Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial

Peter M Yellowlees, Michelle Burke Parish, Alvaro D Gonzalez, Steven R Chan, Donald M Hilty, Byung-Kwang Yoo, J Paul Leigh, Robert M McCarron, Lorin M Scher, Andres F Sciolla, Jay Shore, Glen Xiong, Katherine M Soltero, Alice Fisher, Jeffrey R Fine, Jennifer Bannister, Ana-Maria Iosif, Peter M Yellowlees, Michelle Burke Parish, Alvaro D Gonzalez, Steven R Chan, Donald M Hilty, Byung-Kwang Yoo, J Paul Leigh, Robert M McCarron, Lorin M Scher, Andres F Sciolla, Jay Shore, Glen Xiong, Katherine M Soltero, Alice Fisher, Jeffrey R Fine, Jennifer Bannister, Ana-Maria Iosif

Abstract

Background: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking.

Objective: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method.

Methods: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months.

Results: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention.

Conclusions: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care.

Trial registration: ClinicalTrials.gov NCT02084979; https://ichgcp.net/clinical-trials-registry/NCT02084979.

Keywords: Spanish-speaking; asynchronous telepsychiatry; collaborative care; depression; primary care physician; psychiatric consultation; psychiatrist; synchronous telepsychiatry; telehealth; workforce.

Conflict of interest statement

Conflicts of Interest: The authors report no conflicting financial relationships with commercial interests except PMY, who received royalties from the American Psychiatric Association Press. JS is Chief Medical Officer for AccessCare, a provider of telemental health services, and has received royalties from the American Psychiatric Association Press and Springer Press. AMI has received honoraria for reviewing activities from Elsevier. SRC provided consultation services for Advanced Clinical, University of Wisconsin, Madison, and Orbit Health Telepsychiatry; he has also provided speaking services for North American Center for Continuing Medical Education, LLC; Scholastic Expeditions; Arizona Psychiatric Society; and Guidewell Innovation. He has affiliations with University of California, San Francisco; University of California, Davis; and Stanford University School of Medicine.

©Peter M Yellowlees, Michelle Burke Parish, Alvaro D Gonzalez, Steven R Chan, Donald M Hilty, Byung-Kwang Yoo, J Paul Leigh, Robert M McCarron, Lorin M Scher, Andres F Sciolla, Jay Shore, Glen Xiong, Katherine M Soltero, Alice Fisher, Jeffrey R Fine, Jennifer Bannister, Ana-Maria Iosif. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.07.2021.

Figures

Figure 1
Figure 1
Participants flow through 12-month follow-up. ATP: asynchronous telepsychiatry; STP: synchronous telepsychiatry.

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