Once a month, Jolie Gerding makes the hourlong, 50-plus-mile one-way trip to Sedan City Hospital from her rural Kansas home in Neodesha. Gerding is making the trek for her regular telehealth visit with Elizabeth Penick, Ph.D., a professor in the Department of Psychiatry and Behavioral Sciences at the University of Kansas Medical Center and a psychologist with The University of Kansas Health System.

At the critical access hospital in southeastern Kansas, Gerding makes herself comfortable in a room dedicated to telehealth visits. It is furnished with a television, table and chairs. Meanwhile, Penick, based two hours away on the KU Medical Center campus in Kansas City, Kansas, expertly manipulates the camera, zooming in until it’s like the two are sitting across the table from one another. In their 12 years together, Gerding and Penick have never met in person. Still, the relationship is as warm and genuine as if they’ve been talking face-to-face all this time.

“Telemedicine, for me, works really well,” Gerding said. “I love my doctor, and I would not be able to get this same level of service anywhere close to me.”

In the spring of 2008, Gerding was grappling with mild depression, and in consultation with her family physician, began successfully managing her symptoms with medication. But, after her husband was killed in a traffic accident in July of that year, she spiraled into a deeper depression that required more specialized care.

Gerding initially tried in-person counseling, but had a hard time getting comfortable in the sessions and the high turnover among mental health providers serving her small community made it difficult to establish a rapport with a provider. Her family physician suggested she try telehealth. Gerding thought talking to a doctor through a screen sounded a little odd, but she agreed to take the leap.

Though unsettled at first, Gerding had such an initial positive interaction with a psychiatrist via telehealth that she was sold on the experience ― including the technology, which she actually found helpful.

“In some ways, I think I feel more open to being able to talk about things via telehealth,” Gerding said. “There might be times that I wouldn’t say something in person, but I feel okay saying it to her there.”

PERFECT BLEND

Although the ongoing global COVID-19 pandemic has elevated the number of people seeking online mental health therapy, the ability to connect patients and providers remotely using videoconferencing technology has been part of the health care landscape for the better part of 30 years. Mental health care providers have embraced technology as part of a broader strategy to meet the sky-rocketing demand for trained therapists and counselors. Meanwhile, a growing number of people also are swiping and clicking their way to help through the thousands of mental health related apps currently available for download on a smartphone or other device.

“At the end of the day, it’s all about how we can find another way to make things better for the patients who we care about,” said William F. Gabrielli, M.D., Ph.D., chair of the Department of Psychiatry and Behavioral Sciences at KU Medical Center. “And as patients and doctors learn more about online therapy, the more the process improves.”

YES, IT WORKS

Both the American Psychiatric Association and the American Psychological Association have issued position statements supporting telehealth as a viable and effective option for delivering mental health services. The organizations also maintain robust online toolkits and other educational resources for practitioners.

Convenience, reduced travel time to and from appointments and less time spent away from work are all key benefits of telehealth. But, according to both providers and patients, remote mental health care’s biggest selling point is it provides broader access to care for populations that may not otherwise be able to connect to these specialists.

“One of the wonderful things about this technology is that it affords a level of accessibility to mental health services that we just haven’t really seen before,” said Reed Maxwell, Ph.D., an assistant professor in the Department of Psychiatry and Behavioral Sciences at KU Medical Center and a licensed psychologist with The University of Kansas Health System.

Maxwell devotes eight to 12 hours a week, or roughly the equivalent of a day to a day and-a-half, to telehealth visits. Many of those visits are with rural Kansas residents, including some who had no prior experience talking with a mental health specialist.

“As the technology, the clarity of video and the clarity of the audio improves, the barrier that is created by that lack of in-person contact does diminish somewhat,” he said. “Yes, the person is still on a screen. But the quality is such that, in my personal opinion, it doesn’t adversely affect the therapeutic relationship much.”

Sharon Cain, M.D., a licensed child and adolescent psychiatrist with The University of Kansas Health System, has seen remote counseling successfully deployed in urban settings as well, where families may not otherwise be able to tap into mental health care.

“It has worked very well,” said Cain, who also serves as division chief of child and adolescent psychiatry in the Department of Psychiatry and Behavioral Sciences at KU Medical Center, where faculty and trainees have used telehealth to connect to children at a large urban daycare in Kansas City, Missouri, and also partnered with school districts in Kansas City, Kansas, to operate the Telekid Care program.

“Often this was done in the school nurse’s office, where we can have teachers and school psychologists, social workers come in. Parents just needed to show up at the school, and it worked out so much easier.”

LEANING IN

KU Medical Center was one of the nation’s earliest adopters of telehealth technology, beginning in the 1990s. In fact, part of the university’s initial forays into the innovation included Cain and Penick ― along with other faculty ― exploring the effectiveness of the platform in rural Kansas and presenting their successes at national meetings.

