Journal Article Annotations
2021, 4th Quarter
Annotations by Jai Gandhi, MD
Patients with bipolar disorder and/or posttraumatic stress disorder can achieve clinically significant improvements in the primary care setting through the use of either telepsychiatry collaborative care (TCC), where psychiatric providers deliver consultation, or telepsychiatry/telepsychology enhanced referral (TER), where psychiatric providers assume responsibility for the treatment. The primary outcome (Veterans RAND 12-item Health Survey Mental Component Summary score) and every secondary outcome (including multiple disorder specific symptom checklists) demonstrated statistically significant improvements across both methods of care delivery. Only the PTSD Checklist-5 demonstrated a statistically significant difference across groups, with statistically significant greater reductions in score for those enrolled in TER. Another notable difference found between arms was that the number telepsychiatry encounters were 3-fold greater in TER compared to TCC (mean [SD] of 4.3 [3.1] vs 1.4 [0.9]).
Strength and weaknesses:
This trial has multiple strengths: a large sample size, patients recruited from multiple different federally qualified health centers across multiple states, diversity in sexual orientation, gender identity, and race, and an incredibly inclusive approach to enrollment in the trial. The inclusive approach to enrollment suggests the trial represents a heterogeneous and generalizable patient population; the population notably included 3.8% of patients diagnosed with schizophrenia. While not a weakness, an important piece of information would have been a fiscal analysis of each arm. Ideally, the trial would have included a “usual care” arm to definitively establish the utility of these interventions compared to usual primary care.
These findings further emphasize the utility and scalability of collaborative care interventions, especially in the context of the overwhelming need for increased accessibility of mental health care. The enormous difference in demand on psychiatrist time between the two interventions (a mean of 1.4 encounters for TCC compared to a mean of 4.3 encounters for TER) without clinical superiority of either arm for most outcomes means that the best method to improve access and outcomes for patients within most systems or primary care clinics will be to establish TCC interventions. The important exception based on this trial would be the improved outcomes for PTSD seen with TER, an especially important consideration for populations with higher rates of PTSD.