The lack of resources for mental health diagnosis and treatment contributes greatly to maternal morbidity and mortality. Social and cultural barriers, along with the impact of social determinants of health create burdens that prevent mothers from accessing care and treatment. Telehealth care improves access and is widely accepted by clinicians, patients, and their families by reducing need for in person visits, providing privacy, and decreasing costs.
Key points
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Maternal mental health is an underdiagnosed and undertreated condition, being greatly affected by cultural and social burdens.
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Mental health and substance use disorders are leading contributors to maternal mortality.
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Over 80% of maternal mortality is preventable.
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The dearth of trained persons to address this public health crisis requires additional resources such as telehealth to improve access and therefore, outcomes.
Introduction
In the United States, around 30 million people suffer from undiagnosed and/or untreated mental illnesses. The 2023 State of Mental Health in America Report identifies significant barriers to treatment, including cost (42%), lack of resources and access (27%), misconceptions about the need for treatment (26%), time constraints (19%), and inadequate payment parity for mental health care (17%). The ratio of mental health providers to individuals in the United States is 1:350, a disparity worsened in rural regions where over 50% of counties lack even a single psychiatrist.
Innovation in information technology has radically changed the way that patients engage in medical care. Evolving technologies now allow and even encourage patients to receive care remotely through telemedicine applications. This is especially important and applicable to those who reside in rural or underserved areas, are homebound, or face other impediments that limit their access to care.
Telehealth and Telemedicine incorporate technologies and activities that offer new ways to deliver medical care. Telehealth is defined by the Health Resources and Services Administration as involving electronic and telecommunications technologies to “support and promote distance clinical health care, patient and professional health-related education, and public health and administration”.
Telehealth modalities
Telemedicine employs 3 primary methods for remote information transfer.
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Store and Forward: Information is stored locally and forwarded to a clinician for interpretation at a convenient time with feedback and interaction from the provider at a later time.
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Real-time Telemedicine: Requires synchronous interaction via videoconferences, telephone, or online communications.
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Remote Patient Monitoring: Chronic conditions such as hypertension and diabetes are managed by transmitting medical information like blood pressure and glucose levels remotely.
Telemental health care
Schaffer CT et al. reviewed the efficacy of telepsychiatry for remote delivery of mental health care, which operates without face-to-face interaction. Similar to the findings of Perle and colleagues, they observed that many patients were able to quickly adapt to this modality, establish beneficial connections with their providers, and even provide more information than during in-person sessions. Importantly, they also found that among low-income patients in areas with minimal availability of mental health care resources, the distance to access points did not predict differences in service utilization. This suggests that telepsychiatry can effectively bridge the gap in access to mental health services for underserved populations. They suggest a “hub and spoke” approach for these services especially for rural and underserved communities. Examples of Telehealth services include on line substance use and depression screening questionnaires, cognitive behavior therapy through videoconferencing, medication management, group chats to prevent and/or manage relapses.
Ben-Zeev et al. conducted a randomized controlled trial with patients having general psychopathology and depression. They found that using a smartphone-delivered intervention increased treatment initiation from 58% to 90%, and continued engagement rose from 40% to 56% compared to a clinic-based group intervention. Improved clinical recovery and quality of life were also noted after 6 months for the smartphone intervention group. Zaheer and colleagues reported positive patient feedback to a tele-intervention, noting high rates of consent and retention, with patients appreciating accessibility, convenience, and privacy.
Tuerk and colleagues compared prolonged exposure therapy for post traumatic stress disorder (PTSD) delivered via telehealth versus in-person therapy. They found similar improvements in clinical outcomes between both groups, although the in-person group had a slightly higher treatment completion rate.
