Therapies — 03 October 2014

Let’s talk numbers here, because they’re striking. According to a 2000 report from the Department of Health and Human Services, 10 percent of American children and adolescents suffer from mental illness severe enough to cause impairment—but only one in five receives mental health services. As David Offord, a child psychiatrist with McMaster University, indicated in a presentation before the agency, emotional and behavioral problems dramatically reduce a child’s quality of life. “No other set of conditions is close in the magnitude of its deleterious effects on children and youth in this age group,” he told a conference of government and private health experts. “The cost to society is high in both human and fiscal terms.”

Here’s at least part of the problem: Though experts say school is the best place to get children much-needed mental health services, there aren’t enough school-based mental health professionals to go around. Researchers estimate there are about 8,300 school psychiatrists in the entire U.S., or about one available specialist to every 370 affected children. School psychologists are more common; by contrast, a 2005 study found about 38,000 practicing in the country. But psychologists do not attend medical school (though about a third have doctoral degrees), and they can’t, crucially, prescribe psychotropic medications.

Enter tele-mental health. The awkward hyphenate phrase is difficult to define even by the professionals who use it, but here’s the gist: Tele-mental health is the delivery of mental health services through telecommunications technology, particularly videoconferencing. For overwhelmed professionals, it’s fast and efficient; for schools, it’s relatively inexpensive; for students and their parents, it’s convenient (and oftentimes, research shows, easier on the child than meeting in person). And, after almost six decades of research, it appears that policymakers and insurance companies are coming around to the technology. Tele-mental health services could change the way we administer mental health care in this country. In-school tele-mental health could bring needed care to those who need it most.

In Baltimore, where many psychiatry students in Sharon Stephans program do their work, a local nonprofit estimates that one in twenty children have serious emotional impairments. Like many cities, Baltimore has a disproportionately high trauma exposure rate among its children, which research shows often leads to its own suite of mental health issues. “Almost without fail, those impairments impact the school setting,” says Stephan, a psychiatrist and the co-director of the Center for School Mental Health at the University of Maryland. For underserved kids, that means neglected schoolwork, frequent detentions, and, sometimes, suspensions—a negative feedback loop of missed educational and interventional opportunities.

Since the University of Maryland’s telemedicine program opened in Baltimore seven years ago, Stephan’s colleagues and students have found that delivering mental health care through schools is the best way to guarantee that kids get seen by health care professionals—and seen regularly. Through the Center for School Mental Health, University of Maryland psychiatrists and psychiatrists-in-training provide services to 70 schools in Maryland.computer-313840

The program’s practitioners, who meet with students through encrypted and HIPPA-approved videoconferencing technology, generally do not prescribe psychotropic medications to children (though the practice does occasionally happen, Stephan says). Instead, the Center for School Mental Health program is often used to provide consultation and adjust dosages. Doctors can also use the technology to connect with school professionals to check up on students’ progress and determine how treatment is affecting student behavior and schoolwork.

Medication follow-up may sound like small potatoes; it’s not. Follow-up is particularly important in children, as their constant growth means dosages that worked just months before could quickly stop helping. And unfortunately, follow-up happens rarely, particularly among underserved populations. According to the American Academy of Pediatrics Committee on School Health, 40 to 50 percent of children who actually receive care from mental health services in a given year terminate services early because of lack of transportation, access, finances, or because of stigma.

Historically, doctors have pursued tele-mental health practices to fill in gaps in rural healthcare, where healthcare professionals can be few and far between. But telepsychiatry, Stephan says, fits neatly into the urban context as well. “We were a little skeptical ourselves of using it in an urban setting,” she says. “We didn’t want to send a message that we were unwilling to travel a mile or five miles to come to the school. But even that travel time it takes to go from the university setting to local schools in an urban setting—just that time alone can significantly cut down on productivity.”

Neil Herendeen is a pediatric specialist based out of the University of Rochester Medical Center, and though his program deals mostly in school nurse-level sickness—sore throats, colds and cuts—he says his telemedicine program gives children who wouldn’t see doctors otherwise a chance at medical care. Health-E-Access, which began in 2002, arms a traveling medical assistant with a special suitcase containing $12,000 to $15,000 in highly specialized medical videoconferencing equipment. The assistant makes “house calls” to schools around the city, solving, Herendeen says, “my no-show rate back at the clinic.” Generally, 50 percent of his scheduled appointments never show up. In many nearby suburban clinics, where parents have more regular access to cars and time off, the no-show rate is closer to just three-quarters of a percent.

“Across the board, but also relatively higher in urban settings, families don’t have the resources to make it to traditional mental health settings,” Stephans says. And “most families who do make it in the community, they only make it to one session.” Stephans says her program is changing that.

But does tele-mental health actually work? Rebecca A. Kornbluh, the assistant medical director for program improvement and telepsychiatry at the California Department of State Hospitals, wrote in an August op-ed that telepsychiatry has “a solid track record among young patients.” Eve-Lynn Nelson, a pediatric psychologist who has helped to run the University of Kansas’ tele-mental health program for over 15 years, says kids have “no trouble” with the technology. “They like to see themselves on screen,” she says.

There’s also evidence that the technique reduces the stigma of seeing a mental health professional. A 2004 study found that teenagers would rather see therapists through videoconferencing at school than travel to an office, in part because in-school visits are easier to hide from friends and non-immediate family. (Parents are generally, if not always, involved in treatment.) Nelson of Kansas University says kids who participate in her program are made especially confortable by the presence of a familiar face: the school nurse. Nurses are generally “already a trusted person in a family and child’s life,” Nelson says. “They help socialize the student and family and make it not scary for them.”

A 2009 literature review found strong evidence for the “reliability of clinical assessments” and “high patient and moderately-high provider satisfaction” for a number of tele-mental health services. But it cautioned that the technology was not a panacea. There’s minimal evidence, researchers wrote, suggesting tele-mental health enhances care, or that it’s any good at treating diagnoses like depression and anxiety disorders.

At the very least, though, the technique could be a band-aid for a struggling mental healthcare system. And the good news is that it’s getting cheaper. In Kansas, the program makes use of computer screens and iPads that many schools already own. Districts must pay for bandwidth for consistent service, but many schools already have that, as well. One 2010 study of Kansas’ program—albeit its rural tele-mental health efforts—estimated the program cost $168.61 a session before accounting for the travel costs avoided by practitioners. But the biggest factor for buy-in, Nelson says, is time. “There’s an investment of time from the [school] administration and on the provider side, and you could put a dollar amount on that,” she says.

Telemedicine in general is also increasingly being embraced by insurance companies. According to a September 2014 report from the American Telemedicine Associations, 21 states have laws that compel private insurance companies to cover tele-health services to the same extent as in-person services, though six of those have provider or technology restrictions. Forty-seven states offer some kind of telemedicine coverage through Medicaid, though reimbursements vary. And bills on the technology are wending their way through at least 17 state legislatures.

The technique is also gaining favor among a skeptical community of medical professionals. The American Medical Association released an official telemedicine policy in June of this year, an implicit recognition that the use of the technology is growing, and fast. Tele-mental health services are being offered to an increasing number of U.S. military veterans; according to the Department of Veterans Affairs, many of its 700 VA outpatient clinics are now equipped with the technology necessary to allow patients to videoconference with specialists.

Back in Baltimore, Sharon Stephan says that the University of Maryland program is only becoming more popular among students and medical practitioners. “It’s good to be able to provide [mental health services] in schools, which is a more natural setting for students,” she says. And “the fellows say by far it’s their favorite rotation.”

This article first appeared on ‘City Lab’ on 2 October 2014.

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