How Telehealth Can Increase Access to Mental Healthcare for College Students

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. 

At Cerebral, we work hard to implement one of the best age and identity-verification processes in the telehealth industry, one that meets or surpasses legal requirements while helping patients access mental health care within days. Our process is an improvement over your typical brick and mortar facility, where ID checks are done manually by front-office staff. The verification process is not without friction, however, so it is our goal to create a seamless process that doesn’t restrict access for the patients who need it most. Improving the verification system is not a simple undertaking but we are working closely with providers and using the latest technology in-house to ensure we treat only those who are eligible for care. Our process begins with a manual ID review for new patients by clinicians, who also verify identifiers such as birthdate and address, and then compare photos to prospective patients by video. If a health care provider can’t definitively confirm the data, we direct providers to let prospective patients know we cannot serve them, and promptly cancel their account and make refunds. As an additional level of security, we ask individuals to upload images from a government-issued identification document (such as a passport or driver’s license), which we then compare to live photos of their face using Persona, a sophisticated software program that is a further safeguard in recognizing accounts of those who are under 18. This system is an important part of any new patient experience at Cerebral, but it is especially critical to ensure that we do not provide services to patients under the age of 18.  Psychiatric and behavioral issues affect people of all ages, not just adults, and access to mental health care for those under the age of 18 is especially complicated. In many states, children are prohibited from receiving care without the consent of their parents or legal guardian. At Cerebral, we do not work with patients under the age of 18. The advent of telehealth has brought new possibilities to our field, but also new challenges, such as age verification. We are dedicated to improving access to mental health care services wherever we can, while going above and beyond to ensure compliance with all applicable laws. We are constantly refining and improving our safety and quality measures to ensure we deliver best-in-class care so that our patients can feel better, sooner, and so that we can help our patients achieve positive clinical outcomes.

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.