Telepsychiatry has become one of the most talked about areas of psychiatry as it provides a way for patients who live in areas far from mental health professionals to receive needed therapy through remote video sessions. John Fortney, PhD, who is trained as a geographer, has become one of the nation’s foremost experts on using telemedicine-based interventions to improve care for rural patients.
Fortney, who recently joined the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center from the University of Arkansas for Medical Sciences’ Psychiatric Research Institute, published an important study in JAMA Psychiatry in November about how psychotherapy delivered remotely through video sessions benefited military veterans suffering from post-traumatic stress disorder.
He recently talked with Psychiatry Advisor about the growing interest in telepsychiatry, how it can benefit patients in rural areas and what needs to be done to allow it to grow further.
Psychiatry Advisor (PsychAd): How did you become interested in rural telehealth?
John Fortney: As a medical geographer, I was originally interested in how travel barriers affected people’s use of health care services. I became convinced that long travel distances influenced people’s decisions about whether or not to seek care, what type of services to use, and how often to engage in treatment.
For example, individuals with mental health disorders will often not seek care because services are too far away, or to take psychotropic medications prescribed by their primary care provider instead of engaging in psychotherapy with a mental health specialist. As I came to understand these issues better, I realized that telehealth technologies can provide more options to individuals living in rural areas and give them access to the services that best meets their needs.
PsychAd: What has spurred the increased interest in telepsychiatry?
Fortney: I’d like to think that is the growing body of research evidence that demonstrates that it is a safe and effective way to improve access to psychiatric and psychological services. But, in reality, it is probably due to early adopters sharing their positive experiences with their colleagues. It is also possible that the requirements of achieving Patient Centered Medical Home recognition have motivated some primary care clinics to think more about how to coordinate the delivery of specialty care for their patients.
PsychAd: What are the benefits of providing telepsychiatric services have for patients in a rural setting?
Fortney: Telehealth allows patients to get the specialty care they need in the comfort of their primary care provider’s office. This not only reduces the travel burden, but also reduces the stigma of receiving treatment from a psychiatrist or psychologist. It also has the potential to improve the communication and coordination between primary care providers and mental health specialists in order to provide a more holistic treatment experience for the patient.
PsychAd: Is there any evidence to suggest that receiving care via telepsychiatry is better or worse (or the same), in terms of clinical outcomes, compared with face-to-face, in-person care?
Fortney: The vast majority of studies have found no significant differences in the quality, outcomes or satisfaction of care delivered via interactive video compared to face-to-face. However, many of those studies did not have sufficiently large sample sizes to detect small, but potentially meaningful, differences in clinical outcomes. Nevertheless, taken together, the results of the large, sufficiently powered studies and the numerous smaller studies clearly indicate that telepsychiatry delivered via interactive video is helpful for most patients.
PsychAd: Do telepsychiatry services fit in well with an integrated care team?
Fortney: This question represents the next generation of research in telemedicine. Rural primary clinics are struggling to integrate mental health into their practices because of the difficulties of hiring on-site mental health specialists. Interactive video certainly provides the means to deliver specialty mental health services within the primary care setting.
However, using traditional models of specialty mental health care, there are not enough psychiatrists in the country to deliver services to all the patients in need. Telepsychiatry holds great promise for developing virtually integrated care models that are feasible to deploy in rural primary care settings. A telepsychiatrist that provides provider-to-patient and provider-to-provider consultations can have much greater reach and impact than a telepsychiatrist that treats patients one at a time under the traditional model.
PsychAd: What are the barriers or stumbling blocks in setting up a rural telepsychiatric service?
Fortney: The primary stumbling block is reimbursement. Many states still do not reimburse for telepsychiatry or telepsychology treatments. In addition, there is not necessarily much of a motivation for urban psychiatrists and psychologists to deliver services via interactive video when their schedules are already full of patients.
There needs to be an incentive for the urban psychiatrists and psychologists to care for the most complex patients in the state, rather than treating only those who have access to their clinic. Telepsychiatry aligns particularly well with the missions of academic health centers, where providers are intrigued by the most complex cases, and where residents and interns need exposure to patients with difficult to treat disorders in order to benefit the most from their clinical training.
Fortney: Does telepsychiatric care work well for all age groups and diagnostic categories?
Interactive video works best for patients who can interact with the clinician using the available technology. Interactive video is least suited for patients who are agitated, paranoid, or have cognitive impairment.
Fortney: Do you expect to see an expansion of telepsychiatry?
Given the right reimbursement environment, telepsychiatry has the potential to expand exponentially. Once the financial incentives are properly aligned to maximize population level health outcomes, telepsychiatry will undoubtedly flourish.