Psychosomatics 48:135-141, April 2007
doi: 10.1176/appi.psy.48.2.135
© 2007 Academy of Psychosomatic Medicine
The e-Mental Health Consultation Service: Providing Enhanced Primary-Care Mental Health Services Through Telemedicine
Jonathan D. Neufeld, Ph.D.,
Peter M. Yellowlees, M.D., M.R.C.P.,
Donald M. Hilty, M.D.,
Hattie Cobb, B.A., and
James A. Bourgeois, O.D., M.D.
Received October 19, 2005; revised March 6, 2006; accepted March 14, 2006. From the Dept. of Psychiatry and Behavioral Sciences, Univ. of California, Davis Medical Center, Sacramento, CA. Send correspondence and reprint requests to James A. Bourgeois, O.D., M.D., Alan Stoudemire Professor of Psychosomatic Medicine, Dept. of Psychiatry and Behavioral Sciences, Univ. of California, Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA 95817. e-mail: james.bourgeois{at}ucdmc.ucdavis.edu
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ABSTRACT
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This article describes the University of California, Davis Medical Center eMental Health Consultation Service, a program designed to integrate tele-mental health clinical services, provider-to-provider consultation, and provider distance education. During the first year of operation, consultations were provided for 289 cases. The most common diagnoses among children were for attention-deficit hyperactivity disorder-spectrum problems. Among the adult patients, mood disorders were most common. A convenience sample of 33 adult patients who completed the SF–12 health status measure showed significant improvements in mental health status at 3–6 months of follow-up. This model of comprehensive rural outpatient primary mental health care delivered at a distance shows promise for wider application and deserves further study.
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INTRODUCTION
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Specialty mental health providers have increasingly focused their efforts on service delivery in the primary-care setting, where most mental health care is, in fact, delivered.1 Similarly, many existing telepsychiatry and "tele-mental health" programs provide their specialty mental health services in primary-care settings, often in remote rural and underserved areas, where access to these services would otherwise be limited or nonexistent.2,3
Direct evaluation of patients via two-way videoconferencing is the backbone of most telepsychiatry services. Ample evidence exists that telepsychiatric evaluation services can be delivered economically and with levels of quality and patient satisfaction similar to those found with face-to-face evaluations.4–6 Some outpatient psychiatric consultation programs have also explored the use of telephone consultations as a quick and efficient way to provide consultative, supplemental, and follow-up care,7 as well as consultations provided by some form of electronic messaging (e-mail).8 Also, provider distance-education aimed at improving rural providers’ capacity for managing mental health issues is a natural outgrowth of clinical telemedicine programs and is increasingly listed among their most important benefits.9,10 Few programs, however, have reported on efforts to integrate these multiple services into a comprehensive "virtual mental health clinic" that can both provide a wide range of clinical services and support rural providers by means of educational offerings. In this article, we describe such a project and report our findings on an overall case mix for a 1-year period and health status outcomes for a small convenience sample of referred patients.
In reviews of the mix of psychiatric cases commonly seen in primary care, Katon11 and Katon and Schulberg12 estimated that 20%–33% of patients in primary- or specialty-care medical clinics meet criteria for a DSM-IV diagnosis, with 5%–10% meeting criteria for major depression. Coyne et al.13 found a prevalence of 13.5% for major depression and 22.6% for all mood disorders in 425 patients with elevated Center for Epidemiological Studies–Depression scores, who were among 1,928 patients screened in primary-care clinics. Mauksch et al.14 studied low-income and general primary-care cohorts and found an increased risk of psychiatric illness among low-income patients: overall prevalence of psychiatric disorders was 51%, versus 28% for the general primary-care population; mood disorders: 33% versus 26%; anxiety disorders: 36% versus 11%; alcohol abuse: 17% versus 7%; and eating disorders: 10% versus 7%.
