Practicing psychiatry hundreds of miles away from your patient over a video
link means marrying technology and medicine with mundane subjects like funding
and credentials, said Jay H. Shore, M.D., M.P.H., an assistant professor of
psychiatry at the University of Colorado Health Sciences Center in Denver
(UCHSC), at APA's 2005 annual meeting in Atlanta.
The center runs telepsychiatry programs from Denver serving American Indian
patients hundreds of miles away in several surrounding states. These services
include a posttraumatic stress disorder (PTSD) clinic for north Plains Indian
military veterans and a child and adolescent consulting practice at a South
Both services operate with the University of Colorado psychiatrists in a
room in Denver, while the patients go to sites equipped with a video linkup
near their homes. The Indian Telehealth Network uses an integrated digital
services network (ISDN) or a Department of Veterans Affairs intranet, not the
"Video conferencing over the Internet is not secure, the quality is
not that good, and it varies with the amount of traffic," said Douglas
K. Novins, M.D., an associate professor of psychiatry at UCHSC. "ISDN
gives us much better quality."
Remote setups for veterans are located at clinics on the Rosebud, Wind
River, Crow, and Northern Cheyenne reservations. Trained outreach workers like
Gilbert Jarvis help persuade tribal members suffering from PTSD to come to the
local clinics for evaluation and therapy. Contemporary telepsychiatry is
integrated with a native-healer program that uses sweat lodges, talking
circles, and healing ceremonies, said Jarvis, a Shoshone tribal outreach
worker and a veteran well connected to the veteran community in rural
"Indian culture says you can't let other people know your
problems," said Jarvis, who appeared with the UCHSC doctors in Atlanta.
Many would fear exposure if they were seen coming out of a mental health
clinic, but are willing to visit a Veterans Affairs center with the proper
encouragement, he said. American Indians served in disproportionately large
numbers in the military and have had greater exposure to trauma and higher
PTSD rates than the U.S. norm, he added. Distance creates a barrier to care
because so many also live in remote areas, but outreach workers like Jarvis
can connect with the vets and get them to the clinic door.
"We have one 83-year-old who thinks he's a movie star," said
In the weekly telepsychiatry clinics, the psychiatrists in Denver provide
individual therapy, group therapy, and medication management, said Shore. They
may take two hours to evaluate a new patient, half an hour for a follow-up
session, or one hour for a weekly group therapy session. The program has
logged 1,000 patient contacts in two years.
"The biggest goal in the first session is developing rapport with the
patient, even if we're not getting at all the issues," said Shore."
Trust is critical."
The tribal outreach workers like Jarvis help with "system
transference," vouching for the doctor and cementing the therapeutic
relationship. In some ways, the distance between doctor and patient may even
help, said Shore: "You won't run into the patient in the grocery
The physicians may miss some subtle cues by not being in the room, but they
may gain objectivity, he said. Doctors can tolerate more intense affect: the
patient may get angry, but therapy needn't stop. Nonetheless, they must
establish protocols covering what to do when the line goes down in the midst
of a session with a suicidal patient.
The separate child psychiatry program operates in cooperation with the
Sioux San Hospital in Rapid City, S.D. A former Public Health Service
tuberculosis sanatorium, Sioux San is operated by the federal Indian Health
Service. Sioux San's last child psychiatrist left in 2001 after eight years.
Currently, no child psychiatrists work for the Indian Health Service in North
Dakota, South Dakota, Iowa, and Nebraska, the four states Sioux San
Obstacles to telepsychiatry arose when it was first proposed after 2001,
said Novins. The hospital could offer no funds to support the program, but
federal funds were found for a pilot demonstration project, and the project
The UCHSC group hesitated to provide direct child psychiatric services at
first. However, the Sioux San staff was experienced in general psychiatry and
envisioned telepsychiatry as adding specialist expertise to its own work.
"For us, the telepsychiatry program essentially serves as a second
opinion," said adult psychiatrist Mark Garry, M.D., Sioux San director
of behavioral health, in an interview. "We usually have pretty good idea
of what's happening with a patient, but the system can confirm that or offer a
different opinion or treatment plan."
Patients in Rapid City have already seen Garry or another psychiatrist
before the telepsychiatric consultation. Each patient receives an 80-minute
initial evaluation by the UCHSC team assessing the child and a caregiver.
Those sessions are followed by 40-minute case discussions with local doctors,
nurses, and social workers. The telepsychiatry group performed 21 evaluations
in its first year, most extremely complex, given Sioux San's status as a
tertiary hospital, said Novins.
"Patients and caregivers said it helped to have their own clinician
in the room and to know that an expert was involved," said Novins."
Clinicians reported that the UCHSC group helped with diagnoses. They
learned by watching the child psychiatrists and felt less isolated and more
comfortable seeing these patients."
The child psychiatrists in Denver said they took longer to establish
rapport with patients over the video link and found the session less
emotionally satisfying and harder to remember. There was an average of one
disconnection per session, which added to the sense of discontinuity, said
Technical problems remain the biggest concern for Garry in Rapid City, who
recounted three line failures in one session on the day he spoke with
Psychiatric News. "You can be in a long, sensitive discussion
with a patient when the line goes down, so you need a technical person who can
get things reconnected quickly."
He noted, however, that he and the other general psychiatrists at Sioux San
can usually maintain the discussion in the room during any outages.
Technical issues aside, patients and their families say they are satisfied
with the program. Adolescents sometimes relate to the screen and camera even
better than to a clinician in the room, said Garry. "They look at it
like another video game."
The operating costs of the UCHSC telepsychiatry system were less than six
face-to-face consultations a year ($744 versus $932), but the $8,500 in
initial equipment costs represented a significant difference. Allocating those
hardware costs among other disciplines would ease the financial burden.
"It's hard to convince other UCHSC providers to use the
system," said Shore. "If we could spread the fixed costs across
multiple clinics, the cost per unit would drop."
Although the demonstration funds ran out in February, Sioux San eventually
funded the fixed costs and uses the equipment to consult with a small Indian
Money is only one issue that must be addressed for telepsychiatry to work,
said Shore. Nearly as much administrative time goes into the project as
clinical time, he said. Licensing for physicians working across state lines is
another question. Psychiatrists treating veterans can sidestep that since they
fall under the federal umbrella, but some system of shared state licensing,
national licensing, or limited telemedicine licensing is needed in the long
run, he said. Integration inside and outside the system is essential, he
"You need to develop both the technology and the program in
parallel," he said. "And you need cooperative, dedicated people at
Further information is posted online at<www.uchsc.edu/ai/cnatt/cnattindex.htm>.▪