Access to Care for Veterans With Serious Mental Illness During the COVID-19 Pandemic
Abstract
Objective:
The authors examined access to care among persons with serious mental illness during the pandemic and disparities in use of virtual care among this population versus among individuals with other psychiatric diagnoses.
Methods:
Data from the Veterans Health Administration were used to examine whether the number of visits for serious mental illness differed for January–September 2019 versus the same period in 2020. Mixed-effects regression analyses tested whether the post–COVID-19 rate of growth in virtual care differed for people with serious mental illnesses versus those with other diagnoses.
Results:
Fewer visits for serious mental illnesses occurred during the initial weeks of the pandemic but not subsequently. The rate of growth in video visits during 2020 was slower for serious mental illnesses than for other psychiatric diagnoses.
Conclusions:
Several months after the pandemic’s start, the total number of visits for serious mental illnesses was similar to 2019; however, adoption of video care was slower than for other psychiatric diagnoses.
Highlights
•
Findings indicate that the use of virtual video mental health care for individuals with serious mental illnesses has lagged behind that of their peers with other mental health concerns during the COVID-19 pandemic.
•
Disparities in use of video care among individuals with serious mental illness versus other mental health concerns is troubling because video visits facilitate needed clinician observation.
Individuals with serious mental illness (including schizophrenia and other psychotic and bipolar disorders) are disproportionately at risk of experiencing significant challenges directly related to the COVID-19 pandemic. Potential challenges include cognitive deficits associated with serious mental illnesses that may affect risk mitigation practices, low health literacy, high rates of unstable or congregate living situations, and high prevalence of metabolic disorders. Moreover, for many persons with serious mental illness, the pandemic has led to the further collapse of tenuous and limited social networks and risky delays or reductions in access to care for mental health and medical conditions (1). Indeed, little is known about this population’s access to mental health care during the pandemic, including whether disparities exist between those with and those without serious mental illnesses, both in general and within specific treatment modalities. This is a critical gap given that mental health settings are often a key to connecting, and sometimes the only touchpoint connecting, this population with health care systems.
The use of telepsychiatry has become critical during the COVID-19 pandemic (2), given large-scale public health efforts to shift from in-person services to remote modalities when clinically appropriate to reduce risk to both patients and clinicians. COVID-19 accelerated preexisting trends in this domain; even before the pandemic, rapid growth in telepsychiatry services was reported nationally, particularly in rural settings (3). Evidence supports comparable effectiveness of telepsychiatry via videoconferencing (TP-V) and in-person care (2). As virtual care scaled up rapidly, regulations also supported growth in telephone care, allowing providers and patients flexibility when encountered with barriers to video use (e.g., limited bandwidth). However, telephone visits have some limitations compared with TP-V, including difficulty assessing medication-induced movement disorders, difficulty fully evaluating and establishing rapport with new patients, and less nonverbal information (e.g., visual observation of grooming and response to internal stimuli, olfactory information about hygiene or intoxication) to support assessment and diagnosis (4).
In line with national trends in telepsychiatry care, the Veterans Health Administration (VHA) undertook large-scale efforts before the pandemic to increase and prioritize use of telepsychiatry—focused on TP-V—among mental health providers. Recent reports have documented the dramatic growth in TP-V encounters across the U.S. Department of Veterans Affairs (VA) during the first several weeks of the pandemic, including an 11-fold increase in use of TP-V by June 2020 compared with before the pandemic (2, 5). Less is known, however, about transitions to telehealth overall and to TP-V in particular during this time for populations with long-standing challenges in accessing mental health care prepandemic, such as veterans with serious mental illness. Limited evidence prepandemic suggested the feasibility and acceptance of TP-V among individuals with serious mental illness (6) but did not speak to the breadth of uptake in this population. A recently published study showed relatively comparable smartphone ownership between a population with serious mental illness and the general public but noted that individuals with schizophrenia (compared with those with bipolar disorder), older individuals, individuals with neurocognitive deficits, and individuals receiving disability income were less likely than their counterparts to own and use smartphones, suggesting possible additional challenges in a rapid transition to TP-V (7). Virtual care is likely to be a key care modality for the duration of the pandemic and beyond (5). As a result, it is crucial to understand whether virtual care has equivalent reach for vulnerable groups. Using the VHA as a case study, we aimed to characterize broad patterns in the total volume of care visits for people diagnosed with serious mental illnesses during the pandemic as well as adoption of TP-V by this population. The analyses aimed to identify potential areas for population-specific quality improvement and implementation work to enhance access to and quality of mental health care within the VA system.