Asynchronous technologies
Synchronous and asynchronous telehealth services are 2 different remote methods for managing patient care. Both techniques are useful because they provide convenience and save time for providers and patients alike. Both types of telehealth work best when used together without resorting to an either/or approach. With synchronous communication, the clinician interacts with the patient in real time over a live video feed or audio conferencing. This approach helps facilitate real time clinical diagnoses and devise treatment options. With asynchronous telehealth, also called a “store and forward” method, the patient sends images or other medical information to the clinician who then reviews the images at some later time and then referrals, consultations, tests, or treatments can be communicated and set up. This allows more control of time management for both clinician and patient. Asynchronous telehealth, or “store and forward,” allows patients to send images or other medical information to the clinician for later review. This method improves workflow by removing bottlenecks, automating processes, and reducing the need for simultaneous availability of both parties.
Asynchronous telepsychiatry (ATP) can be applied in clinician-to-clinician, clinician-to-patient, and patient-to-mobile health settings. It integrates technology into the core components of a traditional doctor-patient interaction: the history and physical examination, assessment and diagnosis, and creation of a treatment plan. Yellowlees and colleagues conducted a 2-year randomized controlled trial comparing synchronous telepsychiatry (STP) and ATP in primary care. Both groups showed positive outcomes in patient satisfaction and compliance, with no differences in clinical outcomes. However, the ATP group expressed concerns about slower feedback compared to STP consultations.
Maternal mental health
Perinatal mental health and substance use disorders are significant public health problems, affecting approximately 30% of pregnant and postpartum women. Maternal suicide now exceeds hemorrhage and hypertensive disorders as a leading cause of postpartum maternal mortality. These conditions are underdiagnosed and untreated, with less than half receiving care. Among those identified, less than 20% receive appropriate treatment, and less than 5% achieve remission.
Barriers to addressing maternal mental health and substance use disorders include insufficient screening, misdiagnoses, and a lack of appropriate resources such as trained clinicians or timely appointment availability. Many who need these resources don’t access them due to the perceived stigma of these diagnoses. Untreated perinatal depression is associated with a 1.5-fold increased risk for preterm birth. In 2022, the Centers for Disease Control (CDC) identified mental health and substance use disorders as leading causes of maternal mortality, accounting for approximately 20% of these deaths, with 80% being preventable.
Use of telemedicine is a viable option for delivering services in these circumstances, although the unknowns are accessibility and acceptance of these services. Guille and colleagues conducted online surveys (Telemedicine Satisfaction Questionnaire and Questionnaire for Assessing Patient Satisfaction with Video Consultation) with responses being scored on a 5-point Likert scale to compare round trip travel time and distance between participants’ home and specialty clinic face to face care at an academic medical center versus their local obstetrics clinic where they received telemedicine services. Of the 35 eligible subjects, 91.42% participated. Of these, 43.75% lived in rural areas. Patients reported high levels of satisfaction were reported for quality of care (mean 4.66, SD 0.667; similarity to face to face mean 4.69 SD 0.63; access to care mean 4.47, SD 0.81). Time spent was significantly less in the telemedicine care group versus in the group receiving care at an academic center (67.44 mins vs 256.31 mins, P <.001); as was round trip travel distance (50.33 miles vs 236.06 miles, P <.001).
Medical help-seeking
Medical help-seeking is the ability to actively seek help for medical conditions. This process transitions from personal awareness to sharing and disclosing with others. Instead of replacing in-person health seeking, internet health seeking complements the process.
The quality of care in the maternal mental health internet arena has been questioned. Pregnant women are especially concerned about the accuracy and application of medical information. The majority (83.7%) use multiple information sources that often provide conflicting information, resulting in increased anxiety and avoidance of interventions.
Chung and colleagues studied 164 perinatal women and found that 92.1% preferred to search multiple sources to compensate for inaccurate information. Only 30.8% preferred to obtain information from health care professionals.
Studies have shown that pregnant women often do not share internet-obtained information with their clinicians, which increases the risk of applying incorrect or non-evidence-based treatments , . However, those who sought non-online formal medical help-seeking strategies did not make or change their medical decisions regarding obstetric problems based on online health information. In a study, 70.1% of the participants rated accuracy and reliability as the most important criteria when seeking pregnancy or delivery information online. The authors suggested that the internet serves as a supplementary information source before or after contact with health care professionals, who are viewed as the primary source of information.
