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A STUDY ANSWERING THE QUESTION, HOW DOES THE PROVISION OF VIRTUAL IOP SERVICES COMPARE WITH IN-PERSON IOP SERVICES AT BWG

The provision of mental health treatment took an unexpected turn during 2020 as the COVID-19 virus created significant health risks with the in-person provision of mental health services (Maziotti & Rutigliano, 2021).

Therefore, many mental health providers, in response to the COVID-19 crisis, struggled to rapidly adapt mental health services from in-person to virtual protocols in an effort to meet the ongoing and escalating mental health needs of existing and potential patients with minimal disruption (Chen et al., 2020; Sasangohar et al., 2020). Hence, the aim of this study was to answer the question of whether a cognitive-behavioral treatment group, made up of individuals with serious mental illness (SMI), could obtain equivalent outcome measures when comparing pre- COVID, in-person service delivery to rapidly transitioned virtual service delivery during the COVID pandemic.

This study specifically investigated the question of whether there were any significant differences in pre- and post-outcome measures of depression and anxiety of pre-COVID individuals that participated in an in-person intensive outpatient program (IOP) with cognitive-behavioral protocols developed for in-person service delivery compared to individuals that participated in a virtual IOP with rapidly adapted protocols during COVID.

Background of the Problem

Telemental health (TMH) is defined as “the use of telecommunications or videoconferencing technology to provide mental health services” (National Institute of Mental Health [NIMH], n.d. para. 1) and incorporates a wide variety oftelecommunication options, such as telephone, mobile phone apps, Internet, text, computers, and so forth. And, prior to the COVID-19 pandemic, adapting in-person mental health services to TMH was accomplished through consideration of relevant research, existing guidelines, provider training, and evaluation of outcomes (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021a). However, the escalation in the need and demand for TMH during the COVID pandemic resulted in the rapid adaptation and implementation of TMH with programs originally developed for in- person protocols with little or no investigation into effectiveness and equivalency (Chiauzzi et al., 2020; Li et al., 2021). As such BWG worked to effectively transition an in-person IOP to the virtual provision of services that would maintain the same structure, cognitive-behavioral interventions, psychoeducational materials, and facilitators. In essence, the only aspect of the IOP which was significantly adapted was the service delivery method from in-person to virtual. In the past, the provision of psychoeducation, the learning of cognitive and affective coping skills/tools, and the behavioral practice and reinforcement of these strategies has been shown to produce effective outcomes with BWGs in-person IOP services.

Significance of the Study

The present research investigated the effectiveness of efforts to rapidly adapt mental health services from in-person interventions and protocols to TMH. This research was particularly relevant in the context of a global pandemic as many mental health providers, in response to the COVID-19 Crisis, struggled to rapidly adapt mental health services in an effort to meet the pre-COVID level of need as well as to mitigate the factors creating and exacerbating mental health needs, all without person-to-person contact (AlRasheed et al., 2022; Appleton et al., 2021; Burgoyne & Cohn, 2020; Li et al., 2021). These rapidly adapted mental health interventions and protocols continued to be utilized, even as person-to-person contact became less dangerous, but with little research specific to their effectiveness in relation to treatment outcomes. As a result, services that were originally developed and investigated for in-person delivery were adapted to virtual protocols with minimal consideration for whether these adaptations produced equivalent patient outcomes (Puspitasari et al., 2021; Sklar et al., 2021). This led to a need for further investigation of the effectiveness of rapidly transitioning between in-person and virtual services owing to the research lagging behind the implementation of virtual services in the wake of the pandemic (Chen et al., 2020). Therefore, the present study addressed the gap in the existing literature by investigating the equivalency of outcomes between pre- COVID, in-person IOP groups and virtual IOP groups in the context of the COVID pandemic.

