It took several years for the Fuqua Center for Late-Life Depression at Emory University in Atlanta to implement its telemedicine strategy. But with support from the state and the help of videoconferencing technology set up in more than 30 locations, psychiatrists at the center began seeing older patients remotely in September 2006.
The Fuqua Center is not alone in its efforts. More and more healthcare organizations and policymakers are turning to telemedicine for potential solutions to the ever-growing challenge of treating patients with depression who live in rural or remote areas.
Such efforts range from simply using the telephone to deliver psychotherapy and psychosocial support, to laying sophisticated fiber-optic lines for videoconferencing so that patients in outlying areas can receive specialty care from providers who may be hundreds of miles away. Obtaining reimbursement for such approaches remains a stumbling block in many cases, but progress has been made on that front in recent years, and evidence is mounting that at least some of these applications offer important advantages over the traditional in-person encounter.
Videoconferencing removes stigma of visit
For the Fuqua Center, videoconferencing was a viable solution to treating patients who lived too far away to regularly come in for treatment or who were embarrassed about doing so. “The goal of the Fuqua Center is to provide psychiatric care for elderly adults with mental illness and to decrease stigma,” says William McDonald, MD, a professor in the department of psychiatry at Emory and the director of the Fuqua Center. That’s a challenge because there are few psychiatrists in most of rural Georgia, he says. “There may be one mental health center somewhere, but it is very, very rare to have psychiatrists in rural parts of Georgia. In fact, there is not a lot of psychiatric care even in the medium-sized cities.”
So Fuqua attempted to make care more accessible with help from the state. The state provided the fiber-optic lines needed to establish the telemedicine connection and the coordinators in each of the outlying areas necessary to facilitate encounters with patients. “The coordinator in a [particular] community might get a call from a doctor who says he needs his patient seen by a psychiatrist,” McDonald says. “The coordinator then sets everything up. She gets the patient’s records to us and gets the patient to the site with a nurse [at the scheduled time], so that makes it relatively easy.”
Having support staff at the local site is critical, McDonald emphasizes, because most primary care doctors do not have the time or resources to set up a videoconference visit. However, McDonald stresses that working with providers on a consultative basis has tremendous potential.
“What really works in medicine is presenting . . . your patient’s problems that you have been trying to figure out for the past six months, and then having an expert explain what is going on and develop a treatment plan with you,” McDonald says. “You [work with an expert on these cases] a few times, and then you can do it on your own. So our goal is not really to make money off this, but to train these rural doctors in order to develop psychiatric care in these rural areas.”
In addition to training providers in rural areas how to offer psychiatric care, the program at the Fuqua Center also has removed some of the stigma that people often associate with mental healthcare by making it available in a traditional medical setting. “Many older Americans have this odd idea about what goes on in psychiatry offices, but to actually go to a medical place, and have a nurse there who takes your [blood pressure] and presents you to a doctor, that has actually worked very well,” McDonald says. “It makes it much closer to a medical visit [in the patient’s eyes].”
There are some disadvantages to Fuqua’s videoconferencing approach. Technical glitches sometimes disrupt the audio/video connection, and older patients sometimes have difficulty hearing, a problem often compounded by the involvement of speakers and microphones.
The approach is still relatively new, but physicians who have referred patients to the program seem happy with it, as indicated by the fact that they continue to send more and more patients.
McDonald says he believes that as more practitioners and patients participate in the process, the approach will prove its value—both from a clinical and financial standpoint.
“In these rural populations, there will be real cost savings because there is plenty of evidence to show that patients with depression have much higher healthcare utilization, not just for mental health, but for all sorts of health,” he says. “Older depressed patients are much more likely to go to the ER complaining of chest pain [and other problems]. So there is very good evidence that a little money spent in treating depression can actually decrease overall costs.”
Phone-based psychotherapy delivers results
Another form of telemedicine—psychotherapy offered via the telephone—also appears to offer benefits, according to a study published in the April 2007 Journal of Consulting and Clinical Psychology. In that study, researchers from Seattle-based Group Health followed nearly 400 adult patients diagnosed with depression and placed on antidepressant therapy. Half of the group received brief, telephone-based psychotherapy soon after beginning their medication regimens; the other half received usual care.
Clinical improvement, as measured by the Hopkins Symptom Checklist (HSCL) Depression Scale, occurred in both groups. But within three months, the group receiving phone therapy showed more improvement than the usual care group, and this improvement was sustained for more than a year.1 (See Figure 1 above.)
At 18 months, 77% of those who received phone therapy reported that their depression was much or very much improved, whereas only 63% of those receiving usual care reported similar improvement.
