Telepsychiatry helps mental health patients in rural Missouri 

Holden Comer lives in Owensville, a town of 2,600 22 miles from the nearest interstate highway in east central Missouri. When he was 5, he was diagnosed with post-traumatic stress and attention deficit disorders.

Holden saw his mother suffer domestic abuse, said his aunt, Debbie Fischer. He was mad all the time.

"He would lash out at other people. He tried to physically harm his mom at one point. He was getting into fights with his little brother," said Fischer, who cares for Holden and his younger brother, Samual.

But their county lacks a psychiatrist to treat Holden. Fischer takes him to a nearby community health clinic, where they talk to a psychiatrist monthly via video conferencing.

The frequent virtual visits helped determine the medications Holden needed. At 9, he is a different child, Fischer said. "Without these services, I don't know where we would be. We would probably have to put him in a psychiatric ward."

There has been a rapid growth in "telepsychiatry" services in Missouri. Health care providers see the technology as a powerful solution to the severe shortage of specialists able to diagnose and prescribe medications for mental disorders - a dangerous scenario that has contributed to higher rates of hospitalization, emergency room visits, drug addiction and suicide in rural areas.

Compass Health Network, whose facilities serve rural residents across the state, provided more than 36,000 telepsychiatry sessions last year at its clinics in 26 cities. Just 11,000 sessions were provided just five years ago, officials said.

Mercy Health's primary care clinic in Rolla began providing pediatric telepsychiatry to its patients five years ago and now reaches 650 children a year. Mercy is working to integrate the technology into more of its rural primary care clinics.

The state juvenile justice system has over the past three years equipped many of its residential facilities to receive remote care from psychiatrists at the University of Missouri School of Medicine, which is studying the impact in cost savings and health outcomes.

Whether it's autism, depression, addiction or severe psychosis, providers say telepsychiatry allows them to intervene early and provide better care.

"Something that could be easily averted by treating a child early results in what becomes a huge issue socially, academically and financially," said child psychiatrist Ujjwal Ramtekkar, who sees 70 percent of his patients using a computer from his home or the video conferencing equipment at a clinic in Wentzville.

Fischer said with having to care for her elderly parents and Samual, also diagnosed with ADHD, the frequent visits that have been key to Holden's success would have been impossible if she had to travel hours for care.

"Being able to control him is wonderful, because I have a rough time sometimes," she said."It is a godsend," she said.

Federal data show that 1 in 5 children have behavioral health problems. Most do not get treatment because of issues such as cost, and lack of access and transportation.

In rural Missouri, where almost 40 percent of the state's residents live, the problems are exacerbated. Of the 101 rural counties in Missouri, 98 do not have a psychiatrist.

Patients in rural areas would have to take off from work or miss school to drive - if they had cars - several hours to and from an appointment, said Dr. Cathy Grigg, director of psychiatry services for Compass Health. Or patients would have to wait until a specialist was able to drive to see them, which meant the doctor was spending hours in a car instead of seeing patients.

"We were putting our psychiatrists in the car and driving them to these very rural clinics, and that was really taking their time away from providing patient care," Grigg said.

When treating mental health, timeliness is crucial, she said. Any lapse in medication can exacerbate symptoms. Medication may not work as well if a patient stops taking it and then starts again.

If a patient is referred to a psychiatrist but has to wait several weeks for an appointment, the patient may feel better by that time and not go - missing the opportunity for early diagnosis.

"They get worse if we don't intervene," Ramtekkar said. "We are missing that critical period of intervention."

Problems can emerge between appointments, he said. "When there are red flags that a crisis is impending, we really want them to see a provider right away. Suddenly, things can get out of hand, and they end up in the ER."

Telepsychiatry can also be used to fight opioid addiction, which killed more than 1,000 Missourians in 2015. Treating addiction requires careful monitoring and medication dosing to ease withdrawal, Ramtekkar said. "Frequent visits to a clinic far away can be a barrier."

Rural residents fare worse than their urban counterparts when it comes to mental health. The Missouri health department looked at data between 2003 and 2013 and found that the rural rate of emergency room visits for behavioral disorders was 39 percent higher than the urban rate.

The suicide rate was 15.4 percent higher in rural areas, the report said. Overall, suicide increased 29 percent to become the 10th-leading cause of death in Missouri.

Telepsychiatry has long been in the works to improve outcomes, Griggs said. Compass Health first provided the service on a small scale in 1992. Affordability and improvements in the technology have greatly increased access in recent years.

The Missouri Telehealth Network also dates to 1994. The network educates providers about the technology, helps troubleshoot problems and connects patients to services. Over the past decade, the network helped leverage federal and state grants to purchase equipment and increase broadband internet access across the state.

In a study released a year ago, the University of Missouri looked at how the network helped connect 179 rural children to pediatric psychiatrists, even fewer in number than psychiatrists, over 10 months. The study found the average distance a patient would have had to travel for care was 22 miles, and the farthest was 300.

"If it wasn't for something like this, maybe they wouldn't get any care," said Mirna Becevic, MU assistant research professor of telemedicine.

Providers say psychiatry lends itself to the technology because it requires interviewing but little hands-on care.

"Most of the care is done verbally, by showing empathy and concern, showing your understanding, while guiding and coaching the person through the crisis," Ramtekkar said. He can zoom in on the patient's eyes and focus on body movements such as fidgeting or tics.

Patients with mental health disorders may find that tend to have social anxiety or trouble focusing. They might be embarrassed. Talking to a television screen is less daunting than talking to a person across a desk.

Becevic said research shows patients are happy with the quality of care and some even prefer it. "They feel safer and feel like they can be honest and open," she said.

Jasmine El Khatib, a pediatrician in Jefferson City, has been referring her patients to a telepsychiatrist since last fall. They get seen more quickly, she said, and the virtual collaboration enables her to better monitor their progress.

"If we can get them in as soon as possible and touch base with them and stay in contact with them, they are less likely to drop out of care," El Khatib said. "I am able to keep tabs on them rather than things getting lost."

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