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A Primer on Virtual Reality Exposure Therapy (VRET)

Imagine riding an all-glass elevator to the top of a tall skyscraper, exiting to a narrow bridge projecting off the roof, and then looking down. Such a journey might evoke some level of discomfort in most of us, and for a subset of 3-5% of Americans with acrophobia, it would trigger marked to debilitating anxiety. I completed this very exercise, only without ever leaving the comfort of a conference room, during a product presentation by Psious for its virtual reality therapy platform.

The Role of Presence in Virtual Reality

Effective VR therapy depends on the experience of presence in a virtual environment. Lombard and Ditton suggest that telepresence creates an illusion of nonmediation whereby a person “…fails to perceive or acknowledge the existence of a medium in his/her communication environment and responds as…if the medium were not there.” This illusion may suggest to participants they are receiving all information cues relevant to an interaction, when in fact they are not.

Hodges, Rothbaum, Kooper et. al. present a conception of presence based on three primary determinates. The first, fidelity and extent of sensory information, corresponds to the quality and quantity of information available to a person experiencing an environment. The second, consequences of a participant’s actions, corresponds to the interaction between a participant and the environment. That is, in addition to the participant’s ability to modify his point of view through head movement, or to interact with objects in the environment, consequences would also include physical laws. For instance, if the user stepped off of a platform, gravity would pull the user down, or, if the user collided with a solid surface, the user would experience pain. The third, gestalt of the participant, represents what the participant brings to the environment. Or put another way, a person’s reaction to his or her environment depends on the whole of who he or she is, in addition to his or her previous experiences.

A primary difference between the experience of an event in a virtual environment and a real one lies in the intensity or vigor of the experience. A virtual environment generates fewer consequences for a participant’s actions in terms of the second determinant outlined above. Further, familiarity with a virtual environment does not in itself increase the participant’s sense of presence, and a person’s perceptions of real-world situations and behavior may change based on his experiences within a virtual world. However, a person’s experience of a situation in a virtual environment may evoke the same reactions and emotions as the experience of a similar real-world situation, even when the virtual environment does not completely represent the real-world situation.

Psious, One of a Few Platforms on the Market

Psious’ platform is similar to a few others on the market. The simulation is delivered through a VR headset, in Psious’ case the Gear VR by Samsung. Software simulations are developed by an in-house team for an array of possible phobias that range from fear of heights, fear of driving, fear of animals, agoraphobia, claustrophobia, and fear of public.

In the fear of heights simulation, for example, a patient rides an all-glass elevator outside a tall building to a narrow bridge skywalk that overlooks the city, during which the therapist can modulate the behavior and function of the elevator. In the fear of public simulation, a patient faces an audience in a large hall to deliver a speech amidst a number of distractions, including audience feedback. In every case, a therapist guides the patient through the simulation and exercises discretion over its level of intensity in a progressive, hierarchical fashion matched to the need of the clinical approach.

I found my trial simulation immersive to a considerable extent, even though I was in a room full of talking people. The graphics fell short of photorealism, but the program’s frame rate was smooth, comparable to anything one might stream on TV. On two rare occasions, a loaded scenario froze, but otherwise, all simulations ran smooth, without issue. In a controlled environment, free from people and distractions, I could see my level of immersion being far higher. For another audience member who volunteered, the same simulation delivered significant levels of anxiety, as evident from her verbalizations and physical movements.

Psious operates on a trial-before-commit subscription model. For $99, users can join its Expert Network and receive shipped gear, which includes a Samsung Gear VR headset for trial, after which a user can elect to extend membership. Membership includes access to instructional online video and written materials that describe the functionality and treatment protocols on the integration of virtual reality resources, as well as a training and Q&A session with one of Psious’ staff psychologists.

VRET in the Current Telemental Health Landscape

Relative to computerized CBT (cCBT), internet-mediated CBT (iCBT), and mobile therapty (mTherapy), VR exposure therapy (VRET) is a younger technology platform, which has received less research attention than cCBT or iCBT, but data suggests the technology carries a potential role in the treatment of several psychiatric conditions, including phobias, PTSD, OCD, and substance use disorders. VRET may also possess advantages over conventional forms of therapy when it comes to recreating challenging exposure situations, in addition to the advantage of additional control over the exposure exercise and a sense of increased safety to the patient when confronting phobic stimuli. Exposure therapy is the biggest application for VR technology at present.

VRET vs. Conventional Therapy

Dr. Albert “Skip” Rizzo, Director at the University of Southern California’s Institute for Creative Technologies and an authority on the design, development and evaluation of VR therapy systems, thinks VR therapy presents a number of benefits over conventional therapy, including reduced psychological barriers to treatment, since patients can participate from the comfort of their homes. In addition, he thinks the very medium of VR carries added appeal to a generation that has grown up on video games, such that otherwise averse patients may get through the door to treatment.