Interestingly, the authors also found that, unlike in obstetric health care seeking, when pregnant women addressed mental health problems, they were more inclined to share information gleaned from the internet with their mental health professionals. This tendency was attributed to their acknowledged lower health literacy in the area of mental health, prompting them to seek additional guidance from professionals.
Reducing mental health problems in pregnancy
Stenzel and colleagues reported on whether telemedicine interventions can reduce mental health problems in pregnant women and new mothers. They conducted a randomized controlled trial on pregnant women and new mothers (up to 1 year post partum), using telemedicine of any kind (eg websites, apps, chats, videoconferencing, telephone, emails) and addressing any mental health-related outcomes. The kinds of interventions were monitoring, self-help, support, and treatment.
When patients received telemedicine interventions, mental health-related outcomes were improved in 62% of participants versus controls. Of the interventions, internet-delivered cognitive behavioral therapy showed improvements in depression and stress. Peer support improved outcomes for postpartum depression and anxiety. Interventions targeting preventive approaches and those aimed at symptom reduction were successful. On the other hand, there were no improvements in anxiety symptoms. The authors suggested that although telemedicine was useful in this setting, the specific mental health condition should be targeted rather than employing a “one size fits all” approach.
Postpartum depression (PPD) is a serious and common clinical burden that has adverse consequences for both mother and child. It is often associated with anxiety and may be the result of inadequate social support and unrelieved childcare burdens. Telehealth services have been shown to have good outcomes due to improved access and treatment effectiveness. Zhao and colleagues evaluated the effectiveness of telehealth interventions in reducing depressive symptoms and anxiety in women with PPD as measured by the Edinburgh Postnatal Depression Scale (EPDS). Of the 9 RCTs included in the analysis, PPD was identified in 1958 women. The EPDS (mean difference = −2.99, 95% CI-4.52 to −1.46; P <.001) and anxiety (standardized mean difference = -0.39, 95% CI -0.67 to −0.12; P = .005) scores were significantly lower in the telehealth group compared to controls. However, telehealth was not effective in improving the social support and loneliness aspects of PPD.
Reduction in EPDS scores was found at 24 weeks after the interventions. Significant subgroup differences were found in depressive symptoms according to severity of PPD, telehealth technology (on line peer support using telephones and apps), specific therapy, and follow-up time ( P <.001).
Chow and colleagues reported that the use of interventions for PPD in 83 studies. They found that although interventions such as traditional herbal medicines and aroma therapy did help, use of antidepressants and telemedicine were by far the most effective treatments.
Use of smartphone-based mindfulness training has been advocated for maternal perinatal depression. Sun and colleagues conducted a randomized controlled trial (RCT) on 168 women in an obstetrics clinic who were at risk for PPD. They were randomly allocated to either a self-guided 8-week smartphone-based mindfulness training group (n = 84) or attention control group receiving 8-week regular weChat health consultants (n = 84). Mental health indicators were studied over 5 time points through the PPD period by online self-assessment. The primary outcome was depression and the secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. The dropout rate was 34.5%. The intervention was completed by 52.4%. The mindfulness training group reported significant improvements of depression and anxiety (group x time interaction x24 = 16.2, P = .003) and anxiety (x2 4 = 8.4, P = .04) versus the attention control group. Interestingly, nulliparous mindfulness group patients had significantly improved depression symptoms versus nulliparous patients in the attention control group (group X time interaction X2 4 = 18.1, P = .001).
Gynecology
Menopause, infertility, and pregnancy loss are life events that can result in increased mental stress, depression, and anxiety. Telemedicine can be useful in these circumstances. Lee and colleagues describe its application for infertility including incorporating psychological support. Management of this condition requires financial, time, and emotional outlays which can seem burdensome to the patients and their families. Using Telemedicine can decrease the number and therefore the cost of the visits. Depression and anxiety have been reported in up to 40% of infertility patients. These rates are similar to those found with human immunodeficiency virus, heart disease, and cancer. , Telepsychiatry in the form of individual counseling, therapy, personalized attention, and support for management of these conditions and for stress reduction can help increase chances of achieving a successful pregnancy. , Options for telehealth interventions can include psychological support, teleradiology, videoconferencing with reproductive endocrine and infertility (REI) specialists, medication management, and consults with other specialists if indicated.
