While there is debate about the precise rate of prevalence of post-traumatic stress disorder and mild traumatic brain injury (mTBI) in the population of service members returning from deployment to Iraq and Afghanistan, few would disagree that the sheer number of first and repeat deployments has placed a high demand on the Department of Veteran Affairs and military mental health treatment systems. Compounding the challenge is the key role played by reservists and National Guardsmen in these wars.

The challenge of providing mental health care for these soldiers and veterans is enhanced because these troops often come from cities and states located away from existing military bases and VA centers. Recent statistics from the National Rural Health Association suggest that as many as 40 percent of veterans returning from Iraq and Afghanistan are from rural areas(1).  The VA has done an outstanding job of serving these veterans both by aggressive expansion of its community based outpatient clinics and through innovative applications of technology. The VA operates one of the largest telemental health programs in the world, with over 45,000 video-based and over 5,000 home telemental health encounters each year(2).

The VA’s widespread use of telemental health tools represents the culmination of decades of development both inside and outside the VA. The earliest applications of telemental health date back to the 1960s and ’70s when videoconferencing linked patients and providers largely through grant-funded demonstrations. Today, telemental health tools are used broadly, including for consultation, diagnosis, treatment, and suicide assessment. The maturity of the field of telemental health is evidenced by the recent emergence of a set of standards and guidelines for practice published by the American Telemedicine Association(3).

As one health application of technology matures, a second wave is emerging. Where the first wave was anchored to discrete physical locations (clinics, hospitals, homes), the second wave is mobile and individualized. Where the first wave was synchronous, the second wave provides for asynchronous contact between providers and patients. This second wave has been dubbed mHealth – a term adopted by a 2010 NIH-funded summit which defined the practice as “the delivery of health care services via mobile communication devices.” This mobile revolution in health has been enabled by rapid technological progress. Cell phones have power equal to or greater than the personal computers of five years ago, and mobile network bandwidth is approaching speeds formerly seen only on wired connections. These developments have enabled a variety of new medical applications which permit providers to keep in touch with patients in new ways, to enhance treatment, and possibly even reduce health care costs.

There appear to be few limits to potential applications of mHealth to mental health, as highlighted by a recent hearing held by the Subcommittee on Health of the House Committee on Veterans’ Affairs, which focused on the use of innovative wireless technology to overcome rural health barriers. While many of the applications were oriented to physical health, the testimony before the committee presented a number of cutting edge applications for mental health, including:

• A partnership between the San Diego VA and a wireless health company exploring whether the use of mobile videoconferencing for between-visit virtual check-ins and crisis management can help reduce costs by limiting readmissions; and
• A pilot program in one of the VA’s 21 networks which exploits virtual reality technology to facilitate connections between patients and health care personnel. The application runs on the iPhone and permits a veteran and his or her treatment team to meet and discuss progress and ideas in a virtual 3-D workspace with a variety of tools and resources.

Altarum’s own innovative application was featured at the same hearing. Partnering with The Pathway Home and Life:WIRE, we are working with a cohort of veterans who are emerging from a residential PTSD and mTBI treatment program . The Pathway Home’s program is designed to help veterans whose behavioral health issues are getting in the way of readapting to life in a post-deployment environment. Altarum is working with Life:Wire to deliver a mobile, two-way interactive health management tool that can be used by patients and providers to conduct customized text messaging-based interactions to monitor health status. The project involves using Life:WIRE’s solution to keep in touch with graduates of the Pathway Home’s residential program. Veterans are contacted several times a week and asked to self-assess their functioning.

While final data from the pilot will not be in for several months, initial indications are that the approach is feasible and holds the potential to more than pay for itself. At least one program participant was brought back from the brink of a crisis by Pathway Home staff after his response to a text message triggered intervention from the program’s treatment team.

While mHealth applications like these hold strong promise for applications to mental health and to help address the treatment needs of rural veterans, a number of challenges stand in the way, particularly for rural veterans. Perhaps chief among these are bandwidth limitations. As a recent driving trip through the rural southwest painfully evidenced to me, many rural areas remain without access to mobile broadband networks with capacity adequate to support sophisticated mobile videoconferencing applications like those currently being piloted around the country. A second challenge arises from the nature of PTSD and mTBI themselves. Even where adequate network capacity exists, our experience suggests that there is a danger of device and technology overload. Participants in Altarum’s pilot who are battling these conditions have best responded to technologies that are already familiar to them. Veterans have typically been more open to interacting therapeutically via text messages sent and received using their own cell phones than with a new device they are asked to carry in addition to a personal cell phone. Our experience working with veterans undergoing mental health treatment suggests that mHealth applications need to be easy to use and should avoid introducing additional, unnecessary stress.

As pilot and demonstration programs in the second wave of telemental health come to a close, the next critical step is to outline an agenda for rigorous comparative effectiveness research to identify which devices, protocols, and approaches produce the best outcomes and are most cost-effective, particularly for applications to veterans who do not live close to a VA or military medical facility. It is imperative for federally-funded research programs to play a central role in funding large-scale, multi-site trials to begin the process of identifying the best mHealth applications for use in the veteran population.

As the second wave of telemental health technologies enters a growth phase, a third wave waits in the wings. The Defense Advanced Research Projects Agency recently issued a solicitation for an ambitious program—Healing Heroes—which aims to revolutionize the way that mental health care is provided to veterans and their families. At this early stage, the defining features of the third wave appear to be integration and proactivity. The Healing Heroes project is envisioned as a one-stop referral, treatment, and support portal for the mental health needs of veterans and their families and to exploit tools such as voice-stress analysis and anomaly-sensing algorithms to identify and prevent crises among veterans and service members. At the current rate of technological progress, even these lofty goals are likely to be achieved, perhaps even sooner than anticipated.

References

1. http://www.research.va.gov/resources/pubs/docs/rural-health-brochure.pdf
2. Godleski L, Nieves JE, Darkins A, Lehmann L. VA telemental health: suicide assessment. Behav Sci Law. 2008;26(3):271-86.
3. http://www.atmeda.org/files/public/standards/PracticeGuidelinesforVideoconferencing-Based%20TelementalHealth.pdf

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All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute.