Archives of Psychiatric Nursing
Volume 17, Issue 1 , Pages 20-26, February 2003

Technology and rural mental health☆☆☆

University of Virginia, Charlottesville, VA.

Article Outline

Abstract 

In addition to the specific and pervasive rural issues of isolation and suitability of services, the rural mental health system faces many of the same problems as the health system in general: access and increasing costs. The introduction of technology adds the unknown dimensions of acceptability and feasibility. Technology has the potential to decrease the gap in services and improve education, support, and connectedness between the client and the provider. As an alternative to traditional face-to-face contact for those in rural and geographically dispersed areas, the Internet potentially can bridge the disparities in health care access for rural mental health services. With an improved understanding based on research, demonstration studies of model applications, and evidence of outcomes, the emerging technologies can serve as tools to achieve the major goals of preventing, assessment, and treating serious mental illnesses in the rural communities with less barriers and stigma. Copyright 2003, Elsevier Science (USA). All rights reserved.

 

In addition to the specific and pervasive rural issues of isolation and suitability of services, the rural mental health system faces many of the same problems as the health system in general: access and increasing costs. The introduction of technology adds to the unknown dimensions of acceptability and feasibility. The 1990s have become known as the Information Age. The ability to access, organize, use, and disseminate information presents a major challenge in health care as the scope and depth of information increases exponentially. Yet, information is as vital to providers and consumers of rural mental health care as to those in any other specialty areas of health care. In addition, people living in rural areas already have greater barriers to access because of geographic and transportation factors, lack of specialization nearby, and cultural considerations.

The introduction of telehealth, the delivery of health services over a distance, presents new promise. This article presents the role of telehealth, including the Internet, in the care of seriously mentally ill individuals in rural areas with a rationale for the use of such technology in health care, as well as the potential challenges it presents.

Telehealth is the use of telecommunications and information technology to provide access to health screening, assessment, diagnosis, intervention, consultation, supervision, education, and information across distance. These technologies include the Internet in addition to telephone, television, video, and videophone. As nurses become more aware of the ability of an electronic system to bridge the gap for connecting with consumers, they can determine how telehealth should be applied to a given population based on the nursing, social, or psychologic needs. In this regard, telehealth can be used as a tool to augment/support traditional nursing care.

Mental disorders represent 4 of the 10 leading causes of disability for persons age 5 and older with unipolar depression, second only to ischemic heart disease in disease burden (Murray & Lopez, 1996). Major depression is one of the leading causes of disability in rural women with prevalence rates of 41% compared with urban rates of 13% to 20% (Hauenstein & Boyd, 1994). Furthermore, manic-depressive illness, schizophrenia, and obsessive-compulsive disorder also lead the rankings as contributors to mortality. The Surgeon General's (U.S. Department of Health and Human Services, 2001) supplement to the report on mental health highlights the role culture and society play in mental health, mental illness, and the types of mental health services people seek. It finds that although effective, well-documented treatments for mental illnesses are available, racial and ethnic minorities are less likely to receive quality care than the general population.

Individuals with serious mental illness are defined as adult persons whose emotional or behavioral functioning is so impaired that it interferes with their capacity to remain in the community without supportive treatment. The mental impairment is severe and persistent and may result in a limitation of the individual's functional capacities to handle the primary activities of daily living, interpersonal relationships, employment, and/or recreation. Despite these limitations, mental health policies and procedures have been in effect since the mid-1970s to decrease hospitalizations and encourage individuals to live in the community. As a result of federal, state, and local policy, providers have developed programs and strategies to increase community tenure, defined as time spent out of the hospital (Farrell, Blank, Koch, Munjas & Clement, 1999). Technology, concurrent with innovative program development, can assist those goals for improving access to care, quality of life, and functional outcomes.

Computers are everywhere. Aspects of all industries (e.g., business, education, and health care) are moving forward at a rapid pace in adopting and adapting new technologies to improve customer relations and access to information. Persons with chronic illnesses, especially some of the serious mental health disorders, have both specialized and individualized health care needs that may be met by using information technology tools. Although individuals with serious mental illness may have difficulty with technology, many also can benefit greatly from the advantages of computers and the Internet.

