Feasibility and Acceptability of Clinic-Based Telepsychiatry for Low-Income Hispanic Primary Care Patients

Abstract

Background: The feasibility and acceptability of telepsychiatry for low-income Hispanic patients with major depression were assessed. Subjects and Methods: In total, 167 adult Hispanic patients with major depression recruited from a community health center (CHC) were randomly assigned to receive psychiatry services through a video Webcam (WEB) (n=80) or to treatment as usual (TAU) (n=87). The WEB condition consisted of monthly telepsychiatry sessions at the CHC for 6 months provided by one of two Hispanic psychiatrists using an online virtual meeting program. TAU patients received their care from their providers. Acceptability was assessed by comparing appointment keeping for primary care versus telepsychiatry, patients' perceived working alliance with their provider, visit satisfaction, and antidepressant use. Feasibility was assessed using depression outcomes, functional days (unproductive or days lost), and whether WEB and TAU patients differed in their appointment keeping. Results: WEB patients did not differ in the proportion of completed primary care versus telepsychiatry appointments and rated their working alliance with the psychiatrist and their visit satisfaction significantly higher than the TAU patients with their provider. Significantly more WEB than TAU patients used antidepressants. Although depression severity decreased faster among WEB than TAU patients, no differences were found in the overall depression score. WEB and TAU patients did not differ in the number of days that were lost or unproductive due to depression. Although WEB and TAU patients reported being willing to pay for mental health services provided by the CHC, almost proportionately twice as many WEB patients were willing to pay for telepsychiatry. Conclusions: Results show that for low-income depressed Hispanic patients, telepsychiatry service for depression is acceptable, although its feasibility is questionable. The benefits of telemedicine were discussed in terms of improving patient care in ways other than directly providing services to the patients.

Introduction

The delivery of adequate specialty care to Hispanic individuals with depression is challenged by socioeconomic, linguistic, and cultural factors that create a special need for understanding and sensitivity.¹ Barriers are compounded if these individuals reside in rural areas or in regions with a shortage of mental health professionals. Telepsychiatry can increase access to culturally sensitive mental health professionals while effectively eliminating the distance barrier,² but it has yet to be tested as a methodology for treating depressed low-income Hispanic patients.³ This article describes a project to assess the feasibility and acceptability of providing psychiatry services remotely to low-income Hispanics through Webcams and the Internet (telepsychiatry).

Telepsychiatry is generally well received; clinical interviews through telepsychiatry are found to be reliable, and patients and clinicians typically report high levels of satisfaction.⁴ Patients are more likely to keep telepsychiatry appointments and less likely to be “no shows,” compared with conventional face-to-face psychiatry appointments.⁵ Telepsychiatry care is as effective as face-to-face care^6,7 with little difference in the psychotherapeutic process and outcome between video and face-to-face consultation.⁸

Not all literature on telemedicine for mental healthcare has been positive, however. Some psychiatrists with telepsychiatry experience considered it to be less personal than in-person consultation, citing technical problems such as poor video and audio quality, poor lighting, need for technical support, and scheduling difficulties.⁹ A third of residents in the rural Midwest who were surveyed reported being unwilling to participate in telepsychiatry.¹⁰ For low-income Hispanics residing along the United States–Mexico border, there may also be cultural barriers such as discomfort related to the use of such technology, as well as providers who do not know the patient's language or culture.¹¹ Other traditional care issues for Hispanics include being unwilling to use pharmacotherapy¹⁰ or to admit to a need for psychiatry services.¹² Accessing help for emotional problems may also be less likely among Hispanics who are less acculturated, although this may be due to language problems or not knowing what services are available.¹

For the current project, psychiatrists from the University of Arizona provided telepsychiatry services to Hispanic patients of a community health center (CHC), Saint Elizabeth's Health Center (SEHC) in Tucson, AZ. SEHC serves low-income uninsured and underinsured individuals; over 90% of patients pay on a sliding fee scale. Approximately 64% of SEHC patients self-identify as Hispanics, mostly of Mexican descent. In place of the dedicated telemedicine network that connects SEHC with the University of Arizona through a T-1 line, a Web-based delivery was selected so that SEHC is more comparable with other CHCs along the United States–Mexico border. This project was approved by the University of Arizona's Institutional Review Board.

