prepost analysis: paired t-test
Mental health-related quality of life	Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; Stevanovic, 2011) ²⁹	Health factors from BDTH Program measures embedded in the VA medical record	Within-group prepost analysis: paired t-test
Mental health hospitalization	Binary variable (yes/no): any mental health hospitalization, year before vs. year after BDTH referral	Inpatient bed-section codes embedded in the VA medical record	McNemar’s test

BDTH, National Bipolar Disorders TeleHealth; VA, the U.S. Department of Veterans Affairs.

For the Veterans who completed surveys at the beginning and end of the Life Goals Program (n = 815), we analyzed the changes in the Internal State Scale (ISS) subscale scores, the ISS-defined mood episodes, the health-related quality of life (see below), and the number of positive suicide screens (via the Columbia Suicide Severity Rating Screen). The ISS produces four subscale scores: Activation, Well-Being, Depression, and Perceived Conflict. For all but the Well-Being subscale score, lower scores are preferred. Additionally, the ISS defines a probable manic episode as Activation subscale scores above 155, a probable depressed episode as Well-Being subscale scores below 125, and a probable mixed episode as Activation scores above 155 combined with Well-Being scores below 125.

Initial assessments of quality of life were based on the mental component score (MCS) and physical component score (PCS) of the Veterans RAND Social Functioning 12-item measure (VR-12).²⁸ In March 2018, however, the BDTH Program switched to the Quality-of-Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q).²⁹ The outcome scores for both measures have a t-distribution with a population mean of 50 and a standard deviation of 10. Furthermore, the items on the Q-LES-Q correspond conceptually to the items in the MCS of the VR-12.

Pre- versus posttreatment assessments were analyzed via t tests, McNemar’s tests, Fisher’s exact tests, and Cochran–Mantel–Haenszel tests. In some cases (e.g., for mental health hospitalizations), we compared Veterans who were referred to our program and completed a TMH-V intake to those who were referred but did not complete the intake. In these cases, the index date (i.e., the date to anchor prereferral versus follow-up time periods) was defined as the date of the TMH-V intake for those who completed the intake or the date of BDTH referral for those who did not complete the intake.

Results

VETERAN SAMPLE

Table 2 contains the characteristics of the sample. Between 2011 and 2021, mental health providers from 27 VA medical centers around the country referred over 3,000 Veterans for BDTH services. Of these, 2,456 completed the consult (i.e., had an intake with a BDTH clinician). The overall sample had an average age of 46 (SD = 14) at the time of referral to BDTH; 87% identified as White and 21% were female. More than 80% of the sample had a documented bipolar diagnosis in the year prior to their referral, and the sample featured high rates of mental health comorbidities.

Table 2.