This research also added to the existing knowledge on the topic of whether TMH could be as effective as in-person services for groups with SMI using IOP protocols, which has the potential to increase access to mental health services for those with SMI (Greenwood et al., 2022; Miu et al., 2020). Moreover, there is a limited body of research regarding the provision of TMH services to the seriously mentally ill prior to COVID-19 due to multiple concerns involving factors often seen as more relevant to this population, such as safety and motivation (Lynch et al., 2020; Miu et al., 2020). This study had the potential to provide evidence supporting the effectiveness/equivalence of rapidly adapted mental health services from in-person to virtual protocols for at least a portion of the seriously mentally ill population. Therefore, this study may have helped to expand the impact of psychologically-based services for under-served and at-risk clinical populations by extending prior research into the provision of TMH services to the seriously mentally ill.

During and shortly after the pandemic, it was unknown if current levels of access to mental health services through virtual platforms would continue to be supported by third party payor sources, such as insurances. However, if this access were to be restricted or eliminated, many of the individuals that benefitted from the increased choices in accessing mental health services virtually, may choose to withdraw from services due to less convenience, less accessible in-person options, or increased experiences of stigma (Abraham et al., 2021; Li et al., 2021; Moreau et al., 2018; Vera San Juan et al., 2021). As such, research into the efficacy of the virtual services that were put into place in response to the COVID-19 Crisis could aid in convincing payor sources to continue funding the same level of access with the potential to increase access to services for traditionally underserved populations. Research suggested that, even as the impact of COVID lessens, the best way forward is for consumers of mental health services to have the choice between in-person, virtual, or hybrid models of service deliver (Vera San Juan et al., 2021).

Research Questions

  1. Are there significant differences in pre- and post-outcome anxiety measures between in-person service delivery and virtual service delivery of rapidly adapted and transitioned in-person protocols for CBT-based IOP services in a private psychological practice?
  2. Are there significant differences in pre- and post-outcome depression measures between in-person service delivery and virtual service delivery of rapidly adapted and transitioned in-person protocols for CBT-based IOP services in a private psychological practice?

The research questions of this study were developed out of the unique conditions created by a global pandemic. There was also a call for further research with the necessary resulting extension of TMH due to the public health emergency and shelter-in-place orders, associated new questions, and the opportunity to look at previous research questions in new ways when comparing in-person and virtual services. As such, the aim of this study was to answer the question of whether a cognitive-behavioral IOP treatment group made up of individuals with serious mental illness (SMI) can obtain equivalent outcome measures when comparing pre-COVID, in-person service delivery to rapidly transitioned virtual service delivery during the COVID pandemic.

This study examined the effectiveness of a rapidly adapted adult, virtual IOP skills group conducted in 2021 during and in the immediate aftermath of the public health emergency resulting from COVID in comparison with an adult, in-person IOP skills group conducted in 2019 pre-COVID. The study results did support that there are no significant differences in overall patient outcomes between an in-person IOP group and a rapidly transitioned virtual IOP group – in the context of a global pandemic and using valid, reliable screening measures of anxiety and depressive symptoms. Likewise, the research literature showed that TMH was effective in improving patient outcomes in a variety of ways, including with different delivery modalities such as VCT and telephone. TMH was also supported in the research literature as generalizable across different demographics, disorders, therapy frameworks, and intervention formats. Research further suggested that TMH was both acceptable to patients and allowed development of good working alliance levels with patients. Additionally, studies found TMH to be effective in treating SMI.

The sample patients were self-selecting and consisted of individuals 18 years and older; provided payment for services through private means or private insurance; were seeking a higher level of clinical care due to SMI resulting in significant levels of dysfunction; and were variable in terms of gender identification, race, age, and diagnosis. The sample included two groups of participants: one group of individuals who completed a pre- and post-measure for depression and anxiety between January 1, 2019 through December 31, 2019 while being provided in-person CBT-based IOP services and one group who completed the same version of the pre- and post-measures between January 1, 2021 through December 31, 2021 while being provided CBT-based IOP services that were rapidly adapted and transitioned to delivery through Zoom VC and email dissemination of materials and information. The sample consisted of individuals mostly White, female, and between the ages of 18-40. The subsequent analysis demonstrated that there were no statistically significant differences between the two overall groups of in-person versus virtual services. These results also further supported previous research findings that TMH is an effective choice in providing patient treatment.

