Comparison of Asynchronous Telepsychiatry vs Synchronous Telepsychiatry (CATELEST) in Skilled Nursing Facilities: A Randomized Controlled Noninferiority Clinical Trial.

Objective: Comparison of asynchronous telepsychiatry (ATP) with traditional synchronous telepsychiatry (STP) in skilled nursing facilities (SNFs) in California, United States.

Design: Patient-level randomized, controlled noninferiority trial.

Setting and participants: A total of 235 residents aged ≥18 years from 9 SNFs were referred for psychiatric symptom or medication evaluations.

Methods: Patients were individually randomized to receive ATP or STP. Visits were conducted at baseline and 1, 2, 3, 6, and 12 months. The primary outcome was change in psychiatric symptom severity from baseline to 6 months, using the clinician-rated Clinical Global Impressions (CGI) Severity of Illness scale, with a predetermined noninferiority margin of 0.5 points. Secondary analyses examined medication reduction recommendations. Data were analyzed using generalized linear mixed-effects models.

Results: Both groups showed improvement in symptoms. At 6 months, the intention-to-treat analysis (113 ATP, 109 STP) showed an adjusted CGI change of -0.47 (95% CI -0.64 to -0.29) for ATP and -0.68 (95% CI -0.86 to -0.49) for STP, with a between-group difference of 0.21 (95% CI -0.04 to 0.47), supporting noninferiority. The per-protocol analysis (79 ATP, 68 STP) showed an adjusted CGI change of -0.47 (95% CI -0.67 to -0.28) for ATP and -0.74 (95% CI -0.96 to -0.53) for STP, with a difference of 0.27 (95% CI -0.02 to 0.56). Because the upper bound of the confidence interval (0.56) exceeded the noninferiority margin (0.5), the per-protocol analysis did not support the noninferiority hypothesis. Overall rates of antipsychotic and antidepressant reduction recommendations were similar (P = .35 and P = .12, respectively).

Conclusions and implications: ATP was noninferior to STP in the intention-to-treat analysis but not in the per-protocol analysis, possibly due to the reduced sample size. ATP has significant implications for improving access to mental health care for patients within SNFs. Larger replication studies are warranted to validate and further refine these findings.