The pandemic made telehealth — remote health care, usually over a video application — ubiquitous in Washington. 

But when Veterans Affairs psychiatrist Dr. Debby Tsuang began offering telehealth appointments to her patients, mostly older adults at high risk for complications from COVID-19, many were reluctant to log on to a computer or tablet to set up a video meeting. Most preferred a traditional phone call to discuss their mental health needs.  

“In particular, older adults of color did not have access to such devices” and they “experienced a digital divide that further exacerbated health disparities,” Tsuang said. 

“They were not receiving the most optimal care via telemedicine,” she said. “Through the phone, we can’t see their face. And we miss the nonverbals.”

Medicaid claims for remote mental health appointments were almost nonexistent before COVID-19, but shot up to nearly 300,000 per month during the pandemic, state data shows. People of all ages started using telehealth for mental health appointments — but the number of claims for adults ages 65 and older increased by a significantly smaller degree than that of younger patients. 

Tsuang heard her patients’ complaints: They didn’t always know which buttons to push, or what link to visit to access a video call. Some older adults don’t own a computer or tablet, or have unstable internet access. 


However, telemedicine is “here to stay,” Tsuang said. “And we just want to be able to bridge whatever technological divides might exist in either Black or white [communities], or rural or urban — or any vulnerable individual.”

Tsuang, director of VA Puget Sound Health Care System’s Geriatric Research, Education, and Clinical Center, saw an opportunity to further her research on health disparities. With funding from UW’s Garvey Institute for Brain Health Solutions, she is studying how Black adults ages 60-80 respond to three modes of screening for mental health concerns: through written forms, phone interviews or video calls.

The project is in the pilot stage — she and her colleagues anticipate enrolling 15 participants or so for a yearlong study. But it could offer mental health providers important insight into how they can best assess patients who are among the most likely to have experienced prolonged isolation and loneliness during the pandemic — and can’t or won’t visit medical providers in-person. Tsuang recently discussed how her research might improve telehealth for the most vulnerable. This conversation has been edited lightly for length and clarity. 

The Seattle Times: How is your latest research on telehealth related to what you’ve spent your career dedicated to as a researcher and clinician?

Tsuang: Earlier in my career, I focused on more rare genetic conditions that cause neurodegenerative dementia. Then I moved into a disorder that’s called Lewy body dementia, which is on a continuum between Alzheimer’s disease and Parkinson’s disease.

In the past seven to 10 years, one of my main interests has been the health disparities that we experience or observe in both white and Black older people. We have been doing a lot of work across the nation with the overall goal to look for opportunities to improve the treatment of older adults in the VA healthcare system.


Many of the older adults you work with are reluctant to use telemedicine — even when they have access to a device. What barriers do they encounter?

Even though the VA rapidly rolled out a program where [they] would send the veterans an iPad with a cellular plan so that they could participate in telemedicine, I would hear things like, “I don’t know where it is right now,” or, “It’s not plugged in,” or, “I can’t get to the email.”

I think less than 50% of older adults feel comfortable using a smartphone or an iPad to communicate with their providers. The number of people who opted for phones was much higher than the folks who used telemedicine. And most of the people who used telemedicine usually had a middle-aged adult child helping them. 

In your ongoing study, what do you ask participants?

We assess depression, anxiety, loneliness [and use] cognitive screening assessments. We give them a blood pressure monitor, a thermometer and the last thing is a medical-grade watch to monitor their steps. We’re in the COVID era, so we wanted the participants to have the devices so they can monitor their own health parameters.

We ask very open-ended questions [about the paper, phone or video assessment]. Was this too hard? Easy? Helpful? Burdensome? Is it culturally appropriate to the relevant assessments?

At the end, we’d like to see if there’s a consistent modality [paper, phone or video] that most older adults would prefer. If we’re not going to have folks come back to face-to-face visits, and there’s a need to assess for mental and cognitive impairment, a lot of assessments may need to take place at home.


How has your experience as a clinician shaped the way you think about improving telehealth?

With COVID-19 we have seen the explosion of mental health needs. And the number of mental health providers, especially in rural areas, are insufficient to meet the needs of the mental health crisis.

Older people’s circles of social support are shrinking. And we just want to find ways that transform their connectivity to their families, their providers and their social support networks. That’s really the overall goal.

Are the strategies you’re testing, like mailing paper forms to patients, practical? Do you think older adults can be convinced to try video mental health appointments?

Let’s say somebody likes to do an assessment by paper and they want to reach out to their provider. I would hope [the patient] would say to them, ‘I feel more comfortable filling out the weekly anxiety or depression symptom checklist by paper.’ And then their provider could hopefully adjust medications, refer them to counseling and they could track their symptom severity that way. 

I think most healthcare systems have pivoted to video conferencing by now. But one participant said to me, “If I can’t figure out how to do my computer or smartphone or iPad, will you come over and show me?” Like, make a house call. I was like, “I don’t think I could do that.”

But I started thinking, some [health care] systems, they actually call you. A tech person calls you 15 minutes before [the telehealth appointment] and says, have you logged on? And if you haven’t logged on, what’s the potential obstacle? I don’t know if that would work for older adults.