Providers' Perspectives: Utilizing Telepsychiatry in Schools

Program Description

The Prince George School Mental Health Initiative (PGSMHI) is a school-based mental health program that was initiated in 2006 to provide clinical and case management support to students in special education who have severe emotional and behavioral difficulties. Presently, the PGSMHI is based in eight schools within a large, urban school district. The clinicians who work within the PGSMHI provide counseling services and teacher consultation, while the case managers assist families in accessing resources within the community.

In conjunction with clinical and case management services, psychiatric consultation is also provided for students served by the PGSMHI. The psychiatric consultation is provided remotely by child and adolescent child psychiatry fellows in collaboration with psychiatry faculty (both psychiatrists and clinical psychologists) based at the University of Maryland School of Medicine (Baltimore, MD), approximately 40 miles away from the PGSMHI school district.

Consultation Format and Content

Psychiatrists are available to provide consultation to the school mental health clinicians once weekly for approximately a 2-h period. Typically, one case is discussed in depth during each consultation. Prior to the consultation, clinicians are required to fax or e-mail to the psychiatrists information about the student they would like to discuss. Consultation varies from direct service delivery to clinical consultation, which may involve a discussion of treatment goals and objectives or the need for psychotropic medication.

The frequency and type of consultations utilized within the PGSMHI have evolved as the program has expanded. Initially, consultations took place only by phone. During the 2007–2008 school year, videoconferencing was initiated at two schools. The PGSMHI expanded to six schools in the following school year, and over the subsequent years videoconferencing equipment was placed in two additional schools. When consultations are held via telephone, consultation occurs between the clinician and the psychiatrist, and the psychiatrist does not have the opportunity to interact with the student. At present, the majority of the school sites now have access to videoconferencing equipment, and the psychiatrist has the opportunity to interact directly with the student, school staff, and family members if needed.

Although the PGSMHI clinicians provide prevention and support services to a large number of students within a school, on average, 14 students receive more intensive individualized services from the program staff at each school site. It is the students who receive intensive services who are eligible to receive psychiatric consultation. Since 2006, when the PGSMHI was established, 92 video consultations and 168 phone consultations have taken place. Although the majority of the video consultations have involved different students, a small number of the video consultations involved discussions of the same student on more than one occasion. In addition, some of the phone consultations involved discussions of several different students during one phone call, whereas other phone consultations focused on just one student.

Technical Equipment

For all videoconferencing sessions, a Tandberg Edge 95 Precision camera (Cisco Systems, San Jose, CA) was used, which has a bandwidth of up to 2 megabits. The camera sets atop a full high-definition LCD television, and the videoconferencing takes place via a Transmission Control Protocol/Internet protocol connection. The connection line is encrypted so that nonprivileged individuals are not able to listen to or view the interactions between the clients and the psychiatrist. Prior to participating in the videoconferencing process, parents/guardians of the student participants provide informed consent to allow their children to participate.

Participants

Since the initiation of the PGSMHI, seven psychiatrists have provided consultation services. In most cases, one psychiatry fellow is assigned to provide services to the PGSMHI for the full academic year. Contact information was available for five of those psychiatrists, who were contacted via e-mail and asked to provide feedback on their experiences with psychiatric consultation. Four of the five psychiatrists answered the survey questions; one respondent was a faculty member, and three were psychiatry fellows. For this study, the four child and adolescent psychiatrists were included in primary analyses. Secondary analyses comparing responses of psychiatrists with other school mental health clinicians included the 4 psychiatrists and 6 clinicians, for a total of 10 participants. The psychiatrists' range of experience in providing telepsychiatry services to youth varied greatly, with the licensed psychiatrist faculty member being a recognized leader in telemental health, providing supervision and feedback to the fellows who were initially introduced to telepsychiatry through the PGSMHI. During their involvement with the PGSMHI, the psychiatrists provided consults over the phone as well as through utilization of the videoconferencing technology.

Procedure

Participants were asked to provide feedback on the psychiatric consultation via an anonymous, Web-based survey distributed via e-mail. The psychiatrists were informed that the purpose of the survey was to obtain feedback regarding their experiences providing teleconsultation services to the PGSMHI staff.

Measures

The 10-item survey (see Appendix) contained questions based on those utilized in a previous study of school mental health clinicians' telepsychiatry experiences. ¹³ Eight items were open-ended, and two items prompted responses on a 10-point Likert scale. Open-ended questions queried general experiences providing consultation via videoconferencing, benefits and disadvantages of using videoconferencing technology compared with face-to-face appointments, experiences providing consultation to clinicians over the phone, the nature of consultation with school therapists and other individuals (i.e., parent, pediatrician, psychiatrist) in the context of the school setting, technological disadvantages, and suggestions for how telepsychiatry in schools could be improved. The two quantitative items queried psychiatrists' perspectives of students' comfort speaking via video as well as their own comfort speaking to the students, on a scale from 1 to 10 (where 10 indicating highest levels of comfort).

Perceived Comfort in Video Communication

Psychiatrists' reports of the students' level of comfort ranged from 6 to 9, with an average of 7.25. Psychiatrists' ratings of their own comfort level speaking to students via video were somewhat higher, ranging from 9 to 10, with an average of 9.75.

Overall Experience with Video Consultation

Overall, the psychiatrists reported positive experiences providing consultation via video, with statements such as “It was a great experience” or “The experience…provided exposure to a variety of cases with diagnostic challenges.” Specific advantages noted were being able to assess students in collaboration with the therapists, being able to discuss medication options with students, and being able to collaborate with the therapist in “real-time.” One of the disadvantages noted was that the consultation question was not always very clear.

