Original Research
Team-Based Telecare for Bipolar Disorder
Mark S. Bauer, MD,1,2 Lois Krawczyk, PhD,2
Christopher J. Miller, PhD,1,2, Erica Abel, PhD,3
David N. Osser, MD,2 Aleda Franz, PhD,3
Cynthia Brandt, MD, MPH,3 Meghan Rooney, PsyD,4
Jerry Fleming, MS,2 and Linda Godleski, MD 3,5
1 clinical practice.
VA Center for Healthcare Organization and Implementation
Research, Boston, Massachusetts.
2 Key words: bipolar disorder, implementation, quality, tele-
Department of Psychiatry, Harvard Medical School and VA
Boston Healthcare System, Boston, Massachusetts.
3
Yale School of Medicine and VA Connecticut Healthcare System,
West Haven, Connecticut.
4
Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.
5
VA Central Office, Office of Telehealth Services, West Haven,
Connecticut.
C
Abstract
Introduction: Numerous randomized controlled trials indi-
cate that collaborative chronic care models improve outcome
in a wide variety of mental health conditions, including bi-
polar disorder. However, their spread into clinical practice is
limited by the need for a critical mass of patients and spe-
cialty providers in the same locale. Clinical videoconferencing
has the potential to overcome these geographic limitations.
Materials and Methods: A videoconference-based collabora-
tive care program for bipolar disorder was implemented in the
Department of Veterans Affairs. Program evaluation assessed
experience with the first 400 participants, guided by five
domains specified by the American Telemedicine Association:
treatment engagement, including identification of subpopu-
lations at risk for not being reached; participation in treat-
ment; clinical impact; patient safety; and quality of care.
Results: Participation rates resembled those for facility-based
collaborative care. No participant characteristics predicted
nonengagement. Program completers demonstrated significant
improvements in several clinical indices, without evidence of
compromise in patient safety. Guideline-based quality of care
assessment after 1 year indicated increased lithium use,
decreased antidepressant use, and increased prazosin use in
individuals with comorbid post-traumatic stress disorder, but
no impact on already high rates of lithium serum level
monitoring. Discussion: Clinical videoconferencing can
extend the reach of collaborative care models for bipolar
DOI: 10.1089/tmj.2015.0255 ª M A R Y A N N L I E B E R T , I N C .  VOL. 22
disorder. The next step involves assessment of the
videoconference-based collaborative care for other serious
mental health conditions, investigation of barriers and facil-
itators of broad implementation of the model, and evaluation
of the business case for deployment and sustainability in
health
Introduction
TELECARE TO DELIVER MULTICOMPONENT CARE
MODELS FOR SERIOUS MENTAL HEALTH CONDITIONS
ollaborative chronic care models (CCMs) were es-
tablished to address the needs of individuals with
complex, chronic medical illnesses.1,2 CCMs consist
of six elements: (1) work role redesign for anticipa-
tory continuous care, (2) patient self-management skill en-
hancement, (3) provider decision support, (4) information
management, (5) access to community resources, and (6) or-
ganization and leadership support.3 These elements are oper-
ationalized in various ways depending on facility capabilities
and needs. While initially developed to treat chronic medical
illnesses, CCMs have also been applied to depression treated
in primary care4,5 and a wide variety of mental health
conditions.6,7
However, establishing CCMs to treat complex conditions
requires both a critical mass of patients with the diagnosis of
interest plus providers with specialty expertise in its treatment
in the same venue—requirements rarely met in U.S. health-
care.8 Telehealth modalities have potential to overcome this
limitation in reach9 of CCMs by bringing together specialists
and patients across different sites. Ideally, with modern
communications and informatics technologies, virtual teams
can come together seamlessly across distance to support an
individual’s healthcare needs.
The U.S. Department of Veterans Affairs (VA) recognized
that bipolar disorder could be addressed through telehealth
application of CCM principles. In 2011, the VA telehealth and
mental health leadership established the Bipolar Disorders
Telehealth Program, utilizing a multidisciplinary team, or
‘‘clinical microsystem,’’10 to complement local care through
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BAUER ET AL.

