The Telemental Health Imperative

Telemental health (TMH) has the potential to deliver needed care to millions of people struggling with mental disorders. A child suffering from autism who lives in a rural community of 500 can receive a teleconsultation at the local primary school and benefit from timely expert diagnosis and treatment. Timely diagnosis can help the child to remain in school and optimize both learning and socialization. An elderly woman in a nursing home, who was secluded because of disruptive behaviors, receives a videoconsultation and treatment recommendations from a psychiatrist located over 200 miles away. She is now able to control her temper, her mood is bright, and she interacts positively with other residents and staff. In response to Hurricane Katrina and the devastating earthquake in Haiti, the international community is coming together to develop strategies to provide mental health care even in conditions in which the technical infrastructure is devastated.

These success stories bring human faces to the statistics regarding mental health needs across the world and particularly for the disadvantaged. A study conducted by the World Health Organization ranked mental illness as a leading cause of disability in the United States, Canada, and Western Europe, more disabling than heart disease and cancer (Demyttenaere et al., 2004; World Health Organization, 2001). Mental illness accounts for 25% of all disability across major industrialized countries and the direct cost to the US economy is $79 billion annually (United States Public Health Service Office of the Surgeon General, 1999). Suicide, a tragic outcome closely tied to inadequately treated mental illness, is responsible for more deaths worldwide than homicide or war (Demyttenaere et al., 2004; World Health Organization, 2001). Nonetheless, the World Health Organization found that even in developed countries, 35–55% of people suffering serious mental illness did not receive care in the past 12 months (Demyttenaere et al., 2004). Many who do receive treatment receive inadequate care that does not comply with professional guidelines or evidence-based practice (Kessler, Berglund et al., 2001; Kessler, Demler et al., 2005). Unfortunately, the underserved are often children, the elderly, or disabled who must overcome considerable additional barriers to receive adequate mental health treatment.

Though there are many different barriers to mental health care, the most significant includes the shortage of mental health practitioners, poor access to specialty care, and financial barriers to care. TMH offers a way around each of these barriers. For example, currently there is a nationwide shortage of child psychiatrists. It is estimated that current practitioners can meet only 10–45% of the need in child mental health care (Thomas & Holzer, 2006). Most of this shortage occurs in rural communities. Programs like Connected Kansas Kids, a state-funded initiative, address this need by providing mental health services at rural primary schools through mental health providers located at the University of Kansas (Nelson, Barnard, & Cain, 2003). This collaboration allows children to receive mental health assessment and interventions in the naturalistic setting of their school and the mental health providers do not have to travel long distances at considerable disadvantage to their other clinical responsibilities and families. Both sites may benefit from lower financial costs associated with videoconferencing.

Current Trends Supporting the Broader Adoption of Telemental Health

The view that TMH can address many of the current woes facing the provision of mental health care is not new. TMH, the most commonly utilized aspect of telemedicine, has been practiced in some form or another since 1957 (Lewis, Martin, Over, & Tucker, 1957). Since this initial use, successive cohorts of clinicians and researchers have touted the benefits of TMH and predicted its certain widespread adoption. Though TMH has continued to grow slowly but steadily over the years, it remains outside the realm of mainstream clinical care. This pattern of expansive optimism about potential coupled with slow and, at times, disappointing adoption has drawn cynical comment that TMH has been “just around the corner for about 50 years.” Thus confronted, we are faced with the challenge of arguing that the current wave of enthusiasm is somehow different from that of prior cohorts and that we are, in fact, on the brink of an exciting widespread expansion of the use of TMH into mainstream health care.

There are five critical developments in health care that just might make current conditions truly conducive to the broader adoption of TMH: (1) a growing shortage of mental health providers particularly for special populations such as children or the elderly; (2) advances in the quality and availability of desktop videoconferencing technologies; (3) improved reimbursement from Medicare combined with mandates in some states for private insurers to reimburse telemedicine equal to same-room care; (4) an increasingly large and sophisticated evidence base including randomized controlled trials demonstrating the effectiveness of TMH in the treatment of mental disorders; and finally (5) national-level mandates for health care reform. Throughout the chapters in this book, these issues are discussed with the aim of educating the reader about best practices in TMH and the research evidence supporting these practices.

The first critical development in health care that is influencing the adoption of TMH is a growing shortage of mental health providers. Chapter 2 provides data from the fields of both psychiatry and psychology to support the need for innovative solutions to the workforce shortage in mental health care. Using data from organizations that monitor supply and demand of professional services, this chapter demonstrates both the current and anticipated severe shortage of mental health professionals. It also discusses how TMH can address many, but not all, aspects of this crisis.

The shortage of mental health resources in socioeconomically disadvantaged areas such as inner-cities and correctional facilities is less recognized. Videoconferencing now allows hospital-based specialists to provide consultations to urban nursing homes, prisons, primary care offices, schools, and even day care centers that have difficulty obtaining needed on-site care. TMH allows for the sharing of this scarce valuable resource across geographic and socioeconomic boundaries. In particular, TMH has been used successfully to provide needed services to children, the elderly, rural veterans, and correctional populations and holds promise for reaching the larger population that relies on primary care for their mental health treatment (see Section IV). Cultural and community aspects of care are a crucial component of developing services for these populations. TMH allows patients to be treated within their own communities, whether inner city or rural reservation, accompanied by their families and other supports, if desired. Several chapters provide insights and advice gleaned from clinical practice on how the cultural context must be considered in TMH, particularly when making decisions about how to use TMH technology to provide culturally competent care (in particular see Chapter 4).

The second of the critical developments listed above, advances in the quality and availability of desktop and internet videoconferencing solutions, has greatly increased the feasibility of conducting TMH in multiple, diverse settings. These technological options and their relevance for practice are covered in Section III. The advent of videoconferencing technology that can be conducted on desktop computers and the use of secure Internet transmission of videoconferencing data obviates the need for a separate space dedicated to videoconferencing and large, high-definition and costly units. A desktop, computer-based, system allows the clinicians to alternate between usual same-room and TMH care within the standard workflow of clinical practice. In addition, the widespread increase in the recreational use of desktop videoconferencing, such as SKYPE and Google Talk, has familiarized clinicians with videoconferencing which may reduce their resistance to using TMH. The ease of desktop videoconferencing has also promoted the adoption of TMH from private practitioners’ offices, or even their homes—which allows a unique option when balancing the demands of family and career. This is one of the first developments in TMH that has improved access and opportunities for the provider, rather than the patient. As provider acceptance is necessary for widespread adoption, this is no small benefit.

The relevance of these newer desktop videoconferencing systems, of course, is their ability to provide care comparable to that provided through traditional, more expensive, high-definition systems—and to same-room care. In Section II, clinical technique, therapeutic alliance, and efficient workflow are addressed to...