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Over the past decade, rural health disparities and
access to quality health care in rural settings have
been major priority areas in both Veteran and civilian
populations. Persons in rural settings generally
have fewer health care options and face a
number of barriers to care, such as limited financial
resources and long travel distances relative
to their urban counterparts. Disparities in rural
communities are particularly problematic with
regard to the receipt of mental health care services.
Recent research demonstrates that, relative
to those in rural areas, residents in metropolitan
areas are 47 percent more likely to receive general
mental health services and 72 percent more
likely to receive specialized services (Richardson
et al., 2009). In response to these and similar
data, a number of initiatives have been launched
within the VA and other large health care agencies
to address disparities in access to mental
health care.
One proposed method to overcome barriers to
mental health care access in rural settings is with
the use of telehealth technologies to provide
assessment and treatment services from metropolitan
areas to patients in underserved rural
or geographically remote areas. Telehealth has
several advantages for patients over traditional
treatment approaches, including decreased
patient cost (e.g., lower cost of transportation,
travel time, and missed work), decreased provider
costs, and increased system coverage area.
In addition, telehealth may be useful in overcoming
several other barriers to mental health
treatments, such as perceived stigma associated
with mental health care in active military service
personnel and Veterans, by providing services
directly in patients' homes.
Telehealth has received preliminary support in a
number of treatment settings and with a range
of patient populations, including patients in
rural areas, older adults, racial/ethnic minorities,
patients adjudicated by the courts, and Veterans
(for review, see Richardson et al., 2009). In addition,
there is strong evidence for both high
patient and moderately high provider satisfaction
with mental health services delivered via
telehealth. Of particular relevance to mental
health services in the VA, recent studies support
the effectiveness of telehealth for delivering
evidence-based psychotherapies to rural Veterans
with post-traumatic stress disorder (PTSD)
(Tuerk et al., 2010). Similar beneficial effects of
mental health care delivered via telehealth also
have been demonstrated for other psychiatric
conditions (e.g., obsessive compulsive disorder,
panic disorder, and anger management).
To better understand the effectiveness of mental
health services delivered via telehealth to rural
Veterans, HSR&D, the U.S. Department of
Defense (DoD), and other agencies have recently
funded several treatment outcome studies
within the Charleston Veterans Affairs Medical
Center (VAMC) and its associated VA Health
Services Research and Development Research
Enhancement Award Program (REAP). These
studies include:
- a randomized controlled trial
(RCT) of Behavioral Activation for depression
delivered via telehealth or in-person in elderly
Veterans (n=224 ) (Egede et al, 2009);
-
a RCT
of Behavioral Activation and Therapeutic Exposure
delivered via telehealth or in-person in
OEF/OIF Veterans with PTSD (n=220); and
-
a RCT of Prolonged Exposure delivered via
telehealth or in-person in OEF/OIF Veterans
with PTSD (n=226).
In addition to the above,
the Charleston VAMC recently received funding
from the Office of Rural Health to initiate a
two-year clinical treatment program to provide
evidence-based psychotherapies and pharmacotherapies
to rural VAMCs and their associated
community-based outpatient clinics across three
states. The program provided funding for five
psychiatrists, five psychologists, and two support
staff in addition to telehealth equipment.
Together, these projects will greatly improve and
expand our understanding of use of telehealth
services in the treatment of a wide range of
mental health conditions for rural Veterans or
Veterans who may simply prefer telehealth services
over face-to-face care.
Telehealth services can overcome many of the
current obstacles to quality mental health care
in rural settings, including lack of local providers,
transportation barriers, lost time from work,
and stigma. Preliminary findings suggest that
telehealth services are both effective and are received
favorably by patients and providers alike.
Together with ongoing research and clinical
initiatives of the VA, telehealth services stand to
bridge longstanding gaps in access and mental
health care delivery to rural and underserved
Veterans, ultimately resulting in improved
mental health outcomes, health care-related
costs, and overall quality of life in our
nation's Veterans.
- Richardson LK, et al. Current Directions in Videoconferencing
Tele-mental Health Research. Clinical Psychology: Science and
Practice 2009; 16, 323-38.
- Tuerk PW, et al. A Pilot Study of Prolonged Exposure
Therapy for Posttraumatic Stress Disorder Delivered via
Telehealth Technology. Journal of Traumatic Stress 2010; 23,
116-23.
- Egede, LE, et al. Rationale and Design: Telepsychology
Service Delivery for Depressed Elderly Veterans. Trials 2009; 10, 22.
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