Clinical Predictors of Engagement in Teleintegrated Care and Telereferral Care for Complex Psychiatric Disorders in Primary Care: a Randomized Trial

Abstract

BackgroundTelepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations.ObjectiveAssess clinical predictors of treatment engagement for complex psychiatric conditions in TCC—in which remote specialists consult with primary care teams via an onsite care manager who also provides brief psychotherapy—and TER, in which remote specialists provide direct telehealth treatment.DesignA randomized pragmatic trial from twenty-four primary care clinics without onsite psychiatrists or psychologists.ParticipantsA total of 1,004 adult patients screened positive for posttraumatic stress disorder (PTSD)and/or bipolar disorder were randomized to receive TCC or TER for 1 year.Main MeasuresPsychotherapy engagement was measured by the number of sessions completed, and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ).Key ResultsEngagement in TCC psychotherapy visits was greater compared to TER. There was no association between the PTSD symptom severity and treatment engagement. The internal state scale (ISS) activation subscale, an indicator of mania, was associated with reduced odds of initiating psychotherapy (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) but not the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10(DAST-10) score was associated with receipt of fewer psychotherapy sessions (incidence ratio rate [IRR] = 0.88; 95% CI, 0.81 to 0.95). The number of physical health comorbidities was associated with greater engagement in psychotherapy (IRR = 1.11, 95% CI, 1.03 to 1.19) and pharmacotherapy (OR = 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group.ConclusionsBoth teleintegrated and telereferral care offer an opportunity to treat patients with complex psychiatric conditions. While there was no difference in clinical characteristics predicting engagement, onsite care managers engaged patients in more psychotherapy sessions than remote therapists.Trial RegistrationClinicalTrials.gov Identifier: NCT02738944