A few authors have presented data on the mix of outpatient primary-care clinic patients referred to consultation psychiatrists. Case-mix summary data from these studies (representing the United States, Australia, and United Kingdom general primary-care populations) are presented in Table 1.15–22 It is of interest that two of these studies included the use of telemedicine: Johnston and Jones21 used a telemedicine approach to geriatric patients in nursing homes, and Dossetor et al.22 reported on a pediatric telemedicine sample.
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TABLE 1. Percent Psychiatric Diagnosis/Case-Mix in Outpatient Medical Clinical Populations Seen in Psychiatric Consultation
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Some broad trends can be derived from these case-mix studies. Mood disorders make up a large percentage of referred cases in most studies. Anxiety and adjustment disorders, when taken together, comprise about 30% of cases in several studies. Psychotic disorders are relatively rare in these samples, perhaps because these patients are generally managed in the mental health direct-care system. Somatoform disorders were quite common in three of the studies. In the one child study, attention-deficit hyperactivity disorder (ADHD)-spectrum illness and mood disorders comprised the bulk of cases.
There has been relatively little work on the psychiatric case-mix specific to rural populations. Among the studies reviewed in Table 1, only the Johnston and Jones geriatric telemedicine study21 and the Dossetor et al.22 pediatric telemedicine study focused on a rural psychiatric case-mix. More specific information on rural mental health case-mix might assist in developing primary care-specific educational endeavors designed to better equip rural providers to manage common psychiatric problems and more effectively refer patients for specialty consultation.
Functional health status at intake is another important characteristic of the population referred for specialty mental health consultation. Comorbidity of psychiatric conditions is common among those referred for specialty mental health care, but physical comorbidities can also be common and can affect clinical outcomes. A well-constructed and standardized health status measure such as the Medical Outcomes Study Short Form 12 (SF–12) is necessary to accurately characterize the level of physical and psychiatric disability in a referred population.23
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METHOD
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The UC Davis e-Mental Health Service was funded by the California Telemedicine and E-health Center (CTEC)24 to develop a model tele-mental health service for 10 rural sites in California. The project implemented this plan by transforming a small psychiatric tele-consultation service in an urban medical center into a comprehensive "virtual mental health clinic" that could deliver specialist consultations, clinical services, and educational experiences to physicians in distant rural primary-care clinics. To accomplish this overall goal, the project implemented the following specific objectives:
- Increase total clinic capacity by 70%.
- Add a clinical psychologist, creating a multidisciplinary consultation team.
- Add secure e-mail and telephone consultations to the video format already available.
- Add educational programs to support rural primary-care providers (PCPs) in their efforts to better manage mental health patients locally.
- Explore the sustainability of various financial and administrative models.
To the degree possible, all activities emphasized specialist interaction with rural providers targeted toward enhancing the capability of rural PCPs to deliver high-quality mental health care with or without consultation.
Increased Tele-Psychiatry Hours
Increased psychiatric video consultation formed the core of the enhancement effort. Psychiatrist time was increased by 80%, from 10 to 18 hours per week. These hours included increased clinical time and participation in educational presentations, as well as informal consultation. When patients were seen via interactive two-way video, summary evaluations and brief written treatment recommendations were faxed to rural providers within 15 minutes of ending a consultation. This allowed rural providers to adjust care plans or fill prescriptions locally immediately after the consultation, avoiding the need for an additional appointment. Consultants generally provided multiple treatment options and algorithmic follow-up decision trees for rural providers, so that follow-up care could be handled without additional consultations.
Psychotherapy Services
Psychological evaluation and 2–4 sessions of brief, solution-focused behavioral or cognitive-behavioral therapy were provided to patients for whom this was indicated. This made collaborative treatment involving a psychiatrist and the psychologist possible in some cases. In other cases, psychiatric evaluation was followed up with medication management (directed by the rural provider) and concurrent psychological treatment for patients and/or their families, allowing rural patients access to state-of-the-art collaborative mental health care.
