This brief is part of our Research Roundups series.
In 2020, nearly 1 in 10 people and 1 in 6 adolescents and young adults in the United States reported experiencing a major depressive episode in the past year,1 with rates rising during the COVID-19 pandemic. Health systems across the country pivoted to virtual behavioral health care to help patients access care while staying safe at home. Researchers and clinicians wondered how this shift would affect care access and quality.
Health care professionals frequently evaluate the effectiveness of behavioral health care by using validated symptom screeners to assess the severity of a patient’s depression or anxiety symptoms and their impact on daily life. They then track patient progress and adjust care accordingly.2
Medication order and fulfillment data provide information about whether providers are ordering prescriptions and patients are receiving them. Nationally, psychotropic medication fulfillments declined during the pandemic,3,4 suggesting patients needed additional support in accessing prescriptions.
Kaiser Permanente aims to make effective care and critical medications accessible and convenient for all our patients.
Kaiser Permanente researchers recently published a study that explores key questions:
- How did the pandemic affect important measurement-based care practices, such as completion of symptom screeners, as more care was delivered virtually
- How did the transition to more virtual care affect access to depression treatments, assessed through antidepressant medication orders and fulfillment?
Our 2023 article on virtual treatment for depression in “Medical Care”
In Colorado, Georgia, and the mid-Atlantic region, 3 of the areas where Kaiser Permanente operates, our researchers evaluated changes over time in virtual care for 28,731 patients who had recent diagnoses of major depression.
They compared rates of antidepressant medication orders and fulfillments and completion of patient-reported symptom screeners during 3 time periods: before the pandemic (January 2019-March 2020), after the transition to all virtual care at the height of the pandemic (April 2020-June 2020), and after the transition back to more typical health care operations (July 2020- June 2021, referred to as the recovery period).
Within each of the 3 geographic areas, completion of symptom screeners increased significantly during the peak-pandemic period and continued to increase afterwards. Notably, screener completion rates among Kaiser Permanente patients in the Mid-Atlantic region rose significantly.
Before the pandemic, the rate was 43.2%. At the peak of the pandemic, it increased to 68.4%. During the recovery period, it reached 81%. In each area, Kaiser Permanente invested substantial effort into training health care professionals on virtual care practices. This included training them on how to use secure symptom screener messages and ensuring they had the resources necessary for virtual visits.
These steps likely supported health care professionals in developing effective workflows that supported measurement-based care. It is also possible that the overall shift to virtual care during the pandemic supported health care professionals and patients in leveraging important virtual care tools, including online symptom screeners.
Medication orders and fulfillment remained relatively steady, suggesting patients could access care effectively during the pandemic. There was a small dip in medication orders in 2 areas at the beginning of the pandemic. However, order rates rebounded during the recovery period. There was no significant change in medication fulfillment across the study period. Kaiser Permanente took many steps to make prescription fills accessible during the pandemic.
This included offering same-day home delivery and curbside pick-up at clinics. These steps may have improved order fulfillment. Though this was not a primary focus of the study, researchers also found that the proportion of visits that were virtual stayed high for this patient population during the recovery period.
For example, in Colorado, virtual visits for patients recently diagnosed with depression comprised only 12.89% of depression encounters before the pandemic. This number surged to 99.93% at the height of the pandemic. It then settled at 93.31% during the recovery period. The minimal shift to in-person visits during the recovery period suggests that virtual care was an acceptable mode of care for many patients and health care professionals.
Policy Opportunities
No single study can suggest the full range of policy needs and opportunities. Based on existing research, across multiple studies over time, and internal discussions among Kaiser Permanente behavioral health and telehealth leaders, we recommend several ways policymakers can improve behavioral health access and care:
Promote digital inclusion: Ensure that all individuals and communities can access and use behavioral health telehealth offerings.
- Improve access to video-based visits: Patients should be able to choose the type of visit that works best for their specific needs. Policies could advance this goal by bolstering basic internet infrastructure and making broadband and internet-connected devices more affordable.
- Support outreach and education: Everyone should have the knowledge and support needed to use virtual behavioral health services. Digital navigators and skill development programs in a variety of languages could provide technology education and support technology literacy.
- Expand eligibility for virtual behavioral health services: Eliminate in-person visit requirements where appropriate, including for behavioral health, substance use disorder treatment, and prescribing of controlled substances. This can help to increase access to high-quality mental health and addiction care that is safe, timely, effective, equitable, and patient-centered.
Include telehealth in evidence-based measures of behavioral health care quality and access: As telehealth shifts health care delivery, ensure that measures address these changes.
- Deliver evidence-based care: Standardize quality metrics that evaluate the performance of mental health treatment, to support wider deployment of effective, evidence-based care.
- Incorporate telehealth quality standards into overall care quality measurement: Align quality and outcome measures for in-person and telehealth services, so that digital health is held to the same high standards for quality, safety, patient satisfaction, clinical outcomes, and health equity as in-person care. Digital health research can inform telehealth guidelines, reimbursement policies, and approaches for monitoring and incentivizing excellent care.
- Measure impacts on access: Telehealth broadens access to high-quality, equitable behavioral health care and should be incorporated into network adequacy evaluation frameworks.
Develop guidelines and supports for providing virtual behavioral health services: Support effective implementation and continual improvement.
- Education and professional training: Support education and training that builds health workers’ trust in technology and the skills necessary for safe and effective use of digital technologies.
- Ensure health care professionals have the resources they need: Develop and optimize evidence-based education, training, and workflows on telehealth for clinicians.
- Support research and evaluation: Measure patient and health care professional experience and satisfaction with telehealth services and use the resulting data to drive improvement.