1 Introduction1 Carolyn L. Turveya,b,(cid:1) and Kathleen Myersc aDepartmentofPsychiatry,UniversityofIowaCarverCollegeofMedicine, IowaCity,IA,bComprehensiveAccessandDeliveryResearchand Evaluation(CADRE)Center,IowaCityVAHealthcareSystem,IowaCity,IA, cDepartmentofPsychiatryandBehavioralSciences,Universityof WashingtonSchoolofMedicine,TelementalHealthService,Seattle Children’sHospital,Seattle,WA Introduction The Telemental Health Imperative Telemental health (TMH) has the potential to deliver needed care to millions of peoplestrugglingwithmentaldisorders. Achild sufferingfromautismwholivesin 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 beha- viors, receives a videoconsultation and treatment recommendations from a psychia- trist 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 com- munity is coming together to develop strategies to provide mental health care even inconditionsinwhichthetechnicalinfrastructureisdevastated. 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 1Theviewsexpressedinthischapterarethoseoftheauthorsanddonotnecessarilyreflecttheposition orpolicyoftheDepartmentofVeteransAffairsortheUSgovernment. (cid:1)Corresponding author: Carolyn L. Turvey, Department of Psychiatry, University of Iowa Carver CollegeofMedicine,IowaCity,IA52242.Tel.:11-319-353-5312,Fax:11-319-353-3003, E-mail: [email protected] TelementalHealth.DOI:http://dx.doi.org/10.1016/B978-0-12-416048-4.00001-4 ©2013ElsevierInc.Allrightsreserved. 4 TelementalHealth (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(cid:3)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 bar- rierstoreceiveadequatementalhealthtreatment. Though there are many different barriers to mental health care, the most signifi- cant 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 bar- riers. For example, currentlythere is a nationwide shortage of child psychiatrists. It is estimated that current practitioners can meet only 10(cid:3)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).Thiscollaborationallowschildrentoreceivementalhealth assessment and interventions in the naturalistic setting of their school and the men- tal health providers do not have to travel long distances at considerable disadvan- tagetotheirotherclinical responsibilitiesandfamilies.Bothsitesmaybenefitfrom lowerfinancialcostsassociatedwithvideoconferencing. Current Trends Supporting the Broader Adoption of Telemental Health TheviewthatTMHcanaddressmanyofthecurrentwoesfacingtheprovisionofmen- tal 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. ThoughTMHhascontinuedtogrowslowlybutsteadilyovertheyears,itremainsout- side 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 con- fronted,wearefacedwiththechallengeofarguingthatthecurrentwaveofenthusiasm issomehowdifferentfromthatofpriorcohortsandthatweare,infact,onthebrinkof anexcitingwidespreadexpansionoftheuseofTMHintomainstreamhealthcare. There are five critical developments in health care that just might make current conditionstrulyconducive tothe broader adoption of TMH: (1) agrowingshortage of mental health providers particularly for special populations such as children or the elderly; (2) advances in the quality and availability of desktop videoconferenc- ing technologies; (3) improved reimbursement from Medicare combined with Introduction 5 mandates in some states for private insurers to reimburse telemedicine equal to same-room care; (4) an increasingly large and sophisticated evidence base includ- ing 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 evi- dencesupportingthesepractices. 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 innova- tive 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 pro- fessionals.ItalsodiscusseshowTMHcanaddressmany,butnotall,aspectsofthis crisis. The shortage of mental health resources in socioeconomically disadvantaged areassuchasinner-citiesandcorrectionalfacilitiesislessrecognized.Videoconfer- encingnowallowshospital-basedspecialiststoprovideconsultationstourbannurs- ing 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 par- ticular, TMHhasbeen used successfullytoprovide neededservicestochildren,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 theirowncommunities,whetherinnercityorruralreservation,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 con- sidered in TMH, particularly when making decisions about how to use TMH tech- nologytoprovideculturallycompetentcare(inparticularseeChapter4). 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 recrea- tional use of desktop videoconferencing, such as SKYPE and Google Talk, has familiarizedclinicianswithvideoconferencingwhichmayreducetheirresistanceto usingTMH.Theeaseofdesktopvideoconferencinghasalsopromotedtheadoption of TMH from private practitioners’ offices, or even their homes—which allows a 6 TelementalHealth 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 pro- vider, rather than the patient. As provider acceptance is necessary for widespread adoption,thisisnosmallbenefit. 