Telephone and Electronic-Messaging Consultations
Rapid access to consultants for "virtual curbside consultations" was made available by phone or two-way video during weekly clinics or by appointment. With this arrangement, consultations on multiple patients could be accomplished during a single scheduled session, adding to the convenience and efficiency of the service.
Secure electronic messaging (e-mail) was added to allow for rapid consultation without the requirement for simultaneous (synchronous) availability of both the primary provider and the specialist-consultant. The clinic used a secure Internet-based messaging system marketed by RelayHealth® (Emeryville, CA, www.relayhealth.com). This system provides password-protected authentication, secure (encrypted) access via any Internet browser, notification of waiting messages via fax or regular e-mail, and secure storage of messages.
Provider Education
Members of the clinic team developed and delivered a series of presentations covering various aspects of mental health treatment appropriate for the primary-care setting, including screening and diagnostic procedures, appropriate referrals, basic psychopharmacology, and general principles for addressing mental health needs in primary care. Presentations specifically addressing anxiety disorders and geriatric mental health were added later. These presentations were designed to expand the range of diagnoses and treatments that participating rural PCPs were comfortable providing or managing themselves.
Service Provision, Data Collection, and Analysis
The research grant provided for the time for professional services by "covering" the salary and benefits for each of the three psychiatrists and for the clinical psychologist for time devoted to the project. Because of the nature of the funding of the project, patients were seen irrespective of insurance status. Professional liability and credentialing matters were handled by the University of California Davis Medical Center (UCDMC). Charting was done by dictation at UCDMC. A full report was faxed after transcription and signature by the psychiatrist or psychologist. Technical aspects of the VTC (video) connection were managed by UCDMC CHT technician staff.
The UC Davis Medical Center Psychosomatic Medicine Service professional staff provided all services at the UC Davis telemedicine facility in the UCD Center for Health and Technology (CHT). Diagnoses were made by the UCDMC psychiatrists and psychologist and recorded after each visit. Diagnostic, demographic, and health status data were collected from clinic records and de-identified, and analyses were done retrospectively at project completion.
All adult patients scheduled for video consultations completed the SF–12 V.2 before their initial consultation appointment.25–27 Thirty-six consecutive patients were contacted either by phone or at a later clinic appointment to complete a follow-up administration of the same instrument 3–6 months after their initial consultation. These instruments were scored by a computer program, entered into the clinic record, and later de-identified and analyzed for changes over the course of treatment. Missing or incomplete data were excluded, leaving 33 cases with complete health-status follow-up data.
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RESULTS
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During the project, 289 patients were seen for direct video consultation. Patients included 139 children, 129 adults ages 18–59, and 21 elderly patients, age 60 and over. A little over one-half of all patients (154, or 53%) were women. Ethnic composition was 87% White, 9% Hispanic, 2% African American, and 2% Native American. Among the 165 adults, 47% were married, 39% single, 9% divorced, and 2% separated. In all, 228 patients (79%) were seen by psychiatry only, 42 by psychology only (15%), and 19 (6%) by both specialties. Among patients seen in psychiatry consultation, 75% were for initial psychiatric consultation, 12% for medication management follow-up, and 13% for follow-up visits other than for medication management. Among psychology consultations, 33% were for initial psychological evaluation, 51% for individual psychotherapy, and 16% for family psychotherapy. The mean number of VTC encounters for psychiatrists was 1.1 contacts per patient, whereas, for psychology, there were 1.7 contacts per patient.
In addition to the direct video encounters, there were 28 contacts between referring clinics and UCDMC via the Relay Health secure messaging system and 27 telephone contacts. The majority of the telephone and Relay Health contacts were for advice regarding medication management and educational interventions for rural primary-care practitioners.