Methods
We used national VHA administrative data (from the Corporate Data Warehouse) to study visits from January to September 2019 and January to September 2020. We used ICD-10 codes (F06.0, F06.2, F20.0–F20.9, F22–F31.9, F53) (8) to identify visits for serious mental illnesses versus other psychiatric diagnoses. Data entered by providers were used to classify each visit in terms of modality (telephone, TP-V, in person). Visits in which veterans at one VA site connected by video with providers at another VA site were considered in person because they required travel to a VA clinic. We excluded inpatient, residential, homeless services, vocational rehabilitation, and disability evaluation visits. The study was approved by the VA San Diego Healthcare System Institutional Review Board.
Analyses used mixed-effects regression (9) to assess whether the volume of mental health care visits for persons with and persons without serious mental illness (i.e., total encounters across modalities) differed between 2019 and 2020, accounting for time of year. Analyses also assessed whether, in 2020, pandemic-related changes in care modality (i.e., changes in visit distribution among in-person, telephone, and TP-V modalities) were comparable for visits for serious mental illnesses versus other diagnoses, controlling for the total number of visits. Models tested linear (time) and quadratic (time 2) trends; models comparing visits for serious mental illness versus for other psychiatric diagnoses included interactions between diagnosis and time terms. Nonsignificant interactions were removed, and the model was refit. Stata, version 15.0, was used for all analyses, with α=0.05.
Results
The total number of visits for people with diagnoses other than serious mental illnesses declined from 2019 to 2020 (b=−21,012.37, z=−4.19, p<0.001). In contrast, visits for people with serious mental illness diagnoses were lower in 2020 than in 2019, but not significantly so. To better understand this unexpected finding, we stratified the visits into four blocks of time, encompassing weeks 0–10 (January–March), 11–19 (March–May), 20–27 (May–July), and 28–37 (July–September) and conducted post hoc analyses refitting the model within each block. We found significant differences between 2019 and 2020 for the block after the pandemic’s onset (i.e., weeks 11–19, b=−3,120.11, z=−5.37, p<0.001) but not for the other blocks. That is, there were significantly fewer visits for serious mental illnesses in 2020 than in 2019 for the period from March to May, but the years were otherwise comparable.
Next, we evaluated change in proportion of video, in-person, and telephone encounters during 2020 (Figure 1). After accounting for total encounter volume, we found a time×diagnosis interaction (z=−5.04, p<0.001) indicating that the rate of change in video encounters differed for visits for serious mental illnesses. Simple effects indicated that the slope of the post–COVID-19 increase in video encounters was less steep for visits for serious mental illnesses (b=0.66, z=27.29, p<0.001) than for other mental health visits (b=0.95, z=19.51, p<0.001). In contrast, the model of the proportion of in-person visits included significant effects of both linear (b=−4.35, z=−15.67, p<0.001) and quadratic (b=0.13, z=9.65, p<0.001) time, and a main effect of diagnosis (b=44.08, z=2.29, p=0.022). Time×diagnosis terms were not significant. That is, the proportion of in-person visits declined sharply at the onset of COVID-19 but began to increase gradually around week 20; the slope of change did not vary by diagnosis, but in-person visits were more common for serious mental illness. For telephone visits, we found significant linear (b=3.37, z=14.07, p<0.001) and quadratic (b=−0.12, z=−10.35, p<0.001) terms, indicating an initial post–COVID-19 increase that began to decline around week 15. We found no differences between diagnostic groups.
Discussion
Across modalities, we found that the total volume of care visits for serious mental illness dipped temporarily in the initial weeks of the pandemic but recovered to near baseline levels thereafter. However, this finding masks differences in the rate of increase of TP-V use nationally for those with serious mental illness compared with those with other psychiatric diagnoses. Visits for serious mental illness were less likely to be conducted via video, and this difference may have clinical implications.
