Potential of Tele-Psychiatry for Addressing Needs of Rural HIV/AIDS Patients

Karl Goodkin MD, PhD, chair of the Department of Psychiatry and Behavioral Sciences at East Tennessee State University, Johnson City, TN, delivered a talk at the Annual Meeting of the American Psychiatrists Association in San Diego on strategies for providing care to people living with HIV/AIDS (PLWHA) in rural areas, specifically in the Southeast United States.

Goodkin reported that while more than 80% of PLWHA in the United States live in urban areas, case rates are increasing in rural areas, with rural case rates being highest in the Southeast. Of the 10 states with the highest rates of new HIV cases, 8 of 10 are in the Southeast region. Goodkin said that factors driving higher levels of rural HIV include high rates of poverty and incarceration, lack of educational opportunities, IV drug use, and sex work, as well as inadequate transportation systems and other barriers to accessing healthcare, such as shortages of healthcare professionals.

In describing treatments designed to meet the needs of HIV-infected patients in rural areas, Goodkin touted tele-psychiatry as a good way to provide psychotherapeutic intervention to these patients, either in an in-patient or out-patient clinical setting, or even directly to the homes of PLWHA. “Tele-psychiatry may be the modality of choice for these patients,” he said, enumerating several of its advantages, including the ability for clinicians to administer therapies as diverse as stress management training, social support groups, or coping skills training. “Clinicians can reach patients in in-patient, out-patient, and home treatment settings. Various treatment formats are possible with tele-psychiatry, not only 1 on 1 and group psychotherapy but also couples and family therapy.”

Goodkin also said that patient satisfaction with tele-psychiatry is high, greater than 90%. “The patient is saving money by not needing to travel to an urban area, and the patient does not need to request time off work for appointments as often.” About 75% of patients report that tele-psychiatry is “comparable” to face-to-face care.

There are, nevertheless, issues with tele-psychiatry, Goodkin said. “Initial in-person patient visits may still be needed, and subtle issues can be missed. There is also added potential for decreased rapport between patient and psychiatrist.”

Additional hurdles can involve technological issues due to video conferencing snafus and reimbursement issues. Goodkin told the audience that tele-psychiatry had been successfully performed in Appalachia in the mid-90s in a program known as APPAL-LINK. However, after funding ended the program was not sustained, and other similar programs have not been available on a consistent basis.

Tele-psychiatry issues related specifically to HIV/AIDS include the need to coordinate with primary care providers (PCPs) and for occasional laboratory test evaluations. Goodkin added, “Coordination with specialty care providers is required more so than ever before, such as for the prescribing of stimulants for HIV-associated neurocognitive disorder [HAND]. There is also a need to target special patient concerns that are frequently overlooked in many patient care settings. Beyond treatment of the psychiatric disorder of interest itself, these include pain management, sleep, fatigue, sexuality, and the ever-present issue of stigma.”

In terms of what is needed to make tele-psychiatry a more robust treatment modality, Goodkin had several suggestions. “It’s very important that we take a focus on improving training in tele-psychiatry for both medical students and residents. Most of the studies done in this area have revealed that medical students and residents get very little to no exposure to tele-psychiatry. In the future, tele-psychiatry is not only going to be important in rural areas, but is going to be used nationwide in many metropolitan areas and will take up an increasingly significant portion of the service marketplace for mental healthcare.”

Continuing the list of recommendations, Goodkin added, “We need a focus on the integration of psychopharmacotherapy with primary medication management, specifically with the anti-retrovirals (ARVs). This is due to a high frequency of drug interactions between the psychotropic drugs and ARVs. Likewise, we need a focus on integrating psychopharmacotherapy with psychotherapy.”

In conclusion, Goodkin told the physicians, “Focusing on reducing psychiatric and medical comorbidities by managing meds via tele-psychiatry is key. For example, in HAND there are specific concerns with comorbidities like diabetes and hypertension that are related to control of the neurocognitive disorder but which are also related to the likelihood of having different types of psychiatric complications.”