Overall Experience with Phone Consultation

Although two of the psychiatrists described the phone consultations as a positive experience, citing the ability to provide clinical support and information on resources, they also noted the limitations of the phone consultations, as they were not able to interact with the student to assess any of their mental health, cognitive, or physical challenges. Similar to the consultations conducted via video, an additional challenge noted was that a clear consultation question was not always presented for the phone consultations.

Comparison of Consultation Formats

When asked about the overall benefits and disadvantages of using videoconferencing technology compared with face-to-face appointments, one psychiatrist noted that when working with students who had a history of trauma, the students appeared more comfortable communicating via the video. It was also noted that telepsychiatry was “time and financially efficient.” Another wrote that telepsychiatry was “efficient, flexible” and provided the opportunity to collaborate with other providers. An additional advantage of telepsychiatry that was reported was the ability to communicate with clients who were in remote locations.

School as a Context For Consultation

Although three of the four psychiatrists reported a positive experience collaborating with the school-based therapists, one psychiatrist expressed concern regarding the communication between the school-based therapists and the psychiatrist, noting that at times the therapists did not provide information regarding key events in the student's history.

The psychiatrists were also asked if they ever consulted with anyone other than the PGSMHI clinician and, if so, to explain the circumstances under which the consultation occurred. Two of the psychiatrists reported no consultation, whereas two reported communication with the students' parents on several occasions. Some parents participated in video consultation to provide a more comprehensive view of the student's symptoms and to assess differences between the student's behaviors at home and school. Another psychiatrist noted that some parents were contacted by phone to discuss the students' functioning and to obtain consent related to the provision of a prescription for psychotropic medication. A related challenge endorsed by participants was parent engagement; one psychiatrist specifically noted that one parent was reluctant to participate in the consultation because of apprehensiveness about the student starting a medication trial. An additional challenge specific to the school context involved student absences on days that consultations were scheduled.

Technological Considerations

Although all of the psychiatrists reported feeling “very comfortable” using the video equipment, three of them endorsed technological problems with the equipment at times such as spontaneous disconnections, poor resolution, lack of audio, or general bandwidth issues. It should be noted that in most cases any disruptions in the connection were resolved during the session, but if they were not, the consultation session would continue over a speakerphone.

Participant Recommendations

Two psychiatrists underscored the need for the therapists to provide a specific consultation question and to ensure that all relevant history was shared with the psychiatrist prior to seeing the student. An additional suggestion was to have more schools equipped with the technology so that each school site could have the opportunity to participate in the video consultation sessions.

Comparison of Perspectives: Psychiatrists and Clinicians

In May 2010, six clinicians from the PGSMHI were interviewed to assess their perspectives on the advantages, disadvantages, challenges, and utility of the telepsychiatry component of the PGSMHI. ¹³ The clinicians were either licensed social workers or counselors with 3–23 years of clinical experience. A secondary aim of the current project was to compare the perspectives of the psychiatrists with the perspectives of the PGSMHI clinicians that were provided previously, to assess training needs and future research goals. As reported in the article by Grady et al., ¹³ similar to the psychiatrists, the clinicians reported that, overall, the consultation experience was helpful in providing enhanced clinical support and that they appreciated the opportunities for collaboration. They also agreed that the students appeared at ease when communicating with the psychiatrists via the video and often tended to disclose more via video than they typically did during sessions. Challenges regarding technical problems with the equipment and student absences were also mentioned by the clinicians.

Despite those common observations, there were also some intriguing differences in the perspectives of the psychiatrists and the clinicians. For instance, although the psychiatrists reported feeling rather comfortable in their interactions with the students via video, some of the clinicians believed that the psychiatrists at times appeared “stiff,” uncomfortable, or had a difficult time engaging the students. In addition, although the psychiatrists reported that they didn't have enough information about the students provided to them prior to the session, the clinicians reported that the psychiatrists often did not seem to have read the information that was provided.

Limitations

Although offering insight into the potential of telemental health services, this study also has some limitations to consider when interpreting findings. Foremost, the small number of participants in the study limits the generalizability of the findings. Broadening the study to include more psychiatrists and clinicians, and perhaps engaging other school-based sites, would be helpful. In addition, the study lacked a control or comparison group and was based solely on self-report survey data. Future qualitative inquiry such as focus groups and key informant interviews will likely offer enhanced understanding of the value of telepsychiatry services and how to utilize them most effectively in schools. Also, it is possible that some of the psychiatrists and clinicians did not have a shared vision with regard to the consultation process. It is unclear whether this was a result of communication challenges, a limitation that was specific to this study, or a factor that should be closely monitored for all team-based consultation. Further research is warranted to investigate the quality, frequency, and structure of communication between school-based providers and community-based psychiatrists who provide consultation services. Finally, the cross-sectional nature of the study limits our ability to understand possible changes in providers' experiences over time. For example, it is possible that as psychiatrists gain experience and comfort level that their perceptions related to usability and effectiveness of this treatment modality would shift.

Future Directions

School-based health and mental health service providers are increasingly incorporating telemental health services into their daily activities. As such, telemental health research in schools is critical to enhance our understanding of the comparative effectiveness of this treatment modality versus traditional mental healthcare in school-based settings. In addition to research, we encourage practitioners who are using telemental health to gather evaluative data that can inform the continuous quality improvement of these services. Although this study investigated perspectives of psychiatrists and school-based clinicians, student and caregiver satisfaction and perceived value of telemental health in schools should also be assessed when evaluating the quality of services. Ultimately, research and evaluation activities must assess the impact of school-based telemental health services on student functioning, including both psychosocial and academic indicators. Additionally, research and evaluation on school-based telemental health should take into account the impact of this technology on enhancing the linkages between schools and the larger system of care for children and adolescents. For example, it is likely that tele-equipment would enhance providers' ability to connect with representatives of other child-serving systems, including primary care, juvenile services, and child welfare.