Telehealth Utilization During COVID-19 Among People with Diagnosed Mental Health Conditions

Abstract

Background:

Despite the potential benefits and the demonstrated uptake throughout the coronavirus disease 2019 (COVID-19) pandemic, studies have found that telemental health is still underused. The objective of the study was to explore the associations between mental health diagnoses and telehealth utilization during the pandemic.

Methods:

The study utilized a cross-sectional survey among adult Arkansans (n = 754). Logistic regression was used to determine the association between a diagnosis of anxiety and/or depression and telehealth utilization.

Results:

Forty-two percent of respondents reported utilizing telehealth during the pandemic. Respondents with a diagnosis of anxiety and/or depression had three times greater odds of utilizing telehealth (odds ratio = 2.97) than those with no diagnoses.

Discussion:

Utilization of telehealth care during the COVID-19 pandemic was lower in our sample compared with other nationally representative surveys; however, utilization was higher among people with a diagnosis of anxiety and/or depression.

Conclusions:

The results indicate the need for outreach to increase telehealth utilization.

Introduction

In December 2019, the first cases of coronavirus disease 2019 (COVID-19), the disease caused by novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were diagnosed in the United States, prompting government and public health entities to implement epidemiological mitigation efforts (i.e., quarantine, isolation, and social distancing). COVID-19 mitigation measures significantly disrupted social and economic patterns and forced many in-person functions to begin operating online, including health care services, which adopted and enhanced the use of telehealth practices to facilitate meetings between patients and health care providers.¹

Prepandemic studies have indicated that telehealth, particularly for mental health (i.e., telemental health, telepsychiatry, and telepsychology), may be a promising alternative to in-person services.^2–4 COVID-19 significantly increased mental health issues for individuals with and without prior mental health diagnoses,^5–7 and telemental health services became more widely available for individuals to address these issues, including through health care facilities and independent online community mental health services.^8,9 One study found that patients with pre-existing mental health disorders, as well as their health care providers, were satisfied with newly adopted telepsychiatry services throughout the pandemic.¹⁰ Another study showed a 50% reduction in face-to-face mental health consultations, accompanied by a substantial increase in the uptake of newly introduced telehealth services.¹¹ Despite the potential benefits and the demonstrated uptake throughout the pandemic, studies have found that telemental health is still underutilized.^12,13

To explore the relationship between mental health and the use of telehealth during the pandemic, we conducted a cross-sectional survey among adults (≥18 years) living, working, and/or receiving health care in Arkansas. Our objective was to explore whether having a prior anxiety and/or depression diagnosis increased the odds of using telehealth during the COVID-19 pandemic. Understanding the relationship between mental health diagnoses and telehealth usage, particularly in the time of a pandemic, can help to improve online mental health care and reduce barriers to accessing telehealth services.

Methods

Respondents were recruited between October 30, 2020 and January 16, 2021 from six clinic sites throughout the state of Arkansas. Research Electronic Data Capture (REDCap) was used to administer the consent and survey. Inclusion criteria included being an adult (age ≥18 years) and living, working, and/or receiving health care in the state of Arkansas during the study period. In total, 876 responses were collected. Of those, 809 met the inclusion criteria, and 754 were determined to be nonduplicates who answered questions past the eligibility screeners. A $20 gift card was provided after survey completion as compensation for respondents' time. The study was approved by the University of Arkansas for Medical Sciences Institutional Review Board (IRB#261226).

The outcome of interest, telehealth utilization, was a dichotomous variable of a yes/no response to the question “Have you utilized telehealth during the COVID-19 pandemic?” The predictor variable, a past diagnosis of anxiety and/or depression, was based on respondent self-report. Sociodemographic factors such as age, gender, education, income, and race/ethnicity were included as controls. Self-rated health, included as a control variable, was a categorical variable with response options of excellent, good, fair, and poor. Self-rated mental health for the prior 2 weeks was also included as a control, with response options of excellent, average, somewhat good, and somewhat poor/poor (somewhat poor and poor were combined due to the low number of responses).