clinical video teleconferencing (CVT). More than 100,000 . Structured diagnostic assessment, including comorbid-
veterans receive VA care for this diagnosis each year.11 Bi- ities (CCM element: provider decision support).
polar disorder affects 9 million Americans and is character- . Psychopharmacologic consultation (CCM element: pro-
ized by high rates of morbidity and early mortality.12 The vider decision support).
condition is also characterized by a high prevalence of med- . Life Goals Self-Management Skills Program (CCM ele-
ical13,14 and mental13,15,16 comorbidities, requiring coordi- ment: self-management skill enhancement) consisting of
nated management of multiple conditions. Nonadherence six structured, manual-based modules covering goals
with medications is endemic.17 On the positive side, CCMs for and values, mania and depression profiles and coping
bipolar disorder have an extensive evidence base6,7 and have responses, provider visit preparation.
been endorsed by multiple clinical practice guidelines.18–20 . Follow-up monitoring, including measurement-based
symptom assessment and liaison with primary providers
THE PROMISE AND CHALLENGE OF TELECARE (CCM elements: information management, work role re-
FOR SEVERE MENTAL HEALTH CONDITIONS design for anticipatory continuous care).
Ample evidence demonstrates the feasibility and benefit of
The program is operationalized as a consultative team
using remote clinicians to deliver care for depressive and
model: In addition to conducting self-management sessions
anxiety disorders using telephone,21,22 CVT,23,24 or other
and doing follow-up monitoring, bipolar Telehealth staff
informatics-based modalities.25,26 However, less is known re-
make medication and monitoring recommendations to the
garding the feasibility or impact of telehealth modalities for
primary mental health provider but do not write orders
severe mental health conditions or its use for multicomponent
(Fig. 1). Participants are enrolled for *6 months, although the
models such as CCMs (see Discussion section), and we are aware
length of enrollment is determined by completion of tasks
of no studies of telecare for bipolar disorder. Moreover, sub-
rather than strictly chronological time. As illustrated in
stantial implementation challenges exist, including provider
Figure 2, the intake is completed by the program psychiatrist,
skepticism, technology barriers, licensing and credentialing,27
focusing primarily on diagnostic, psychopharmacologic, and
and concerns about privacy and security risks.28
medical issues, as well as administering health status self-
Thus, more evidence regarding the feasibility and impact of
telehealth modalities is needed, particularly in naturalistic
settings outside of clinical trials.29 We, therefore, undertook
an evaluation of the acceptability and clinical impact of the
CVT-based bipolar CCM deployed in the VA healthcare system
after enrolling the first 400 participants.

Materials and Methods

PROGRAM DESCRIPTION
Bipolar Disorders Telehealth Program currently supports
0.6 FTE psychiatrist and 2.6 FTE psychologists based across
two facilities in New England. Clinicians are credentialed and
privileged to deliver care through memorandum of under-
standing between the Office of Telehealth Services and each
patient site, providing clinical care consistent with American
Telemedicine Association (ATA) guidelines for telemental
health.30 Sites were recruited by means of word-of-mouth Fig. 1. Bipolar Telehealth represents a clinical microsystem, con-
initially and then through conference calls with regional VA stituted in time-limited manner,10 to focus on the individual’s un-
mental health leadership across the country. met biopsychosocial needs in the context of bipolar disorder. As
outlined in the text, the Bipolar Telehealth psychiatrist provides
Clinical procedures are based on the Life Goals Collaborative
differential diagnosis and psychopharmacologic consultative rec-
Care Program, a bipolar CCM31,32 which is guideline en- ommendations to be acted on (or not) by the individual’s on-site
dorsed18,19 and listed on the Substance Abuse and Mental mental health provider. The Bipolar Telehealth psychologist then
Health Administration’s National Registry of Evidence-Based works directly with the individual in treatment, using the Life Goals
Self-Management Skill Enhancement Program30,31 and monitoring
Programs and Practices (www.samhsa.gov/nrepp). Core com- health status. The dotted line represents consultative recommen-
ponents include the following: dations and the solid lines represent direct treatment.

