Turning to telemedicine for prisoners' mental health treatment

On one end sits a prisoner facing a screen, the sound of a freeway hundreds of miles away faint through the computer speakers. On the other end, next to that freeway, sits a doctor in a nondescript office building near Houston. Telemedicine brings the two together, allowing Dr. Li-Yun Chuo, a psychiatrist for University of Texas Medical Branch, to see patients in prisons across Texas.

While the nation struggles with an overall shortage of mental health providers, so do prisons, where the demand for mental healthcare is stunningly great: Of the 2.2 million people currently in prison or jail in the U.S., 26% of those in jail and 14% of those in prison met the Bureau of Justice Statistics' "threshold for serious psychological distress," compared to just 5% in the general population.

"There's a huge need inside for mental health support," said Brad Brockmann, executive director of the Center for Prisoner Health and Human Rights. "One of the big issues is the stigma of mental illness. It's particularly true in hypermasculine environments, like a prison setting."

So, just as rural populations are turning to telemedicine, so too are state correctional systems. They're using the technology not only for the physical health of the incarcerated but for mental health as well. Video-connected care may not solve the U.S.' mental healthcare provider shortage, but it may ease the problem, especially in prisons, where barriers to care stem from the physical constraints of the facilities themselves.

"Without telemedicine, we'd really be hurting," said Dr. Joseph Penn, director of mental health services for UTMB Correctional Managed Care.

Before new telepsychiatry providers see imprisoned patients virtually in Texas, they'll often spend time in the prisons. "They really need to get a sense of the milieu of the prison or jail," Penn said. "If you bring in someone who's green, they don't understand that it takes time to transport someone from point A to point B, for example," he said. "They don't understand the slang or nuances or hierarchies."

Most of the telepsychiatry offered to Texas inmates is aimed less at therapy and more at making diagnoses and managing medications. "It really improves access to care, continuity of care, and it gives us so many efficiencies to see patients in a more timely manner," Penn said.

Getting prisoners to providers in person raises a slew of problems. For one, there's transportation. "We're dealing with a potentially dangerous offender population," Penn said. "There's the risk of escape and assault. By doing telepsychiatry, we increase public safety."

Chuo certainly feels safer behind a screen. "Being on this side of a camera is safer," he said, recalling how when he sees inmates in person, he puts his chair closest to the door so he can be the first one out in an emergency.

Indeed, it's not just prisoners being treated for mental illness who feel a stigma—it's also their providers. "A lot of practices don't want our prisoners," Penn said. "They're worried about the danger."

Having providers come to the patients, in prison, poses its own problems. "The providers who are available, they don't want to be driving to a prison and patted down," Penn said. "We've had clinical staff be assaulted or threatened." It's also tough to orchestrate travel between the facilities, which can be miles apart.

So since 1994, Texas has had a telemedicine program for its prisons. Every day, each psychiatrist gets a list of the patients he or she will see virtually the next day. The provider can review the patients' labs and notes, which are held in a statewide electronic health record. "We're all about trying to strive for efficiency," Penn said.

By reviewing a patient's case ahead of time, the provider will not only be more efficiently prepared, but he or she will also be more effective. "The key of telepsychiatry is engaging the patient," Penn said.

Like Texas, California has long provided mental healthcare via telepsychiatry to state inmates, though the program has really ramped up in the past few years, with approximately 70 doctors treating patients at nearly 30 facilities. "We've found that, in many cases, it's saved institutions from the brink of disaster," said Dr. Edward Kaftarian, who was statewide chief of telepsychiatry for California Correctional Health Care Services through the end of 2017 and now is CEO of Orbit Health Telepsychiatry. "By providing services remotely, we've been able to alleviate the staffing shortages and deliver care to patients who would otherwise not have been seen by psychiatrists."

Telemedicine "allows us to be thoughtful with how we place the resources," Dr. Edward Kaftarian said.

The visits themselves work similarly to on-site care. After checking each morning that all the equipment works, the doctor sits at a desk and first connects with a telepresenter on the other end who helps coordinate the care. Then custody officers bring in patients to the telepsychiatry clinic one by one. Just as the doctor would normally, after the visit is over, he or she charts the visit in the EHR and orders any tests and medications.

Each doctor sees, on average, about 12 patients daily. The whole thing is financed by the California correctional budget, which was $10.6 billion for fiscal 2017. Just $397 million of that goes to mental healthcare. The telemedicine program saves money by simplifying logistics, he said. "There's extraordinary savings to not have to spend money on the nursing staff that escorts the patient in the care, plus the two officers."

It also saves money by improving the timeliness of care. "If there's any delay in patient care, a patient's mental illness can get worse, and then it's more costly to treat that patient because they might need to go to a crisis unit," Kaftarian said.

Because it doesn't matter where the providers are physically, it's easier to shift staff as necessary. "It allows us to be thoughtful with how we place the resources," Kaftarian said. "With a telepsychiatrist, within a moment's notice, they can go from a prison in the north to a prison in the south."

For the most part, though, prison telepsychiatry clinicians in California, like Texas, try to maintain continuity of care, so therapeutic relationships can develop.

Prisoners' rights advocates caution against taking telemedicine as the end-all, be-all approach to mental health in prisons. Some worry that telemedicine removes the human touch necessary for truly improving mental health outcomes.

"Part of the challenge with telemedicine is creating something that feels like a human connection and creating a therapeutic alliance," said Dr. Josiah Rich, director of the Center for Prisoner Health and Human Rights. "Group interaction is therapeutic, and prisoners don't necessarily get that."

They also might not get nonverbal cues sensed in person. "I can't tell if someone's rolling their eyes or not," Chuo said. "Sometimes you can sense certain vibes when the patient walks in."

Those limitations have led some to be hesitant, if not downright resistant, to adopting a practice that doesn't involve in-person, face-to-face interactions.

When Kaftarian first started expanding the program in California, "we had a lot of opposition, with hospital administrators saying you need to be in the same room as the patient to be in touch with what's going on in the prison." But, he said, "we found the opposite to be true. Our quality is higher than with on-site doctors." That's because administrators can more carefully control quality. "Very few naysayers remain today," he said.

Technology hasn't caused many problems for California's telepsychiatry either. "The technology has gotten so sophisticated and easy to use, and in fact, it's not that expensive anymore," Kaftarian said. "Fortunately, we have sufficient connectivity to have smooth appointments."

That's not necessarily the case in Texas, where technology can pose challenges. Recently, Chuo called into a prison unit for an appointment and found that he could hear the patient but couldn't see him. Other times, he's had to cancel appointments when storms have interrupted the internet connection.

"Bandwidth is a constant struggle," Penn said. "Being a state system, we're reliant on the state Legislature to fund us for equipment and upgrades."

Still, technology woes haven't prevented UTMB from looking into how to expand the program to weekends and after-hours. The cost wouldn't be too great, Penn said, because the equipment is already there, so additional cost would result from paying additional staff.

Offering more telepsychiatry would also meet patient demand. In California and Texas, there's widespread satisfaction among patients, who appreciate that with telepsychiatry, they don't have to move around.

"They love it," Penn said. "I've had offenders stand up and try to shake my hand or do a high five through the telemedicine screen."

Correction: An earlier version of this article misstated the California correctional budget and its mental health spending; it is $10.6 billion, and $397 million is devoted to mental healthcare.