Most studies that have evaluated telepsychiatry used face-to-face psychiatry sessions as the comparison. Literature reviewed to date shows no difference in process and impact between the two modes of mental healthcare. In contrast, we will compare telepsychiatry services through the Internet using a Webcam (WEB) with treatment as usual (TAU) in a primary care setting. In a usual clinic setting, depression treatment reduced symptoms more rapidly and effectively than patients randomly assigned to a physician's usual care.¹³ Thus, rather than expect depression outcome to be the same between WEB and TAU patients, we expected better outcomes for patients assigned to the WEB condition.

Subjects and Methods

Several factors were addressed to minimize potential barriers to the acceptability of telepsychiatry. They include:

1. Language and cultural concerns. Two Hispanic psychiatrists (both Mexican Americans fluent in English and Spanish, one male, one female) provided telepsychiatry services to the patients.

2. Organizational readiness, an important concept for adopting a new practice.¹⁴ SEHC had already adopted telemedicine for chronic disease education and support.

3. Appreciating the importance of mental health treatment. For more than 5 years, SEHC had attempted to increase access to depression treatment for their patients.

4. Cost. The WEB and the TAU patients were not asked to pay for the telepsychiatry or any mental health services provided in the clinic.

With these potentially problematic barriers addressed, we expected telepsychiatry to be acceptable and feasible for low-income uninsured depressed Hispanics.

Research Design

This is a randomized control study in which eligible subjects were randomly assigned to telepsychiatry using WEB or TAU with both conditions having an equal chance of being selected. Randomization was achieved using a computer-generated list. The assignment was unknown to both the recruiter and the patient until the patient had undergone informed consent procedures and eligibility screening. Following all screenings, the patient opened the numbered envelope that contained information about either the TAU or the WEB condition, including the timeline for research follow-up and, for the WEB patients, the schedule for the telepsychiatry sessions. To ensure adherence to randomization, the sequence of assignments was checked against the random assignment master list periodically by the recruiter's supervisor.

Those assigned to the WEB condition agreed to arrive at SEHC for telepsychiatry sessions once a month for 6 months (1 h for intake and six 30-min follow-ups). Those assigned to the TAU were told that their SEHC provider would be responsible for their mental health needs. SEHC providers were notified through the patients' electronic medical record. This is necessary to avoid WEB patients from being prescribed antidepressants by their SEHC providers and to ensure that TAU patients were not neglected because the providers assumed that the patient was assigned to the WEB condition. SEHC providers were immediately notified if patients were suicidal (not eligible for participation) or if the TAU patients scored 20 or above on the depression screen (indicating severe symptoms) at baseline.

Treatment by the psychiatrists followed the measurement based approach as described in the “Sequenced Treatment Alternatives to Relieve Depression” (STAR*D) study.¹⁵ Medication was based on the “Texas Medication Algorithm Project” strategies for treatment of nonpsychotic major depressive disorder.¹⁶ Treatment as usual at SEHC included having one of several in-house mental health specialists to whom the providers could refer patients if needed. Appointments for the SEHC mental health specialists tended to be for 1 h. WEB patients could also access the mental health specialist if such an event was considered appropriate by the psychiatrist. Each psychiatrist or mental health specialist had his or her own caseload. Although the psychiatrists did not discuss TAU patients with the SEHC providers, they were available as a resource regarding pharmacotherapy.

Because the subject's participation was for 6 months and the project was only for 2 years, we were unable to extend data gathering beyond the 6-month interval for all patients. Thus, outcome data collected were at baseline and 3 and 6 months post-baseline to coincide with the beginning, middle, and end of the subject's participation in the project. The measures used included the following.

Measures

The Personal Health Questionnaire 9 (PHQ-9), a reliable and valid measure of depression severity, uses Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for depression and asks about symptoms present in the past 2 weeks.^17,18 This instrument was used as an initial screen, and the recruiter administered it each time the WEB patient came for the telepsychiatry session as part of the measurement-based approach. The PHQ-9 was administered to the TAU patients at baseline and 3 and 6 months post-baseline.

