The psychiatric profession can help fill the need for its services in rural
areas by expanding collaboration with providers of primary care, said several
psychiatrists from around the United States, who offered their experiences
during a forum at the APA Assembly meeting in Washington, D.C., last
The forum was chaired by Speaker-elect Jeffery Akaka, M.D., who said that
psychiatrists have a duty to offer care to persons outside metropolitan areas
and that the lack of such services has provided ammunition for psychologists
pushing for prescribing rights, a major issue in Akaka's home state of
David Moltz, M.D., chair of the Clinical Practice Committee of the Maine
Association of Psychiatric Physicians (MAPP), described a program his district
branch has set up. Most psychiatrists in Maine work in cities in the southern
part of the state, but there are few mental health resources in the rural
north. Even travel from one end of the state to the other is difficult: it
takes six-and-a-half hours for Moltz to drive from Portland to Maine's
northern border, as long as it does to drive to New York City.
To fill some of the need for psychiatrists in the north, the Maine district
branch sponsored a volunteer effort in which members served as consultants to
rural primary care physicians. The project was cosponsored by the Maine
Association of Family Physicians. The psychiatrists provided "informal
consultation" rather than "supervision," a distinction
suggested by risk managers to reduce liability. In fact, the risk of liability
was limited since the psychiatrists didn't know the patient's name and were
not paid for offering their opinions on each case. Twenty psychiatrists signed
up to consult with 22 family practices.
Despite the high hopes, the program produced mixed results in the first
year, said Moltz. No one complained about lack of access to the psychiatrists,
but there was also very little activity. Only half of the consultants were
called, and only 25 percent said the consultation involved significant
"At that point we could have chugged along the way we were or we
could change," said Moltz. The MAPP decided to change its approach
because the purely voluntary system lacked the resources and commitment to
function as well as program organizers had hoped.
With the help of an American Psychiatric Foundation grant, MAPP hired a
part-time coordinator who committed five hours a week to the project. The new
coordinator, psychiatrist Cynthia Burnham, D.O., initiated contacts with all
the family practices and consulting psychiatrists. She visited the practices
in person to introduce herself and learned that even more important than
talking to the physicians was getting to know the practice coordinators. She
also used more conventional marketing approaches to getting the word out,
printing 1,700 brochures and setting up tables or giving presentations at
medical meetings around the state.
Burnham is also organizing three conferences each year for participants.
The first included the consulting psychiatrists as a way for them to build a
bond to the project. The second will be aimed at both psychiatrists and family
physicians and will address issues of youth suicide.
Under the revised plan, 21 new practices have been added to the program,
said Moltz. "We learned that follow-up, marketing, and a paid staff
person are essential to making it work."
Halfway across the country, child psychiatrist S. Arshad Husain, M.D., is
trying another approach to bringing expertise to remote primary care
Husain, a professor and chief of child and adolescent psychiatry at the
University of Missouri-Columbia School of Medicine, surveyed 23 physicians and
29 nurse practitioners in the 13 most underserved counties in southwestern
Missouri. He found that they were treating an average of 36 patients for
psychiatric problems each week. More than two-thirds said they saw patients
with anxiety, bipolar disorder, major depression, ADHD, substance abuse, or
posttraumatic stress disorder. About 86 percent provided medication follow-up,
24 percent offered individual psychotherapy, and 8 percent family therapy.
They referred seven patients a month on average to psychiatrists or mental
health professionals to deal with diagnostic questions, treatment failure,
suicidal ideation, significant drug dependence, or a need for inpatient care.
Many patients had long waits for any sort of mental health care.
Husain and his colleagues from the University of Missouri International
Center for Psychosocial Trauma have trained 2,000 teachers around the world as
lay therapists to provide psychological help for tens of thousands of children
in the aftermath of wars and natural disasters. He decided to apply a similar
model to train primary care providers in South-west Missouri in psychiatry and
The U.S. Department of Labor granted $2.7 million over three years to
Project TErmh (for Training Enhancement in rural mental health) to offer
primary care physicians and nurse practitioners 84 hours of classroom and
clinical study in general psychiatry, child psychiatry, and
psychopharmacology. The course covered DSM-IV diagnostic classes,
interventions, and interviewing techniques. To further entice prospective
attendees, Husain held the training sessions one weekend a month at a lake
resort in the Ozarks and invited participants' families as well.
To study the effects of the training, he tested participants on the content
before and after the course, using fourth- and fifth-year psychiatry residents
as a control group. The primary care providers scored 45 percent on the
pre-test, which rose to 64 percent after completing the course—not far
from the residents' 76 percent.
After completing the program, participants were invited to join an
integrated mental health team that offered them immediate access to a
psychiatrist, a 24-hour hotline for consultations, medication guidance, more
intense outpatient options, and inpatient hospitalization, if needed.
Now the Department of Labor has given the Missouri group a new grant for a
nonaccredited fellowship in psychiatry and child psychiatry, Husain reported.
They will expand the original program to 120 hours of training, including 56
classroom hours and 64 hours of inpatient practicum, and will add a
specialized child-psychiatry track for general psychiatrists and
One psychiatrist at the Assembly forum offered an even more direct
alternative to easing the crisis in the countryside: moving there. Roberta
Stellman, M.D., a native New Yorker, had worked in Albuquerque, N.M., since
1976. In 1997, Stellman's husband closed his law practice and decided to
nurture 12 acres of pecan saplings north of Hatch in southern New Mexico,
where the couple had a vacation home.
Stellman called the local health center, a federally funded primary care
clinic, and asked about working there. There were only five psychiatrists in
all of southern New mexico at the time, so the center was happy to hear from
her and offered her a job with no decrease in her salary.
"You can ensure an income and still live in a rural area," said
Stellman. "In a small community, you can have a bigger
To further expand options in underserved regions, APA will offer a new Web
site for members early next year, said Nada Stotland, M.D., M.P.H., chair of
APA's Task Force to Review Psychiatric Needs in Underserved Areas. The site
will include information on using the J-1 visa waiver program to attract
foreign medical graduates to rural areas, understanding federal government
Health Professional Shortage Area guidelines, expanding telepsychiatry, and
letting district branches know what their colleagues are doing around the