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Fig. 2. Enrollment in Bipolar Telehealth begins with a comprehensive
biopsychosocial intake by the psychiatrist, covering primarily
(1) assessment of differential diagnosis and psychiatric comorbidities,
(2) psychopharmcologic and medical comorbidity management, and (3)
self-report health status assessment using standardized health status
measures. This is followed by 7 weekly Life Goal self-management skill
enhancement30,31 modules conducted by the psychologist focusing on
self-management skill enhancement and health status monitoring.
Approximately 1 month after the final Life Goals session, a booster
session is scheduled to reinforce Life Goals skills, terminate the con-
sultation, and readminister the health status assessments. We inform
providers and individuals in treatment that the overall program en-
rollment may last 6 months, with the actual time in program varying due
to wait times between intake and Life Goals, scheduling flexibility of Life
Goals sessions, and the use of additional Life Goals modules to address
other issues (e.g., physical wellness, harm risk, psychosis, anxiety).
report rating scales. This is followed by six Life Goals Skills
Management Program modules delivered by the program
psychologist, with additional optional modules as clinically
indicated. At *1 month after the final Life Goals session, the
psychologist conducts a booster session to reinforce Life Goals
lessons and to administer the health status self-report rating
scales. We estimated that these activities would take *6
months, given scheduling complexities and the need for extra
sessions for some individuals.
The target population consists of veterans enrolled in VA
outpatient care with known or suspected bipolar spectrum
disorders, including cyclothymia and schizoaffective disorder,
without other exclusion criteria. Individuals are required to be
in treatment with a local mental health provider and agree to
CVT-based evaluation.
In the first year of the program, we added a chart review
consultation option for individuals who could not or would
not participate in CVT evaluation, to provide at least some
consultation to all providers who requested our assistance.
This consultation focuses on diagnostic and psychopharma-
cologic aspects of care, with asynchronous communication
between consultant and referring provider inspired by Project
ECHO33 methods (chart review consultation followed by in-
vitation to the referring provider to dialogue with the con-
sultant by e-mail and telephone).
Services are accessed by means of consultation request in the
patient-site electronic health record. Clinical communications are
made using chart note in the patient-site electronic health record
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TEAM-BASED TELECARE FOR BIPOLAR DISORDER
plus e-mail, telephone, and secure messaging communication
with providers as needed. Safety contingency plans are estab-
lished with each site before the program is opened at that site.
PROGRAM EVALUATION PLAN
This program evaluation was approved by the VA Con-
necticut Institutional Review Board. Evaluation was informed
by ATA guidelines for evaluating telemental health,34 par-
ticularly treatment engagement, including identification of
subpopulations at risk for not being reached; participation in
treatment; clinical impact; patient safety; and quality of care.
DATA ANALYSIS
Program evaluation focused on the first 400 participants
(November 2011 through May 2014) with data analyzed in
2015 to allow for a 1-year prospective follow-up for the 400th
participant. Demographic, diagnostic, medication, laboratory,
and clinical service utilization administrative data were
gathered from the VA Corporate Data Warehouse.
Self-report health status rating scales were obtained as part
of routine clinical care at intake evaluation and termination.
These included the Internal State Scale35 for manic and de-
pressive symptoms, well-being, and perceived conflict; the
AUDIT-C36 adapted for both alcohol and drug use; the VR-
1237 for overall mental and physical quality of life; and the
standardized VA assessment for risk of harm to self or others.
To characterize quality of care, we selected a priori four
characteristics that were endorsed in VA clinical practice
guidelines and were among the foci of our psychopharmacologic
consultation: increased lithium use, decreased antidepressant
use, increased prazosin use among those with comorbid post-
traumatic stress disorder (PTSD), and increased lithium serum
level monitoring among those taking this medication.
Two complementary sets of contrasts were of interest. First,
we conducted within-group pre/post-analysis on participants
for whom we were able to obtain health status self-report at
intake and termination; this includes those who completed
both the CVT interview and the Life Goals Self-Management
Skills Program (n = 79). Second, we reasoned that some impact
on psychopharmacologic strategies should result even for those
who only received chart review consultation; we again used a
pre/postanalytic strategy here, comparing the year before
versus the year after consultation, including those who com-
pleted CVT intake and those received only a chart-review
consultation (n = 379); the former group contained both those
who did and did not subsequently enroll in Life Goals. Our