As the COVID-19 pandemic has progressed from an initial period of massive societal upheaval and a focus on populations at highest risk of poor outcomes from the disease to a sustained period of broad mitigation efforts, it is critical to understand the impacts of these changes and disruptions on the well-being of specific vulnerable populations. In the context of mental health, individuals with serious mental illness are a key example. This population faced challenges to accessing care even before the pandemic, with factors such as low income, poor insurance access, unstable housing, low education level, cognitive impairment, and limited social networks affecting engagement in health care (1).
For persons with serious mental illness in particular, TP-V may be of increased importance to facilitate more complete assessment of clinically meaningful symptoms (e.g., response to internal stimuli, extrapyramidal medication side effects) while minimizing COVID-19 exposure. There is a robust evidence base suggesting that TP-V services are equivalent to in-person care (10). Mental health providers are also often the primary points of contact within the health system for patients with serious mental illness, and TP-V could provide an opportunity for these clinicians to observe new medical symptoms and facilitate connections to medical services if needed. Given these considerations, our findings suggest that virtual care for individuals with serious mental illness may not yet be optimized.
There are several potential reasons for the slower uptake of TP-V in this population. Although this study excluded visits specifically conducted in the VHA’s homeless program, patients with serious mental illness in any mental health setting are more likely than those with other psychiatric diagnoses to experience residential instability and homelessness (11), which can make video visits more challenging even for individuals without serious mental illness. Although data show that many individuals with serious mental illness have access to smartphones (7), lack of stable wireless or broadband connectivity in their living or work spaces could impede their ability to complete a video visit. Patients with serious mental illness are likely to have narrower social support networks available to help access or troubleshoot technology in the face of cognitive or psychiatric symptoms that might impede successful use of videoconferencing.
These data had limitations, including a focus on the VA population, which may not be generalizable, and the potential for errors in categorization of virtual care modality. Data were limited to VA visits and could differ from those for care provided in the community. VA care includes support services not consistently found in non-VA mental health venues, such as vocational rehabilitation and services targeting homelessness, as well as the full continuum of services ranging from inpatient mental health, to residential rehabilitation, to a wide array of outpatient mental health programs, to medical care (12). These services all exist within an integrated health care system that may allow for greater ability to route patients with serious mental illness back within the VA to some level of mental health contact from various entry points. We looked at total encounters by modality but did not examine differences in continuity of care or treatment outcomes. We also did not examine acute care utilization, such as hospitalizations or emergency department care, which might also have been affected differentially among these populations, or performance measure changes, because these were beyond the scope of the study.
If uptake of TP-V remains slower for patients with serious mental illness versus those with other psychiatric diagnoses and if closer examination suggests a negative clinical impact, these findings suggest potential actionable next steps. There may be benefit in considering performance metrics quantifying the percentage of individuals receiving video versus telephone care within populations with serious mental illness or other vulnerable populations over time. Because local barriers to use of video care may differ from site to site, performance metrics may allow facilities to use comparative data in conjunction with local insights to investigate and narrow gaps in care. Findings also suggest potential value in developing and implementing brief, manualized sessions geared toward optimizing digital competencies among those with serious mental illness (13). Efforts to test these interventions in multiple settings and measure the impact of training on TP-V could have substantial value across health care systems. Work is ongoing within the VHA to expand the cadre of staff who can serve as digital navigators or supports for patients. In both the short and long term, investment in staff with expertise in navigating digital services with vulnerable populations might be valuable.
Conclusions
The findings reported here raise additional questions for further study. Given the higher rates of medical-cause morbidity and mortality among those with serious mental illness (14) and the advantages of video care over telephone when remote care is clinically appropriate, the question of whether a similar slower rate of switch to TP-V is seen across primary care visits among this population warrants examination. Obtaining qualitative data from patients to understand reasons for low uptake could be valuable. To improve mental health care, an improved understanding of the drivers and clinical consequences of lower TP-V use among individuals with serious mental illness during the pandemic is critical to inform optimal care delivery.
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Information & Authors
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Published In
History
Received: 9 December 2020
Accepted: 10 February 2021
Published online: 25 May 2021
Published in print: November 01, 2021
Keywords
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This study was supported in part by U.S. Department of Veterans Affairs (VA) Health Services Research and Development Career Development Award (15-074 to Dr. Gabrielian). The views expressed in this article are those of the authors alone and do not represent the views of the VA or the U.S. government.
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