The Mini International Neuropsychiatric Interview (MINI) uses diagnostic algorithms consistent with DSM-IV and International Statistical Classification of Diseases and Related Health Problems, 10th Revision to assess the major adult Axis I disorders in DSM-IV.¹⁹ This instrument was used only once for exclusion and inclusion criteria screening.

The Acculturation Rating Scale for Mexican Americans (ARSMA II)²⁰ uses cultural behaviors to indicate acculturation. This scale provides two scores: Anglo Orientation (alpha coefficient=0.83) and Mexican Orientation (alpha coefficient=0.88).

Other information collected included demographic information (age, sex, marital status, education level, employment), treatment-related information (depression treatment experience, hospitalizations, outpatient, medications), and health services utilization in the past 3 months including psychiatric hospitalizations, mental health counseling, and other pertinent information.

Sheehan's Disability Scale (SDS)²¹ consists of three main domains in which the respondent rates the level of impairment caused by his or her psychiatric condition, on a scale of 0 (not at all) to 10 (extremely). Patients were also asked to indicate the number of days lost (e.g., not going to work or school) and the number of days that they were underproductive (e.g., went to work but productivity was reduced) as a result of their symptoms. This was used at baseline and 3 and 6 months post-baseline.

The following instruments were used at the end of the monthly telepsychiatry sessions for the WEB patients and at baseline and 3 and 6 months post-baseline for the TAU patients.

The nine-item Visit Specific Satisfaction Questionnaire (VSQ-9)²² was developed from Rand's Medical Outcomes Study. The VSQ-9 was found to reflect patient–doctor communication if used immediately after the clinical visit.

For the Working Alliance Inventory Short Form,²³ respondents rate questions regarding the working relationship between them and the clinician/therapist during the specific clinic visit. It measures three subscales of the alliance that are related to the goal, task, and client–therapist bond.

Approximately 6 months prior to the end of data collection, a request from SEHC was made to assess whether patients would be willing to pay for mental health services. A brief survey was developed (ratings, multiple choice items, and a comments section), and the protocol was approved by the University's Institutional Review Board to use the questionnaire with all remaining subjects at their 6-month follow-up.

Administrative Data

Information on patients' appointment keeping during the 6 months that they were in the study was collected. The total number of possible visits was made up of the number of times they were “no shows” for the appointment and the number of times they completed the appointment. Visits that were canceled by the providers or patients were not included.

Questionnaires were previously translated into Spanish either by the instrument developers or for clinical trials and other studies apart from the small questionnaire developed specifically for this study regarding payment. The translated questionnaires had already been tested on Hispanics in the Tucson area, and the project-specific questionnaire was reviewed by SEHC personnel.

Hypotheses and Analyses

The following proposals were generated to assess acceptability for telepsychiatry:

1. WEB patients will show no difference in the proportion of completed telepsychiatry appointments compared with primary care appointments (using administrative data).

2. WEB patients' ratings on their working relationship with the psychiatrist will be more favorable than TAU patients' ratings with their primary care provider (using WAI scores).

3. WEB patients' satisfaction with their appointment experiences will be more favorable than TAU patients' ratings of their visits with the primary care provider (using the VSQ-9).

4. WEB patients will be more likely to use antidepressant medication than TAU patients.

The following proposals were generated to indicate feasibility:

1. WEB patients will have significantly less severe depression symptoms than the TAU patients (using the PHQ-9).

2. WEB patients will have greater patient functionality, showing fewer days lost and fewer unproductive days (using the SDS).

3. WEB patients will be more likely to keep their appointments than TAU patients (using administrative data).

Repeated-measures analyses of variance were conducted with data collected from instruments (PHQ-9, Working Alliance Inventory, and SDS). Independent-sample t tests were used for the appointment data (administrative data). For frequency data, a chi squared test was used. No statistical analyses were conducted for the data collected regarding the patients' willingness to pay for the care they received. Comments were reviewed and recurring themes were noted using a bottom-up approach, and no a priori themes were developed.

Data collected were entered into a Microsoft Access database within a week so that any missing item or out-of-range responses (e.g., coded in error) could be followed up immediately with the patient. The project recruiter (Spanish–English bilingual Mexican American) conducted all data collection activities (intake and follow-up interviews) reported in this study and was responsible for all other patient interactions, including the recruitment, screening, consenting, and appointment scheduling for the project. To ensure accuracy in collecting clinical data, a researcher experienced in clinical trials research trained the project recruiter to administer the screening tools with periodic reliability checks.