Clifton and colleagues reported that patients who received internet-based psychoeducational support had lower rates of depression and anxiety and higher pregnancy rates versus those who received no support during their treatments.
Telemedicine in adolescents
Adolescents and teenagers with mental health disorders may be an ideal group to benefit from this intervention. This option helps the patient have access to a qualified clinician, without interference in school and other activities. Additionally, it allows the patient to maintain a sense of control and normalcy because it eliminates the necessity of being physically present in an office setting and of interacting with hospital personnel. Management of substance use disorders is ideal for this intervention. On the other hand, a patient’s individualized treatment approach may not be possible with this intervention. Thus, there is the possibility of inadequate or incomplete treatment.
Licensure
Because telehealth service delivery often crosses state lines, clinicians may have to navigate complex, time-consuming, financially burdensome processes in order to provide telehealth services. Although the Federation of State Medical Boards has been successful in lessening this burden over the past decade, research is needed to better understand the relationship between facilitating interstate licensing and quality of care outcomes to protect against any adverse consequences.
A recent survey by the American Medical Association indicated that in order for clinicians to adopt telehealth, adequate liability coverage was a “must-have.” However, at present, there is not a “typical” liability insurer for telehealth. From a public policy point of view, most liability carriers define coverage by using the physician’s state of licensure versus a patient’s location.
Medicolegal aspects
Farmer and colleagues remind that during a telehealth visit, the clinician’s duty of confidentiality applies to telehealth interactions with special emphasis on awareness of others within earshot or visual proximity of the interaction. This is especially important for a mental health visit in which additional information such as the home environment, patients’ grooming, and family circumstances can be gleaned. Telehealth may allow for involvement of others (seen and unseen) which may potentially be contrary to the patient’s best interests. An example is in the setting of domestic violence where the presence of the offender may jeopardize the clinical encounter and may even pose a direct risk to the patient. Another example is when a person or circumstance is present within the location where the patient is accessing the interaction and can thus trigger the depression or anxiety. It should be noted that unlike a traditional clinical encounter where the interaction is limited to the parties within the room, or to those who are approved to access the information, in the telehealth realm, a wide audience can potentially review video footage of the encounter as if they were actually present and this possibility can remain for an indefinite period of time. Recordings and their potential edits can have undesired and unintended outcomes. Another concern is that a patient or another individual may record an encounter without the knowledge or consent of all parties involved. The legality of such recordings varies by state jurisdiction. Some states require the consent of all parties involved (known as “all-party consent” states), while others allow recording if at least 1 party consents (referred to as “one-party consent” states). Therefore, the legal implications of recording without consent depend on the specific laws of the state in which the encounter takes place.
On the other hand, any patient information that is recorded by the clinician, irrespective of consent, is considered health information and is thus subject to all requirements for storage and safe keeping. It is generally held by the clinician or health care system where the care is rendered. Efficient and safe storage of telehealth recordings would include options such as remote or cloud based. This is further compounded by the omnipresence of smart phones and other personal digital devices which can record data that are not always stored in adherence to legal and compliance requirements. Clear documentation of consent to recording of the telehealth interaction should express the intent and the limitations. Inclusion of other health care parties (eg for consults), can add to the challenges.
Thus, in order to make telehealth safe and effective, whenever clinical interactions are recorded, consideration must be given to the proper handling, dissemination, storage, compliance, and security of this health information.
