Age Verification and What it Means for Access to Care

The mental health care system is in crisis – overwhelmed in the pandemic’s wake, with patients nationwide suffering from rising cases of anxiety, depression and other disorders. As a result, they are frequently left unable to find psychiatric and behavioral care. Telehealth companies like Cerebral are leading the way in addressing that need, but like any new innovation in health care, there is resistance. Traditional mental health providers feel threatened by this new model, which exponentially improves access for patients across the U.S. The fact is that there’s room and need for both traditional in-person care and telemedicine. Without both modalities, there’s no way we will make a dent in the acute challenges facing people from every walk of life and across the country. Telehealth isn’t a panacea, but it undoubtedly improves access and reduces the stigma associated with services that are out of reach for far too many people. Americans do not have adequate access to mental health care. Nearly one-third of Americans live in an area that has a shortage of mental health care professionals and 60 percent of all U.S. counties – including 80 percent of all rural counties – do not have a single psychiatrist. If patients are lucky enough to secure an appointment, they often have to wait months before their first session.  However, it is typical for non-psychiatrists to treat mental illness. In conventional health care, 79 percent of antidepressants are prescribed by primary care doctors, so it’s a misconception to think that psychiatrists are prescribing the lion’s share in traditional settings. Nurse practitioners have a critical role to play. A key to improving access to care is to use experienced clinicians – often nurse practitioners – who play a vital role in the health care system, especially in underserved communities. As front-line clinicians, nurse practitioners are practiced hands in dealing with many aspects of mental health care, and Cerebral’s nurse practitioners are particularly well-equipped and supported to manage mental illnesses.  Besides being carefully screened and interviewed before joining the Cerebral team, our nurse practitioners receive additional training and clinical support for the treatment of the psychiatric conditions we see most frequently, including depression, anxiety, bipolar disorder, insomnia, and PTSD, among others. Should they want to discuss a challenging clinical situation, they can easily get in touch with a staff psychiatrist within minutes; this ‘second opinion’ line, which we call Curbside Consults, is an innovation that is available to our NPs 12 hours a day, 7 days a week  They are well positioned to monitor and counsel patients throughout the process of initial evaluation, treatment, and recovery.  A new study out this month (September 2022) found that the ranks of psychiatric mental health nurse practitioners (PMHNPs) are surging as caseloads increase. Notably, the number of PMHNPs who care for Medicare patients jumped 162 percent between 2011 and 2019, compared to a 6 percent decline in psychiatrists, which further underscores how important nurse practitioners are to match the burgeoning demand for care.      By utilizing nurse practitioners and telehealth, we are democratizing access to care, and supporting patients who have historically been disenfranchised by the mental healthcare system.     .  Indeed, nearly 2/3 of Cerebral patients have never had the privilege of receiving mental health care prior to coming to Cerebral. We can only improve what we measure. The vast majority of mental health professionals do not measure clinical outcomes. This would be unacceptable in any other field of medicine: you wouldn’t trust a diabetes doctor who did not regularly check your labs in order to monitor the progression of the disease. Why should depression or anxiety disorders be treated so differently?  Telehealth allows us to measure clinical outcomes using  tools that are integrated within the care experience. By monitoring how patients are doing via surveys, we are able to better understand whether treatment plans are working, or whether adjustments need to be made. Overall, knowing how patients are doing helps us improve clinical quality and maintain patient safety. Collecting patient outcomes data at scale can also be a benefit. It can establish new baselines for what is most effective for different types of patients, paving the way for the kind of precision medicine approach that has transformed cancer care and other specialties.         The bottom line is that the current mental health care system can’t improve access for desperate patients who desperately need care. While there have been missteps and necessary learnings along the way, telehealth has a vital role to play in this process. For tens of millions of Americans who need our help, their well being, and their lives, are on the line. 