secondary analyses compared these three groups to determine
whether quality impacts were limited to one of these subgroups.
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BAUER ET AL.
Two-group comparative data were analyzed using the t-test
or v2 test, while pre/postcomparisons were analyzed using the
paired t-test, McNemar’s test, or Fisher’s exact test (in the
context of unpaired pre–postdata). Tests of differential change
over time for distinct subgroups were explored using Mantel–
Haenszel tests.
Results
TREATMENT ENGAGEMENT
Bipolar Telehealth partnered with 13 medical centers, in-
cluding 9 hospital-based clinics and 6 community clinics
distributed across 8 VA regional networks and 11 states.
Consults per facility ranged from 2 to 153, received from a
total of 129 providers (range: 1–22 consults per provider).
Participation rates were comparable to31 or better than32 Life
Goals participation rates in facility-based bipolar CCMs.
Twenty-one consults (5.3%) were discontinued for adminis-
trative reasons. Of the remaining 379 consults, 296 (78.1%)
completed CVT intake and the remainder received chart review
consultation through telephone. Those completing CVT as-
sessment spent a mean of 183.7 – 74.4 days enrolled (median
168, range 59–398).
Of 254 participants judged clinically appropriate for Life
Goals self-management follow-up, 181 (71.3%) entered Life
Goals. Of these, 129 (71.3%) completed the program, while 52
(28.7%) began but did not complete. Life Goals completers had
a mean of 9.23 – 3.58 CVT sessions, while noncompleters still
participated in a mean of 3.75 – 2.46 sessions.
PREDICTORS OF PROGRAM PARTICIPATION
Participant demographic and clinical characteristics are
summarized in Table 1, which compares those who un-
derwent CVT evaluation and those who could or would not
and received a chart review consultation only. Those who
underwent CVT evaluation were significantly more likely
to be married, but did not differ on a wide variety of other
demographic and diagnostic characteristics. Those who
underwent CVT evaluation were less likely to have been
hospitalized but did not differ in other treatment experi-
ence in the prior year. Of the 254 judged appropriate for
Life Goals Self-Management Program enrollment after CVT
evaluation, completers (n = 129) did not differ from eligible
noncompleters (n = 125) on any of the characteristics
summarized in Table 1.
CLINICAL IMPACT
Among Life Goals Self-Management Program completers for
whom self-rating scales from intake and program completion
were available (n = 79), significant improvements were seen in
4 TELEMEDICINE and e-HEALTH O C T O B E R 2 0 1 6
manic, depressive, and conflict symptoms,35 as well as mental
but not physical quality of life37 (Table 2). No difference was
seen in well-being self-ratings,35 likelihood of being in any
mood episode,35 reported harm risk, or problem drinking.36
Among all individuals completing CVT evaluation
(n = 296), there was a small but nonsignificant decrease in the
rate of mental health hospitalization from 1 year after eval-
uation based on McNemar’s test (n = 71 [24.0%] to n = 61
[20.6%], p = 0.31). There were no significant differences be-
tween eligible Life Goals completers and noncompleters.
PATIENT SAFETY
There were no suicides while enrolled in Bipolar Telehealth.
We learned of two suspicious (accident vs. suicide) deaths
subsequent to the end of program contact: one death in an
individual who was referred but did not respond to enrollment
attempts and one death 3 months after CVT evaluation in an
individual who wished only initial evaluation without Life
Goals follow-up. There was one medical death several days
after chart review consultation in a veteran who could not be
enrolled in CVT evaluation.
We identified two suicide attempts during program en-
rollment, one despite activating the home medical center for a
higher level of vigilance. There were eight occasions when
program staff engaged on-site clinicians to address suicidal
ideation disclosed during a CVT session, and three hospitali-
zations for suicidal ideation.
QUALITY OF CARE
Quality of care indices are summarized in Table 3. As pre-
dicted, among those who completed CVT evaluation (n = 296),
lithium use increased in the year after CVT evaluation com-
pared to the prior year (McNemar’s test: n = 106 [35.8%] to
n = 154 [52.0%], p < 0.001), while antidepressant use decreased
(n = 143 [48.3%] to n = 103 [34.8%], p < 0.001). Among those
with a comorbid PTSD diagnosis, prazosin use increased (n = 30
[21.9%] to n = 48 [35.0%], p = 0.02). Rates of obtaining lithium
levels among those taking lithium, already high among indi-
viduals referred to our program, did not change in the subse-
quent year (n = 81 [76.4%] to n = 114 [75.5%], p = 0.88).
Two further analyses explored potential mechanisms for
these quality enhancements. We first explored whether medi-
cation use changes applied to CVT completers only or to all
individuals referred to our program (Table 3). In each case, the
Mantel–Haenszel test indicated that improvements in these
domains were significantly higher among CVT completers than
noncompleters. We then assessed whether those among CVT
completers who completed the Life Goals Self-Management
Program differed from those who did not complete Life Goals.
ª MARY ANN LIEBERT, INC.
 TEAM-BASED TELECARE FOR BIPOLAR DISORDER

