Telehealth Visits for Mental Health Offset Decreased In-Person Services During Pandemic

In-person mental health services declined by more than 50% after the onset of COVID in March 2020 but were offset by a 16- to 20-fold increase in telehealth services among adults covered by private payers. 

According to a new study, mental health services declined by more than 50% after the onset of COVID-19 in March 2020 but were offset by a 16- to 20-fold increase in telehealth services among adults covered by private payers. 

This is a key finding from data published in JAMA Health Forum¹ which examined trends in mental health service utilization before and after the onset of COVID-19 among commercially insured adults in the United States between January 2020 and December 2020. 

Lead author of the study, Ryan K McBain, PhD, MPH of the Rand Corporation, in a podcast² discussing the study, said the decline in in-person mental health services during the pandemic was expected but the magnitude of the decline was surprising. 

The other surprise, he said, was the rapidly increased use of telehealth for these services during the first year of the pandemic offset the large decline in in-person services, which resulted in mental health services remaining stable over 2020.

He noted, however, while the supply (ie, providers delivering health care services) may have stayed stable during 2020, the demand (ie, patients) for these services increased with the rising prevalence of mental health conditions, particularly anxiety and depression, during the onset of the pandemic. He cautioned that the deficit in the supply side is a bit larger overall than prior to the pandemic.

Dr McBain underscored that this study is the first to offer an in-depth look at mental health services by diagnostic category during the first year of the pandemic in a large sample of commercially insured adults in the United States. As such, it offers useful insight the future use of telehealth for mental health services and issues critical to its implementation such as reimbursement and access. 

Conducted by researchers from the RAND Corporation and Castlight Health (a health benefits manager for employer-sponsored health insurance plans based in San Francisco, CA), the study included county-level utilization data from a national US database of commercial medical claims on over 5 million adults (18 years and older) across all 50 states from January to December. Using this dataset, Dr McBain and colleagues looked at weekly mental health services utilization rates for 5 diagnostic mental health conditions: major depressive disorder, anxiety disorders, bipolar disorder, adjustment disorder, and posttraumatic stress disorder (PTSD).

Researchers considered March 13, 2020, the date the United States declared SARS-CoV-2 a public health emergency, as demarcating utilization trends pre-COVID-19 (January 5 to March 13, 2022) and post-COVID-19 (March 13 to December 21). 

Results of the show COVID-19 was associated with an overall 50% drop in in-person mental health service utilization, which was fairly stable when looking at specific disorders. For example, utilization dropped by 52% for patients with bipolar disorder and 57% for those with major depressive disorder. In contrast, the study found as in-person weekly utilization rates fell, weekly utilization of telehealth services increased 16- to 20-fold, with the highest utilization for anxiety disorder and the lowest for bipolar disorder.

Overall, utilization of mental health services for major depressive disorder, adjustment disorders, and anxiety all increased in 2020 when combining both in-person and telehealth care. The greatest increase was seen for anxiety at 20%. 

When looking at the data by sex and age, utilization rates were higher for women seeking care for anxiety compared to men, lower for younger adults compared to older adults (aged 46 years and older), and lower among people living in rural counties nonadjacent to urban areas. 

Dr McBain said unlike cancer screening, for example, mental health care is well-suited for telehealth given that diagnosis and treatment do not require an in-person physical exam or lab work as is often necessary for physical conditions. He noted evidence based on prepandemic data showing the comparable efficacy between telehealth and in-person care for mental health services. 

Hannah Greenwood, a PhD student and research assistant, faculty of health sciences and medicine, Bond University, Queensland, Australia, who is a coinvestigator on a number of systematic reviews and meta-analyses of randomized clinical trials that assessed the difference between telehealth and face-to-face interventions for mental health conditions, said the findings of their studies indicate that telehealth is a good alternative to face-to-face therapy. The studies include an assessment of comparable effectiveness of telehealth and in-person interventions for anxiety, depression, and PTSD.^3-5 The researchers found similar results⁶ when looking at less common mental health conditions such as substance use disorder, eating disorders, tic disorders, or childhood disorders, as well as physical conditions requiring psychological support such as diabetes, cancer, and chronic fatigue syndrome

“Broadly, we found no evidence of a difference between in-person and telehealth delivery of services for the outcomes assessed (symptom severity, symptom improvement, function, working alliance, and satisfaction),” Ms Greenwood said. She cautioned, however, the studies do not show the 2 modes of treatment delivery are equivalent, as the study was designed only to assess evidence of differences. 

Going forward, Dr McBain expressed fear that some of changes in local, state, and federal policies which allowed comparable reimbursement for telehealth and in-persons services, may backslide. He thinks this may create an impetus for policy makers to consider whether to make permanent some of the policies that have allowed easier access to and reimbursement for telehealth services.

Dr McBain is not alone. The American Hospital Association (AHA) continues to advocate for Federal, state, and commercial payers to permanently adopt telehealth wavier provisions, such as payment parity, eliminating the originating and geographic site restrictions, and expanding telehealth eligibility to certain practitioners, according to Jennifer Holloman, AHA’s senior associate director of policy.

“Expansion of virtual care has transformed care delivery, expanded access for millions of Americans, and increased convenience in caring for patients,” said Ms Holloman. She said this is particularly true for behavioral health, citing research⁷ showing approximately 40% use of telehealth for behavioral health services at the peak of the pandemic, which has remained at around 36% for outpatient visits compared to less than 1% prior to the start of the pandemic.

Emerging evidence also supports the increased use of telehealth during the pandemic was not additive or overutilization of services, but rather that telehealth was a substitute for in-person care, Ms Hollomon said. The majority of telehealth⁸ visits did not require an in-person follow-up appointment for the next 3 months after the telehealth visit. “For behavioral health, which had over 4.3 million visits, only 15% needed an in person visit within three months and often this was attributed to cadence of therapy or monthly visit,” a spokesperson said.

Ms Hollomon underscored the potential for telehealth to help meet the increasing demand for behavioral health services during what is and is expected to be a provider shortage. She again cited data⁹  showing an expected shortage of between 14,000 and 31,000 psychiatrists by 2024, with already over half of US counties lacking any psychiatrists. “This is where telehealth hold potential to meet the demand for geographically dispersed patient populations, leveraging provider capacity from other locations,” she said.

Looking ahead, Dr McBain sees telehealth playing a prominent role in what he sees as a trend toward the development of more comprehensive, integrated models of care that use value-based payment models to provide more personalized, community- and home-based services.