Millions of students are set to return to college campuses all over the country over the next few weeks. While this is an exciting time for many students, it can be a challenging one as well, and one that has only been complicated by the effects of the pandemic. According to the CDC, three out of four Americans between the ages of 18 and 24 now report poor mental health resulting from the pandemic. This is among a population that is already more prone to mental health issues, with significantly greater portions of young adults in college reporting struggling with conditions such as anxiety and depression than their unenrolled peers. For example, a recent survey conducted by Fortune found that 43% of college students report struggling with anxiety and 33% report struggling with depression, compared to 29% and 27%, respectively, of US adults in general. Suicide and suicidal ideation rates are also especially high in college students: according to the National College Health Risk Behavior Survey, 10.3% of respondents reported seriously considering attempting suicide, 6.7% had made a suicide plan, and 1.5% reported they had attempted suicide one or more times in the 12 months preceding the survey. The good news is that many students suffering from these conditions see the value in seeking support from mental health care providers. According to a recent survey, 60% of prospective college students now say that mental health services are a very important factor in their search for a university, a statistic that has jumped significantly in the wake of the pandemic. University presidents and leadership also recognize the need: according to the American Counsel on Education, 68% of university presidents view student body mental health as one of their most pressing issues. The bad news is that, despite that awareness, many universities struggled for years to adequately meet that demand, making access challenging for students and creating barriers to care for many. The reason for this gap is largely due to resourcing issues. Most schools only offer in-person counseling options, and there are simply not enough credentialed providers to go around. Colleges have attempted to address this in the past by triaging patients through a “stepped care” model, under which students initially receive the least resource-intensive form of care and are only allowed a more fulsome approach if it is deemed necessary. Other schools have capped the number of sessions an individual can schedule with a provider in an attempt to free up appointment time. Either way, it is clear that there are not enough traditional mental healthcare resources to meet the needs of America’s college students. This is where telehealth and Cerebral come in. As a telemental health care provider, Cerebral can help plug the resourcing gaps that many colleges are experiencing. Cerebral provides students suffering from mental health issues with the ability to book an appointment with a provider within days, alleviating some of the historically lengthy wait times for college counseling services. Cerebral is also able to quickly adapt to a patient’s needs, allowing students to increase or decrease their care as needed and without restrictions. Furthermore, students can now receive care in the comfort and privacy of their dorm, which will lower the threshold for seeking care. Some students find it intimidating or shameful to walk into the counseling centers. We already actively partner with a number of universities to offer this kind of hybrid approach to mental health care for students. For example, we partnered with Arkansas Colleges of Health Education (ACHE) to provide all students access to Cerebral’s telehealth services. A hybrid approach such as the one deployed by ACHE should be considered the future of mental health care on college campuses as university officials continue to look for ways to expand access and meet demand among their student populations. College is a stressful and intense time for many, and adequate mental health support can make navigating it all the more manageable.

In May, we announced that of the patients who come to Cerebral with suicidal ideation (SI), 49.7% no longer harbor suicidal thoughts after treatment for an average of 6 months. Since publishing that data, there has been a lot of interest in this study, and we wanted to provide additional insight and call attention to its significance. We conducted an analysis of the “before” and “after” results of 60,000 patients’ responses to the PHQ-9, the gold standard assessment scale for depression severity. Our data scientists examined all Cerebral patients’ responses from their initial intake through the present to determine if they reported an improvement in their experience of having suicidal thoughts. We found that 49.7% of these patients had indeed reported lower levels of SI at present compared to where they were during their initial intake appointment.  Intuitively, this data makes sense. At Cerebral, we are committed to providing our patients with high-quality care that improves their overall mental wellness, and many of our programs strive to find ways to actionably decrease SI. For example, we recently conducted a randomized quality improvement study in which we compared targeted interventions (text messages, phone calls, etc.) aimed at improving follow-up care for patients who express SI. We found that patients who received a caring text scheduled a follow-up in less than half the time compared to those who didn’t receive the text, indicating that proactively reaching out to patients can be critical in improving patient engagement and health outcomes.  However, it is also important to note that these data points are preliminary, and our findings still need to be validated further. Suicidal thinking is not static, and fluctuates with time, so it will be important to determine which specific factors are driving this decrease in suicidal thinking. In terms of next steps, we will work with leading researchers at Harvard to better understand and establish causality, and we are working to get our work published in peer-reviewed journals.    Still, gathering and analyzing data like this is an important first step in measuring mental health issues and treatment. Typically, the vast majority of traditional mental health providers do not keep records of clinical outcomes, much less data on suicidal thinking, in a systematic way. Our early results can start to improve our understanding of how our patients think and feel over time, allowing us to track the level of suicidal thinking, or suicidal ideation, they are experiencing as well.  In the past, we’ve asked many clinics a simple question: do you continually track the level of suicidality for your patient panels? 100% of responses were ‘No’. Some say they don’t have the technology, and others candidly reported that they are worried about legal liability: you can’t be liable for what you don’t know. This is a problem. We believe that sharing this kind of self-reported patient wellness data is critical to advancing our profession and advancing outcomes for patients.  The U.S. mental health system is failing patients, in large part because patients continue to be evaluated only subjectively, when objective measures do exist. We are working to establish a baseline where no baseline exists. This is actually a topic we hope to discuss at SXSW early next year. Data from this preliminary study, and other studies like it, can help advance precision psychiatry – which will improve the standards of care in the mental health industry by personalizing treatment, reducing suffering, and saving lives.