LETTERS

To the Editor:

I was moved to write this letter after reading the excellent series of articles on telemedicine in the Winter 2008 Sonoma Medicine and finding no mention of the use of video technology in the practice of psychiatry.

There is currently a serious shortage of psychiatrists, and demand for services is high. This problem is particularly serious in rural areas. Telepsychiatry is one solution that has been employed here and abroad. In California, UC Davis has been collaborating with the Department of Corrections and Rehabilitation to provide telemedicine support for a number of specialties within the prison system.

In addition to providing medical services within the prisons, the Department of Corrections offers outpatient psychiatric care to paroled felons through its Parole Outpatient Clinic (POC), a multidisciplinary organization that places mental health clinicians, including psychiatrists, in parole offices throughout the State. Despite being invisible to the public, POC has an enormous impact on our communities.

The steady erosion of our mental health services over the last 40 years has paralleled a dramatic and steady increase in prison populations. Estimates of the proportion of people incarcerated in state prisons with significant psychiatric disorders range from 6-14%. Here in California, with a prison census over 170,000, that equates to a mid-range estimate of 17,000. The primary stated mission of POC is to continue treatment initiated in prison in order to minimize the risk that mentally ill parolees will be returned to custody. Due to the large number of parole offices in remote locations, it is not possible to provide a psychiatrist for each site. The use of telepsychiatry is a potential solution to this problem.

I recently spent over five years employed by POC, spending most of my time at the parole office in Santa Rosa. The office was at various times responsible for parolees in Marin, Sonoma, Napa and Lake counties. Sometimes patients were hard-pressed to travel to the office for treatment, but attendance was usually a condition of their parole.

The situation was worse farther north. There were no psychiatrists at all in the Eureka or Ukiah offices, both of which also covered vast areas. The solution was to install video equipment in my office as well as the offices in Eureka and Ukiah. In each case a time slot was set aside each week for video appointments. Psychiatric social workers at the other two offices would schedule the appointments, operate the equipment from their end, and be present during each session. The networked electronic record system operated by POC enabled me to check the schedule beforehand and read up on any clinical evaluations and progress notes. At the end of each session, I would enter a progress note and any prescriptions I wanted to write. The prescriptions would be printed out and faxed to whichever pharmacy the patient was using. If patients did not have insurance coverage for prescriptions, POC would pay for medications through a contracted pharmacy benefits manager.

In my opinion, the videoconference system functioned very well. After a brief period of adjustment, patients were able to interact with my video image as if they were sitting in the same room with me, although one Eureka patient decided to find an outside psychiatrist he could meet with in person. The quality of the image was good enough for me to clearly assess mental status, as well as monitor patients for movement disorders and other physical concerns associated with psychiatric medication management. UC Davis handled any technical issues; the support staff was available to clinicians by phone.

Prior to the advent of videoconferencing, mental health clinicians at these offices would have to scramble to find physicians to provide medications, and often only well-intentioned primary care doctors were available because of the long waits in community programs.

The UC Davis video system connects POC offices throughout the state. From any office with video installed, a clinician can call up any other location. Unfortunately, not all the equipment is used, partly because of clinician anxiety with new technology, and partly because of administrative inattention. But in one part of the POC system, a regional psychiatric administrator sat in his office in Sacramento much of the week doing video work with parole offices throughout the Central Valley. The videoconferences were his primary patient contact.

Edward L. Merrin, MD