Baseline Characteristics

CHARACTERISTIC	OVERALL SAMPLE (N = 3,027)	CONSULT COMPLETED (N = 2,456)	CONSULT NOT COMPLETED (N = 571)
Age at intake	46.28 ± 13.57	46.46 ± 13.63	45.48 ± 13.31
Gender, n (%)
Female	621 (20.52)	523 (21.29)	98 (17.16)**
Race/ethnicity, n (%)
White	2,519 (87.40)	2,045 (87.69)	474 (86.18)
Black	274 (9.51)	216 (9.26)	58 (10.55)
Other race/ethnicity	89 (3.09)	71 (3.04)	18 (3.27)
Hispanic/Latino	155 (5.12)	130 (5.29)	25 (4.38)
Marital status, n (%)
Married	1,083 (35.99)	900 (36.84)	183 (32.33)**
Disability Status ≥50%, n (%)	2,031 (83.20)	1,649 (83.07)	382 (83.77)
Mental health characteristics, n (%)
Diagnosis of bipolar disorder in prior year	2,367 (78.20)	2,010 (81.84)	357 (62.52)*
Bipolar I diagnosis in prior year (of those with bipolar disorder diagnosis)	811 (34.26)	709 (35.27)	102 (28.57)**
Schizophrenia spectrum competing diagnosis in prior year	203 (6.71)	179 (7.29)	24 (4.20)*
Substance abuse	1,302 (43.01)	1,043 (42.47)	259 (45.36)
Anxiety disorder	1,144 (37.79)	948 (38.60)	196 (34.33)
PTSD	1,437 (47.47)	1,190 (48.45)	247 (43.26)**
ADHD	302 (9.98)	264 (10.75)	38 (6.65)*
MST	552 (18.69)	462 (19.34)	90 (15.96)
Medical characteristics, n (%)
Diabetes	419 (13.84)	345 (14.05)	74 (12.96)
Obesity	309 (10.21)	273 (11.12)	36 (6.30)*
Hyperlipidemia	734 (24.25)	610 (24.84)	124 (21.72)
Dementia	19 (0.63)	17 (0.69)	2 (0.35)
Tobacco use disorder	289 (9.55)	256 (10.42)	33 (5.78)*
Cardiac dysrhythmia	101 (3.34)	81 (3.30)	20 (3.50)
Liver disorder	179 (5.91)	141 (5.74)	38 (6.65)
Kidney disorder	106 (3.50)	88 (3.58)	18 (3.15)
Thyroid disorder	192 (6.34)	163 (6.64)	29 (5.08)
TBI	41 (1.35)	34 (1.38)	7 (1.23)
Treatment characteristics in prior year, n (%)
Mental health hospitalization	681 (22.50)	528 (21.50)	153 (26.80)*
Any hospitalization	992 (32.77)	783 (31.88)	209 (36.60)**
Antidepressant use	1,525 (50.38)	1,264 (51.47)	261 (45.71)**
Lithium use	671 (22.17)	580 (23.62)	91 (15.94)*
Anticonvulsant use	1,308 (43.21)	1,117 (45.48)	191 (33.45)*
Antipsychotic use	1,674 (55.30)	1,390 (56.60)	284 (49.74)*
Prazosin use	484 (15.99)	392 (15.96)	92 (16.11)

Values differ at p < 0.01.

Values differ at p < 0.05.

ADHD, attention deficit hyperactivity disorder; MST, military sexual trauma; PTSD, posttraumatic stress disorder; TBI, traumatic brain injury.

CLINICAL OUTCOMES

Clinical outcomes among Veterans with pretreatment and 1-month posttreatment measures are presented in Table 3. Overall, Veterans completing these measures showed robust reductions (p < 0.001) in the ISS symptoms associated with both depression and mania during treatment. Additionally, they showed robust reductions (p < 0.001) in perceived conflict, a measure of global psychopathology.²⁷ Roughly 78% of Veterans had ISS scores that were indicative of a mood episode at program intake, while about 62% had ISS scores indicative of a mood episode at 1-month postcompletion of the program. This change, which was driven primarily by the decrease in the number of mixed episodes and depressed episodes, was significant at the p < 0.001 level. Similarly, mental health-related quality of life, whether measured by the VR-12 MCS or the Q-LES-Q, improved significantly from pretreatment to 1-month postcompletion of the program (p < 0.001). In contrast, the PCS of the VR-12 did not demonstrate statistically significant change over time.

Table 3.

Clinical Outcomes

	COMPLETED PRETREATMENT SURVEYS (N = 1,862)	COMPLETED PRE- AND POSTTREATMENT SURVEYS (N = 815)
	PRETREATMENT SCORES	PRETREATMENT SCORES	POSTTREATMENT SCORES^a
ISS
Activation	193.53 ± 124.85	188.21 ± 122.74	156.98 ± 116.92*
Well-Being	141.54 ± 77.21	141.24 ± 75.81	167.69 ± 72.80*
Depression	79.11 ± 59.18	75.87 ± 56.82	53.62 ± 50.66*
Perceived Conflict	155.20 ± 106.20	145.60 ± 96.04	114.75 ± 90.45*
ISS-defined mood episode n (%)
(Hypo)manic	647 (34.75)	285 (34.92)	267 (32.72)
Depressed	380 (20.41)	182 (22.34)	145 (17.95)**
Mixed	430 (23.09)	171 (21.12)	91 (11.23)*
Any mood episode	1,457 (78.25)	638 (78.28)	503 (61.72)*
Change in Activation index when intake mood episode was (hypo)manic or mixed		−85.48 ± 130.37^*
Change in Depression index when intake mood episode was depressed or mixed		−45.69 ± 64.32^*
Change in Perceived Conflict index when in mood episode at intake		−42.51 ± 106.35^*
VR-12
Mental	28.74 ± 11.31	29.60 ± 10.69	37.95 ± 12.40*
Physical	41.16 ± 13.61	40.84 ± 13.11	41.11 ± 12.27
Q-LES-Q	40.70 ± 8.64	41.56 ± 8.30	46.22 ± 8.59*

We administered the posttreatment measures 4.9 months after the pretreatment measures, on average.