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Applications of computers in mental health 

One of the first applications of the computer in mental health care was for assessment, using the computerized psychiatric interview (Weizenbaum, 1976). Researchers reported that patients not only responded positively to computer interviews but also gave honest answers. Subsequently, medical, marketing, personnel, and social science researchers have explored the use of the computer as a means for reducing social desirability bias and obtaining more sensitive information from respondents than can be obtained by using traditional formats. The evidence that the computer encourages self-disclosure has led to the development of important applications such as computer interviews to detect risk conditions and behaviors (Erdman et al., 1992).

One example of a computer-based assessment tool is the Depression Awareness, Recognition, and Treatment program, which was designed to screen for depression and increase public awareness of the illness (Regier, Hirschfeld, & Goodwin, 1988). Many individuals who have taken this computerized screening test preferred it to a written test and reported that it was not threatening (Ogles, France, & Lunnen, 1998). Houston et al. (1998) have taken computerized depression screening further using an Internet-based screening tool. Because the Internet tool was able to reach more vulnerable populations, the program identified a number of individuals with depression who might have otherwise gone unidentified. They also found that the Internet screening tool was more effective in identifying depression in younger individuals than other screening tools such as the Depression Awareness, Recognition, and Treatment program. Similarly, Bendtsen and Timpka (1999) found that a computerized assessment of alcohol habits was acceptable to the 57 men and women in the study, though many subjects expressed concern about confidentiality and loss of personal contact. Satisfaction studies suggest the acceptability of computers in rural settings, although most of these studies were not performed with individuals with serious mental illness (Ermer, 1999; Preston, Brown, & Hartley, 1992; Rohland, 2001). The advantages for the use of computer technology in the care of seriously mentally ill persons living in rural areas include providing a means of education, support, and continuity of care.

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Education 

Because computers have a strong role in education they may be useful in the care of rural persons with serious mental illness. Psychoeducation approaches have been used successfully in community mental health for years and are considered an evidenced-based approach (Mueser, 1998). Finfgeld (2000) suggests that psychoeducation is one of the strategies most amenable to a computerized approach. To date, computer-assisted education for patients with schizophrenia has focused on attention training (Ahmed, Bayog, & Boisvert, 1997; Hermanutz & Gestrich, 1991). Computer-based psychoeducation also has been used in the treatment of individuals at risk for eating disorders (Celio et al., 2000; Zabinski et al., 2001). Several consumer health sites of pharmaceutical companies offer psychoeducation resources for patients and families. One company, for example, has a consumer entry in their medication site (Seroquel.com) for a program called Learning to COPE, which provides practical information for understanding and coping with schizophrenia-related disorders on a day-to-day basis (AstraZeneca, 2002).

Fox, Blank, Rovnyak, and Barnett (2001) suggest that community educational interventions can be effective in reducing barriers to help for mental disorders for persons in rural and impoverished areas. This study also underscores the complex nature of help seeking and suggests the potential for innovative programs to screen, assess, and treat individuals living in remote rural areas. Supported employment also is useful for individuals with serious mental illness is another evidenced-based practice (Bond et al., 2001). Although supported employment programs vary in content, almost all of them use computer technology to provide educational support as part of the program and could give rural agencies ways to connect to the consumer. Psychiatric rehabilitation programs include the clubhouse model of care (Farrell & Deeds, 1997), and are good examples of programs already in place that can be part of improving access to computers in rural communities.

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Support 

Unavailability of mental health providers, long distances to travel to care, and general distrust of the mental health specialty system have been identified as barriers to mental health care in rural areas (Fox, Merwin, & Blank, 1995). Yet supportive therapies, case management, and social support are all known to be helpful in the recovery process. Natural supports are considered a strength of rural communities (Fox et al., 1995; Letvak, 2002) and must be incorporated into any adoption of technology. The role of computer technology in providing support is an undeveloped area. The role of telephone technology has provided some preliminary evidence for more innovative program development research in the area. In a study of 83 seriously mentally ill persons who failed to return to a rural community mental health clinic (Blank, Chang, Fox, Lawson, & Modlinski, 1996), those who received telephone calls were much more likely to attend the next appointment than clients who received no follow-up contact to the failed appointment. In another study in community mental health, Beebe (2001) found that a telephone intervention increased community tenure in persons with schizophrenia. Computer technologies may have even more potential to connect with the client for reminders and support.

