Mental health treatment's new frontier: telepsychiatry

June 07--By mid-July, due to several recent retirements, Yakima will be left with only one private-practice psychiatrist, worsening an imbalance between the number of people who need mental health treatment and the medical professionals who can help them.

And as long as demand exceeds supply, the community's problem with untreated mental illnesses will continue to manifest in several costly ways, from homelessness to a significant portion of the jail population whose untreated problems likely played a role in their incarceration.

"Yakima could probably use a dozen psychiatrists. The shortage is noticeable," said Matt Kollman, chief operating officer of Memorial Physicians, which has been trying to recruit psychiatrists in recent years with little success. "We'd like to start with one."

While there are still psychiatrists employed by Comprehensive Mental Health and some community health centers here, the overall shortage of medical doctors who specialize in psychiatry is pushing health care leaders to innovate. For example, they are making broader use of telemedicine technology and employing mid-level providers like psychiatric nurse practitioners, such as Kathy Jolin of Maine.

Jolin, who lives in the rural central Maine town of Dover-Foxcroft, population 4,213, contracts full time with Comprehensive to provide mental health services for its patients.

"I like telepsychiatry because I think there's this, for lack of a better word, intimacy," she said in a telephone interview last week. "You're focused, both the patient and yourself are very focused on the issue at hand."

The dearth of psychiatrists -- medical doctors who specialize in psychiatry -- is not just a local problem. But it is a problem of distribution. Nationwide, the 40,000 or so practicing psychiatrists are concentrated in urban areas, while more than half of all counties in the U.S. don't have a single one.

Rural areas bear the brunt of the shortage, as older doctors retire without anyone coming in to take their practice.

With no end of the shortage in sight, providers say innovative models of mental health care aren't just a stop-gap measure, but the new normal.

Acute shortage

Washington state has about 600 practicing psychiatrists, but only about 50 live outside of the Seattle and Spokane areas, said Dr. Jurgen Unutzer, chairman of the Psychiatric and Behavioral Health Department at the University of Washington.

In Yakima, Comprehensive Mental Health employs five psychiatrists and Yakima Valley Farm Workers Clinic has two. Both organizations treat primarily Medicaid patients.

Dr. Fred Montgomery retired recently from his private practice, and Dr. George Vlahakis will do the same at the end of June. In July, Yakima Valley Memorial Hospital's Outpatient Psychiatric Services at Lake Aspen will lose Dr. Howard Harrison to retirement -- two years after he originally planned to leave.

Industry leaders blame the dearth of medical students pursuing psychiatry mostly on the specialty's relatively low reimbursement rates, which fall just above primary care. A lack of training programs and a shift toward using psychiatrists primarily to prescribe medications also contribute to the shortage.

Mental health providers won an important victory this year when the state Legislature passed a bill requiring payment parity between telemedicine services and services delivered in person. Telepsychiatry, in particular, will help existing resources better meet demand.

And demand has been growing. The Affordable Care Act improved access to mental health services by requiring basic insurance plans to cover it in comparable fashion to other medical services.

Comprehensive Mental Health CEO Rick Weaver said many patients, especially kids, now prefer telepsychiatry to the traditional one-on-one session in a closed room with a psychiatrist.

What's more, telepsychiatry allows people in rural areas to access mental health care, where an in-person psychiatrist would never have enough demand to sustain a practice in a small town like Goldendale or Toppenish. It also helps people who lack mobility, such as the long-term disabled.

"We had a doctor who moved away because he got married. He's in Seattle, and says, 'I'll work for you guys, but from here,'" Weaver said.

Telepsych adds another 1.5 providers to Comprehensive's roster, but Weaver said he must still continue to recruit more local providers to meet demand.

Memorial, too, is finalizing its telepsych setup to bolster its mental health staff, Kollman said.

He acknowledges, however, that there are "certain limitations" to providers and patients in the treatment-from-a-distance model.

"It's not ideal, but it is a way for us to provide resources to the community while we're working to find a more ideal solution," he said.

Meanwhile, Memorial is hoping to hire some temporary "locum tenens," temporary substitute doctors, for high-need cases, while continuing aggressive recruitment.

"Short of actually abducting somebody from a university, we're doing everything up to that point," Kollman said.

Because of the low reimbursement rates, the outpatient psych office operates at a loss, he said, but preventive services end up saving money down the road by treating problems before they become expensive, so it's valuable to the system overall.

"It's a substantial investment for a health system to make, but it's absolutely mission-critical," he said.

Dr. Donald Williams, who's practiced here for 38 years, said having skilled psychiatrists in a community is as important as any other medical specialty.

"Having a highly skilled medical oncologist to manage rare and challenging malignancies is really important, as opposed to somebody just in primary care," Williams said. Specialized psychiatrists are needed to manage complex mental illnesses and disorders.