Table 1. Baseline Demographic, Clinical, and Treatment Characteristics of First 400 Participants
OVERALL CLINICAL VIDEO TELECONFERENCE CHART REVIEW
CHARACTERISTIC SAMPLE (N 5 400) PARTICIPANTS (N 5 296) EVALUATION ONLY (N 5 83)
Demographic characteristics

Age at intake (years) 50.21 6 13.09 49.8 6 12.5 51.8 6 14.5

Min: 24, max: 83 Min: 25, max: 83 Min: 25, max: 83

Distance

Distance (miles) from residence 20.9 6 19.8 19.9 6 19.4 23.0 6 21.6
to site of clinical video intake

Gender, n (%)

Female 74 (18.59) 57 (19.3) 15 (18.1)

Race/ethnicity, n (%)

White 339 (85.18) 254 (85.8) 67 (80.7)

Black 31 (7.79) 21 (7.1) 8 (9.6)

Hispanic/Latino 10 (2.50) 5 (1.7) 4 (4.8)

Other race/ethnicity 11 (2.76) 16 (5.4) 3 (3.6)

Any minority 58 (14.91) 39 (13.2) 15 (18.1)

Disability status ‡50%, n (%) 182 (45.73) 132 (44.6) 38 (45.8)

Marital status, n (%)

Married 139 (35) 113 (38.2)a 19 (22.9)a

Clinical characteristics, n (%)

Diagnosis bipolar disorder in prior year 367 (92.21) 275 (91.9) 75 (91.4)

Bipolar type I diagnosis in prior year (of 276 (84.10) 210 (84.7) 55 (83.3)
those with bipolar disorder diagnosis)

Schizophrenia spectrum competing 66 (16.58) 49 (16.6) 14 (17.1)

diagnosis in prior year

Diabetes 79 (19.85) 60 (20.3) 16 (19.5)

Obesity 196 (49.24) 148 (50.1) 35 (42.7)

Hyperlipidemia 238 (59.80) 178 (60.3) 47 (57.3)

Substance abuse 229 (57.53) 164 (55.6) 51 (62.2)

Anxiety disorder 248 (61.32) 193 (65.2) 45 (54.2)

Post-traumatic stress disorder 220 (55.00) 166 (56.1) 43 (51.8)

Dementia 7 (1.76) 5 (1.7) 2 (2.4)

Tobacco use disorder 227 (57.04) 168 (56.9) 47 (57.3)

Cardiac dysrhythmia 66 (16.58) 45 (15.3) 19 (23.2)

Liver disorder 36 (9.05) 24 (8.1) 9 (10.8)

Kidney disorder 44 (11.06) 29 (9.8) 10 (12.0)

Thyroid disorder 55 (13.82) 41 (13.9) 13 (15.9)

Traumatic brain injury 17 (4.27) 11 (3.7) 5 (6.1)

