Too many Americans don't have access to sufficient mental health support, but innovative partnerships are helping bridge the gap for some patients.
When psychiatrist Dr. Jon Martin sat down to speak with his patient, he could tell she was distressed. Taking a slew of prescribed medications, the only certainty this patient had was that she felt as if she was falling apart.
Living in a rural area, Martin's patient did not have local access to any mental healthcare professionals, leaving her to rely on general health providers for mental health issues. However, with access to a computer, this changed.
Sitting in front of a webcam in her local health clinic, Martin's patient cried while describing her feelings of anxiety and depression. She explained that she never identified with the symptoms or signs of the condition she'd been told she had, and even felt worse on her medications. On the screen was Martin, who sat in his office at Baptist Health Corbin in Kentucky, explaining to her that her sentiments were both valid and understandable--because she had been misdiagnosed, and the medications she was prescribed contributed further to her distress.
"She was on four or five psychotropic medications. I started reducing them one by one because she was still complaining of a significant amount of depression, anxiety, despite being on these medicines," he says.
"It was like we got to start fresh. Now she's in a much better place. She isn't having as much depression, anxiety. She feels mentally better. She feels physically better," Martin said. "She is happier that she's not on all these medications. She feels good that diagnosis was taken off because she never truly identified with it."
Martin was able to start this process after 15 minutes on a Zoom call—a medium that provides care to these rural patients without the stigma or traveling costs of finding an in-person healthcare provider.
After beginning his telehealth career as a resident in the University of Kentucky's telepsychiatry program, Martin believed in the power of telehealth so much that he carried it into his career at Baptist Health Corbin.
The past five years saw an influx of telecommunication use for other healthcare initiatives. The most common telehealth use cases, according to the American Hospital Association, include pharmacy services, chronic care management, telestroke services, tele-ICU tools, and telemedicine consults.
Looking ahead, doctors often point to mental health as the next step for telehealth, but aren't exploring it to the same extent as physical health, even though these kinds of options could be the answer to a widespread call for help with mental healthcare, providing a convenient, affordable option for rural Americans who might not otherwise receive treatment.
The obstacles to mental health assistance in rural areas
"Half of the counties in the United States don't even have one psychiatrist. Of course, that's disproportionately rural. One of the problems for rural places is there just aren't providers," says Holly Andrilla, researcher at the WWAMI Rural Health Research Center.
She expands upon this assessment in the Geographic Variation in the Supply of Selected Behavioral Health Providers report, which she coauthored with Davis Patterson, Lisa Garberson, Cynthia Coulthard, and Eric Larson.
Access to mental health professionals is a nationwide problem, the report found, but the problem is most prominent in rural communities: 19% of metropolitan counties lack a psychologist, compared with almost half (47%) of non-metropolitan counties. About two-fifths (42%) of metropolitan counties lack a psychiatric nurse practitioner, and this proportion doubles in non-metropolitan counties.
These statistics drop lowest in counties with less than 10,000 residents. Within the 1,339 of these counties in the US, 80% lack a psychiatrist; 61% lack a psychologist; and 91% lack a psychiatric nurse practitioner, according to the report.
A large reason for this disparity is that physicians aren't moving to rural areas. "If you're a provider and you get to pick where you work, you won't necessarily pick a rural place. They frequently have a spouse who also has a career, so that adds another layer of difficulty in terms of getting providers," Andrilla says. "That's true across the board for rural: Rural has a much lower provider to population ratio."
The lack of availability and access to mental health professionals makes it difficult for rural Americans to get the help they need. And for individuals in rural areas who do want to seek mental healthcare, accessing the care isn't an easy process.
"Sometimes, it can take months to get somebody in with a psychiatrist," says Timothy Allen, a physician and an associate professor of psychiatry at the University of Kentucky College of Medicine in Lexington, Kentucky.
"For instance, if they have to send them to Lexington, travel can be quite a barrier. A lot of these people with chronic mental illness often don't have a lot of resources. So, to drive two hours to Lexington: The gas, the time, finding somebody who can drive you, which often means somebody has to take off work. It's a very difficult process."
Allen notes: "One of the things that's a barrier to treatment and mental health, especially in small rural communities, is the stigma of going to the mental health center."