The descriptive statistics report means and standard deviations for continuous variables and the frequency and percentages for categorical variables. Multivariable logistic regression, using full information maximum likelihood estimation to account for missing data, was used to determine the association between a diagnosis of anxiety and/or depression and telehealth utilization. Analysis was completed using MPLUS, and a p-value ≤0.05 is considered statistically significant.

Results

Table 1 presents the characteristics of the respondents. The mean age of the participants was 47.4 years (±16.3). The majority of the respondents were female (70.6%) and white (72.4%). A third (35.4%) had at least some college education or a technical/vocational degree; however, half (49.4%) reported making <$25,000 per year. The majority of respondents reported being in good (50.9%) or fair (28.3%) health. Concerning self-rated mental health for the prior 2 weeks, nearly two-thirds (60.7%) rated their mental health as average or somewhat poor/poor. A diagnosis of anxiety and/or depression was reported by half (50.9%) of the respondents. Less than half (42%) reported utilizing telehealth during the pandemic.

Table 1.

Descriptive Statistics

	n (%) OR M (SD)
Age (in years)	47.4 (16.3)
Gender
Female	531 (70.6)
Male	221 (29.4)
Education
High school or less	212 (28.3)
Some college or tech school	265 (35.4)
College degree or more	271 (36.2)
Income
<$25,000	281 (49.4)
$25,000 to under $50,000	133 (23.4)
≥$50,000	155 (27.2)
Race/ethnicity
White	539 (72.4)
Black	134 (18.0)
Other race/ethnicity	72 (9.7)
Self-rated health
Excellent	53 (8.8)
Good	306 (50.9)
Fair	176 (28.3)
Poor	66 (11.0)
Self-rated mental health
Excellent	104 (17.5)
Somewhat good	130 (21.8)
Average	189 (31.7)
Somewhat poor or poor	173 (29.0)
Anxiety and/or depression diagnosis
Not diagnosed	286 (49.1)
Diagnosed	296 (50.9)
Telehealth utilization
Did not use during COVID-19	333 (58.0)
Used during COVID-19	241 (42.0)

COVID-19, coronavirus disease 2019; M, mean; SD, standard deviation.

Table 2 reports the results of the multivariate logistic regression model for the association between the diagnosis of anxiety and/or depression and telehealth utilization. The results indicate respondents with a diagnosis of anxiety and/or depression had three times greater odds of utilizing telehealth (odds ratio [OR] = 2.97, p < 0.001, 95% confidence interval [CI] [1.95–4.52]) than those without a diagnosis. Respondents who had a college degree or higher had more than one and a half greater odds of utilizing telehealth (OR = 1.67, p = 0.050, 95% CI [1.00–2.77]) than those with a high school diploma or less. No other associations were found for the sociodemographic variables, self-rated health, or self-rated mental health.

Table 2.

Logistic Regression Predicting the Odds of Telehealth Utilization for People with a Mental Health Diagnosis (n = 754)

	OR	SE	p	95% CI
Age (in years)	1.01	0.006	0.218	0.99–0.02
Malea	0.78	0.21	0.224	0.52–1.17
Educationb
Some college or tech school	1.10	0.24	0.688	0.69–1.76
College degree or more	1.67	0.26	0.050	1.00–2.77
Incomec
$25,000 to under $50,000	1.37	0.24	0.198	0.85–2.21
≥$50,000	1.23	0.27	0.434	0.73–2.09
Race/ethnicityd
Black	1.33	0.26	0.271	0.80–2.23
Other	1.68	0.33	0.115	0.88–3.20
Self-rated healthe
Excellent	0.69	0.35	0.287	0.35–1.36
Fair	1.40	0.22	0.141	0.90–2.14
Poor	1.04	0.32	0.892	0.56–1.94
Self-rated mental healthf
Excellent	1.40	0.30	0.266	0.78–2.52
Somewhat good	0.95	0.26	0.845	0.57–1.58
Somewhat poor or poor	1.08	0.24	0.764	0.67–1.72
Anxiety and/or depression diagnosis	2.97	0.21	<0.001	1.95–4.52

Bolded p-values are significant at the p < 0.05 level.