Case-mix among the child patients included 51% with childhood psychiatric disorders (defined as DSM-IV-TR disorders usually first diagnosed in infancy, childhood, or adolescence), 28% with mood disorders, and 17% with DSM "V-code" conditions. Case-mix among the adult patients ages 18–59 was the following: 74%, mood disorders; 24%, anxiety disorders; and 20%, substance use disorders. Case-mix among the geriatric patients comprised 57% mood disorders and 24% other psychiatric disorders (Table 2). For all three groups, the average initial Global Assessment of Functioning (GAF) score was between 57 and 62, reflecting moderate levels of psychiatric symptoms and distress.
Health-status measures showed a high degree of morbidity and comorbidity among patients and significant improvements in mental status after consultation (Figure 1). The mean intake Physical Component Summary (PCS) scores on the SF–12 V.2 were 41.1 (standard deviation [SD]: 13.9), nearly a full SD below the standardization sample mean. This level is similar to scores for persons with self-reported diagnoses of cancer (40.9), diabetes (41.9), or heart disease (39.2) in the standardization sample.19 Mean post-consultation PCS scores increased (but not significantly) to a mean of 42.4 (SD: 13.3; p=0.38). Mental Component Summary (MCS) scores at intake were extremely low, with a mean of 28.1 (SD: 10.7). MCS scores improved significantly at follow-up, however, ending 8.7 scale-points higher, at a mean of 36.8 (SD: 15.2; p=0.001, two-tailed). This follow-up level is similar to the mean reported by patients with chronic depression in the standardization sample (36.9).19
Three network-wide educational presentations were provided in addition to initial training visits conducted at each site. A total of 83 rural providers and clinic staff attended initial training sessions at the 10 rural sites, and over 50 clinic personnel (some individuals duplicated) attended the three subsequent educational presentations delivered via video streaming. Anecdotal reports and repeated requests for these educational services suggest a high level of satisfaction and a significant perceived benefit for these services among rural providers. Systematic evaluation of these services is underway.
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DISCUSSION
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This project extends the geographic range of university medical center-based mental health services. The application of telemedicine technology allows the provision of outpatient mental health consultation and clinical services to communities with little access to mental health care of any sort and essentially no access to psychiatric care. Our case-mix of psychiatric illness in children, showing an expected preponderance of childhood disorders (primarily ADHD-spectrum) and mood disorders, parallels the one similar study by Dossetor et al.22 Expanded use of consultative-care models such as this project may help to address this need and facilitate consultant-assisted primary-care management of these childhood psychiatric disorders.
Among our adults ages 18–59, the preponderance of mood disorders (74% of cases) far exceeds those of similar outpatient clinical populations studied.15–19 Similarly, our rate of 24% anxiety disorders is much higher than those in previous reports.15–19 This may represent a greater awareness and sensitivity for anxiety disorders currently, especially comorbid mood and anxiety disorders (e.g., patients with major depression and panic disorder or posttraumatic stress disorder [PTSD]), or may reflect differences in referral patterns relative to previous studies. Curiously, our finding of 5% prevalence of psychotic disorders in adults from 18–59 years and 60-or-older is higher than expected in a primary-care population and higher than reported previously in similar studies.15–19 This finding may reflect a lack of adequate resources in the rural mental health counties served by the project, something that many of the rural clinicians reported during the study. Rural primary-care clinics (which have structural challenges in attracting psychiatrists) may be well served by pursuing tele-mental health models for care of these patients, who are increasingly underserved and typically burdensome for primary care.
Taken together, our rates of diagnosis of mood, anxiety, and psychotic disorders in this population suggest that the frequency of these diagnoses in the rural population deserves greater study from an epidemiological perspective. Our cohort of geriatric patients, admittedly small, at 21 patients, shows a much higher rate of mood-disorder diagnoses than previous studies by Wilkinson et al.20 and Johnston and Jones.21 As with the adult patients ages 18–59, this may represent a referral bias among depressed geriatric patients treated by rural PCPs.
