The prevalence of mental illness and the need to expand mental health services have been recognized for many years.
Rural and remote areas in particular face significant challenges, as rural populations may experience higher levels of stress than those in urban centers. This is due to a combination of factors, including higher rates of poverty and unemployment, and increased vulnerability to accidents and natural disasters.1 Furthermore, access to psychiatric services in rural communities is hindered by the shortage and unequal distribution of psychiatrists and other mental health professionals, as up to 75% of the rural population of the United States does not have access to mental health clinicians.2
Traveling to remote regions to provide services to a limited number of patients can be seen as inefficient, leading to a reluctance among clinicians to visit these communities for service provision. This reluctance passes the burden and expenses onto patients, who have to travel to urban centers for mental health care,3 a phenomenon known as “Greyhound Therapy.” 4 This represents a costly scenario for patients when considering lost work hours and the cost of travel and lodging, expenses that likely deter many patients from seeking the services they need.1 It must also be acknowledged that simply traveling to an unfamiliar environment without family support may cause undue hardship for those who are in need of care.1
These challenges, highlight the need for strategies to recruit and retain psychiatrists in rural and remote communities. There is evidence that training more medical students from rural areas, as well as incorporating rural health into medical education, has been associated with an increased likelihood that students will practice in rural areas upon graduation.5 However, implementing such measures can take years. Consequently, there is a compelling case for promoting widespread adoption of telemental health services in rural and remote communities, as part of a larger effect to enhance the access of such communities to mental health services.
In this article, we discuss telemental health as an effective and cost-efficient method for addressing the gaps in mental health care, particularly in rural and remote regions. We also discuss the reluctance among some clinicians to embracing this method on a larger scale, as well as strategies to enhance telemental health adoption.
Telemental health
Telemental health, or telepsychiatry, refers to the use of videoconferencing - also known as information and communications technologies (ICT) - to provide healthcare services remotely.4,6,7 Telehealth has a wide array of applications, such as direct patient care, consultations and continuing education.4,6,7 These activities may take place in a variety of settings including institutional settings, community settings, and patients’ homes.6 There is substantial evidence that telemental health is an effective means of delivering treatment across a wide range of diagnoses including depression, anxiety, schizophrenia, posttraumatic stress disorder, dementia, eating disorders, substance use, and suicide prevention.1,8 Furthermore, research suggests that using videoconferencing does not compromise the therapeutic alliance and that, overall, patients appear to be satisfied with services provided via ICT.1,9
Several studies have found that telepsychiatry is an effective method for providing consultation services and patient care in rural communities 3,10 and that it does, in fact, result in a high degree of satisfaction among both patients and healthcare providers.10,11 From the patient’s perspective, telepsychiatry not only facilitates access to mental health services but may also increase their appeal. Because videoconferencing eliminates the need for traveling outside of their community, patients may perceive these services as “low-profile”, an advantage to those that might decline treatment for fear of being stigmatized.4 In addition to bypassing the geographic factor, telemental health can help patients overcome other barriers to accessing healthcare. For example, physical limitations stemming from impaired mobility or chronic pain, and psychological challenges such as agoraphobia and social anxiety, may hinder or even prevent access to in-person services,1 making telemental health an ideal option.
Telepsychiatry also holds significant potential for addressing the large care gaps affecting rural communities, where it is particularly challenging to recruit and retain psychiatrists and other health professionals. Practicing in these areas places clinicians in a state of professional isolation, where decreased interaction with their peers creates the added burden of practicing with limited support.4 While psychiatrists are likely to remain concentrated in urban centers, telemental health can help in the recruitment and retention of other healthcare professionals, such as primary care physicians, psychologists, nurses, and social workers, by providing essential clinical back-up and fostering working relationships between rural care providers and their urban counterparts.12
Enhancing Telemental Health
Despite the advantages presented in the literature, resistance expressed by healthcare professionals may limit the development or advancement of telemental health programs.12 Research has highlighted the significance of both user satisfaction and user acceptability, as factors affecting the sustainability of telehealth programs. Clinicians’ attitudes towards the usefulness and convenience of telepsychiatry directly affect their degree of engagement with the technology. Specifically, the “perceived usefulness” and “perceived ease of use” of ICT are key factors in predicting both actual use and user satisfaction.7 There is also evidence that those who have been introduced to telepsychiatry during residency are more likely to incorporate it into their practice than those who have not.13 Accordingly, formal training with videoconferencing technology, along with a higher perceived ease of use, has been associated with increased frequency of use,1 a finding that is consistent with existing research on technology acceptance.7
On the other hand, the lack of adequate formal training is consistently discussed in the literature as a barrier to more widespread adoption of telemental health. Although there is growing interest in the field, telepsychiatry is not offered in all residency training programs, nor is it a required component of these programs.13 Where telepsychiatry does form part of the curriculum, there are often significant challenges, such as the effort required for the education of faculty members, as well as competing educational priorities during residency.14 This is problematic as it has been demonstrated that the absence of hands-on training with videoconferencing equipment predicts low confidence among mental health workers toward using these technologies.1 If this gap in training is not addressed, it seems unlikely that the potential benefits of telepsychiatry will be fully realized. Consequently, medical schools and other health-related training programs must incorporate telehealth into their curricula. Psychiatry residency programs, particularly, need to expand their training to include telemental health, with an emphasis on rural health.