Procedure

Connecting through the Internet

To begin a telepsychiatry session, the psychiatrist used the Macromedia Breeze Manager Web application to create a virtual meeting room that can be entered using a software-generated URL specific to that meeting. Prior to beginning the session, the psychiatrist at his or her office at the University of Arizona sent the URL to the project recruiter at SEHC to enter the virtual room. The connection was checked for video and audio qualities before the patient entered the telemedicine consulting room. During the session, the psychiatrist and the patient sat in front of their respective computers and Webcams to talk. If the psychiatrist needed to communicate with the project recruiter during or at the end of the session, the psychiatrist would communicate through the telephone.

Screening

Hispanic patients at SEHC were identified and recruited for the project using a two-stage design between June 2008 and October 2009. Recruitment occurred in several ways: Through annual registration, advertisements/signs, and provider referral. SEHC providers were periodically reminded of the study's inclusion and exclusion criteria.

At registration, all adult registrants were asked to self-administer the PHQ-9. The project recruiter reviewed the completed forms and selected those forms that were completed by Hispanics (self-identified) and had a score of 10 or higher. Patients who saw the study signs would ask clinic staff or providers about the study and be referred to the project recruiter. Providers would also refer patients they suspected of being depressed to the project recruiter. Once the project recruiter received information about the potential subjects (including those through the registration process), she would call, ascertain that the patient is a Hispanic adult, and describe the study to the individual. If the patient was interested in participating in the study, the recruiter would make an appointment for depression screening and to formally obtain informed consent.

At the first meeting, the recruiter administered the preliminary PHQ-9 screen to ascertain that the patient scored 10 or higher (indicating possible moderate depression). Those who did underwent informed consent procedures during which the patient was informed of a second eligibility screening, random assignment, and the activities involved in the WEB and TAU conditions. Inclusion criteria were as follows: An adult of Hispanic ethnicity, willing to be randomly assigned, to participate in the program for 6 months, and to be followed up, and have a diagnosis of major depression disorder based on the MINI. Patients were excluded if they (1) had a diagnosis of bipolar affective disorder, schizophrenia, schizoaffective disorder, dementia, or current substance dependence based on the MINI or had any concurrent DSM-IV Axis I disorder that required inpatient or crisis residential treatment at the time of screening, (2) manifested signs or symptoms of serious medical or neurological illness (i.e., severe liver or renal failure, etc.) that in the opinion of the primary care provider was likely to increase the risk of complications during treatment, (3) manifested signs or symptoms of serious medical illness that may explain the observed depressive symptoms (i.e., traumatic brain injury, uncontrolled seizures, etc.), (4) had active suicidal or homicidal ideation or be felt by one of the investigators based on clinical presentation and past history to pose a significant risk to harm themselves or others, (5) were pregnant or lactating, or (6) lacked mental capacity to provide informed consent.

Prior to the beginning of the study, discussions with SEHC providers were held to ensure support and to provide clarification of their roles in the project. They were apprised of the criteria and periodically reminded so that the referrals were appropriate for the study.

Results

Of the 182 Hispanic SEHC patients invited to participate in the study, 4 refused, and 11 were ineligible (i.e., did not follow up for a baseline interview or screened out because of exclusion criteria or the SEHC provider unintentionally prescribed medication prior to subject randomization). Of the remaining 167 individuals, 87 were randomly assigned to TAU and 80 to WEB. No significant differences were found between the TAU and WEB patients at baseline. All patients were followed up (in person or through the telephone), regardless of whether or not they accessed services, unless they refused to participate in the study follow-up. The follow-up rate was above 80% at the 3- and 6-month follow-up periods. A total of 15 individuals never returned to the clinic (6 TAU and 9 WEB), and 5 patients (3 TAU and 2 WEB) actively dropped out of the study. Table 1 describes the patients in the project.

Table 1.