continued /

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BAUER ET AL.
Table 1. Baseline Demographic, Clinical, and Treatment Characteristics of First 400 Participants continued
OVERALL
CHARACTERISTIC SAMPLE (N 5 400)
Treatment characteristics in prior year, n (%)
Mental health hospitalization 106 (26.5)
Any hospitalization 140 (35)
Antidepressant use prior year 184 (46.0)
Lithium use prior year 130 (32.5)
Anticonvulsant use prior year 144 (36.0)
Antipsychotic use prior year 240 (60.0)
a
Values differ at p £ 0.01.
b
Values differ at p £ 0.05.
We found no significant differences in any of the four quality
indicators (data not shown).
Discussion
RESULTS IN CONTEXT
These data demonstrate that CVT-based modalities can
successfully utilize multicomponent CCM interventions to
reach, engage, and impact health indicators for individuals
with complex, chronic mental health disorders such as bipolar
disorder. The program’s first 400 participants came from a
wide geographic area across 11 states, including small, rural
community-based clinics. Notably, as demand increased, the
specialty ‘‘hub’’ of the hub-and-spokes system expanded from
one to two medical centers, demonstrating that the clinical
microsystem10 can be implemented even with a virtual center
of clinical expertise.
What is known to date about telecare for serious mental
health conditions? The VA has seen steady growth of CVT-based
treatment for various mental health conditions since the mid-
2000s,38 with consequent reductions in hospitalizations and
days hospitalized in the year after versus year before initiation of
CVT-based treatment.39 However, relatively few reports of
telehealth-based interventions specifically for serious mental
health conditions exist, within or outside of the VA. For PTSD,
systematic review data indicate medium to large effects for
telepsychotherapy of various types over short term, although
enduring effects at 1–6 months are variable.40 Multicomponent
CCMs involving telephone-based supplements of on-site care
have demonstrated efficacy for PTSD41 as well as depression
treated in primary care,42,43 with one trial also providing access
to CVT-based consultation.41 We are aware of no reports of
CVT-based interventions for bipolar disorder, while for schizo-
6 TELEMEDICINE and e-HEALTH O C T O B E R 2 0 1 6
CLINICAL VIDEO TELECONFERENCE CHART REVIEW
PARTICIPANTS (N 5 296) EVALUATION ONLY (N 5 83)
71 (24.0)b 29 (34.9)b
93 (31.4)b 37 (44.6)b
143 (48.3) 35 (42.2)
106 (35.8) 29 (34.9)
113 (38.2) 32 (38.6)
191 (64.5) 48 (57.8)
phrenia, evaluation of technology-assisted treatment has been
limited to informatics-based technologies, but not CVT.44
Acceptability of CVT-based treatment for individuals with
mental health conditions has been mixed. One study demon-
strated high acceptability for low-income Hispanic women
volunteering to be randomized to CVT versus in-person
treatment for depression.45 However, another study of low-
income depressed individuals in the United States demon-
strated that while 76% endorsed the idea of CVT-based de-
pression treatment, only 38% made appointments and 17%
attended sessions.46 In a controlled trial of in-person versus
home-CVT delivery of exposure therapy for PTSD, CVT par-
ticipants reported difficulty tolerating the more stressful as-
pects of treatment.47 Qualitative data on CVT-based medical
consultation indicated that patients valued the increased ac-
cess and less travel, but did not consider it the ‘‘best care’’
compared to in-person consultation.48 Therapeutic alliance
ratings by observing psychologists were lower in CVT than in
in-person sessions.49
BIPOLAR TELEHEALTH PROGRAM EVALUATION ACROSS
FIVE ATA DOMAINS
Participation rates were at least similar to those of the
facility-based face-to-face bipolar CCMs on which the inter-
vention was based.31,32 CVT participation was acceptable to a
broad population, as analysis of predictors of participation
revealed no subpopulations at risk for nonengagement.
Clinical impact can be contextualized in light of the chro-
nicity and severity of bipolar disorder. Individuals who com-
pleted CVT evaluation and the Life Goals Self-Management
Skills Program experienced significant improvements in mental
quality of life as well as manic, depressive, and conflict
ª MARY ANN LIEBERT, INC.
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Table 2. Clinical Status at Baseline and Pre/Post-Treatment Clinical Status Among Life Goals Completers
CVT COMPLETERS BASELINE PRETREATMENT TERMINATION
(N = 296) (N = 79) POST-TREATMENT (N = 79)
Internal State Scale

Activation (manic symptoms) in 196.94 – 127.12 201.87 – 131.40a 163.38 – 114.28a

all patients regardless of mood state

Well-being in all patients regardless of mood state 135.18 – 82.74 137.34 – 80.38 153.38 – 79.41
b
Depression Index in all patients regardless of mood state 84.82 – 59.90 86.53 – 56.17 52.96 – 47.67b

Perceived conflict in all patients regardless of mood state 148.66 – 106.78 148.13 – 114.48a 109.00 – 90.30a

ISS-defined mood episode, n (%)

(Hypo)manic 84 (30.22) 22 (29.33) 24 (33.80)

Depressed 57 (20.50) 14 (18.67) 20 (28.17)

Mixed 80 (28.78) 23 (30.67) 9 (12.68)

Any ISS-defined mood episode (vs. euthymic), n (%) 221 (79.50) 59 (78.67) 53 (74.65)
b
Change in activation when intake mood -74.88 – 120.8
episode was (hypo)manic or mixed