Gammon and Rosenvinge (2000) found that the Internet was helpful in reducing social anxiety in subjects with serious mental illness in Norway. By avoiding the anxiety of face-to-fact contact, these subjects were able to increase their social contacts through the use of e-mail and online support groups. Wright, Bennet, and Gramling (1998) have described a telecommunications intervention for caregivers of elders with dementia. This intervention is designed specifically to overcome barriers of isolation that such caregivers experience by building a therapeutic relationship between the nurse and the caregiver. Because the caregiver remains at home, the relationship is less clinical although the nurse uses extensive therapeutic skills in building and maintaining the relationship. In mental health care, multiple variables such as communications skills, eye contact, and treatment negotiations can all affect the patient-provider relationship.

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Connection 

When individuals with serious mental illness are discharged to the community, continuous care is highly desirable and necessary. Lack of continuity places the individual at risk for becoming lost to services (Farrell, Koch, & Blank, 1996). For those in rural and geographically disperse areas, technology has the potential to decrease gaps in services, improve the connections between the client and provider, and provide an alternative to traditional face-to-face contact. Early on, psychiatry was perceived as the ideal specialty for the application of telemedicine owing to the fact that assessment and treatment relies more on audiovisual information than use of laboratory tests and procedures (Baer, Elford, & Cukor, 1997).

Mediated communication is defined as non-face-to-face interaction conducted via a communication medium. Electronic communication between rural provider and mental health consumer has the potential to improve connections between rural consumers and health care delivery systems. The use of the Internet for communication between rural providers and health care consumers can include a variety of mechanisms, including but not limited to 1- or 2-way videoconferencing, e-mail, chat rooms, discussion boards, newsgroups, and Web portals.

Videoconferencing has been studied in various areas of telehealth in the mental health arena. Positive outcomes comparing videoconferencing with face-to-face mental health assessments include satisfaction (Frueh et al., 2000; Reid, John, Toone, & Storey, 2000; Rohland, Saleh, Rohrer, & Romitti, 2000) and cost (Doze, Simpson, Hailey, & Jacobs, 1999). However, more research is needed, especially on cost and clinical outcomes (Brown, 1999).

The uses of other mediated communication mechanisms such as e-mail, online groups, and Web portals have begun to enter the literature as a method of communication between provider and patient. For uses of e-mail, the standards and protocols are still under discussion (Beverley & Sands, 1998; Baur, 2000) and address issues of contractual relationship, privacy, and medical legal prudence. Online chat and discussion also offer opportunities for support groups (Selmi, Klein, Greist, Sorell, & Erdman, 1990; Weinert, 2000). Lange, Van de Ven, Schrieken, and Emmelkamp (2001) promote using standardized clinical procedures with the Internet as an alternative to face-to-face procedures. In a controlled trial, using a protocol for posttraumatic stress, they found clinical significant improvement in the participants in the experimental condition. More research and application of the finding to rural differences are needed. Web portals, another emerging technology tool, are specialized homepages created specifically for the needs and interests defined by the user. There are no long-term studies and little information about the impact of these technologies on rural mental health. One can only anticipate that, with the pace of rapidly emerging digital systems, consumers will be demanding such services before mental health clinicians and institutions are quite ready for the implications.

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Continuity of care: Body and mind 

Simpson (2000) suggests that the Internet may be used in a variety of ways with regard to chronic disease management, including Web-based care management solutions; information databases; newsgroups, e-mail, or chat rooms; and clinical workstations that bring together best-practice guidelines, access to medical records, and support for coordinating care across a continuum of services. All of these applications are appropriate in the care of individuals with serious mental illness. Persons with serious mental illness need comprehensive mental and physical care (Holmberg & Kane, 1999; Kane & Ennis, 1996), even more than those with other problems because many mental illnesses co-exist with other chronic and disabling conditions including diabetes, cardiovascular disease, pulmonary diseases, and cancer.

A survey of American adults found that one third of chronic disease sufferers who sought disease information online reported taking their medications more regularly after a visit to a disease-specific Web site (Cyber Dialogue, 1999a). This study is especially important for persons with serious mental illness because it identifies one way in which the Internet may be helpful with treatment compliance and medication adherence. Smith and Allison (1998) report finding that the Appal-Link Network they implemented in rural Virginia improved continuity of care for rural consumers and reduced the length of stays and readmission rates to state psychiatric facilities. Hersh et al (2001) reviewed 25 research studies on the efficacy of telemedicine and concluded that chronic disease management is one of the areas in which there is the strongest support for its use.