The lead author of the study, Evette Ludman, PhD, a researcher with Group Health, notes that the telephone gave the patients flexibility and required less time and effort on their part than traditional psychotherapy, but the psychotherapists had to work especially hard to reach patients. “Therapists are usually trained to set up an office and wait for people to come. In our setting . . . sometimes they had to call 20 times before they reached somebody,” she says. “We learned that we need very energetic therapists who are willing to put in the amount of outreach effort needed and not take it personally [when patients fail to respond].”
The therapists also need to be available on nights and weekends, when people typically have the most time to devote to a phone-therapy session. And even those conditions aren’t ideal, because there can be myriad distractions going on in the background at a patient’s home. “That can mean screaming children, television—a variety of things—and it takes some getting used to,” Ludman says. However, she stresses that this may actually benefit the patients because they are learning to incorporate depression-fighting techniques in their real world.
Interestingly, some of the therapists felt that the fact that patients did not see them in person offered a comfort level or a level of anonymity that made the patients more accepting of the therapy. “It made people almost more willing to open up,” Ludman says. “We thought about sending pictures of the therapists to people so that they could have someone to imagine they were meeting, but then we realized something was working in our favor.”
One curious result from the study was that medication adherence was only slightly better in the phone-therapy group than the usual care group. In previous studies, patients receiving telephone follow-up have consistently had better adherence rates than patients in usual care. Ludman suggests that this may be because medication monitoring and follow-up have improved in usual care in recent years. She also points out that this makes it much more likely that it was the psychotherapy—and not the medication—behind the improved clinical results in the phone-therapy group. “We wanted to see if psychotherapy added to the medication, and given in a real-world, primary care setting, would provide an added benefit,” she says. “And we really think [that it did].”
Remote services need reimbursement
Next on the agenda for Ludman and colleagues is a cost-effectiveness analysis of the approach, from which they hope to be able to make a strong business case for phone psychotherapy. As it stands now, although Medicare will pay for the type of telemedicine visits that McDonald and other psychiatrists are providing in Georgia, there is no similar reimbursement mechanism for phone-based psychotherapy.
However, Ludman is optimistic that this will soon change. “I think there will be increased recognition of all types of remote services—Internet-delivered and telephone-delivered. I think we are on the cusp of a change there,” she says.
1. Ludman E, Simon G, Tutty S, et al. “A Randomized Trial of Telephone Psychotherapy and Pharmacotherapy for Depression: Continuation and Durability of Effects.” Journal of Consulting and Clinical Psychology 2007, 75 (2): 257–266.
Psychological barriers interfere with telemedicine applications in older populations
Healthcare organizations and providers interested in implementing a telemedicine application for senior patients would be well-advised to get input from those patients before moving forward, according to a new report by the New Millennium Research Council (NMRC), a think tank based in Washington, DC. The report, Overcoming the Psychological Barriers to Telemedicine: Empowering Older Americans to Use Remote Health Monitoring Services, reviews existing literature on the subject, and suggests that older Americans often have different concerns related to telemedicine than younger generations.
For example, Americans older than age 60 are much more hesitant to use computers or Internet-based applications than younger Americans and tend to have heightened concerns about confidentiality and privacy. “One of the big concerns people have relates to transmitting personal demographic information or health records online,” says Matt Bennett, executive director of NMRC. “People are worried that their information is going to go out there onto the Internet, and that someone is going to get their hands on it and use it for nefarious purposes.”
The report suggests that older Americans also worry that a telemedicine application may somehow interfere with the personal relationship they have with their provider or the clinic staff with whom they are used to interacting. “What we found in some of the literature is that people have the fear that they will become socially isolated [if a telemedicine application is implemented], and they don’t understand that it is actually a way to avoid isolation,” Bennett says.
Some of these psychological barriers will resolve themselves over time as the baby boomer generation ages; baby boomers tend to be much more comfortable with computers and technology than their parents. But that’s still a little way off.
In the meantime, telemedicine applications are more likely to be successful if providers spend time and effort educating and training senior patients on the front-end, the report suggests. “It is a matter of making the patients aware of what the technology can and can’t do, and what the benefits are for them,” he says. “It is investing in systems that are simple to use, that patients can understand without too much [explanation], and setting up support networks so that if [patients] are using something they don’t understand or there is a technical glitch, they can easily get access to support.”
The report goes one step further, suggesting that older individuals or peers actually offer this user education and support. Such a tactic can make the older patient more open to learning about how to use a new application and less embarrassed about asking questions.
Visit NMRC’s Web site at www.thenmrc.orgto access the full report.