The U.S. military has invested heavily in VR in response to veterans who served in Operation Iraqi Freedom and returned with high incidences of PTSD. In fact, Dr. Rizzo’s lab has built a virtual Iraq and Afghanistan simulation, which can simulate the smell of diesel, rotting garbage, and burning rubber. According to Rizzo, much of the technology driven by the military can translate to the civilian world. Other advantages of VR therapy include the ability to access patients in remote areas and considerable cost savings when compared to in vivo therapy.

Perhaps three main weaknesses of existing applications of VRET include the upper threshold of graphical realism, the fact that certain conditions still necessitate face-to-face contact, and the lack of clinical research data on VRET relative to other forms of CBT. When it comes to graphical realism, a specific challenge of medical VR is to convey finely-detailed 3D structures with real-time interactivity.

Open Questions

There are a few open questions about how VR therapy could operate alongside cCBT, iCBT, or mTherapy in a patient treatment program. To what extent is VRET complimentary to the above approaches? How might psychiatric care be optimized or compromised through application of VRET alongside other forms of CBT, including traditional CBT? The answers to these questions, in addition to further study on VRET, would advance our understanding of telemental health in an important way.

What the Affordable Care Act Means for Mental Healthcare

The U.S. government for decades has struggled to devise programs that integrate needed services for people with severe mental illnesses. Implementation has been limited by inadequacies in the behavioral health policy framework, poorly designed payment approaches, and dysfunctional regulations. Fortunately, the Affordable Care Act has brought a number of policy changes that improve access to mental and behavioral health services for millions of Americans.

Expansion in Insurance Coverage

The proliferation of health insurance coverage through the Health Insurance Exchanges (HIE) and state-specific Medicaid dramatically expands coverage for those not eligible for Medicare. The ACA also prohibits insurance companies from denial of coverage to individuals with pre-existing conditions. This is significant because mental health disorders were among the most common pre-existing conditions triggering health insurance denials before the full implementation of the ACA.

Improved Mental Health Coverage and Funds for Behavioral Health Treatment

Through the expansion of the Mental Health Parity and Addiction Equity Act (MHPAE) of 2008, mental health and substance use treatment is now one of the ten “essential health benefits” for all health insurance plans in the individual and employer market, inside and outside HIEs. Insurance plans must now treat physical and mental illness with parity when considering necessity for medical treatment.

Second, the Medicare Improvements for Patients and Providers Act (MIPPA) ends the discriminatory mental health coverage that required patients pay up to 50 percent of the cost of approved services, in contrast to the 20 percent copayment applied to other types of outpatient services. 100 percent parity now applies in copayments for outpatient service; thus, Medicare will now cover 80 percent of the cost of mental health outpatient services, consistent with other types of outpatient services.

Third, ACA establishes the Community Health Center Fund, which provides $11 billion to expand services offered in Community Health Centers and to construct additional sites, including those for behavioral health treatment. These funds can potentially enable access to mental health treatment in rural areas where such services are often scarce.

What this Means

The dramatic expansion in insurance coverage for American and improved mental health coverage and allotment of funds for behavioral health treatment in rural settings means more funds are now accessible for the delivery mental and behavioral health services in the U.S.–healthcare tech companies in this space stand to benefit from the new opportunities in reimbursement.

Using Telehealth for Behavioral Crisis Assessments in Rural Communities

The third in a series of articles on developments in telepsychiatry.

Rural communities throughout the U.S. face severe shortages of trained mental health professionals. Here are some key statistics:

  • More than 60% of rural Americans live in mental health professional shortage areas.
  • More than 90% of all psychiatrists and psychologists and 80% of all MSWs work exclusively in metropolitan areas.
  • More than 65% of rural Americans obtain their mental health care from their primary care provider.

As a consequence, more than 91 million Americans live in areas with a mental healthcare provider shortage. Further, nearly 1 in 8 patients who present to the hospital emergency department (ED) come with a mental health and/or substance abuse issue, which on average require a lengthier boarding period than patients with non-psychiatric complaints. Telehealth presents a potential solution to the challenges confronted by patients and providers in rural settings, especially within the context of the ED.

Small towns face a number of unique behavioral care challenges. These challenges include elevated stigma around issues of mental health, increased liability and inpatient admissions, inadequate medical necessity documentation, higher rate of patient return visits to the emergency department, and a general lack of access to behavioral health resources. To tackle these issues, small towns should aim for better assessment and clearer patient psych picture in the ED, increased support for patients discharged from the ED, reduce repeat visits to the ED, and reduced re-admissions to the behavioral health unit.