The need for culturally-competent clinicians cannot be overstated. The cultural, social, and geographic characteristics of the community in which services are being provided must be taken into account, and particular emphasis should be given to studying and understanding the utility of telemental health among cultural and linguistic minorities.6,12 Accordingly, we strongly recommend that clinicians who deliver telemental health services to these communities be provided with training to enhance their cultural, social and geographic competency. The training should also familiarize the clinicians with the resources and services that are already available within the particular communities that they would be serving.
Finally, increasing the evidence base may also be a key piece in the promotion of telemental health. Despite the fact that multiple studies have demonstrated the utility and advantages of telemental health, more research is needed to understand the factors that contribute to the feasibility and acceptability of these services among clinicians. Understanding these factors further would be crucial to enhancing the adoption and sustainability of telemental health services.
Conclusion
As the need for mental health services continues to rise, it is imperative that we implement innovative approaches, in tandem with long term solutions, to address the concurrent demand. Given the demonstrated cost-effectiveness and utility of telemental health services, there is an urgent need to develop, expand and sustain telepsychiatry programs. In a country with a large geographic area and multiple communities residing in rural and remote regions, telemental health has great potential to address the care gap by enhancing direct patient care, consultation services, education and even the recruitment and retention of healthcare professionals in remote and rural communities. Enhancing the adoption of telemental health services among psychiatrists through education, training and research will take some time. However, we are optimistic about the current direction of telemental health service implementation, and we are hopeful that larger scale adoption will allow individuals residing in rural and remote areas to receive the healthcare services they deserve.
2. The Substance Abuse and Mental Health Services Administration. Workforce. Available online at: https://www.samhsa.gov/workforce. Updated September 15, 2017. Accessed on September 28, 2017.
3. O'reilly R, Bishop J, Maddox K, et al. (2007). Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatric Services, 58(6), 836-843.
4. Kirby MJ, Keon WJ, Dinsdale HB. (2006). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada.
5. Malko AV, Huckfeldt V. (2017). Physician shortage in Canada: a review of contributing factors. Global Journal of Health Science, 9(9), 68-80.
7. Gibson K, O'Donnell S, Coulson H, et al. (2011). Mental health professionals' perspectives of telemental health with remote and rural First Nations communities. Journal of Telemedicine and Telecare, 17(5), 263-267.
8. Frueh BC, Monnier J, Yim E, et al. (2007). A randomized trial of telepsychiatry for post-traumatic stress disorder. Journal of telemedicine and telecare, 13(3), 142-147.
9. Cuevas CDL, Arredondo MT, Cabrera MF, et al. (2006). Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. Telemedicine Journal & e-Health, 12(3), 341-350.
10. Jong M. (2004). Managing suicides via videoconferencing in a remote northern community in Canada. International Journal of Circumpolar Health, 63(4), 422-428.
11. Health Canada. (2004). Telemental health in Canada: a status report.
12. Volpe T, Boydell KM, Pignatiello A. (2014). Mental health services for Nunavut children and youth: evaluating a telepsychiatry pilot project. Rural and remote health, 14(2).
Authors’ Bios:
Hossam Mahmoud, MD MPH
Dr. Hossam Mahmoud is the Medical Director at Regroup Therapy. He is a board-certified psychiatrist, licensed in Illinois and Massachusetts. He is a Clinical Assistant Professor at Tufts University School of Medicine and holds a Masters of Public Health from the American University of Beirut, Lebanon.
Mireille Sers, MLIS
Mireille Sers is the Research Support and Systems Librarian at the International Development Research Centre in Ottawa, Canada. She has a background in medical librarianship and holds an MLIS degree from Western University in London, Ontario.
Jason Tuite, LCSW
Jason Tuite is a clinical social worker at the University of Illinois Hospital and Health Sciences System in Chicago, Illinois. He received his Master of Social Work from Loyola University Chicago and is a certified alcohol and drug counselor.
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