Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic

Abstract

IMPORTANCE Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown. OBJECTIVETo evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022. EXPOSURE Receipt of a video-enabled tablet.MAIN OUTCOMES AND MEASURES Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs). RESULTSThe study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, −0.012; 95% CI, −0.014 to −0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, −0.0017; 95% CI, −0.0023 to −0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, −0.0011; 95% CI, −0.0016 to −0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide. (continued) Key Points Question Was the US Veterans Affairs initiative to distribute video-enabled tablets during COVID-19 associated with mental...

VA’s implementation of universal screening and evaluation for the suicide risk identification program in November 2020 –Implications for Veterans with prior mental health needs

“…Universal screening likely lowered these barriers for Veterans in rural areas and led to increased likelihood of being screened/evaluated across both mental and non-mental health settings, as suggested by our exploratory sub-analyses ( S3 Table ). VA’s use of virtual care may have further contributed to leveling the field across rural and urban Veterans by increasing access to virtual care for rural Veterans [ 33 ]. Future studies should explore potential mechanisms by examining rural-urban differences in care settings (whether mental health or other) where screens/evaluations occurred and by determining whether rural Veterans were more likely to get screened/evaluated via telehealth modalities.…”

Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic

“…We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person) for these services among SUD-diagnosed tablet-recipients vs. SUD-diagnosed non-recipients before and after tablet-receipt. SUD psychotherapy visits were defined using Current Procedural Terminology (CPT) codes and SUD diagnosis codes, following prior work ( Gujral et al, 2022 ). SUD group therapy visits were visits for group evaluation, consultation, follow-up, and treatment provided by a VA facility's formal SUD Treatment Program ( U.S. Department of Veterans Affairs, n.d. ) and SUD individual outpatient visits were individual visits for evaluation, consultation, follow-up and treatment provided by the SUD Treatment Program.…”

“…Together, these patterns suggest that in many cases, video visits replaced in-person visits. Prior work has noted the clinical importance of such increases in psychotherapy ( Gujral et al, 2022 ) and group therapy for SUD care ( Oesterle et al, 2020 ) and the importance of continuation of SUD care when in-person services were declining ( Oesterle et al, 2020 ). These results indicate that VA's distribution of tablets facilitated continuity of SUD care among tablet-recipients through video telehealth during the COVID-19 pandemic.…”

Treatment utilization and modality preference among veterans receiving outpatient substance use disorder treatment during a pandemic

“…One possibility is that telephone appointments might negatively impact one's ability to disclose their substance use, since assessment often relies on nonverbal cues that are easier to get during in‐person visits or video appointments, where the veteran is visually observed 22 . A recent study found video‐enabled tablets were associated with a 20% reduction in emergency room visits during COVID‐19 among rural veterans with a history of mental health care; 27 distribution of tablets to veterans also resulted in increased utilization of psychotherapy visits and reductions in suicidal behaviors. Pandemic‐related stress can impact individuals coping with SUD, as stress, isolation, poor coping, and poor access to recovery‐based group meetings, can all culminate in cravings, preoccupation with use, and return to use, particularly among those in early recovery 28 …”