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 help poten- tial TMH providers glean the relevant issues in selecting equipment. This section also addresses the ethical, privacy, and regulatory requirements of clinical practice thatmustbeconsideredinchoosingtechnologyandestablishingapractice. The third critical area influencing the adoption of TMH is reimbursement. Medicare reimbursement for TMH has made great strides since the year 2000 and now includes coverage for psychiatric diagnostic interviews, pharmacologic management, and individual psychotherapy (Centers for Medicare and Medicaid Services, 2009). Further, reimbursement is the same as the current fee schedule for same-room care, and the facility where the patient is treated can also submit a “facility fee” (approximately $30(cid:3)35 per visit). As Medicare guidelines in these areas are dynamic and influence regulations by private payers, potential TMH providers should consult the web site for the Centers for Medicare and Medicaid for further and up-to-date information (www.cms.gov/Manuals/ downloads/bp102c15.pdf). As of 2011, 39 states have some form of reimbursement for telemedicine within their Medicaid population (Center for Telehealth and eHealth Law, 2011). In addi- tion, state governments faced with large mental health provider shortages and geographic access issues are now passing legislation requiring private insurers within their states to reimburse for telemedicine, including TMH (American Psychological Association Practice Central, 2012). Reimbursement by private insurers opens many opportunities for private practitioners who typically are not eligible for Medicare or Medicaid payments. Further information can be obtained athttp://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx. Issues related to the fourth critical development, the establishment of an evi- dence base, is addressed in Chapter 19 (see Section VI). This candid look at the strengths and weaknesses of the current research allows potential providers to assess the quality of psychiatric assessment, psychiatric follow-up, and psychother- apy provided through TMH. In the past 10 years, well-designed randomized con- trolled trials have not only demonstrated that TMH is comparable to same-room care, it has also demonstrated that TMH is effective in treating mental illness. However, the importance of an evidence base underlies all of the chapters in this text, particularly the chapters addressing the treatment of special populations (see SectionIV)andthoseaddressingspecificinterventions(seeSectionV). Finally, the fifth critical development, a national mandate for health reform, is evidenced by the active debate within the United States on the need for and nature of health care reform. On March 23, 2010, President Obama signed the Affordable Care Act enacting comprehensive health insurance reforms to expand the provision Introduction 7 of health care to uninsured and underinsured Americans. At the time that this book goes to press, the constitutionality of this act will be determined by the US Supreme Court making some skeptical about whether the reform will actually occur. The decision of the Supreme Court is unknown, as is its impact. However, the open national debate has led to widespread acknowledgment that health care reform, in some version, is imperative given the inequities and spiraling costs of health care in the United States. In April 2012, the Centers for Medicare and Medicaid Services issued a report stating that the Affordable Care Act will save over $200 billion for taxpayers through 2016 (Centers for Medicare and Medicaid Services, 2012). This suggests that even if the Affordable Care Act is struck down, the imperative for health care reform lies within the larger federal structures responsible for providing health care for millions of Americans and is not tied solelytoasinglepresidentialadministration. Organization of This Book This book was inspired by the converging evidence that the time for TMH has come. The book seeks to stimulate conversation and action among health providers and those interested in health innovation. Though innovations in TMH span video- conferencing, online therapy, eHealth, mobile technology, and health information technology,thisbook,withsomeexceptions,isprimarilyconcernedwiththeprovi- sion of mental health care through real-time videoconferencing. This platform is most consistent with current approaches to mental health care, has the strongest evidence base supporting its feasibility, acceptability, and effectiveness, and is increasingly being accepted and reimbursed by both public and private payers. Other exciting platforms for providing TMH care have the potential to augment videoconferencing as well as to eventually stand on their own as service delivery models.Hopefully,theirapplicationswillsoonbeexploredinothertexts. Eachchapterpresentsnewapproachesforunderstandingandsolvingthedispari- ties in mental health care by providing hands-on guidance on how to start and maintain a TMH practice including