Home-based, telemental health care delivers better quality of life for veterans

Home-based telemental health care for depression is well received by patients and delivers as good a quality of life as in-person visits, according to the results of a clinical trial in 241 depressed elderly veterans reported in the Journal of Clinical Psychiatry by investigators at the Medical University of South Carolina and the Ralph H. Johnson VA Medical Center (VAMC).

Depression affects 10 percent of Americans and is a leading cause of disability and mortality.  And yet, only an estimated 56 percent of patients with depression seek treatment.  Barriers to treatment include mobility issues (especially in the elderly), transportation costs, missed days of work, geographic isolation, and fear of the associated stigma. By overcoming some of those barriers, telemental health could improve access to care for these patients.

Leonard E. Egede, M.D., director of the MUSC Center for Health Disparities and the Allen H. Johnson Endowed Chair for General Internal Medicine and Geriatrics, led a strong collaborative team of MUSC and VAMC investigators, along with Christopher Frueh, Ph.D., director of clinical research at The Menninger Clinic and adjunct professor from Baylor College of Medicine.

“This is the largest randomized clinical trial to date examining whether differences exist in patient perceptions, satisfaction, therapeutic alliance, and quality of life between telemental health and same-room care,” Egede said.

Male and female veterans aged 58 years and older who met the criteria for major depressive disorder (DSM-IV), including Vietnam era veterans, were eligible for enrollment in the trial. All participants received eight weeks of behavioral activation therapy and were randomly assigned to telemental health or in-person counseling.  Behavioral activation reflects the notion that the patient’s activity plays a role in how he or she feels and the goal of therapy is to reduce behaviors that promote depression.

Telemental health treatment sessions were delivered via in-home videoconferencing using a standard telephone line and did not require an internet connection. The 36-item Short Form Survey was used to assess quality of life and the Charleston Psychiatric Outpatient Satisfaction Scale was used to assess patient satisfaction. Scores on these scales did not differ significantly at 12-month follow-ups between veterans who received depression care via telemental heath and those who received in-person care.

Egede and colleagues had previously reported primary outcome and cost analysis results from this same trial of 241 depressed elderly veterans. In a 2015 Lancet Psychiatry article, Egede showed that telemental health care was non-inferior to same-room delivery in patients with a major depressive disorder for eliciting a treatment response. A treatment response was defined as a 50 percent decrease in depression symptoms at a 12-month follow-up appointment vs baseline and the absence of a diagnosis of major depressive disorder at a12-month follow-up. In an article published online on September 28, 2016 by the Journal of Affective Disorders, Egede showed that the overall inpatient costs as well as outpatient and pharmacy costs for treating depression increase over time in elderly veterans, regardless of whether the treatment is delivered in person or via telemental health. This increase in cost is likely a result of the rising number of visits.

In conjunction with these earlier findings that primary outcomes (i.e., treatment response) and costs for telemental health care are similar to those for in-person depression care, the report in the Journal of Clinical Psychiatry that telemental health also delivers similar quality of life and patient satisfaction suggests that it is a viable alternative to in-person visits for treating elderly patients with depression.

Most of the elderly veterans enrolled in this study were male, and patients with active psychosis or dementia, a substance dependence, or suicidal ideation and clear intent were excluded from the trial. As such, the study’s findings may not be generalizable to those populations.

Simple solutions such as home-based videoconferencing that does not require an internet connection may be an effective way to address the mental health needs of rural patients, particularly elderly ones. However, not all payers currently reimburse for telemental health care for depression. Evidence that telemental heath care delivers similar treatment response, patient satisfaction, and quality of life at a similar cost as in-person clinics suggests that it may be time for that to change.

“Taken together, these three studies demonstrate that telemental health is equivalent to in-person care for depression in terms of primary outcomes, secondary outcomes and quality of life, as well as cost,” Egede said. “It is time for telemental health to take its rightful place alongside in-person counseling as a viable option for depression care, one that will remove many barriers to care.”

About MUSC
Founded in 1824 in Charleston, The Medical University of South Carolina is the oldest medical school in the South. Today, MUSC continues the tradition of excellence in education, research, and patient care. MUSC educates and trains more than 3,000 students and residents in six colleges (Dental Medicine, Graduate Studies, Health Professions, Medicine, Nursing, and Pharmacy), and has nearly 13,000 employees, including approximately 1,500 faculty members.