Mental health stigma is not a new phenomenon; however, the stigma in rural communities is elevated because of the lack of knowledge about mental health, as well as the accessibility to care.
Rural residents have lived without mental health providers for so long that many may feel the care is not necessary, and even look down on those who choose to seek help. This social climate often leaves no room for any discussion of mental health issues, nor any anonymity for those who want to find help in small towns. Without help, rural communities are forced to ignore their issues.
However, telehealth appointments solve these issues, Allen argues, because it can help with eliminating stigma, distance, and accessibility issues.
"I think telehealth is going to be huge for rural mental health," Andrilla says.
Turning to telehealth for mental health services
Telehealth technology is not new, but the University of Kentucky is introducing a use case for telemental health that solves a long-standing problem in rural America. By partnering with Big Sandy Healthcare clinics around Kentucky, the university is bringing licensed mental healthcare providers to rural Kentuckians.
Big Sandy Healthcare is a federally-qualified community health provider with six clinic locations in Eastern Kentucky—a region of the state with many rural communities. "In our clinics, we largely have family medicine doctors. We do have a couple of pediatricians. We have three obstetrician/gynecologists, but all of our clinics have doctors, nurses, behavioral health therapists, lab, x-ray, and pharmacy," said Ancil Lewis, CEO of Big Sandy Healthcare.
While the behavior health therapists are helpful, they aren't able to prescribe medication--that would fall on the family doctors, according to Lewis.
These family doctors are able to treat "your garden variety depressed patient," but that isn't their specialty. This lack of expertise causes the physicians to hesitate in increasing medication dosages or fulfilling the patient's complete needs, Lewis says.
"There's a lot of patients here in Eastern Kentucky that have emotional distress, or they have psychiatric disorders," Lewis says. "There are few psychiatrists here, and although we were trying to provide some treatment in our own clinics, with the behavioral health therapists, and the family docs, we realized there was a gap, and that gap could only be filled with a psychiatrist."
Hiring full-time psychiatrists had costly consequences. Psychiatrists need time to build a caseload, and therefore start generating revenue, but Big Sandy would have to begin paying a full salary to these psychiatrists immediately. Since hiring their own psychiatrists is not an option, Lewis started looking outside of the small towns.
Partnership between Kentucky TeleCare and Big Sandy Healthcare
Allen, who is responsible for the daily operations of Kentucky TeleCare, has worked with telemedicine at the university since 2002. As video calls developed, he began looking for more use cases to implement the technology, reaching out to primary care providers and clinics throughout the state to see if any had a need for telemental health services.
In June 2018, they got Lewis on the phone. In February 2019, University of Kentucky psychiatry residents began seeing rural Kentuckians via telehealth.
"We have one half day block of time each week when we put our patients in front of the camera to be seen by a psychiatrist" at the University of Kentucky Lewis says. "The psychiatrist then can make recommendations regarding medications and dosage. With that information in hand, our own medical providers feel more comfortable then prescribing that medication."
Big Sandy pays the university for the services and bills the patient for the visit. In the state of Kentucky, telehealth services for psychiatry are covered by Medicare, Medicaid, and most health insurance providers. Coverage varies by state, but most states cover telehealth in some capacity.
Since Big Sandy already has behavioral healthcare therapists, the University of Kentucky's residents are able to receive a profile of the patient before the initial appointment. This information helps to expedite the process, allowing residents to see more patients, Allen said.
"We're really doing medication consultation and sometimes diagnostic clarity," Allen says. "My plan is to see [the patients] two to three times on average, and ideally stabilize them on a new medication; then follow it up once or twice, make sure it's okay, and then sign off, unless they ever need me again.
"We're seeing, in four hours, anywhere from six to nine patients on an average day. We're doing a pretty good job of being very efficient, getting their backlog, because they had this huge backlog of patients that they would have referred to a psychiatrist, if there was somebody locally," Allen says. "With us, they have psychiatrists. If you build it, they will come."
Allen said that 20% to 30% of primary care visits typically have mental health as a major component, so he isn't surprised that these rural areas have the demand for services. While Big Sandy has six clinics, Allen said his team is currently conducting telemental health appointments with visitors at the three largest.
"We alternate. So clinic No. 1, we go to this week, and we'll be back in three weeks," Allen said. "That gives us a three week follow-up if we need, or a six week [follow-up], if we can stretch it out a little bit."