Change in Depression Index where intake mood episode was depressed or mixed -62.5 – 52.30b

Change in perceived conflict when in mood episode at intake -41.96 – 104.2a

Harm risk, n (%)

Self—Thoughts 55 (19.37) 19 (24.68) 14 (19.44)

Others—Thoughts 33 (11.58) 16 (20.78) 10 (14.08)

AUDIT-C, n (%)

Alcohol: met criteria for problem drinking 44 (15.88) 9 (12.33) 6 (8.57)

Any drug or alcohol problem 60 (20.91) 11 (14.29) 9 (12.50)

VR-12 (mental and physical quality of life)

Mental Component Score 30.80 – 13.70 29.97 – 14.01b 36.86 – 13.47b

Physical Component Score 42.34 – 13.59 43.89 – 13.36 42.01 – 12.37

a
Values differ at p £ 0.02.
b
Values differ at p £ 0.001.
CVT, clinical video teleconferencing; ISS, Internal State Scale.

symptoms. For context, in over a 10-year prospective follow-
up, individuals with bipolar disorder spend approximately half
their lives with clinically significant symptoms, accompanied
by substantial psychosocial impairment.50,51 Thus, although
regression to the mean cannot be excluded without random
assignment, program completion was associated with signifi-
cant clinical improvement, consistent across multiple measures.
Patient safety considerations can also be viewed in context.
Meta-analytic data indicate that the suicide rate in bipolar
disorder exceeds the standardized mortality ratio 15-fold,52
and the disorder is the single diagnosis most highly associated
with completed suicide among veterans.53 Not only was CVT-
based consultation not associated with lapses in patient safety,
the care model increased vigilance, activating the individual’s
home medical center staff on multiple occasions to respond to
suicidal ideation; this enhanced response may have contrib-
uted to the lack of reduction in hospitalizations in the year
before versus after consultation. Although there were no
suicides during program enrollment, two suicide attempts
were identified. We cannot calculate an accurate event rate

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Table 3. Quality of Care 1 Year Before Intake Versus 1 Year Following

CVT COMPLETERS (N = 296) CVT NONCOMPLETERS (N = 83)
YEAR BEFORE YEAR AFTER YEAR BEFORE p-VALUE
BIPOLAR BIPOLAR BIPOLAR (MCNEMAR’S TEST p-VALUE
TREATMENT TELEHEALTH TELEHEALTH TELEHEALTH YEAR AFTER BIPOLAR OR FISHER’S EXACT (MANTEL–HAENSZEL
CHARACTERISTICS INTAKE (%) INTAKE (%) CONSULT (%) TELEHEALTH CONSULT (%) TEST)a TEST)b
Lithium use 106 (35.8) 154 (52.0) 30 (36.1) 36 (43.4) <0.001 <0.001

Antidepressant use 143 (48.3) 103 (34.8) 35 (42.2) 28 (33.7) <0.001 <0.001

Prazosin use 30 (21.9) 48 (35.0) 12 (27.9) 12 (27.9) 0.02 0.05

(if comorbid PTSD
diagnosis)

Lithium level obtained 81 (76.4) 114 (75.5) 26 (86.7) 29 (80.6) 0.88 0.77
(if receiving lithium
prescription)
a
McNemar’s test was used to compare proportion meeting criteria 1 year before versus 1 year after consultation (paired samples) in those completing CVT evaluation
(n = 296) for lithium level and prazosin use; Fisher’s exact test was used because the population of lithium users and the population of those with a PTSD diagnosis
changed from 1 year before to 1 year after consultation (unpaired samples).
b
Mantel–Haenszel test was used to identify differences in pre- versus post-consultation between those who completed CVT evaluation (n = 296) and those who received
only chart review consultation (n = 83).
PTSD, post-traumatic stress disorder.

