Defending Telepsychiatry

To the Editor: As clinicians, researchers, and advocates for persons with mental illness living in rural areas, we disagree with the dramatic conclusions of Werner and Anderson (1) in their column entitled "Rural Telepsychiatry Is Economically Unsupportable: The Concorde Crashes in a Cornfield" in the October 1998 issue. Based solely on cost estimates for a telepsychiatric medication management session (ranging from $257.50 to $322.50), Drs. Werner and Anderson conclude that telepsychiatry is not economically feasible. We believe that such dramatic conclusions from preliminary analyses are overstated and potentially harmful.

Our objections fall into three categories. First, the authors' analyses consider cost alone without comparison analyses. Second, new technologies are most expensive when first implemented, becoming more cost-effective over time and after full integration into a system. Third, while cost is important, cost alone should not determine the existence of a service.

Cost-comparison analyses provide a crucial context for understanding the potential impact of new developments. However, analyses based solely on costs are difficult to interpret. A cost of $322.50 per session may not be expensive when compared with the cost of a psychiatrist's otherwise reaching these remote areas, including hours of travel. Nor may it be expensive considering that without this technology, some people will receive no care.

There is no question that technology is initially expensive. However, cost-savings down the line are not fantasy. In one example, the Northern Arizona Regional Behavioral Health Authority estimated that telemedicine technologies saved $41,000 in 1997 (2).

Technology installed for telepsychiatry can also extend medical and preventive health services to remote mental health clinics. Indeed, many eschew the idea of "telespecialty" for the broader term "telehealth," emphasizing the potential to increase access to many services. Comprehensive programs are well documented as more cost-effective than stand-alone projects (3). This technology could serve as a stepping-stone for extending integrated services to persons with severe mental illness living in rural communities that are chronically underserved. In addition, it brings services to people in community settings where they are familiar and comfortable and where access to family members, local caregivers, and case managers is relatively easy.

Current discussions about telehealth technology harken back to the 1970s, when CAT scans emerged (4,5). It was initially asserted that CAT scans were too costly, used indiscriminately, and driven by an industry unrelated to the concerns of the health of the community. However, rather than crashing in a cornfield, CAT scans have become important tools throughout medicine. Furthermore, they were the stepping-stone for development of functional imaging. Without these imaging tools, advances in neuroscience and improved treatments for brain disorders, particularly newer atypical medications, would have been significantly delayed.

Mental health services have needed to grapple with relatively few expensive developments. However, in this "Decade of the Brain," new medications and technologies have emerged rapidly. The sophistication of cost-effectiveness analyses needs to parallel the sophistication of these developments.

Technology may prove cost-effective for bringing services to persons living in remote, difficult-to-reach communities. Providers and policy makers nationwide are exploring the possibilities telemedicine brings in this regard. We believe that rather than abandon telepsychiatry during this time of increased attention to telemedicine, mental health professionals, researchers, and advocates must ensure that telepsychiatry is included in this process.