From a population health perspective, the mental health care system in the USA faces two fundamental challenges: (1) a lack of capacity and (2) an inequitable geographic distribution of services. Telepsychiatry can help address the equity problem, and if applied thoughtfully, can also help address the capacity problem. In this paper we describe how telepsychiatry can be used to address the capacity and equity challenges related to the delivery of mental health services in rural areas. Five models of telepsychiatry are described, including (1) the traditional telepsychiatry referral model, (2) The telepsychiatry collaborative care model, (3) the telepsychiatry behavioural health consultant model, (4) the telepsychiatry consultation-liaison model, and (5) the telepsychiatry curbside consultation model. The strong empirical evidence for the telepsychiatry collaborative care model is presented along with two case studies of telepsychiatry consultation in the context of the telepsychiatry collaborative care model. By placing telepsychiatrists and tele-therapists in consultation roles, telepsychiatry collaborative care has the potential to leverage scarce specialist mental health resources to reach more patients, thereby allowing these providers to have a greater population level impact compared to traditional referral models of care. Comparative effectiveness trials are needed to identify which models of telepsychiatry are the most appropriate for patients with complex psychiatric disorders.

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Objective To describe the characteristics of primary care patients with bipolar disorder enrolled in a statewide mental health integration program (MHIP). Methods Using the Composite International Diagnostic Interview Version 3.0 and clinician diagnosis, 740 primary care patients with bipolar disorder were identified in Washington State between January 2008 and December 2011. Clinical rating scales were administered to patients at the time of enrollment and during treatment. Quality of care outcomes were obtained from a systematic review of the patient disease registry, and compared to a previous study of patients with depressive symptoms in MHIP. Descriptive analysis techniques were used to describe patients’ clinical characteristics. Results Primary care patients with bipolar disorder had high symptom severity on depression and anxiety measures: Patient Health Questionaire-9 (18.1 +/− 5.9) and the Generalized Anxiety Disorder-7 (15.7 +/− 4.7). Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Referral to specialty mental health treatment occurred in only 27% of patients. Patients with bipolar disorder had a greater amount of contact with clinicians during treatment compared to patients with depressive symptoms from a prior study. Conclusion Primary care patients with bipolar disorder enrolled in MHIP had severe depression, symptoms of co-occurring psychiatric illnesses, and multiple psychosocial problems. Patients with bipolar disorder received more intensive care compared to patients with depressive symptoms from a prior study. Referral to a community mental health center occurred infrequently despite most patients having persistent symptoms.

This article reports how a large Medi-Cal managed care plan addressed challenges in accessing health care for approximately 7,000 enrollees with multiple chronic conditions through a project known as the Behavioral Health Integration and Complex Care Initiative. The initiative increased staffing for care management, care coordination, and behavioral health integration. In our evaluation of the initiative, we demonstrated that participation in it was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. The initiative may be best understood as a new type of ongoing strategic partnership among the health plan, its providers, and their patients. Changes in funding to support models of value-based care are needed to sustain these efforts in the long term.

Clinicians working in rural primary care clinics value the availability and flexibility of an integrated primary care/mental health program as an option for providing mental health care for their patients. Clinicians working in rural settings could benefit from additional training and program implementation support to best meet the needs of their patients.