That is why the Department of Psychiatry and Behavioral Sciences continues to promote the use of telehealth with faculty who also serve as clinicians with The University of Kansas Health System. They have been logging more than 300 telehealth visits a month, and that number is expected to grow as the shortage of mental health providers across Kansas bumps up against exploding demand for mental health services.

The department currently partners with 10 primary care clinics in rural locales in the state, taking patient referrals from physicians with no access to mental health providers. Lauren Lucht, executive director of behavioral and mental health at The University of Kansas Health System, is asked on a weekly basis about taking on more patients.

“It’s really difficult to recruit a psychiatrist the farther west you get in Kansas. We expect the demand and volume to exceed our capacity now, and we’re working hard to recruit so we can be able to expand our mission further to support the state,” Lucht said.

TRAINING THE NEXT GENERATION OF PROVIDERS

The success of those recruiting and expansion plans rests, in part, on creating and maintaining a pipeline of trained providers willing and able to embrace using technology to interact with their patients. The emergence of remote and online mental health treatment is requiring current practitioners to learn in real time how to translate traditional in-person interactions into an online environment.

Fortunately, psychology and psychiatry training programs are beginning to integrate telehealth into their curriculums to help prepare the next generation of providers. For example, the American Academy of Child and Adolescent Psychiatry is developing a national curriculum that universities would be able to insert into their existing programs. Meanwhile, training programs in the Department of Psychiatry and Behavioral Sciences at KU Medical Center have integrated telehealth in their curriculums for years.

Having the technical skill to operate successfully in the telehealth environment is important, but other skill sets are crucial as well, such as knowing how to properly collect and assess clinical information, understanding ethical and legal concerns and being sensitive to access and equity issues like physician and cultural biases for and against telehealth, said Eve-Lynn Nelson, Ph.D., a licensed psychologist with The University of Kansas Health System and a professor of behavioral psychology at KU Medical Center.

“I think we’ve hit that tipping point where people are seeing the technology more in their health care, and there is a building excitement about that technology,” Nelson said. “I know that our students and residents really like their experiences with telehealth ― in part because they want to be competitive in internships and postdoctoral fellowships.”

A DISTINCT DIFFERENCE

The growth of technology in clinical care has, perhaps not surprisingly, given rise to an explosion of mental health-related apps designed to tackle everything from mood tracking to managing stress, anxiety and depression. There are an estimated 10,000 mental and behavioral health apps available for download onto smartphones, tablets or other devices, aimed at every major psychiatric illness and therapeutic strategies for treating those conditions.

Telehealth services are often covered by insurance, accessed via secure videoconferencing platforms and guided by stringent privacy and confidentiality policies that protect individuals’ private data. By contrast, mental health apps frequently operate on a fee-for-service model with wide variability in how well they protect users’ personal data, said John Todorus, M.D., a licensed psychiatrist at Beth Israel Deaconess Medical Center in New York and a member of the American Psychiatric Association’s smartphone app evaluation work group. The working group has studied and made recommendations about using mental health apps.

Todorus also said many apps lack strong, high quality data to support their effectiveness.

“I think there’s been a lot of focus on commercializing these products and less focus on producing and providing high quality evidence that these apps work the way their developers claim,” he said. “It’s hard science to reproduce because a technology company may decline to share any of its data or other relevant information it considers proprietary.”

Although mental health providers have been slow to incorporate apps into their clinical work with patients, Todorus believes apps will eventually find firmer footing in the field.

The American Psychiatric Association’s work group has developed a hierarchical model practitioners and patients can use now to evaluate mental health apps. The model encourages users to review an app’s privacy policies and security features before considering its usability and whether it can help users reach their identified goal or purpose.

“Similar to the way different people may respond differently to the same medication, all people will not respond in the same way to a certain app. Not to mention apps are constantly being updated and changed,” Todorus said. “In developing our model, we looked at how we could help patients and clinicians focus on the important aspects of an app without us seeming like we were making a judgment about the app. What we’ve created is more of a checklist of things to consider.”

As apps evolve and become increasingly mainstream, KU Medical Center’s Gabrielli thinks these technologies can co-exist easily and peacefully within the traditional model, especially with current demand for mental health services far exceeding the availability of trained specialists to provide that care. Rather, these options help provide reinforcement and boost efficiency, while still leaving room for in-person services.

“There’s not a true threat that these apps or similar technologies will replace traditional therapists and in-person treatment,” Gabrielli said. “It’s simply a way of making services more available and making them more useful and more efficient.”

WHERE ARE WE GOING?

Going forward, the question isn’t if technology will reshape health care, and specifically mental health care, but to what extent it will remake the landscape. One of the only certainties is that the technology is evolving so rapidly, there’s no way to accurately predict the possibilities.

“The limits are endless depending on what technology we will have,” said Maxwell. “Who knows? Maybe one day we’ll have therapist holograms.”

Though Jolie Gerding understands how some people might prefer a more personal touch, telehealth is a perfect fit for her needs.

“It has made a tremendous difference in my life, and I know it can help a lot of people living in smaller underserved communities.”