Telehealth administrators should anticipate and prepare to respond to several concerns that emergency room providers may voice, including the potential for delay to ED patient care, loss of decision-making rights, and concerns about the process specific to behavioral health. Administrators must also manage effective networking and partnerships for successful treatment of patients in rural settings, including between the care team, patient and family, community providers, hospitals and clinics, and technology partners.

Providers can assess the success or failure of a telehealth implementation at their care site by measuring a number of metrics around patient care, including: (i) number of discharged patients connected to care (ii) percentage reduction in inpatient lengths of stay (iii) percentage reduction in inpatient re-admissions (iv) percentage reduction in re-assessments (v) percentage reduction in total admissions (vi) percentage reduction in denials (vii) percentage reduction in 1-to-1 patient watch (viii) percentage reduction in transportation costs (ix) percentage reduction in wait times (x) percentage increase in shared decision-making (xi) percentage improved assessment and documentation (xii) percentage bed access rate.

A successful telehealth program can provide small town providers with increased ED care team education, appropriate treatment recommendations, clearer clinical picture with thorough documentation, improved communication between the ED and follow-up care, and expansion of behavioral health services. In addition, telehealth enables providers increased access to health history and leads to better performance in provider reviews and surveys and, for patients, provides reduced travel expenses, comprehensive care, access to more providers, and timely access to follow-up care.

Prescribing Controlled Substances via Telemedicine

The second in a series of articles on developments in telepsychiatry.

Controlled Substances Act

The Controlled Substances Act (CSA) of 1970, a key structural element of the DEA’s authority, combined existing federal drug laws and expanded their scope, changed the nature of federal drug law policies, and expanded federal law enforcement pertinent to controlled substances. Several amendments to CSA followed over the next several decades up through 2010, which together circumscribe the prescription of controlled substances via telemedicine.

Definition of Controlled Substances

Controlled substances may fall under one of five schedules, as described in the following table (state and local laws may be more restrictive):

Schedule I No accepted medical use; high potential for abuse (e.g. heroine, ecstasy)
Schedule II Accepted medical use with severe restrictions; high potential for abuse (e.g., cocaine, morphine)
Schedule III Accepted medical use; moderate to low potential for abuse (e.g., codeine, Vicodin)
Schedule IV Accepted medical use; potential for abuse, but less than Schedule III (e.g., valium, Ambien)
Schedule V Accepted medical use; low potential for abuse (e.g., Robitussin AC)


Ryan Haight Online Pharmacy Consumer Protection Act

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 amends the Controlled Substances Act to prevent the illegal distribution and dispensation of controlled substances by means of the internet. The Act was passed by Senator Feinstein in response to the death of Ryan Haight, a teenager who overdosed on pain killers that he obtained in an illegal manner by exploiting gaps in the U.S. pharmacy system.

The Ryan Haight Act specifies that a prescribed controlled substance, as determined under the Federal Food, Drug, and Cosmetic Act, may not be delivered, distributed, or dispensed by means of the internet without a valid prescription. A valid prescription is a prescription issued for a legitimate medical purpose in the usual course of professional practice by a practitioner who has conducted at least 1 in-person medical evaluation of the patient, or a covering practitioner. A covering practitioner is a practitioner who conducts a medical evaluation (other than an in-person medical evaluation) at the request of a practitioner who has (a) conducted at least one in-person medical evaluation of the patient, or an evaluation of the patient through the practice of telemedicine within the previous 24 months and (b) is temporarily unavailable to conduct the evaluation of the patient. The intent of the Act is to prevent the generation of a prescription by an online pharmacy that also dispenses the medication; in other words, to separate the prescriber from the dispenser.

In addition, the Act exempts practitioners from the in-person exam requirement so long as they meet the federal definition of telemedical practice. A physician who practices telemedicine may prescribe a controlled substance without an in-person evaluation if (a) the patient is treated by and physically located in a hospital or clinic with a valid DEA registration, and (b) the telemedicine practitioner treats the patient in the usual course of professional practice.

DEA Electronic Prescriptions for Controlled Substances Rule

The DEA Electronic Prescriptions for Controlled Substances Rule of 2010 further revises DEA prescription regulations to (i) provide practitioners the option to write prescriptions for controlled substances electronically, (ii) permit pharmacies to receive, dispense, and archive these electronic prescriptions, and (iii) provide pharmacies, hospitals, and practitioners the ability to use modern technology for controlled substance prescriptions while maintaining the closed system of controls on controlled substances. The regulations supplement and do not replace existing DEA rules.

