Tele-Mental Connectivity: Pseudo-Therapy or The New Reality?

Abstract

Examination of Potential Differences in Reporting of Sensitive Psychosocial Measures via Diagnostic Evaluation Using Computer Video Telehealth

LaFrance WC Jr, Ho WLN, Bhatla A, Baird G, Altalib H, Godleski L. J Neuropsychiatry Clin Neurosci. 2020:appineuropsych19080177. doi:10.1176/appi.neuropsych.19080177

Objective:

The authors compared baseline characteristics and reporting of psychosocial measures among veterans with seizures who were evaluated in-clinic or remotely via computer video telehealth (CVT). It was hypothesized that the CVT group would report less trauma history, drug use, and comorbid symptoms compared with veterans seen in-clinic.

Methods:

A cross-sectional design was used to compare 72 veterans diagnosed with psychogenic nonepileptic seizures (PNES) or concurrent mixed epilepsy and PNES who were consecutively evaluated by a single clinician at the Providence Veterans Affairs Medical Center (PVAMC) Neuropsychiatric Clinic. In-clinic evaluations of veterans were performed at the PVAMC Neuropsychiatric Clinic (N = 16), and remote evaluations of veterans referred to the VA National TeleMental Health Center were performed via CVT (N = 56). All 72 patients were given comprehensive neuropsychiatric evaluations by direct interview, medical examination, and medical record review. Veterans’ reporting of trauma and abuse history, drug use, and psychiatric comorbidities were assessed, along with neurologic and psychiatric variables.

Results:

No significant differences were found between veterans evaluated in-clinic or remotely with regard to baseline characteristics and reporting of potentially sensitive information, including trauma and abuse history, substance use, and comorbid symptoms.

Conclusions:

Veterans with PNES evaluated via telehealth did not appear to withhold sensitive or personal information compared with those evaluated in-clinic, suggesting that CVT may be a comparable alternative for conducting evaluations. Baseline evaluations are used to determine treatment suitability, and telehealth allows clinicians to gain access to important information that may improve or inform care.

Commentary

Diagnosing, treating, and studying psychogenic nonepileptic seizures (PNES) has always been challenging. Both neurologists and psychiatrists find this condition difficult, especially in ascertaining etiologies of the events. Controversy still exists in terms of pathophysiology, notwithstanding the diagnostic standard of tangible epileptiform findings on a video EEG. The high number of patients with both electrical and nonelectrical events makes it difficult to deduce a unifying explanation for the phenomena. Questions of comorbidity and components of combined treatment necessarily emerge.

In practice, so long as underlying psychiatric conditions such as major depression or panic disorder are aptly addressed, the path to healing PNES is often through psychotherapy. Patients who are able to talk through stressors have a good chance of recovery.¹ However, with PNES, stressors are typically hidden from view. In other psychiatric conditions, even if the issues are difficult to articulate, they are not necessarily unknown. With PNES as with other conversion disorders, the core problems are masked by a one-dimensional medical façade, ripe with high anxiety and acuity that make everyone uncomfortable. Patients often consider that if the “seizures” would just stop, then their lives would be fine. But clinicians know that the events often reflect deep-rooted underlying stressors and detangling them requires creative methods to help patients gain insight.

The skill set required for effective psychotherapy in PNES differs from that of other conditions. Building a therapeutic alliance and rapport may be complicated, since patients typically experience negativity or disdain from medical practitioners. A clinician must be able to accept that such patients are not malingering, instead are exhibiting an extreme mental state. A brain and behavior relationship exists, even if the exact neuropsychiatric circuitry is unclear. A tolerance for ambiguity is essential for both the clinician and the patient, and the clinician must be able to accommodate that uncertainty. Success requires that a patient becomes secure enough to confront uncomfortable truths, and ultimately put words to powerful emotions that are strong enough to cause a mind/body rift yielding psychogenic seizures.

Intuitively then, it would seem that for PNES particularly, remote, video-based mental health care would be unlikely to succeed. Conventional wisdom suggests that face-to-face psychotherapy is best for addressing complex psychological issues in most conditions, let alone those with the complexity of PNES. However, in recent months, because of the coronavirus disease 2019 (COVID-19) pandemic, tele-mental health care has become ubiquitous. Could telehealth be as effective as traditional health care delivery for complex neuropsychiatric illness? That question is addressed by LaFrance et al in this study of video interviewing in patients with psychogenic nonepileptic events.²

Telehealth is commonly used in the Veterans Administration Health Care system, so the infrastructure is well established. The study tapped into that system and compared veterans with diagnosed PNES, though some also had electrical seizures. The patients engaged in neuropsychiatric evaluations with the same physician either in person at a local medical facility or in a local telehealth center with computer aided video. The same physician being involved astutely removes an important potential confound to the results. The assessment included standardized psychiatric symptom questionnaires emphasizing anxiety and depression. Medical symptoms were also obtained and compared between the groups.

Although the groups were small and markedly skewed toward the remote evaluations, the subject numbers were sufficient to identify significant differences. The evaluations were very detailed and included issues of abuse victimization, trauma, as well as current and past substance abuse. Interestingly, for those parameters, there was no difference in reporting between the two groups.There were differences in results for the self-report Beck Anxiety and Depression Inventories, but the summary scores were actually higher in the remote assessment group.

Ultimately, the notion that video sessions are insufficient to have patients reveal psychiatric symptoms was not true. In person evaluations did not appear to present an advantage in identifying intensely personal psychiatric symptoms. Even remote questionnaire completion had a higher yield in detecting psychiatric symptoms. Apparently, therapeutic alliance and rapport was the same in terms of symptom identification even for patients with complex issues such as PNES.

From this sample, we now know that the computer-based video is just as effective for evaluation purposes even for very sensitive topics and vulnerable patients. However, we still don’t know what techniques of ongoing tele-therapy are most effective. The majority of the sample had prior psychotherapy treatment, so the groups were experienced with mental health care and possibly also with a telehealth platform. However, details of the efficacy of that treatment are unknown. It may be that a particular style of tele-mental health psychotherapy works better for some patients or conditions.

Also unknown is whether patients will be even more open when talking in the comfort of their own homes. They may feel more private and protected in their own space, where they can determine who else is present and how exposed they want to be. The patients in this study had to go to a medically staffed telehealth center to engage with clinicians on computer video. So the sessions still involved logistical stress and being in an unfamiliar location.

Now, telehealth approaches are even more flexible in terms of originating sites and clinician locations. The COVID-19 pandemic has markedly changed the regulatory context of medical and mental health care delivery.³ Improved convenience may make it more likely for patients to engage with psychiatrists. Thanks to LaFrance and team, it appears that the platform is sound and that patients are quite willing to divulge sensitive information. It also seems that telehealth is here to stay for the neuropsychiatric treatment of PNES, and may even be a preferred method of engagement.

By Jay A. Salpekar