clinical, administrative, ethical, and financial guidance.Theevidencebaseforthisguidanceisprovidedthroughoutthebook. The aims for this text are ambitious and comprehensive. There are six sections. Section I provides the context for the remaining sections by describing major demographic and professional changes that underlie the problem TMH seeks to remedy that of poor access to mental health services. Though Chapter 2 focuses on the declining psychiatry workforce, data on the declining psychology workforce andurban/ruraldifferencesinaccesstoanyformofmentalhealthcarearealsodis- cussed. The other sections describe potential solutions to this problem. Section II providesguidanceonhowtoconductclinicalsessionsthroughTMHwhileoptimiz- ingethicalandculturallycompetentcareandminimizingrisk.Cliniciansandinves- tigators with many years of experience in the use of videoconferencing to provide TMHservicesofferinsightsandadvicetooptimizeTMHpractice. Section III follows with some “nuts-and-bolts” discussion of both the business and technical infrastructure needed to provide TMH. These chapters include 8 TelementalHealth discussions of the newer business models that are emerging in TMH care. Together, Sections II and III provide a tutorial on how to develop a TMH practice thatmeetsalloftheclinical andregulatoryrequirementsfoundinsame-roomcare. TMH has arisen in response to provider shortages, most often in populations faced with multiple barriers to care, and TMH has the goal of redistributing the provider workforce. Section IV describes the research supporting TMH and offers guidelines for clinical practice with special populations. Children, the elderly, incarcerated, and geographically remote patients all suffer poor access to care so it is not surprising that the early development of TMH has focused on these popula- tions. Section V complements Section IV with discussions of assessment and treat- mentprovidedthroughTMH. Section VI focuses on future applications of TMH. There is growing excitement about the potential of TMH to address much needed mental health care in disaster relief. Chapter 17 discusses the challenges of such care as well as the cause for growingoptimism. Italsosetstheagendaforwhatneedstobeaccomplishedsothe potential of TMH in this context can be realized. Like disaster relief, the potential of social networking in TMH care is just starting to be realized. Chapter 18 dis- cusses the few case studies of how videoconferencing has entered the sphere of mental health care. The chapter also provides hands-on guidance for clinicians to consider before “friending” their professional relationships. As already stated, the aim of this text is to provide the evidence base for the topic addressed in each chapter. Therefore, Chapter 19 serves as an editorial review of the strengths and weaknesses of the current evidence base and indicates directions for future work. It also addresses the newer developments in TMH such as mobile applications and eHealth. Telemedicine has been “just around the corner” for decades. How do we know that its time has truly come? The chapters in this book illustrate again and again that the convergence of unmet mental health need, technologic advances, changes in health care structure, a growing evidence base and clinical practice history make the time now. This book aims to facilitate the process by convincing readers inter- ested in health innovation that a powerful solution is at our fingertips, and con- certedeffortstopromoteTMHwillbenefitall. References American Psychological Association Practice Central (2012). Reimbursement for telehealth services. Legal and Regulatory Affairs Staff. ,http://www.apapracticecentral.org/ update/2011/03-31/reimbursement.aspx.Accessed25.05.12. Center for Telehealth and eHealth Law (2011). Medicaid reimbursement. ,http://ctel.org/ expertise/reimbursement/medicaid-reimbursement/.Accessed25.05.12. Centers for Medicare and Medicaid Services. (2009). The Medicare benefit policy manual (Chapter 15). ,http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ downloads/bp102c15.pdf.Accessed25.05.12. Introduction 9 CentersforMedicareandMedicaidServices(2012).Theaffordablecareact:Loweringmedicare costs by improving care. ,http://www.cms.gov/apps/files/ACA-savings-report-2012.pdf. Accessed25.05.12. Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., & Lepine, J. P., etal.(2004).Prevalence, severity, and unmet needfor treatment ofmental disorders in the World Health Organization world mental health surveys. Journal of the American MedicalAssociation,291,2581(cid:3)2590. Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., et al. (2001). The prevalence and correlates of untreated serious mental illness. Health ServicesResearch,36,987(cid:3)1007. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., et al. (2005). Prevalence and treatment of mental disorders 1990 to 2003. New England JournalofMedicine,352,2515(cid:3)2523. Lewis, R. B., Martin, G. L., Over, C. H., & Tucker, H. (1957). Television therapy: Effectiveness of closed-circuit television as a medium for therapy in treatment of the mentallyill.A.M.A.ArchivesofNeurologyandPsychiatry,77,57(cid:3)69. Nelson,E.L.,Barnard,M.,&Cain,S.