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 month.

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 Hawaii.

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 activity.

"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 clinicians.

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 psychopharmacology.

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 pediatricians.

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 impact."

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 country. ▪