Characteristics of Patients Participating in the Project

	TAU	WEB
Total n	87 (100.0%)	80 (100.0%)
Age (years) [mean (SD)]	43.2 (11.9)	42.8 (12.0)
Male	12 (13.8%)	7 (8.8%)
Female	75 (86.2%)	73 (91.3%)
Education
None	3 (3.4%)	4 (5.0%)
Grades 1–8	20 (23.0%)	22 (27.5%)
Grades 9–12	25 (28.7%)	25 (31.3%)
Completed grade 12 or GED	19 (21.8%)	16 (20.0%)
College 1–3 years	11 (12.6%)	6 (7.5%)
College 4 years or more	6 (6.9%)	5 (6.3%)
Some vocational training	3 (3.4%)	2 (2.5%)
Employment
Employed	43 (49.4%)	40 (50.0%)
Unemployed (but looking for work)	8 (9.2%)	8 (10.0%)
Homemaker	31 (35.6%)	29 (36.3%)
Student (not working)	3 (3.4%)	2 (2.5%)
Retired	0 (0.0%)	1 (1.3%)
Unable to work	2 (2.3%)	0 (0.0%)
Income
<$5,000	36 (41.4%)	25 (31.3%)
$5,001–15,000	29 (33.3%)	39 (48.8%)
$15,001–25,000	17 (19.5%)	13 (16.3%)
$25,001–50,000	5 (5.7%)	3 (3.8%)
Marital status
Married/living together	50 (57.5%)	52 (65.0%)
Divorced/separated/widowed	29 (33.3%)	24 (30.0%)
Never married/single	8 (9.2%)	4 (5.0%)
Acculturation (range 1–5) [mean (SD)]
Mexican Orientation Score	4.2 (0.4)	4.2 (0.3)
Anglo Orientation Score	1.9 (0.7)	1.8 (0.7)
In general is your health:
Poor	1 (1.1%)	1 (1.3%)
Fair	2 (2.3%)	2 (2.5%)
Good	22 (25.3%)	18 (22.5%)
Very good	40 (46.0%)	45 (56.3%)
Excellent	21 (24.1%)	12 (15.0%)
Chronic illness (yes)	37 (42.5%)	36 (45.0%)
Average number of chronic illnesses (SD)	1.2 (0.53)	1.4 (0.7)
Have you ever been hospitalized for a medical problem? (yes)	26 (29.9%)	30 (37.5%)
Have you ever been treated for any psychological or emotional problem (not including substance abuse, employment, or family counseling:
In a hospital or inpatient setting (yes)	2 (2.3%)	5 (6.3%)
As an outpatient or private patient (yes)	7 (8.0%)	2 (2.5%)

Data are mean (%) values unless indicated otherwise.

GED, general education diploma; SD, standard deviation; TAU, treatment as usual group; WEB, group that received psychiatry services through a video Webcam.

Most of the participants in this project were women (88%), and the majority (61%) were married or had a partner. Many of the participants (59%) did not complete high school; half were not in the work force, and three-fourths of them reported a household income of $15,000 or less. The subjects were more oriented toward the Mexican culture than the Anglo culture. All clinical and research interactions with the patients were conducted in Spanish. Over 50% of them did not have a chronic illness, with the majority rating their health as good or better, although a third had been hospitalized at one point for a medical problem. Most of them had not received mental health treatment previously.

Acceptability of Telepsychiatry

Table 2 shows the results for appointment keeping, visit satisfaction, and patient rating of the working alliance with their provider.

Table 2.

Acceptability of Telepsychiatry

	TAU	WEB
Appointment keeping^a
Number of subjects who made a primary care appointment	76 (87.4%)	56 (70.0%)
Mean number of completed appointments^b	3.2 (2.7)	3.2 (3.8)
Mean number of no shows^b	1.6 (0.8)	1.8 (0.8)
Mean proportion of completed primary care visits/(completes+no shows)^b	0.8 (0.3)	0.7 (0.4)
Number of subjects who made a mental health appointment	29 (33.3%)	77 96.3%
Mean number of completed appointments^b	4.3 (3.6)	4.8 (2.7)
Mean number of no shows^b	1.6 (0.8)	1.7 (1.0)
Mean proportion of completed mental health visits/(completes+no shows)^b	0.7 (0.3)	0.7 (0.3)
Visit satisfaction (range 0–36)^c
Baseline	32.5 (3.2)	34.0 (2.8)
Month 3	35.0 (1.9)	35.6 (1.5)
Month 6	35.6 (1.2)	35.8 (1.2)
Working Alliance Inventory (range 0–72)^d
Baseline	47.9 (4.9)	51.8 (4.5)
Month 3	51.9 (5.9)	57.2 (3.5)
Month 6	55.2 (6.1)	58.5 (3.1)
Antidepressant use^e
Did not use antidepressants	33 (45.2%)	24 (30.0%)
Used antidepressants	40 (54.8%)	56 (70.0%)