(2003).Treatingchildhooddepressionovervideocon- ferencing.TelemedicineJournalandE-health,9,49(cid:3)55. Thomas,C.R.,&Holzer,C.E.,III(2006).Thecontinuingshortageofchildandadolescent psychiatrists.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry,45, 1023(cid:3)1031. United States Public Health Service Office of the Surgeon General (1999). Mental health: A report of the surgeon general, United States Public Health Service Office of the SurgeonGeneral,Rockville,MD. World Health Organization (2001). The world health report 2001—Mental health: New understanding, new hope. Geneva, Switzerland: World Health Organization Press. ,http://www.who.int/whr/2001/en/.Accessed29.05.12. 2 Telemental Health as a Solution to the Widening Gap Between Supply and Demand for Mental Health Services Michael Flaum(cid:1) DepartmentofPsychiatry,UniversityofIowaCarverCollegeofMedicine, IowaCity,IA Workforce Shortages in Mental Health: The Example of Psychiatry What Is the Current Supply of Psychiatrists in the United States? As of 2010, there were just under 50,000 psychiatrists practicing in the United States. (Note: source of all data in Figures 2.1(cid:3)2.5 is from American Medical Association (2010).) This makes psychiatry the sixth most common specialty in medicine (behind internal medicine, pediatrics, family practice, obstetrics/gynecol- ogy, and anesthesia). Figure 2.1 shows how psychiatrists are distributed in terms of specialty and practice setting. Approximately 18% of US psychiatrists are certified in Child and Adolescent Psychiatry. More than 11% of all psychiatrists are currently in residency or fellowship training. About three-quarters (78%) are pri- marilyinoffice-basedoutpatientsettings. In order to put these numbers into a meaningful context, it is necessary to look at trends over time, how these trends compare to the numbers of other physicians, and most importantly, how the trends over time correspond with trends in utiliza- tionofservices. Rate of Growth in Psychiatrists and All Physicians Over Time Figure 2.2 shows the numbers of general and child psychiatrists over the past 40 years and Figure 2.3 shows the number of all physicians in the United States over (cid:1) Correspondingauthor:MichaelFlaum,DepartmentofPsychiatry,UniversityofIowaCarverCollege of Medicine, 1-400 Medical Education Building, Iowa City, IA 52242. Tel.: 11-319-353-4340, Fax: 11-319-353-3003,E-mail:[email protected] TelementalHealth.DOI:http://dx.doi.org/10.1016/B978-0-12-416048-4.00002-6 ©2013ElsevierInc.Allrightsreserved. 12 TelementalHealth Teaching Other, Administration 695 Research 328 1562 967 Child Psychiatrists 7358 Hospital Based 7505 Residents and Office Based Fellows 5404 31,801 Adult Psychiatrists 40,904 Total Psychiatrists = 48,262 Figure2.1 SpecialtyandTreatmentSettingforPsychiatristsintheUnitedStates,2010. 50,000 45,000 Psychiatry (General) 40,000 Child Psychiatry 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 1970 1980 1990 2000 2010 Figure2.2 NumberofGeneralandChildPsychiatristsintheUnitedStates,1970(cid:3)2010. 10,00,000 9,00,000 8,00,000 7,00,000 6,00,000 5,00,000 4,00,000 3,00,000 2,00,000 1,00,000 0 1970 1980 1990 2000 2010 Figure2.3 TotalNumberofPhysiciansintheUnitedStates,1970(cid:3)2010. TelementalHealthasaSolutiontotheWideningGap 13 300.0% All Physicians Adult Psychiatrists 250.0% All Psychiatrists Child Psychiatrists 200.0% 150.0% 100.0% 50.0% 0.0% % increase % increase % increase % increase 2010 vs 2010 vs 2010 vs 2010 vs 2000 1990 1980 1970 Figure2.4 PercentIncreaseinGeneralandChildPsychiatristsandAllPhysiciansoverthe PastfourDecades(2010versus2000,1990,1980,and1970). 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 1970 1980 1990 2000 2010 1970 1980 1990 2000 2010 Figure2.5 PercentofPsychiatristsofallUSPhysicians,1970(cid:3)2010. the same time period. Several points are worth noting. First, while the increase in all physicians has been relatively constant over this time, the increase in numbers of psychiatrists has flattened out over the past two decades. Second, the rate of growth is substantially lower for psychiatrists than for all physicians (Figure 2.4). Forexample,whilethere has been anearly 20%increaseinthenumberofUSphy- sicians in the past decade, there has been less than a 6% increase in the number of psychiatrists during the same period. Third, growth in child psychiatry has substan- tially outpaced that of general psychiatry. Specifically, there has been a 20.2% and 69.4% increase in the numbers of child psychiatrists over the past 10 and 20 years, respectively, versus 3.6% and 16.3% for general psychiatrists over those two dec- ades. Finally, as the increase in the numbers of psychiatrists has not kept pace with that of the increase in the numbers of physicians, the percentage of psychiatrists amongphysicianscontinuestofall(Figure2.5).