Teleintegrated vs Telereferral Care for Complex Psychiatric Disorders

Megan Brooks

September 01, 2021

Two models for treating patients with complex psychiatric disorders in primary care are equally effective, new research suggests.

Results from a pragmatic, randomized comparative effectiveness study involving more than 1000 patients showed that both integrated telepsychiatry collaborative care (TCC) and telepsychiatry/telepsychology enhanced referral (TER) provided "significantly and substantially" improved clinical outcomes, researchers note.

However, the referral model required substantially more mental health specialist time than the integrated model.

Therefore, from a societal perspective, the integrated care approach "more efficiently uses this scarce resource," lead author John Fortney, PhD, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, told Medscape Medical News.

The findings were published online August 25 in JAMA Psychiatry.

Clinically Meaningful Improvement

The Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT) trial included 1004 adults with untreated posttraumatic stress disorder and/or bipolar disorder. The participants were from 24 primary care clinics in rural and underserved areas in which there were no on-site psychiatrists or psychologists.

In SPIRIT, 508 patients were randomly allocated to TCC, and 496 were assigned to TER.

With TCC, an on-site behavioral health care manager and an off-site telepsychiatrist consultant support the primary care clinician in prescribing medications. With TER, an off-site telepsychiatrist prescribes medication, and an off-site telepsychologist delivers therapy.

The primary outcome was mental health functioning at 12 months, as measured by the Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score. MSC scores range from 0 to 100.

Baseline MCS scores for the study participants were two standard deviations below the national average. The mean MCS scores were 39.7 and 41.2 in the TCC and TER groups, respectively.

There was no significant difference between TCC and TER in 12-month MCS score (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). In addition, no significant differences in treatment effects were identified.

Patients in both groups experienced "large and clinically meaningful" improvements in MCS scores from baseline to 12 months (Cohen d =  0.81 and 0.90 for TCC and TER, respectively), the researchers report.

"Bit of a Surprise"

The comparative effectiveness of both models in this study was "a bit of a surprise," Fortney noted.

"We hypothesized that TCC would have better outcomes than TER because we thought patients would be more likely to engage in treatment," he said.

In collaborative care, the familiar primary care practitioner is the prescriber. The local care manager's job is to keep patients engaged in care, said Fortney.

"However, because the medical school telemental health providers were privileged and credentialed to practice in the primary care clinic, the referral process to the telepsychiatrist and telepsychologist was much more successful than it usually is. So engagement was the same in both groups, and thus outcomes were equally as good," Fortney said.

He noted that the referral model is used more than the collaborative care model "because it is similar to the more traditional approach to managing complex psychiatric disorders. I would say this is true both before and after COVID-19, but moreso after."

From a healthcare system perspective, "clinical leadership should implement whichever approach is most sustainable," the investigators conclude.

Good News for Clinics

Commenting on the study for Medscape Medical News, Adam C. Powell, PhD, president of Payer+Provider Syndicate, said the "similar efficacy" of teleintegrated care and telereferral care for delivering behavioral health services in primary care is "good news for clinics," because it suggests that clinicians may pick between the two modes of delivery and achieve similar outcomes.

"The resources available within a clinic may determine which of these approaches is most viable. The teleintegrated care approach requires the clinic to have more extensive resources locally," Powell noted.

However, he pointed out that the study did not report relative costs of the two approaches, which may also be a factor in determining which one clinics choose to implement.

"Overall, the study shows that advances in telemedicine are making it possible for patients to access telepsychiatry and to achieve improvements in their mental health. Given the lack of access that many patients face, telepsychiatry offers one potential solution," Powell concluded.

The SPIRIT study was funded by a grant from the Patient-Centered Outcomes Research Institute. Fortney and Powell have reported no relevant financial relationships.

JAMA Psychiatry. Published online August 25, 2021. Abstract

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