Data are mean (SD) values unless indicated otherwise.

All appointment-keeping comparisons were not significant.

Denominator includes only those who had made a primary care or mental health appointment.

By the nine-item Visit Specific Satisfaction Questionnaire.²³ Assignment (WEB versus TAU): F(1,97)=6.9, p<0.01. Time (baseline, 3 and 6 months): F(2,194)=46.6, p<0.001. Time×Assignment: F(2,194)=10.8, p<0.05.

By the Working Alliance Inventory Short Form.²⁴ Assignment (WEB versus TAU): F(1,94)=31.6, p<0.01. Time: F(2,188)=87.4, p<0.001. Time×Assignment: F(2,188)=2.1, not significant.

By chi squared test: χ²(1,152)=3.8, p≤0.05.

No differences were found in terms of whether WEB or TAU patients kept their primary care or mental healthcare appointments during the 6 months that they were in the study. Proportionately more TAU patients made a primary care appointment than the WEB patients (87% versus 70%), whereas the reverse was true for mental health appointments (33% versus 96%). No significant differences were found when the proportion of completed primary care versus mental health appointments was compared for the WEB and the TAU patients.

WEB patients were significantly more likely to use antidepressant medications than the TAU patients. They were also significantly more satisfied with their visits with the psychiatrists and reported significantly higher alliance with the psychiatrist compared with the TAU patients when asked to rate their visits with their primary care provider. Although the visit satisfaction and the working alliance scores improved for both WEB and TAU patients, TAU patients showed a significantly steeper increase in their visit satisfaction score than the WEB patients (time×assignment interaction). However, it should be noted that by Month 6, the mean score for the WEB patients had almost reached the maximum satisfaction score possible.

Feasibility of Implementing A Telepsychiatry Program

Table 3 shows the results that were used to indicate the feasibility of telepsychiatry in terms of patient outcome.

Table 3.

Feasibility of Telepsychiatry

	TAU	WEB
Depression (n)^a	69	63
Baseline	17.3 (4.9)	18.3 (4.5)
Month 3	9.9 (6.5)	8.4 (5.5)
Month 6	6.8 (6.0)	4.7 (5.1)
Days lost (n)^b,c	68	65
Baseline	0.5 (1.1)	1.7 (5.4)
Month 3	0.4 (1.4)	0.7 (1.9)
Month 6	0.3 (1.3)	0.2 (0.7)
Unproductive days (n)^d,e	67	65
Baseline	3.4 (2.8)	4.1 (5.1)
Month 3	2.0 (2.3)	1.8 (2.1)
Month 6	1.2 (1.9)	1.0 (1.8)
Proportion (n) of completed primary care visit versus mental health visit^f	27	56
Primary care visit	0.8 (0.3)	0.7 (0.4)
Mental health visit	0.7 (0.4)	0.7 (0.3)

Data are mean (SD) values.

By Personal Health Questionnaire 9.^18,19 Assignment (WEB versus TAU): F(1,130)=1.1, not significant. Time: F(2,260)=254.4, p<0.001. Time×Assignment: F (2,260)=4.4, p<0.05.

Assignment (WEB versus TAU): F(1,131)=2.9, not significant. Time: F(2,262)=4.0, p<0.05. Time×Assignment: F(2,262)=2.5, not significant.

In response to “On how many days in the last week did your symptoms cause you to miss school or leave you unable to carry out your normal daily responsibilities?”

Assignment (WEB versus TAU): F(1,130)<1, not significant. Time: F(2,260)=32.3, p<0.001. Time×Assignment: F(2,260)=1.0, not significant.

