Letter

In Reply: We share Nieves and Stack's concerns about the use of telepsychiatry to treat underserved minorities and rural residents without sufficient evidence about whether the interventions are culturally appropriate or whether differences exist between (and within) racial and ethnic groups in their use of and satisfaction with telecommunications-based care and in its outcomes. We also share their concerns about whether language translations can be effectively provided through technology and whether widespread technology literacy and acceptance exists among such populations. These and related issues are discussed in greater detail in a publication from a workshop sponsored by the Office of Rural Mental Health Research (ORMHR) that identified research gaps in "e-mental health research" ( 1 ).

A key issue that requires attention is language. Nearly half of the U.S. Latino population is either Spanish-language dominant or feels more competent speaking Spanish. Latino patients are more likely to be satisfied with mental health treatment when it is offered in Spanish. In addition, many Latinos live in rural or low-density areas situated on the periphery of cities, far from major clinical centers, where specialty mental health services are usually located.

Our experience shows that Latino patients frequently complain of the impersonality of clinics, of treatments offered without any sense of personal connection, and of clinicians who seem distracted—or who even admit to linguistic and cultural limitations. Often family members understand very little about the intent or value of treatments received by their loved ones in mental health clinics. Their exclusion from the treatment process can result in misunderstanding and unawareness of the familial role in treatment. This raises the larger question: can these differences between providers and clients be bridged by telepsychiatry- e-mental health care?

Can telepsychiatry be culturally appropriate and acceptable, and for which aspects of care? On the face of it, e-mental health technologies show promise for overcoming barriers in the delivery of mental health care to remote and underserved populations. Yet an analysis of the literature reveals a paucity of e-mental health research about whether care delivered long-distance is as effective as care delivered in an office setting. It is also not clear what degree of participation can be attained in a population with lower access to personal computers and significant problems with poverty and literacy. It is clear that we need to increase basic research on culturally appropriate telepsychiatry-e-mental health care.

Nieves and Stack are correct: further research is needed concerning the use of e-mental health and how culture influences its efficacy, effectiveness, and efficiency. To facilitate expansion of research supported by the National Institute of Mental Health (NIMH), ORMHR is conducting an incremental series of scientific meetings that includes experts in e-mental health infrastructure design, cost-benefit analysis, research methods, and clinical interventions with racial and ethnically diverse populations. NIMH hosted a meeting entitled "Culturally and Linguistically Appropriate Care and e-Mental Health: A Rural Perspective" at a recent conference sponsored by the Center for Reducing Health Disparities at the University of California, Davis; the California Telemedicine and eHealth Center; and the California Endowment. Several manuscripts are forthcoming from that conference that may provide an impetus for feasibility and effectiveness research with Latino patients and families.