Values differ at p < 0.001.

Values differ at p < 0.01.

Q-LES-Q: Quality of Life Enjoyment and Satisfaction Questionnaire–Short FormVR-12: Veterans RAND Social Functioning 12-item measure.

The analyses of patient subgroups produced comparable results. In all three subgroups (i.e., the bipolar I subgroup [n = 244], the bipolar II subgroup [n = 467], and the other subgroup [n = 104]), there were significant decreases in depression and perceived conflicts scores (p < 0.01), a significant reduction in the rate of manic, depressed, or mixed mood episodes (p < 0.01), and a significant improvement in mental health quality of life scores (p < 0.01). In fact, we only found three differences in these analyses compared with the analyses for the entire sample of Veterans; namely, there were nonsignificant changes in the following: (1) manic scores in the nonbipolar group, (2) the rate of mixed episodes in the nonbipolar group, and (3) the rate of depressed episodes in all three subgroups considered individually.

PATIENT SAFETY

For the Veterans who completed a consult, there was a significant decrease in the rate of mental health hospitalizations (McNemar’s test, p < 0.001). A total of 528 Veterans (21.5%) had at least one mental health hospitalization in the year before their intake compared with 362 Veterans (14.7%) in the year after the intake. The Veterans who did not complete a consult, however, saw a similar drop in rates (from 26.8% to 18.4%). For the Veterans who completed the Columbia Suicide Severity Rating Scale at intake and the end of treatment (n = 274), there was a significant decrease in the percentage of positive screens from 11.7% to 5.8%, respectively (McNemar’s test, p = 0.011).

PRESCRIPTION QUALITY METRICS

Analysis of a priori identified prescription quality can be found in Table 4. Those Veterans who completed a Life Goals intake were significantly more likely to be prescribed lithium in the 1-year period following that intake than they were in the previous year (35% versus 24%). Similarly, among those Veterans with a PTSD diagnosis, those who completed a Life Goals intake were more likely to be prescribed prazosin in the year following their intake than they were in the previous year (42% versus 28%). In both cases, Veterans who were referred to the program but who did not complete an intake did not see a corresponding change, on average, in lithium or prazosin prescriptions.

Table 4.

Indices of Quality Care

COMPLETED INTAKE (N = 2,456)	DID NOT COMPLETE INTAKE (N = 571)	p-VALUE (MCNEMAR’S TEST OR FISHER’S EXACT TEST)^a		p-VALUE (COCHRAN–MANTEL–HAENSZEL TEST)^b
YEAR BEFORE BIPOLAR TELEHEALTH INTAKE (%)	YEAR AFTER BIPOLAR TELEHEALTH INTAKE (%)	YEAR BEFORE BIPOLAR TELEHEALTH CONSULT (%)	YEAR AFTER BIPOLAR TELEHEALTH CONSULT (%)
Lithium use	580 (23.6)	867 (35.3)	91 (15.9)				93 (16.3)	<0.001	<0.001
Antidepressant use	1,264 (51.5)	992 (40.4)	261 (45.7)	235 (41.2)	<0.001	0.134
Prazosin use (if comorbid PTSD diagnosis)	335 (28.2)	539 (41.8)	72 (29.1)	76 (28.8)	<0.001	0.008

For lithium level and antidepressant use, McNemar’s test was used to compare proportion meeting criteria 1 year before versus 1 year after intake (paired samples) in those completing a telehealth intake (n = 2,456). For prazosin use, Fisher’s exact test was used because the population of those with a PTSD diagnosis changed from 1 year before to 1 year after intake/consult (unpaired samples).

