Telepsychiatry: Moving Mental Health Care Closer to Rural Patients

by Leslie Zganjar

In Alabama, 42 percent of the population lives in a federally designated mental health professional shortage area. In the state’s rural communities, mental health services are in even shorter supply.

Thaddeus Ulzen, MD, a psychiatrist and interim dean of the College, knows these statistics all too well. Not only is there tremendous need for mental health services in rural areas, he says, but mental health challenges there are often greater because, with less access to care, patients may present later with more complications. In addition, rural residents often have no choice but to seek help from their primary care physicians, who are already overwhelmed with heavy patient loads, he says.

Ulzen says for rural populations that are geographically isolated or financially unable to travel long distances to urban areas for care, moving mental health services closer through telepsychiatry is invaluable to improving access.

The College began work on a telepsychiatry program in 2007 when it partnered with the Alabama Department of Mental Health, West Alabama Mental Health Center and others on a $1.2 million grant awarded by the Bristol-Meyers Squibb Foundation to improve mental health services in Alabama’s rural and impoverished Black Belt region. The grant enabled the College to begin providing telepsychiatry services to assist the Demopolis- based West Alabama Mental Health Center, which has facilities in five rural West Alabama counties.

Two years later, the College’s Institute for Rural Health Research was awarded a $99,800 grant from the U.S. Department of Agriculture’s Distance Learning and Telemedicine Grant Program to purchase cameras, monitors and other equipment to bring telepsychiatry services to rural Alabama clinics that parterned with the Institute on the  grant. The clinics include Capstone Rural Health Center in Walker County, Carrollton Primary Care in Pickens County, Cahaba Medical Care in Bibb County and Monroeville Primary Care in Monroe County.

Last year, the College began providing telepsychiatry services to DeKalb County Youth Services.

Today, the College continues efforts to expand its telepsychiatry program with plans to provide services to additional sites in DeKalb County and sites in Etowah and Cherokee counties, to Northwest Alabama Mental Health Center and to other mental health centers, county jails and youth services facilities in Alabama that have asked the College to provide adult and child telepsychiatry to their clients.

Lloyda Williamson, MD, a psychiatrist and assistant professor in the College’s Department of Psychiatry and Behavioral Medicine, currently provides telepsychiatry services to Dekalb County Youth Services. In the past, she has provided telepsychiatry services to patients of West Alabama Mental Health Center. She says with fewer medical students choosing psychiatry as a specialty, and with the recognized need for mental health care, particularly in rural communities, “we are going to have to think outside the box and telepsychiatry is one way to do this.”

A Growing Need

Telepsychiatry is a growing trend in mental health care and regarded as one of the most promising telehealth applications. Telepsychiatry allows qualified mental health providers  to remotely deliver mental health services to individuals with limited access to care,  including those living in rural or underserved communities.

Mental health providers use video conferencing over a broadband network connection to conduct virtual sessions with patients located at remote sites. Patients and providers are connected through the use of computer cameras and microphones. Treatment is up close and personal. “You can talk back and forth in real time,” Williamson says.

The rise in telepsychiatry has come largely out of need. Mental illness is common problem in the United States. According to the National Institute of Mental Health, one in every four American adults aged 18 and older (58 million people) experiences a mental illness or substance-related disorder each year. Approximately 10 percent suffer severe, chronic and debilitating conditions, including schizophrenia, bipolar disorder, depression, anxiety and drug addition, the NIMH says.

Children are also affected. The American Academy of Child and Adolescent Psychiatry says between 7 million and 12 million youths suffer from mental, behavioral or developmental disorders. A recent survey funded in part by NIMH indicates that 50 percent of children in the United States who have certain mental issues, such as generalized anxiety disorder and depression, are not being treated by a psychiatrist or other mental health professional.

The picture is grim in rural areas. According to the U.S. Department of Health and Human Services, 60 percent of rural Americans live in a designated mental health professional shortage area where many communities have limited or no access to psychiatrists, psychologists and social workers. Frequently, rural Americans suffering from mental illness go untreated.

Children in rural areas are at greatest risk, Ulzen says. Prevalence estimates of childhood psychiatric disorders are generally about 20 percent, and nearly three-quarters of 21-year-olds with a psychiatric issue had problems as children, he says.

Zelia Baugh, MSW, LCSW, leads the Alabama Department of Mental Health. She says more than half of Alabama’s 4.5 million residents are in need of some mental health services but ongoing state budget shortfalls are leaving thousands of citizens without access to mental health services.

“There is a psychiatrist shortage in Alabama. The average wait to see a psychiatrist is three months. And we have a strained public health system that only provides services for 33 percent of adults with serious mental illness,” Baugh says. “There are other challenges, especially in rural Alabama where people, if they are able, have to travel long distances to have their mental health needs met.”

Enhancing the Mission

The College was founded nearly 40 years ago with a mission to train primary care physicians to practice in rural communities and to support them in their efforts. The telepsychiatry program is helping the College enhance and expand this mission, Ulzen says.

Several days each week, Elaine Leynes, MD, the College’s Rural Public Psychiatry fellow, sees patients at West Alabama Mental Health Center in Demopolis, which has facilities in five surrounding rural counties – Choctaw, Greene, Hale, Marengo and Sumter. Using telepsychiatry, Leynes can consult directly with psychiatrists at University Medical Center, which the College operates.

Last year, the College began offering telepsychiatry services to DeKalb County Youth Services and hopes to soon provide telepsychiatry services to the DeKalb County Jail, the DeKalb County Juvenile Court and to Northwest Mental Health Center, which has locations in Fayette, Lamar, Marion, Walker and Winston counties. Plans are underway to bring telepsychiatry services to Capstone Rural Health Center, Carrollton Primary Care, Cahaba Medical Care and Monroeville Primary Care. The clinics also serve as rural health training sites for the College’s medical students and residents.

In addition, the College is working to integrate its Behavioral Health in Family Medicine Fellowship and Rural Public Psychiatry Fellowship with its telepsychiatry program. Williamson says telepsychiatry needs to be introduced into the medical curriculum and needs to be a priority in medical education.

“Telepsychiatry needs to be integrated into the general medical curriculum from the very beginning,” adds Marisa Giggie, MD, a psychiatrist and assistant professor in the Department of Psychiatry and Behavioral Medicine. “We need to expose students early in their training and their residencies.”

Giggie, who specializes in child, adolescent and forensic psychiatry, also works with county jails in Alabama to conduct psychiatric assessments and evaluations of juvenile offenders using telepsychiatry. She hopes the College’s telepsychiatry efforts will eventually reach all rural and underserved areas throughout the state.

“Telepsychiatry truly does help improve their access to care,” she says. And for medical students and resident physicians, “they receive exposure to a technology that is expected to be used more widely in the future.”

There are a few barriers to providing telepsychiatry services. Reimbursement is sometimes difficult to receive, especially from third-party payers. But those involved with telepsychiatry say both patients and providers are satisfied with the care they are receiving and giving.

Giggie says she was apprehensive at first about telepsychiatry. “You observe much through eye contact and body language, but I was surprised at how satisfying it was. I am glad I can provide treatment to someone who might not otherwise get treatment.”

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