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Challenges to telehealth 

According to the Census Bureau (CyberAtlas, 2001), more than half of U.S. households had one or more computers in 2000, and more than 80% of those households had at least one member using the Internet. In a national poll by Fox and Rainie (2002), respondents reported that they used the Internet for health care information 63% of the time. Lead by pharmaceutical companies and major commercial Web sites, health care providers are jumping on the bandwagon to use the Internet for patient education, management, and even diagnostic features (Kleeberg, 1998). What is not known is whether individuals with serious mental illness differ from the general population in their acceptance of the Internet for health and mental health education, communication, and support.

Jadad (2001) found a wide gap between patients and providers and noted that some members of the public had no interest in using the Internet. In contrast, other surveys suggested that consumers are driven to the Internet for health information out of a desire for the empowerment that comes with information. One such survey found that nearly one half of online users said they would use a Web site operated by their doctor's office (Cyber Dialogue, 1999b). In addition, public libraries and rural churches offer potential connection sites for use of the Internet.

Before telehealth can be accepted by the industry, used by patients, and reimbursed by government agencies, a number of questions must be answered, including whether electronic visits can be effective in improving the quality of care delivered to patients and whether telehealth can have a positive impact on controlling escalating health care costs. Interest in telehealth may grow with managed care systems in which both primary and specialty services are capitated. In addition, with the promise of improved connections in visual, audio, and cost aspects, there is increased interest in clinical applications.

A new paradigm has emerged with telehealth and ways to provide mental health care services in a more interactive fashion by providers at remote locations. Telehealth changes current processes, structure, knowledge, models, values, and culture. People who live in rural areas away from large tertiary care centers often have their own cultural views of health care and health care practices based on experience. Developing and testing mechanisms that are culturally appropriate, reliable, and valid are needed to identify areas for improvement in delivery of health care services in rural areas. Recognized challenges to telehealth include reimbursement, confidentiality and privacy, licensure and regulation, and cost effectiveness. It is the organizational operational and user challenges that constitute success of telehealth programs. Social and cultural acceptance of a new technology paradigm is achieved through collaborative efforts. There has been very little research on these issues or on telehealth program development and outcomes specific to rural mental health. In addition, little is known about the specific resistances to new technologies emanating from the professionals themselves. For example, May, Gask, Atkinson, Ellis, Mair, and Esmail (2001) found that the introduction of videophone technology threatened “deeply embedded constructs about the nature and practice of therapeutic relationships” (p. 1889).

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Digital divides: Rural have-nots? 

Assuming that mental health professionals eventually develop guidelines and reconcile the issues related to professional standards, acceptance of technology is only the beginning of the hurdles. The census data show that Americans live in a digital divide in which Internet connectivity and usage vary greatly along the lines of demographic variables. The difference in access to telephones, computers, and the Internet has been called a digital divide between information haves and have nots. Americans living in rural areas, regardless of income, are behind in Internet access. Indeed, at the lowest income levels, those in urban areas are more than twice as likely to have Internet access as those earning the same income in rural areas (U.S. Department of Commerce, 1999). In this and subsequent reports, the solutions to this divide are outlined and are varied. For some individuals the solution is economic. Lower prices, leasing arrangements, and even free computer deals will bridge the digital gap for them. For other individuals, language and cultural barriers need to be addressed. For the disabled, products will need to be adapted to meet special needs. For example, touch screens may have advantages for some groups and Web portals may provide new capabilities for rural clinicians to push information and reach the consumer and the community. Innovative programs to reach the information disadvantaged and all of these people can be developed through foundation and other funding opportunities.

Technology's ability to provide a tool for rural dwellers is an untapped resource and a potential to bridge the phenomenon known as the digital divide. Technology has the potential to decrease gaps in services and improve education, support, and connectedness between clients and providers in rural areas. As an alternative to traditional face-to-face contact, the Internet can potentially overcome the disparities in health care access for rural mental health care services. With improved research, demonstration studies of model applications, and evidence of outcomes, the technologies can serve as tools to achieve the major goals of preventing, assessing, and treating serious mental illnesses in the rural communities with less barriers and stigma.

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Archives of Psychiatric Nursing
Volume 17, Issue 1 , Pages 20-26, February 2003

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