In response to “On how many days in the last week did you feel so impaired by your symptoms that even though you went to school or work, your productivity was reduced?”

Telepsychiatry for WEB or mental health sessions for TAU. WEB: t(55)<1, not significant. TAU: t(26)=2.0, not significant.

Both WEB and TAU patients showed a significant decrease in depression symptoms from intake to the 6-month follow-up. However, the significant interaction between assignment (WEB/TAU) and time (baseline, 3 months, and 6 months) indicated that WEB patients improved at a significantly higher rate than TAU patients. Both the WEB and TAU patients reported a significant decrease in the number of days in which their symptoms rendered them less productive or worse, unable to carry out their normal responsibilities. However, both groups showed a similar rate of increase in visit satisfaction or improvement in working alliance. The proportion of visits that were kept did not differ for both primary care and mental health appointments (telepsychiatry for WEB or mental health sessions for TAU patients) for either TAU or WEB patients.

Satisfaction with Care

In total, 25 TAU and 28 WEB patients were asked about their willingness to pay for mental health services and their thoughts about the current project. When patients were asked to rate how pleased they were with the depression care they received, mean rating for TAU patients was 8.8±2.4, and that for WEB patients was 9.4±1.1, on a scale of 1 being not at all pleased and 10 being very pleased. Patients were informed that if they were to receive mental healthcare, they would most likely have to see the mental health professional more often than they would a primary care provider. Even with this caveat, 76% of TAU and 46% WEB patients were willing to pay the same price for a mental health session as for a primary care visit, whereas 12% of TAU and 50% WEB patients were willing to pay more. For telepsychiatry, 36% TAU and 61% WEB would pay the same, 4% TAU and 25% WEB would pay more, and 52% TAU and 14% WEB would pay less than a primary care visit. Asked if they were satisfied with the assignment (WEB or TAU) they received, everyone except one WEB patient was satisfied.

The majority (84%) of TAU and WEB patients reported that the project helped or made them better, with 50% of both groups indicating that the project and SEHC staff provided much appreciated support. It is surprising that approximately 12% of each group wanted more time, with the WEB patients commenting that the sessions (30 min) were too brief, whereas the TAU patients wanted more sessions. Among the WEB patients, 22% mentioned that they liked the Webcam sessions, and 14% reported needing some time to adapt.

Conclusions

Results of this project suggest that telepsychiatry is acceptable as a method for reaching low-income and relatively unacculturated Hispanic patients with depression. Our hypotheses were only partially supported, with strong support for acceptability and less definite support for the feasibility of telepsychiatry.

Patients were accepting of the psychiatrists and telepsychiatry as seen by the completed appointment rates for telepsychiatry, positive ratings regarding their working alliance with the psychiatrist, satisfaction with their telepsychiatry sessions, and the WEB patients' use of pharmacotherapy. Although Hispanic patients were reported to be less likely to access mental health treatment,^23,24 this was not evident among the patients of this project. According to SEHC providers, many of the patients were referred by them to the study as a result of patient enquiries regarding the study signs or advertisements placed in the SEHC. Unfortunately, the actual number who asked about the signs was not enumerated. Several culture-compatible components in the study may also have increased patient acceptability and minimized patient dropouts. The psychiatrists, project recruiter, and clients were all Mexican Americans, and the project was housed in an agency located in the community.²⁵ SEHC is easy to get to because it is on a major thoroughfare and is adjacent to a community college that is serviced by public transportation. Additionally, by providing depression treatment in a medical clinic, the patient can be less concerned about being stigmatized—the recruiter also made certain that patients went to the telemedicine room from her office rather than directly from the waiting room.

The measures for feasibility of telepsychiatry as indicated by the results did not fare as well. Contrary to expectations, WEB and TAU patients showed similar treatment gains for depression (although WEB patients improved significantly faster) and did not differ in the number of unproductive or lost days at work or the proportion of primary care or mental healthcare appointments that were completed. Although the results seem to suggest that telepsychiatry may not be feasible, we note that there are several factors at play here that probably will not be present elsewhere.