Cochran–Mantel–Haenszel test was used to identify differences pre- versus postconsultation between those who completed a telehealth intake (n = 2456) and those who did not complete one (n = 571).

Analysis of antidepressant prescriptions revealed a more complex picture. Among those who were referred to BDTH, both subgroups (i.e., those who completed an intake and those who did not complete one) had lower rates of antidepressant prescriptions in the following year compared with the previous year. Thus, while completion of an intake was associated with a statistically significant reduction in rates of antidepressant use (52% versus 40%; p < 0.001), that reduction was not significantly different from the reduction seen among Veterans who did not complete an intake (46% versus 41%).

In a post hoc analysis, we found that the difference in the percentage of Veterans with a Life Goals intake who were prescribed lithium in the 1-year period following intake versus the previous year was even more pronounced for patients with a bipolar diagnosis (McNemar’s test: 41% versus 26%, p < 0.001). Within that group (i.e., patients with a bipolar diagnosis), the change for Veterans with a bipolar I diagnosis was 46% versus 34% (p < 0.001) and Veterans with a bipolar II diagnosis was 39% versus 23% (p < 0.001).

Discussion

The provision of health care services through TMH-V holds promise for addressing enduring challenges with mental health care access. For over a decade, the BDTH Program has been delivering TMH-V care, first via a clinic-to-clinic model, and then via virtual sessions at Veterans’ homes and workplaces. Services in the BDTH Program follow a hub and spokes model with expert psychiatrist diagnostic and psychopharmacology consultations and provision of the Life Goals Program³⁷ by psychologists, consistent with the principles of the CCM.^22,23

The clinical findings in this article expand upon the previous findings for the BDTH Program.^17,18 For example, symptom scores for Veterans who completed the Life Goals Program improved in all four domains of the ISS. These improvements were associated with a reduction from pre to posttreatment in the estimated proportion of the sample that was experiencing a manic, depressed, or mixed mood episode (78% versus 62%; see Table 3). Moreover, the positive changes extended beyond the changes in mood ratings. Specifically, Veterans who completed the program had an average of a seven-point increase in mental health-related quality of life. This seven-point increase represents about 35% of the gap between the sample at baseline and the general population without bipolar disorder.^28,29

With three exceptions, these findings were generally consistent among the diagnostic subgroups (i.e., the bipolar I subgroup, the bipolar II subgroup, and the others subgroup). Two of the exceptions do not need much explanation: nonsignificant changes in both manic scores and rate of mixed episodes in the others group (i.e., those without a bipolar I or II diagnosis). The third, a nonsignificant change in the rate of depressed episodes in all three subgroups, may be related to the less than fully robust finding in the overall sample. Among the positive results in Table 3, the change in the number of depressed mood episodes is the only one that is significant at the p < 0.01 level (instead of the p < 0.001 level).

BDTH services were also associated with improvements in prescription quality metrics and rates of positive suicide screens. For the former, medication recommendations have typically included lithium as a frontline mood stabilizing agent³⁸ and cautions against antidepressants, given the risk of manic switch and rapid cycling.³⁵ Furthermore, for Veterans with PTSD, prazosin has been a common recommendation, especially to address trauma-related nightmares and poor sleep quality.^32,39

In general, prescription data indicated that Veterans who completed an intake—typically with a BDTH psychiatrist—were more likely to receive prescriptions consistent with these recommendations in the year following their intake compared with the previous year. In contrast, the Veterans who were referred for BDTH services but did not complete an intake did not see significant changes in lithium or prazosin prescription rates (although such Veterans saw modestly reduced chances of being prescribed an antidepressant in the year following their referral to the program). While specific recommendations change over time as new medications enter the market and new studies are conducted, it is encouraging that expert psychiatric recommendations are associated with changes in medication choices by Veterans’ prescribing clinicians. At the same time, though, there may be room for improvement in the future. Despite the positive findings, the changes are smaller than expected, given the frequency that our psychiatrists recommended such changes. Possible factors for the relatively small change could include the multiple complexities of the local situations, patient preferences, and side effects of the medications.