The pediatric patients had a mean of 1.33 psychiatric diagnoses, reflecting similar complexity (in terms of diagnoses per patient) to that found in previous studies.15–17,19,21 Among the adults age 18–59, however, our cohort had a mean of 1.70 diagnoses, and our geriatric patients had a mean of 1.62 diagnoses, reflecting a greater rate of psychiatric comorbidity than previous studies.15–17,19 It is likely that only the relatively more complex adult patients with psychiatric illness were referred for consultation. The issue of psychiatric comorbidity in primary-care telepsychiatry consultations has not been reported in detail previously, and thus replication and validation of this construct in similar studies are necessary.
Health-status findings for adult patients were consistent with a highly comorbid population, both physically and psychiatrically. Physical health was on par with levels seen in chronically ill medical populations (cancer, diabetes, and heart disease), suggesting that many patients had medically complex presentations in addition to their psychiatric conditions. Mental-health status at intake was very poor (over two SDs below the standardization sample mean) but improved significantly during the 3–6 months after initial consultation. Follow-up mental-health status was comparable to that of general-population respondents who self-reported a diagnosis of depression.
Our overall cohort size of 289 is the third-largest of similar studies; thus, the results may be reasonably generalized to other telepsychiatry service models serving rural primary-care clinics. Larger studies addressing the case-mix of psychiatric illness in rural primary care are desirable to further elucidate the specific range of psychiatric illness in this population. Also, similar studies specifically targeting child and geriatric populations in rural environments would be needed to further elucidate and clarify the psychiatric clinical needs of these populations at the beginning and end of life.
Telephone and secure-messaging consultations were provided only by psychiatrists. None were provided by or requested of the psychologist. This may be because the use of these modalities fits better into a pure consultation model, where the rural practitioner remains the treating and prescribing provider throughout the process of consultation. In contrast, psychological services needed to be provided directly to the patient, rather than to the rural provider, making telephone and secure-messaging modalities less useful for the psychologist.
Effects of the educational programs were informally reported to be positive; however, more thorough evaluation is necessary. Because access to consultation services was not adequate to meet the demand (despite significant increases provided by the e-Mental Health service), rural providers expressed interest in gaining skills to manage more of their patients themselves, freeing up limited consultation slots for more complex cases. More precise measurement of changes in PCPs’ patient-management styles and referral patterns might reveal a subtle shift in the type or severity of patients referred versus those managed in primary care with (or even without) consultation. The ability to show increased capacity of rural providers to deliver specialty care themselves, at least for some patients, would be a significant accomplishment. Our data do not provide any evidence of this, and initial results of our 12-month findings suggest that our evaluation paradigm may be inadequate to detect such changes. Certainly this approach deserves further study as a promising way to improve access to specialty care for rural populations.
We should note several limitations of this study. First, it was observational in nature, and in fact occurred in treatment settings that were experiencing and continue to experience a high degree of flux. Telemedicine services are new to some providers and relatively new to most rural clinics. Many of the observed changes might have occurred without the expansion of the program or the addition of any one component, and many of the case-mix characteristics reported here are dependent on rural provider preferences and habits that we neither measured nor controlled. Furthermore, some of the administrative procedures developed for handling telemedicine consultations were being developed during the observation periods and may have affected case volume and mix in non-random ways.
The UC Davis e-Mental Health Consultation Service is an example of the expansion of an existing psychiatric consultation–liaison service into a comprehensive "virtual mental health clinic" designed to improve mental health care access and quality for patients and providers in rural communities. Preliminary findings suggest that the program increased access to mental health services for a broad mix of rural patients with complex mental and physical health needs. A convenience sample of patients showed significantly improved mental-health status at 3- to 6-month follow-up. We hope that more detailed evaluation of patient satisfaction, administrative processes, and clinical outcomes will show this to be a viable model for addressing the growing mental health needs of patients and providers in rural primary-care settings.
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ACKNOWLEDGMENTS
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This project was funded by a grant from the California Telemedicine and e-Health Center.
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ABSTRACT
INTRODUCTION
