Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, United States.
Stanford University School of Medicine, Stanford, CA, United States.
J Med Internet Res. 2021 Jul 20;23(7):e24047. doi: 10.2196/24047.
Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking.
This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method.
Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months.
For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention.
This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care.
ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.
异步远程精神病学（ATP；延迟时间）咨询是初级保健环境中一种新颖的精神科咨询形式。缺乏比较 ATP 和同步远程精神病学（STP）临床效果的纵向研究。
本研究旨在确定 ATP 在改善英语和西班牙语初级保健患者的临床效果方面是否优于 STP，后者是远程精神病学的常规护理方法。
共有 36 名来自 3 个初级保健诊所的初级保健医生为具有非紧急精神障碍的 401 名寻求治疗的成年患者转诊了一个异质样本。共有 184 名（94 名 ATP 和 90 名 STP）英语和西班牙语参与者（36/184，19.6%西班牙裔）被纳入并随机分组，其中 160 名（80 名 ATP 和 80 名 STP）完成了基线评估。患者由他们的初级保健医生使用协作式护理模式进行治疗，并与加利福尼亚大学戴维斯分校健康分校的远程精神病医生协商，后者每 6 个月使用 ATP 或 STP 为患者提供咨询，最长可达 2 年。主要结局（临床医生评定的临床总体印象量表[CGI]和总体功能评估量表[GAF]）和次要结局（患者自我报告的身心健康和抑郁情况）每 6 个月评估一次。
对于临床医生评定的主要结局，ATP 在 6 个月随访时并未比 STP 更能促进改善（ATP 与 STP 相比，6 个月随访时的随访差异与基线差异的 CGI：0.2，95%CI-0.2 至 0.6；P=.28；和 GAF：-0.6，95%CI-3.1 至 1.9；P=.66）或 12 个月随访（ATP 与 STP 相比，12 个月随访时的随访差异与基线差异的 CGI：0.4，95%CI-0.04 至 0.8；P=.07；和 GAF：-0.5，95%CI-3.3 至 2.2；P=.70），但两组患者在这两个结局上都有统计学和临床意义上的显著改善。在任何随访中，ATP 和 STP 之间在任何患者自我报告的评分上都没有从基线改善的显著差异（所有 P 值均在.17 和.96 之间）。失访率高于预测，但在两个组之间相似。在有基线就诊的患者中，46.8%（75/160）在 1 年内没有随访，72.7%（107/147）在 2 年内没有随访。干预措施没有导致严重不良事件。
这是第一项表明 ATP 可以改善英语和西班牙语初级保健患者临床效果的纵向研究。虽然我们没有发现 ATP 在改善临床效果方面优于 STP 的证据，但它可能是初级保健中可用的阶梯式心理健康干预措施的关键部分。ATP 提供了一种可能的解决方案，以解决精神科医生的劳动力短缺问题，并为改善现有护理系统提供了一种策略。
ClinicalTrials.gov NCT02084979；https://clinicaltrials.gov/ct2/show/NCT02084979。