LIMITATIONS

Our findings should be considered in the context of several limitations. First, the data are derived from routinely collected medical record data rather than a randomized controlled trial. Thus, third-variable confounding cannot be ruled out. Nevertheless, it remains noteworthy that BDTH care was associated with improvements in prescription quality metrics, mental health-related quality of life, mood symptoms, and rates of positive suicide screens in a real-world clinical setting without robust research infrastructure. Second, the prescription quality indicators were chosen prior to the release of the most recent VA/DoD Clinical Practice Guidelines⁴⁰ and have, to a certain extent, been superseded by more recent studies. Moving forward, medication recommendations by BDTH psychiatrists will incorporate this updated guidance (e.g., regarding quetiapine as a first-line treatment for bipolar disorder alongside lithium). Third, the sample for our study consisted of Veterans with bipolar disorder or suspected bipolar disorder who received care from one health care system (i.e., the VA). Findings may not generalize to other populations or settings.

Conclusions

These analyses provide further support for the general effectiveness and safety of telemental health via teleconferencing. Moreover, they contribute to the literature on the effectiveness and safety of telemental health for individuals with serious mental illness—in this case, bipolar spectrum disorders. In the future, researchers should test the generalizability of the findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

Footnotes

Authors’ Contributions

N.R.S.: Conceptualization, methodology, investigation, resources, writing—original draft, and supervision. K.L.S.: Conceptualization, methodology, software, formal analysis, investigation, data curation, and writing—original draft. E.A.A.: Conceptualization, methodology, investigation, and writing—review and editing. C.M.B.: Conceptualization, methodology, investigation, and writing—review and editing. A.F.: Software, formal analysis, investigation, data curation, and writing—review and editing. S.L.C.: Investigation and writing—review and editing. N.M.: Investigation, and writing—original draft. H.M.B.: Project administration, visualization, and writing—review and editing. D.N.O.: Writing—review and editing. E.G.S.: Writing—review and editing. M.S.B.: Writing—review and editing. L.G.: Writing—review and editing. C.J.M.: Conceptualization, methodology, investigation, resources, writing—original draft, supervision, and funding acquisition.

Disclosure Statement

M.S.B. receives royalties (of less than $400/year) for sales of a Life Goals treatment manual, which informed the treatment in the Bipolar Disorders TeleHealth Program. None of the other authors have any conflicts of interest to declare.

Funding Information

This work was supported in part by the Quality Enhancement Research Initiative [QUE 20–026] (Co-PI: Miller).

References

The White House. FACT SHEET: President Biden to Announce Strategy to Address Our National Mental Health Crisis, As Part of Unity Agenda in his First State of the Union. 2022. Available from: https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/

Centers for Disease Control and Prevention. Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html [Last accessed: April 7, 2020 ].

Abel

, Shimada

, Wang

, et al. Dual use of a patient portal and clinical Video telehealth by veterans with mental health diagnoses: Retrospective, cross-sectional analysis. J Med Internet Res, 2018; 20(11):e11350; doi: 10.2196/11350

Patel

, Huskamp

, Busch

, et al. Telemental health and us rural-urban differences in specialty mental health use, 2010-2017. Am J Public Health, 2020; 110(9):1308–1314; doi: 10.2105/ajph.2020.305657

Buzza

, Ono

, Turvey

, et al. Distance is relative: Unpacking a principal barrier in rural healthcare. J Gen Intern Med, 2011; 26,(Suppl 2):648–654; doi: 10.1007/s11606-011-1762-1

Weeks

, Wallace

, West

, et al. Research on rural veterans: An analysis of the literature. J Rural Health, 2008; 24(4):337–344; doi: 10.1111/j.1748-0361.2008.00179.x

Abrams

, Sossong

, Schwamm

, et al. Practical issues in delivery of clinician-to-patient telemental health in an Academic Medical Center. Harv Rev Psychiatry, 2017; 25(3):135–145; doi: 10.1097/hrp.0000000000000142

Bashshur

, Shannon

, Bashshur

, et al. The empirical evidence for telemedicine interventions in mental disorders. Telemed J E Health, 2016; 22(2):87–113; doi: 10.1089/tmj.2015.0206

Godleski

, Darkins

, Peters

. Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatr Serv, 2012; 63(4):383–385; doi: 10.1176/appi.ps.201100206

10.