Unlike most other primary care facilities, SEHC has an enhanced model of primary care with in-person mental health services available to patients. It should be noted that the mental health services were not in place when the project was first proposed. The WEB group would probably have superior outcome to the TAU group if SEHC did not have such enhancement. Additionally, SEHC providers may have been more willing to treat the TAU patients for depression knowing that the patients had been screened and found to be depressed. Third, the period of monitoring may not be long enough to show a difference between TAU and WEB patients. If the patients were monitored for a longer period, WEB patients may show a more sustained treatment gain because the chances of relapse are high,²⁶ especially among primary care patients who generally receive low-intensity pharmacotherapy and inconsistent follow-up.²⁷ If the depression outcome is sustained for the WEB and not the TAU patients, the impact on healthcare and other costs may also be substantial because the number of lost or unproductive work days could remain low. Further research should be conducted on the long-term impact of telepsychiatry.

One of the findings in this study that bears highlighting is the impact of the patients' experiences with a psychiatrist and/or telepsychiatry. WEB patients were more willing to pay for telepsychiatry services than TAU patients, indicating a positive disposition toward the telepsychiatry modality. The influence of experience on subsequent choices has been reported elsewhere.²⁸ When naive patients were given a choice to select in-person versus telepsychiatry care, the majority chose in-patient care. However, when patients were asked to rate their satisfaction with the care they had received, both groups showed high levels of satisfaction, and the majority of the telepsychiatry group opted for future care through telepsychiatry.²⁹ Similarly, in this project, the proportion of WEB patients who did not return after the assignment was twice that of the TAU patients, and yet, among those who received the services, WEB patients were more positive toward their treatment experience than the TAU patients. Thus, to assess acceptability, one should not rely only on the opinions of individuals who have never had the relevant experience.

In addition to bringing much needed service to patients, there are several other benefits of Web-based telepsychiatry. Convenience for the psychiatrist includes no travel time because the session can be conducted in the psychiatrist's office in much the same way as an office visit with the patient. Second, the collaboration between the CHC and the psychiatrist adds to the quality of patient care and helps the development of a consultative liaison between the psychiatrist and the community provider.²⁹

Although our study shows that telepsychiatry for this population is acceptable, and most likely feasible, there are several factors that will make telepsychiatry difficult for at least some individuals and CHCs that service uninsured patients. Although patients were willing to pay for telepsychiatry sessions, the cost of frequent sessions would be a huge financial burden for uninsured individuals who may have to pay up to $100 per session on a sliding fee scale. Unless the psychiatrists were willing to accept a small nominal fee or to volunteer their time, the financial compensation would most likely be unacceptable. One possibility is to use telepsychiatry as an educational tool to allow psychiatry residents and students to volunteer time and gain experience while helping educational institutions and CHCs forge links.²⁹

Another problem we encountered was the difficulty in engaging individuals who were employed. Because they have low-income jobs, their job prospects were already precarious, and taking more than 30 min off for their lunch hour was a hardship. This led to canceled appointments and no-shows. This suggests that to reach such a population, evening or weekend hours may be needed.

Limitations of this project include not being able to generalize to low-income non-Hispanic patients who make up 40% of SEHC patients, patients with psychiatric disorders other than depression, or CHCs that have not adopted telemedicine or have such experience. Although telepsychiatry appears to be accepted by the patients, it has not been established whether the acceptance was due to the cultural congruence between patients and project staff (including psychiatrists) in terms of language spoken and ethnicity and/or acceptance of the technology because these potential barriers were removed in this study. Because of the difficulty in providing employed male patients with schedules that would allow them to attend sessions without jeopardizing their employment, males were not well represented in the overall project. Indeed, employed female Hispanic patients were also a rarity in the subject pool. Future research should determine how cost-effectiveness can be achieved with telemedicine while providing needed specialty services to uninsured and underinsured patients.

Footnotes

Acknowledgments

The authors would like to thank the patients and providers at SEHC, in particular, Martha Preciado, Sr., Michelle Humke, Dr. James Dumbauld, and Nancy Johnson, as well as the Finding Answers team members from the University of Chicago (Dr. Scott Cook and Kimberly King). This project was funded by the Robert Wood Johnson Foundation through its Finding Answers Program (April 2008–April 2009).

Disclosure Statement

No competing financial interests exist.

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