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Article Excerpt
Due to a shortage of mental health professionals (MHPs) in rural areas, primary care physicians (PCP) are often the first, and in many cases, the only providers of depression treatment for rural individuals. This study was an investigation of the acceptability of behavioral telehealth to PCPs and patients with depression as a way of making mental health treatments more accessible to rural patients. The researchers conducted 10 focus groups across rural Nebraska with PCP's and patients they had treated for depression. A qualitative multiple-case study approach was used to analyze the transcriptions. The participants felt that behavioral telehealth is a reasonable solution to the access-to-care problem. They expressed concern that professional and therapeutic relationships would be difficult to maintain at a distance and they provided suggestions for how to preserve these relationships when using technology to deliver treatment such as focusing on fostering collaborative relationships between MHP's and PCPs. It is essential for MHPs and PCPs to develop and maintain a collaborative working relationship that will facilitate frequent communication.
Keywords: depression, rural medicine, telehealth, primary care
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Due to the shortage of mental health providers (MHPs) in rural areas (U.S. Substance Abuse & Mental Health Services Administration, 1997) primary care providers (PCPs) are often the first, and in many cases, the only depression treatment providers for rural individuals (Hartley, Korsen, Bird, & Agger, 1998; Lambert, Agger, & Hartley, 1999). This is a primary barrier to getting necessary treatment for depression for rural residents because despite best efforts (U.S. Public Health Service, 2007), the assessment and treatment of depression often exceeds the resources, training, and practice capabilities of PCPs (Quine et al., 2003; Susman, Crabtree, & Essink, 1995; Health Resources and Services Administration. Rural Task Force., 2002; Von Korff, Katon, Unutzer, Wells, & Wagner, 2001). For example, PCPs with busy rural practices may not have the training or time needed to be able to provide patients with the counseling that would normally be provided by a mental health counselor (Susman, Crabtree, & Essink, 1995; Geller, 1999). While they may be able to treat the depression medically, sometimes the depression is of sufficient severity that treatment is best managed by a psychiatrist or other MHP (Geller, 1999; Von Korff et al., 2001). To prevent inadequate treatment, a greater diversity of referral options is often needed (Quine et al., 2003; Susman et al., 1995; Health Resources and Services Administration. Rural Task Force., 2002; Von Korff, et al., 2001).
Discovering and implementing solutions that would allow rural residents greater access to mental health services could yield significant benefits to individuals with depression and the overburdened rural health care system. For example, a study conducted in rural Arkansas that demonstrated through cost-offset analyses that every $1.00 that was spent in depression treatment was associated with a decrease of $2.61 in health-related problems among rural individuals diagnosed with depression (Rost, Fortney, Zhang, Smith, & Smith, 1999). In a similar study, there was a 21.5% reduction in health care costs for patients who received treatment from a marriage and family therapist (Law & Crane, 2000).
Telehealth (use of therapy via the Internet, satellite transmission, or other technological means) is one of the most commonly suggested solutions for providing improved depression treatment in rural areas (Griffiths & Christensen, 2007; President's New Freedom Commission on Mental Health, 2003; U.S. National Institute of Mental Health, 2000; LaMendola, 1997) Telehealth may appear to be a viable solution in part because other forms of telemedicine are already regularly implemented in rural primary care settings such as: emergency consultation for rural PCPs providing emergency care; and continuing education (Cole, Medrano, Satterfield, Nesbitt, & Marcin, 2004; Nesbitt, Rose, & Katz, 2003). But the biases and beliefs of both PCPs and patients not experienced in the use of telehealth for the treatment of depression can be either facilitators or barriers to the use of telehealth in providing mental health treatments. The literature focusing specifically on physician and patient perceptions before the implementation of telehealth is nonexistent. Existing literature primarily focuses on perceptions gathered after participation in telehealth (Bischoff, Hollist, Smith, & Flack, 2004; Goldfield & Boachie, 2003; Grubaugh, Cain, Elhai, Patrick, & Frueh, 2008; Lessing & Blignault, 2001). The purpose of this study was to elucidate perceptions and biases of PCPs and patients diagnosed with depression about telehealth as a potential solution for depression treatment in rural communities. Understanding PCP and patient perceptions about telehealth can provide information about how to best implement effective treatments and whether these treatments would be utilized.
METHOD
Research Design
We used a qualitative multiple case study design. In this method, each case is first analyzed independently of the others. Once these separate analyses are conducted and the data is interpreted within the context of the specific case, results from each case are compared to allow common themes across cases to emerge. This method allows the data to be considered in context while at the same time identifying commonalities across cases (Merriam, 1998).
Data Collection
The data were collected as part of a larger study of the unique issues faced by PCPs and patients in treating depression in rural areas (Robinson, Swinton, Geske, Backer, & Jarzynka, in review). The study was approved by the Institutional Review Board of a large medical school in the Mid west, and was conducted by a multidisciplinary team consisting of a physician--a methodologist and two marriage and family therapist-researchers.
Two focus groups--one with PCPs and one with patients--were conducted in each of five rural Nebraska communities. The focus groups...
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