with so few suicide attempts and an inexact person-year de-
nominator for follow-up. However, using the mean follow-up
of 183.7 days for 129 Life Goals completers plus 52 Life Goals
noncompleters, we can estimate the duration of follow-up as
(183.7/365) · 181 = 91.1 person-years, yielding a suicide at-
tempt rate during Bipolar Telehealth enrollment of 2.2% per
year. In comparison, summary data from a large number of
naturalistic follow-up studies of unselected populations with
bipolar disorder estimate the suicide attempt rate at 2% per
year.54 Thus, it is perhaps surprising that there were not more
suicide attempt rates among participants since they were,
by definition, sufficiently complex or unstable that they were
referred for specialty care.
Broad-based improvements in quality of care indices were
seen in the year after Bipolar Telehealth evaluation, and it is
difficult to ascribe these improvements to regression to the mean
or secular trends. Lithium use is highly evidence based, and
stands alone among antimanic agents as having antidepres-
sant55 and antisuicidal effects.56 However, rates of use have been
low and have continued to drop over recent years,57 likely, in
part, due to the relatively narrow therapeutic-toxic window and
the need for careful monitoring in comparison to other agents.
Nonetheless, lithium use increased 45.3% in the year after Bi-
polar Telehealth consultation. In addition, antidepressant use,
which can cause manic episodes and is recommended for sparing
use in most guidelines, dropped 28.0%, while prazosin use in
individuals with comorbid PTSD increased 59.8%. Thus, it is
likely that Bipolar Telehealth enrollment had impact on the
clinical care of enrollees. Moreover, because this program
was evaluated outside of the confines of a formal randomized
controlled trial, these data provide a needed extension of the
existing literature.29
LIMITATIONS
The impact of CVT implementation of the bipolar CCM cannot
be determined assuredly without a randomized controlled trial.
Regression to the mean for particularly symptomatic individu-
als, secular trends, random changes in clinical course, incom-
plete ascertainment of events, and confounding by indication
cannot be ruled out. Assessments were not blinded, but self-
reports were used to minimize the risk of interviewer bias. In an
exploratory program evaluation such as this one, correction for
multiple comparisons is less critical than in a scientific study
seeking to disprove a hypothesis, although we can conclude
only that the program appeared to be widely accepted and as-
sociated with a broad spectrum of improvements in health status
and quality of care.
CONCLUSIONS AND FUTURE DIRECTIONS
The Bipolar Telehealth experience indicates that CVT-based
modalities can be utilized to implement multicomponent CCM
treatment to reach, enroll, and impact the clinical course of

8 TELEMEDICINE and e-HEALTH O C T O B E R 2 0 1 6 ª MARY ANN LIEBERT, INC.


individuals with severe mental health conditions such as bi-
polar disorder. The program had beneficial effects across four
prespecified ATA domains: patient engagement, participation
in treatment, clinical impact, and quality of care. Thus, these
data support the use of CVT modalities for complex mental
health populations requiring complex treatment models such
as CCMs to maximize health outcome.
While randomized clinical trials will always be useful in
further defining effects of clinical interventions, the beneficial
effects of Bipolar Telehealth broadly align with results of earlier
randomized controlled trials of the facility-based bipolar CCM
on which the program is based.31,32 It would be more infor-
mative at this point to focus attention on the following:
. extension of videoconference-based CCMs to other seri-
ous mental health conditions,
. investigation of the barriers and facilitators to broad
implementation58 of such CVT-based models, and
. evaluation of the business case for their deployment and
sustainability in clinical practice.
Acknowledgments
Although this work was funded by the U.S. Department of
Veterans Affairs, the views expressed in this article are those
of the authors and do not necessarily reflect the position or
policy of the Department of Veterans Affairs or the U.S.
Government. The authors appreciate the comments of Eric
Smith, MD, MPH, on a prior version of this article. This work
was supported by clinical funds from the U.S. Department of
Veterans Affairs and VA Health Services Research and De-
velopment center grant #CIN-13-403 and VA Quality En-
hancement Research Initiative grant #QUE-15-289.
Disclosure Statement
Dr. Bauer receives royalties from Springer Publishing and
New Harbinger Publishing for work related to the collabora-
tive chronic care model for bipolar disorders. No other authors
report conflicting interests. This work was supported by
clinical funds from the Department of Veterans Affairs Office
of Telehealth Services. Dr. Bauer receives royalties on publi-
cations based on the Life Goals model from New Harbinger
and Springer. Other authors have no disclosures.
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Address correspondence to:
Mark S. Bauer, MD
VA Boston Healthcare System, 152M
150 South Huntington Avenue
Jamaica Plain, MA 02130
E-mail: mark.bauer@va.gov
Received: December 11, 2015
Accepted: January 27, 2016
ª MARY ANN LIEBERT, INC.