Hilty

, Ferrer

, Parish

, et al. The effectiveness of telemental health: A 2013 review. Telemed J E Health, 2013; 19(6):444–454; doi: 10.1089/tmj.2013.0075

11.

Pifer

. Telehealth Groups Applaud CONNECT Reintroduction in Senate. Available from: https://www.healthcaredive.com/news/connect-for-health-act-reintroduced-telehealth-cheers/653630 [Last accessed: February 14, 2024 ].

12.

Patel

, Mehrotra

, Huskamp

, et al. Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States. Health Aff (Millwood), 2021; 40(2):349–358; doi: 10.1377/hlthaff.2020.01786

13.

Carmassi

, Bertelloni

, Dell’Oste

, et al. Tele-psychiatry assessment of post-traumatic stress symptoms in 100 patients with bipolar disorder during the COVID-19 pandemic social-distancing measures in Italy. Front Psychiatry, 2020; 11:580736; doi: 10.3389/fpsyt.2020.580736

14.

Sánchez-Guarnido

, Urquiza

, Sánchez

, et al. Teletherapy and hospitalizations in patients with serious mental illness during the COVID-19 pandemic: A Retrospective Multicenter Study. PLoS One, 2022; 17(4):e0267209; doi: 10.1371/journal.pone.0267209

15.

Morland

, Greene

, Rosen

, et al. Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. J Clin Psychiatry, 2010; 71(7):855–863; doi: 10.4088/JCP.09m05604blu

16.

Ruskin

, Silver-Aylaian

, Kling

, et al. Treatment outcomes in depression: Comparison of remote treatment through telepsychiatry to in-person treatment. Am J Psychiatry, 2004; 161(8):1471–1476; doi: 10.1176/appi.ajp.161.8.1471

17.

Bauer

, Krawczyk

, Miller

, et al. Team-based telecare for bipolar disorder. Telemed J E Health, 2016; 22(10):855–864; doi: 10.1089/tmj.2015.0255

18.

Bauer

, Krawczyk

, Tuozzo

, et al. Implementing and sustaining team-based telecare for bipolar disorder: Lessons learned from a model-guided, mixed methods analysis. Telemed J E Health, 2018; 24(1):45–53; doi: 10.1089/tmj.2017.0017

19.

Govindarajan

, Ramamurti

. Delivering world-class health care, affordably. Harvard Business Rev, 2013; 91(11):117–122.

20.

Ali

, Chwastiak

, Poongothai

, et al. INDEPENDENT Study Group. Effect of a collaborative care model on depressive symptoms and glycated Hemoglobin, blood pressure, and Serum Cholesterol among patients with depression and diabetes in India: The INDEPENDENT Randomized Clinical Trial. JAMA, 2020; 324(7):651–662; doi: 10.1001/jama.2020.11747

21.

Miller

, Grogan-Kaylor

, Perron

, et al. Collaborative chronic care models for mental health conditions: Cumulative meta-analysis and metaregression to guide future research and implementation. Med Care, 2013; 51(10):922–930.

22.

Von Korff

, Gruman

, Schaefer

, et al. Collaborative management of chronic illness. Ann Intern Med, 1997; 127(12):1097–1102; doi: 10.7326/0003-4819-127-12-199712150-00008

23.

Wagner

, Austin

, Von Korff

. Organizing care for patients with chronic illness. Milbank Q, 1996; 74(4):511–544.

24.

Department of Veterans Affairs Office of Research and Development. Program Guide: 1200.21. VHA Operations Activities That May Constitute Research. Available from: https://www.research.va.gov/resources/policies/ProgramGuide-1200-21-VHA-Operations-Activities.pdf [Last accessed: February 14, 2024 ].

25.

Bauer

, Kilbourne

, Greenwald

, et al. Overcoming Bipolar Disorder: A Comprehensive Workbook for Managing Your Symptoms and Achieving Your Life Goals. New Harbinger Publications; 2009.

26.

U.S. Department of Veterans Affairs. 172VA10P2: VHA Corporate Data Warehouse - VA. 79 FR 4377. 2023.

27.

Bauer

, Vojta

, Kinosian

, et al. The internal state scale: Replication of its discriminating abilities in a multisite, public sector sample. Bipolar Disord, 2000; 2(4):340–346; doi: 10.1034/j.1399-5618.2000.020409.x

28.