Williams will be the last remaining private-practice psychiatrist after next month. While falling reimbursement rates and greater documentation demands are making it more difficult for all kinds of doctors to sustain an independent practice, he doesn't plan on being absorbed into a larger organization.

"They're employees and they lose autonomy, and have less opportunity to be creative," he said of doctors who sell their practices to hospitals. With the freedom to do both individual and group therapy, along with medication management, he said, "I'm very content. Couldn't be happier."

Remote consultation

With the shortage of psychiatrists, primary care doctors often end up diagnosing and treating some mental illnesses, such as depression. That can be problematic for some primary doctors who recognize the limits of their training.

But a novel approach started about eight years ago at the UW, where Seattle-based psychiatrists act as expert consultants to primary care providers all over the state, helping them feel more comfortable in prescribing medications and treatments.

"I think we can make more of a difference, because we're partnering with people already in the community," Unutzer said of the Mental Health Innovation Program, or MHIP.

"Psychiatrists, because there aren't enough, should be used to consult to those doctors and take care of the patients who either diagnostically are more challenging or not responding," he said.

The MHIP doctors consult on a set group of patients, so they get to know their cases over time, and participate in a phone call every week with care teams at the local clinics, then visit the clinics in person a few times a year.

It's also true that patients prefer to get their mental health care and their primary care taken care of in one place, according to Rebecca Sladek, communications director with the UW AIMS (Advancing Integrated Mental Health Solutions) Center, which administers MHIP.

"I think the new normal is that nationwide, people are trying to figure out how to offer behavioral health care, mental health care, in a primary care office," Sladek said.

The MHIP model involves a primary care provider, a psychiatrist, and a care manager, who may be a nurse, social worker or other provider. The care manager typically does psychotherapy when needed, Sladek said.

The model works for the most common mental health problems: depression, anxiety, even bipolar disorder in some cases. Severe mental illnesses are still usually treated in more specialized offices.

Having psychiatrists backing them up helps primary care providers feel less skittish about prescribing serious drugs, Sladek said.

"There's data that show that primary care providers who prescribe antidepressants, they're prescribing a medication that isn't working, or they're prescribing it in really low doses because they're really nervous about upping the dosage," Sladek said.

Nonspecialists also may not know what results to look for.

"Antidepressants take a minimum of two weeks to see any effect at all, and while you're waiting for the positive effect, you have to put up with negative side effects," said Harrison, who practiced at Memorial Outpatient Psychiatric Services for 18 years.

Yakima Neighborhood Health Services gets all the psychiatric expertise its providers need through the UW's MHIP.

"It's an awesome program," said Neighborhood Health behavioral health director Peg Davenport. "Our providers are well-educated with psychotropics because of the training that the UW psychiatrists have done. ... Now our providers, with the help of UW psychiatrists, are prescribing meds for schizophrenia, for bipolar, for sleep, PTSD."

When she started more than six years ago, Davenport said the clinic used to have regular "code pink" situations, when a patient was out of control and needed to be restrained. Now, with the improved education and medication management skills, they can't remember the last time one happened.

Trying solutions

Team care and nonpsychiatrist providers, including social workers, behavioral health specialists and licensed mental health counselors, are increasingly a big part of the solution to the psychiatric shortage.

And Washington is one of a growing number of states that lets nurse practitioners operate their own practices without the oversight of a physician. Yakima has several independent psych-specialty NPs, and Comprehensive employs some, as well. Another will start at Neighborhood Health this summer. NPs can choose any specialty, including psychiatry, to focus on.

Jolin, the Maine nurse practitioner with a psych specialty who contracts with Comprehensive, said NPs should not be compared to physicians but noted they have rigorous training.

She was trained in a two-year program at Boston College with clinical work to become an adult psychiatric mental health nurse practitioner. She was also a registered nurse for 20 years and believes nurses bring a "wholistic, comprehensive perspective to patients."

However, not all doctors agree on the role NPs should play because they don't receive as much clinical training as MDs.

"If they have a psychiatric specialty, they can do a reasonably good job," Harrison said. "But if you have a very complex patient on multiple medications, they may get over their heads."

"Do they fill the need? Absolutely. Are they interchangeable (with psychiatrists)? No," Williams said.

Doctors of pharmacy (referred to as Pharm-Ds) are also being used more as prescribers, another trend that raises some eyebrows.

But Weaver of Comprehensive said psychiatrists are no longer the only answer when it comes to meeting a community's mental health needs, just as medication is not the only answer for an individual patient's needs.

"Being short of psychiatrists is a bad thing," Weaver said. "But there are lot of things we can do to help ameliorate that. And again, that team approach really makes a difference."

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