State Policies On Controlled Substance Prescription

In addition to the Ryan Haight Act and Electronic Prescriptions for Controlled Substances Rule, providers must be cognizant of state-specific laws and policies, as published by the National Association of State Controlled Substance Authorities. Further, controlled substances may be prescribed only through an electronic health record (EHR) system. An even split exists between states that require controlled substance registration and states that do not.

The following chart describes recent policy changes by a subset of states:

Arizona Providers do not pay a fee
Delaware Providers must complete 2 hours of controlled substances CME
Florida Prescriber profile designation
Minnesota Providers are exempt from registration
Mississippi Providers are exempt from registration, unless handling a controlled substance
Montana Providers are exempt from registration, but must pay a fee
New Hampshire Providers must participate in a drug monitoring program
North Carolina Solo practitioners are exempt from registration
Ohio Businesses that generate prescriptions must register
Oklahoma Providers must possess state residency



Practitioners engaged in the electronic prescription of controlled substances must develop comfort and familiarity with the Ryan Haight Online Pharmacy Consumer Protection Act, DEA Electronic Prescriptions for Controlled Substances Rule, and relevant state and local policies. Further, the variability in laws and policies state to state on this issue suggests that practitioners ought to take an active role in the influence of policymaking, work with EHR vendors to optimize process, and engage with associations and popular press to advance requirements and best practices central to electronic prescription of controlled substances.


Telemedicine and the Interstate Medical Licensure Compact

The first in a series of articles on developments in telepsychiatry.

A Barrier to Telemedicine Adoption

One barrier to the adoption of telemedicine services over the last several years has been a lack of integration within the state medical licensing system. Requirements vary by state, however, the general consensus is that a physician must be licensed in both the state where he or she is located and the state in which the patient is located.

Physicians who wish to treat patients in multiple states must proceed through a lengthy and expensive licensure application for each state in which they wish to practice. The process also often requires extensive paperwork, lengthy processing times, and in some cases, written exams. A flood of bills in recent years, including the Telehealth Enhancement Act of 2015, VETS Act, and TELE-MED Act of 2015, have sought to eliminate the geographic restrictions on telehealth services and, thus, enable doctors to deliver care to patients across the U.S. In this regard, the Interstate Medical Licensure Compact system developed by the Federation of State Medical Boards marks a major milestone in eliminating one of the barriers to telemedicine adoption.

Interstate Licensure Compact System

An Interstate Compact Commission will meet later this year to discuss the specifics of management and administration of the newly enacted Compact, but many important points have already been established. First, since telemedicine must be practiced appropriately and within the standards of licensing boards, the Compact maintains the existing authority of all participating state’s licensing boards. Secondly, the Medical Practice Act, which outlines the laws and regulations governing the practice of medicine within state boundaries, is maintained. Lastly, states will still receive the licensing fees of physician applications and maintenance of licensure and there will be no increase in state spend with the Compact.

The Compact does not provide one universal license for all participating states. It does, however, increase the ease and reduce the time required to obtain a medical license in other member states. Once physicians have completed the Compact process to receive another state medical license, they follow the same rules and regulations as if he or she had applied the traditional route. In order to join, physicians must meet the following requirements: (i) possess a medical license in one of the Compact states (ii) have a specialty certification (iii) have no discipline on any state medical licenses, and is not under investigation (iv) passed the USMLE or CMLEX (v) completed a GME program. In the application, physicians simply designate his or her state of principal licensure and select the other member states in which licensure is sought.

State-Level Adoption and Introduction of Compact Legislation

12 States have adopted the Interstate Medical Licensure Compact, including Alabama, Idaho, Illinois, Iowa, Minnesota, Montana, Nevada, South Dakota, Utah, West Virginia, Wisconsin, and Wyoming. States who participate in the Compact agree to expedite license applications for physicians who seek to practice medicine across state lines. Compact legislation has been introduced in 14 additional states, including Alaska, Arizona, Colorado, Kansas, Maryland, Michigan, Mississippi, Nebraska, New Hampshire, Oklahoma, Pennsylvania, Rhode Island, Vermont, Washington, with more expected to join this year. Most states’ physician licensure guidelines adhere to the telemedicine guidelines set forth by the Federation of State Medical Boards.


The Compact will join the ranks of similar professional regulations that facilitate interstate health care like the Nurses Licensure Compact (NLC) which launched in 2000. Other healthcare professions are also following suit and exploring their own licensure compact structures. The Compact represents a major step forward in the nationwide adoption of telemedicine and, in turn, the critical effort to bring quality patient care to rural and underserved areas.

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