Results

In summary, this study did support that in-person mental health treatment can be effective when rapidly adapted and transitioned to virtual service delivery with SMI. Moreover, study findings demonstrated that these transitioned virtual services are not significantly different from their in-person counterparts. There was also the benefit of further evidence that SMI can be effectively treated with virtual services. In the same way, these results have the potential to inform stakeholders about the value of TMH, support the continuation of TMH and payment parity, and provide patients with options of what service delivery methods best promote their access to, utilization of, and benefit from mental health services.

With this evidence that virtual services can be as effective as in-person services, we encourage everyone who feels they might benefit from mental health services to contact BWG to participate in the virtual IOP or individual therapy services. In-office individual therapy is also offered.

REMEMBER, YOU DON’T HAVE TO STRUGGLE ALONE; YOU ARE DESERVING OF COMPASSIONATE HELP; BWG ENCOURAGES EVERYONE TO ASK FOR WHAT THEY NEED!

Barbara Ballash, Psy.D.
Health and Wellness IOP Assistant

References

Abraham, A., Jithesh, A., Doraiswamy, S., Al-Khawaga, N., Mamtani, R., & Cheema, S. (2021). Telemental health use in the COVID-19 pandemic: A scoping review and evidence gap mapping. Frontiers in Psychiatry, 12, 748069. https://doi.org/10.3389/fpsyt.2021.748069

AlRasheed, R., Woodard, G.S., Nguyen, J., Daniels, A., Park, N., Berliner, L., & Dorsey, S. (2022). Transitioning to telehealth for COVID-19 and beyond: Perspectives of community mental health clinicians. Journal of Behavioral Health Services & Research. https://doi.org/10.1007/s11414- 022-09799-z

Appleton, R., Williams, J., Vera San Juan, N., Needle, J. J., Schlief, M., Jordan, H., Sheridan Rains, L., Goulding, L., Badhan, M., Roxburgh, E., Barnett, P., Spyridonidis, S., Tomaskova, M., Mo, J., Harju-Seppänen, J., Haime, Z., Casetta, C., Papamichail, A., Lloyd-Evans, B., . . . Johnson, S. (2021). Implementation, adoption, and perceptions of telemental health during the COVID-19 pandemic: Systematic review. Journal of Medical Internet Research, 23(12), e31746. https://doi.org/10.2196/31746 ‐

Burgoyne, N., & Cohn, A. S. (2020). Lessons from the transition to relational teletherapy during COVID 19. Family Process, 59(3), 974-988. https://doi.org/10.1111/famp.12589

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Puspitasari, A. J., Heredia, D., Coombes, B. J., Geske, J. R., Gentry, M. T., Moore, W. R., Sawchuk, C. N., & Schak, K. M. (2021). Feasibility and initial outcomes of a group-based teletherapy psychiatric day program for adults with serious mental illness: Open, nonrandomized trial in the context of COVID-19. JMIR Mental Health, 8(3), e25542. https://doi.org/10.2196/25542

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The Behavioral Wellness Group is a counseling center providing therapy and behavioral health services and assessment including chemical dependency/drug addiction treatment, cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT) and other therapies. We also provide mental health or psychological assessments, and psychological,educational and bariatric testing. Providing services to the following communities in Ashtabula, Cuyahoga, Geauga and Lake County: Cleveland, Ashtabula, Beachwood, Chardon, Concord, Eastlake, Euclid, Fairport, Geneva, Grand River, Highland Heights, Kirtland, Leroy, Lyndhurst, Madison, Mayfield, Mayfield Heights, Painesville, Pepper Pike, Perry, Russell, Solon, South Euclid, Thompson, Wickliffe, Willoughby, Willoughby Hills, and Willowick, from our offices in Mentor, Ohio.