Video mental health care may have clinical advantages versus phone or in-person visits

1. In this retrospective cohort study, veterans receiving most outpatient mental health care by video had lower adjusted rates of mental health hospitalization, emergency department visits, and suicidal behaviors than those receiving mostly phone or in-person care.

2. Video-based care was also associated with greater appointment completion, although differences in health status and resources among patients choosing video care may have confounded results.

Evidence Rating Level: 2 (Good)

Study Rundown: Tele-mental health expanded rapidly during the COVID-19 pandemic and has remained an important component of outpatient psychiatric care, including within the Veterans Health Administration, where remote visits now account for a substantial share of mental health encounters. Previous randomized trials have generally suggested that video-based psychotherapy can achieve symptom outcomes comparable with in-person treatment for conditions such as depression and posttraumatic stress disorder. Far less evidence has directly compared video with audio-only telephone care, despite concern that telephone visits may limit clinicians’ ability to assess nonverbal behavior and establish therapeutic rapport. In this retrospective comparative effectiveness study, investigators evaluated veterans receiving ongoing outpatient mental health treatment and classified them according to whether most of their care occurred by video, phone, or in person. During subsequent follow-up, predominantly video-based care was associated with lower rates of mental health hospitalization, emergency department use, and suicidal behaviors compared with both other modalities. Video care was also associated with better appointment completion. However, patients using video tended to be healthier, better resourced, and had fewer unrelated medical or surgical hospitalizations, suggesting that statistical adjustment did not fully account for baseline differences. Generalizability was further limited by the veteran population, exclusion of patients without a dominant modality, and possible access-related differences in use of in-person emergency services. Overall, video mental health care appeared associated with modest advantages, particularly over telephone care.

Click to read the study in JAMA

Relevant Reading: Systematic review and meta-analysis of no show or non-attendance rates among telehealth and in-person models of care

In-Depth [retrospective cohort]: This retrospective comparative effectiveness study used national Veterans Affairs administrative data from patients who completed at least 3 outpatient mental health appointments between July 2021 and October 2022. Patients were assigned to video, phone, or in-person cohorts when more than 50% of their outpatient mental health visits occurred through that modality. Patients without a majority modality, those with insufficient visits, missing covariates, or data from excluded VA facilities were omitted. Outcomes were assessed over a 1-year follow-up period and included mental health hospitalization, mental health emergency department visits, suicidal behaviors, and appointment completion. Models were adjusted for demographic characteristics, socioeconomic status, rurality, broadband access, psychiatric and medical comorbidities, previous health care utilization, and facility characteristics. The final cohort included 813,699 veterans; 42.2% predominantly received video care, 37.5% in-person care, and 20.3% phone care. Unadjusted mental health hospitalization rates were 0.9% with video, 2.1% in person, and 1.6% by phone. After adjustment, video care was associated with a 0.5-percentage-point lower expected probability of hospitalization compared with both phone and in-person care (average treatment effect [ATE], −0.005 for each comparison; both p<0.001). Mental health ED visits were similarly lower with video versus phone (ATE, −0.006; p<0.001) and in-person care (ATE, −0.005; p<0.001). Suicidal behaviors were also less frequent with video versus phone (ATE, −0.003; p<0.001) and in-person care (ATE, −0.001; p<0.001). Video users completed 71.1% of appointments, compared with 68.0% for in-person and 68.4% for phone care; adjusted appointment completion was 4.1 percentage points higher versus phone and 3.6 points higher versus in-person care (both p<0.001). Importantly, the negative-control analysis showed fewer medical or surgical hospitalizations among video users, supporting the likelihood of residual confounding and cautioning against causal interpretation of the observed associations.

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