Selim

, Rogers

, Fleishman

, et al. Updated U.S. population standard for the Veterans RAND 12-item health survey (VR-12). Qual Life Res, 2009; 18(1):43–52; doi: 10.1007/s11136-008-9418-2

29.

Stevanovic

. Quality of life enjoyment and satisfaction questionnaire-short form for quality of life assessments in clinical practice: A Psychometric Study. J Psychiatr Ment Health Nurs, 2011; 18(8):744–750; doi: 10.1111/j.1365-2850.2011.01735.x

30.

Bajor

, Balsara

, Osser

. An evidence-based approach to psychopharmacology for Posttraumatic Stress Disorder (PTSD) - 2022 update. Psychiatry Res, 2022; 317:114840; doi: 10.1016/j.psychres.2022.114840

31.

Bajor

, Ticlea

, Osser

. The psychopharmacology algorithm project at the harvard south shore program: An update on posttraumatic stress disorder. Harv Rev Psychiatry, 2011; 19(5):240–258; doi: 10.3109/10673229.2011.614483

32.

Skeie-Larsen

, Stave

, Grønli

, et al. The effects of pharmacological treatment of nightmares: A systematic literature review and meta-analysis of placebo-controlled, randomized clinical trials. Int J Environ Res Public Health, 2022; 20(1); doi: 10.3390/ijerph20010777

33.

Pacchiarotti

, Bond

, Baldessarini

, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry, 2013; 170(11):1249–1262; doi: 10.1176/appi.ajp.2013.13020185

34.

El-Mallakh

, Vöhringer

, Ostacher

, et al. Antidepressants worsen rapid-cycling course in bipolar depression: A STEP-BD randomized clinical trial. J Affect Disord, 2015; 184:318–321; doi: 10.1016/j.jad.2015.04.054

35.

Goldberg

, Truman

. Antidepressant-induced mania: An overview of current controversies. Bipolar Disord, 2003; 5(6):407–420; doi: 10.1046/j.1399-5618.2003.00067.x

36.

McGirr

, Vöhringer

, Nassir Ghaemi

, et al. Safety and efficacy of adjunctive second-generation antidepressant therapy with a mood stabiliser or an atypical Antipsychotic in Acute Bipolar Depression: Randomised systematic review and meta-analysis of a placebo-controlled trials. Focus (Am Psychiatr Publ), 2021; 19(1):129–137; doi: 10.1176/appi.focus.19102

37.

Bauer

, McBride

, Williford

, et al. Cooperative Studies Program 430 Study Team. Collaborative care for bipolar disorder: Part I. Intervention and implementation in a randomized effectiveness trial. Psychiatr Serv, 2006; 57(7):927–936; doi: 10.1176/ps.2006.57.7.927

38.

Department of Veterans Affairs–Department of Defense Working Group. Management of bipolar disorder in adults, version 2.0 (full version). Department of Veterans Affairs & Department of Defense: Washington, DC; 2010.

39.

Raskind

, Peterson

, Williams

, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry, 2013; 170(9):1003–1010; doi: 10.1176/appi.ajp.2013.12081133

40.

VA/DoD Clinical Practice Guideline. Management of Bipolar Disorder Work Group. U.S. Government Printing Office: Washington, DC; 2023.

Ten Years of Bipolar Telehealth: Program Evaluation of a Team-Based Telemental Health Clinic

Abstract

Objectives:

Methods:

Results:

Conclusions:

Introduction

ACCESS TO CARE

TELEMENTAL HEALTH

THE BIPOLAR DISORDERS TELEHEALTH PROGRAM

INITIAL EVALUATION OF THE PROGRAM

PROGRAM EVALUATION GOALS

Methods

OVERVIEW

PROGRAM DESCRIPTION

VETERAN SAMPLE

DATA ANALYSIS

Results

VETERAN SAMPLE

CLINICAL OUTCOMES

PATIENT SAFETY

PRESCRIPTION QUALITY METRICS

Discussion

LIMITATIONS

Conclusions

Footnotes

Authors’ Contributions

Disclosure Statement

Funding Information

References