^a Ref = female; ^bRef = high school or less; ^cRef = <$25,000; ^dRef = white; ^eRef = good; ^fRef = average.

CI, confidence interval; OR, odds ratio; SE, standard error.

Discussion

COVID-19 has increased mental health issues for individuals with and without prior mental health diagnoses,^5–7 and telemental health services became more widely available for individuals to address these issues.^8,9 In our sample, 42% of the respondents reported telehealth utilization during the COVID-19 pandemic, which is lower than those found in other nationally representative studies (83%).¹⁴ These findings are indicative of a need to expand telehealth access and utilization among Arkansans as a whole.

Our results show that Arkansans with a diagnosis of anxiety and/or depression reported accessing telehealth almost three times more often than those without either of these diagnoses during the COVID-19 pandemic, even when accounting for sociodemographic factors, self-rated health, and self-rated mental health. This is especially reassuring in a largely rural southern state where access to mental health care is limited in many areas and where 65.5% of individuals with mild mental illness and 39% of individuals with moderate mental illness do not receive care.¹⁵

However, education matters in accessing telehealth services. People with a college education or higher were more likely to access telehealth services than people with a high school degree or less. The difference by education level provides additional evidence that telemental health is currently underused, including in Arkansas.^12,13 Individuals who are older with less educational attainment and lower socioeconomic status are usually among the last to adopt innovations, including telehealth.^16,17 Furthermore, in the United States, differential access to internet based on socioeconomic factors prevents many people from receiving needed care.^16,17 Future research is needed to understand the barriers to uptake of telehealth innovations by educational attainment and other socioeconomic factors to create programming that can address these differences.

The results of the study should be considered with limitations in mind. First, the sample was limited to people who were current or past patients at 1 of 6 clinic sites across the state of Arkansas and is over-representative of women and college-educated individuals. Therefore, these findings may not be generalizable to the general Arkansas or United States adult population. Second, all of the measures used in this study were self-reported and are reliant on respondent recollections, which may result in biases in responding.

Conclusions

Despite these limitations, the study makes a significant contribution to the literature as the first study to examine the relationship between diagnosed mental health conditions and telehealth utilization reported by individuals during the COVID-19 pandemic. Furthermore, it is the first study to examine telehealth utilization among individuals living in a largely rural southern state where access to mental health care is limited in many areas. Understanding the relationship between mental health diagnoses and telehealth usage, particularly in the time of a pandemic, can help to improve online mental health care and reduce barriers to accessing services. The results indicate that despite the increase in telehealth utilization during the COVID-19 pandemic, there is still a need for outreach and programming to increase telehealth utilization, especially among those with lower educational attainment.

Data Sharing Statement

The deidentified data underlying the results presented in this study may be made available upon request from the corresponding author, Dr. Pearl A. McElfish, at pamcelfish@uams.edu. The data are not publicly available in accordance with funding requirements and participant privacy.

Authors' Contributions

Conceptualization, supervision, methodology, formal analysis, writing—original draft, and writing—review and editing by J.A.A. Data curation, project administration, conceptualization, writing—original draft, and writing—review and editing by B.R. Project administration, conceptualization, writing—original draft, and writing—review and editing by E.G. Supervision, conceptualization, methodology, data curation, and writing—review and editing by P.A.M.

Disclosure Statement

No competing financial interests exist.

Funding Information

Support was provided by University of Arkansas for Medical Sciences Translational Research Institute funding through the National Center for Research Resources and National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR003107).