Overcoming obstacles to mental healthcare in rural Kentucky
With the partnership, Allen said they are covering an area of about 100 miles between the three clinics, solving the accessibility obstacles rural Kentuckians face.
"Now people don't have to drive to the next county or two counties over," he says. "We're making this as convenient as possible and as accessible as possible to the patients."
Telehealth also helps with the stigma aspect of mental health services. "That goes away with this process because you're just going to your family doctor, and nobody knows that you're seeing the psychiatrist," Allen says.
The partnership is less than two years old, but despite its nascent state, it's received extremely positive responses.
"This really makes [mental healthcare] so much more accessible, and the patients like it, and I've gotten overwhelmingly good responses from the clinicians. The patients seem to like it--they show up to their appointments," Allen says.
"We're having a really positive experience," Allen adds. "It's fulfilling to me because I feel like I'm making an impact on so many people."
"We quit collecting patient/provider satisfaction data because it was consistently overwhelmingly positive," notes Rob Sprang, director of Kentucky TeleCare within the University of Kentucky College of Medicine. "Frankly, people vote with their feet: They keep doing it, they keep coming to this."
Each telemental health appointment is conducted via Zoom, which is both HIPAA compliant and equipped with a security system.
"Everybody has FaceTimed their grandchildren or someone at some point, so everybody's fairly familiar with the technology," Allen says. "All these clinics have broadband internet--the technology is good enough that it's seamless. It's like looking at somebody on TV--the video quality is so good."
While seeing a psychiatrist can be an intimidating experience, another perk of telehealth is the comfortability, according to Martin. "[Telehealth] kind of takes the edge off. I'm not in the room right there, I'm just on a computer screen. That makes it a little easier for them to feel comfortable," he says.
The face-to-face video call still makes the appointment more personal than a simple voice call, and it removes the apprehension of being in the room with a stranger.
Martin thinks that telehealth could be the answer to the disparity in mental healthcare for rural Americans. Doctors and physicians often do flock to bigger cities to begin their practice, but telehealth allows them to still provide care to rural residents, without living in the area, Martin argues.
"Telehealth might be the way to go because, not only can you get these people in rural areas care, but you can get them good care," he says. "You can get them people who are qualified for what is going on, and it's no different; it doesn't interrupt my day in any way as I come into the office. I just come in, I log on to the video software, and then I sit at my desk, and I see patients over the computer just the same way that I would see them here."
Why universities set the precedent for telemental healthcare
Telehealth for mental health has the potential to really take off. With many health insurance companies willing to cover telehealth appointments, patient demand for the services, and physicians willing to provide care, telehealth can solve the mental healthcare gap in rural areas, Martin said.
Universities lead telehealth services because they are some of the first entities to have the equipment and the skills, Sprang says.
Academic medical centers throughout the US began applying for grants in the early 1990s, using the funds for telecommunication technology in an attempt to bring education to more students. The video conferencing technology was initially used for broadcasting large university courses to community colleges, but instructors began considering other use cases for the technology as it developed, one of the first being telehealth.
With the skills and technologies in place, as well as legislation in the late 1990s and early 2000s starting to relegate Medicare in favor of telehealth, partnerships between medical schools and hospitals formed, Sprang says. The beginnings of telehealth focused on physical checkups, with mental health following years later.
However, the University of Kentucky is at the forefront of the telepsychiatry movement, beginning its program 26 years ago. The partnership with Big Sandy, geared toward rural Kentuckians specifically, is less than two years old.
Since academic institutions have the talent and equipment, they are the perfect resource for launching these programs. Universities in other states including Texas, South Carolina, Iowa, Wyoming, New Mexico, Vermont, and elsewhere are getting involved, hosting their own telemental health initiatives.
While these schools are doing impressive work, a handful of universities won't solve for sparse nationwide mental health accessibility. But for some patients it is a much needed support.
To learn how to implement a telehealth program at your university or organization, check out the Rural Health Information Hub.
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- Coronavirus: How Texas' digital divide hampers healthcare (CBS News)
- 5 online therapy services to help with depression, anxiety and stress (CNET)
- Telemedicine, AI, and deep learning are revolutionizing healthcare (free PDF) (TechRepublic)
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