Disparities in health care
Disparities refer to differences in treatment among racial, ethnic, or other demographic groups that are not directly attributable to variations in clinical needs or patient preferences and persist even after adjusting for socioeconomic factors. Their impact on health outcomes is well-documented and a significant concern. Despite the original intent of newer technologies to improve overall access, these disparities persist and may even be exacerbated, creating a digital 2-tier system. While patients with mental health conditions have benefited from the augmentation of care through telehealth, those who are impoverished, uninsured, or belong to minority racial groups remain disenfranchised and poorly served due to insufficient or unreliable internet access.Conteh and colleagues describe the impact of social determinants of health on mental health outcomes in pregnancy and postpartum. The barriers to access caused by mistrust in the perinatal mental health realm can be mitigated by incorporating telehealth so that patients can remain within their own communities and not be burdened by financial and time constraints while still receiving the necessary mental health care.
However, the use of telepsychiatry has been shown to be beneficial. Brief, periodic telemedicine check-ins by nurses have been strongly associated with improved medication adherence in patients with schizophrenia and bipolar disorder
Telepsychiatry visits for managing PTSD have also been identified as being equally effective as face-to-face visits and the satisfaction rates and doctor-patient relationship quality also remained high despite the lack of in-person contact.
Thus, not only does Telehealth augment or improve care in certain scenarios, it also helps to remove barriers such as lack of transportation, and gives access to providers who may be normally geographically distant. It is also useful for those with mobility and physical access issues and those with time constraints. This can be a boon for marginalized low-income/rural patients who are disproportionately burdened by such health disparities.
Because Telehealth and other health information technologies not only require adequate internet access, sufficient devices, and a private space to have discussions with providers but also require a certain level of health and digital literacy in order to be utilized well, this may become a concern for mental health patients because they are more likely to have generally lower levels of health literacy. Furthermore, even without the access issues, these patients might preferentially use telepsychiatry in order to avoid in person interactions with the health care providers. This may potentially result in missed information and misdiagnoses.
The erratic nature of internet and smart phone availability can create frustrations due to poor connectivity. These frustrations and impediments are magnified when applied to mental health care visits that may already be filled with anxiety and confusion. A psychiatric interview is heavily reliant on good interpersonal communication. Interruptions and freezing of the video or audio capability might cause misunderstandings when a mental status examination is crucial to understanding the patient’s condition. It could likewise be unnerving for the patient to have to repeat accounts of traumatic events.
One example of a beneficial tool was the availability of an app called “Suicide-Prevention Result” that was triggered by keywords related to suicide such that the top result of such a search provided telephone numbers for a suicide preventive hotline and resulted in a 9% increase in utilization of the hotline. However, in some under-resourced communities, there was missed use or misuse because the hotline information was inaccurate or unavailable.
Ethics
In telehealth and telemedicine, as in other modes of health care, patient-physician interactions give rise to differing levels of accountability for physicians. At one end of the spectrum are health-related websites where any interaction b/w a person seeking health care information and the clinician who provides it is indirect. Although the clinician has broad obligations to all the website users, there is no responsibility to any 1 individual because there is no control regarding how that information is used or applied. Another situation is where a specific health care question may be posed and the clinician’s response is more tailored to the needs of the one asking, therefore resulting in greater accountability. Teleradiology and teledermatology are even more focused on a specific patient’s condition whereby the specific information/image is reviewed and a medical opinion given, even though it was done by a remote option. The impact on the patient’s decision and subsequent care increases the level of accountability by the clinician. At the far end of the spectrum is telepsychiatry whereby the participation into a patient’s clinical care is via telecommunication, without both being on the same physical space. While these options increase the channels whereby care can be accessed, there are obvious concerns not only regarding privacy and confidentiality but also because of the absence of direct physical examination and possible disruption of the clinician-patient relationship. The potential loss of privacy is due to the necessary insertion of third parties, that is, telecommunications service providers and their potential business affiliates. This area is not as well-regulated as it could or should be.
Artificial intelligence
Improved identification and reporting of mental health disorders have revealed an increased prevalence of these conditions ( Box 1 ). This rise in mental health issues, combined with a shortage of mental health care professionals, necessitates the use of non-traditional approaches while maintaining evidence-based clinical care standards. One promising solution is leveraging artificial intelligence (AI) to pair mental health care experts with technology experts.
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