“Ms. A” was seen by a psychiatrist who provides ongoing psychiatric consultation and treatment one half-day per week via telepsychiatry to a primary care clinic located in a rural area. The clinic is located 1,500 miles away from the psychiatrist, who is located in an urban area. The psychiatrist uses a desktop computer with an external camera to connect via a secure platform to a mobile videoconferencing cart in the primary care clinic. The cart, located in a private examination room, contains a 27-inch standard-definition television monitor with a full-remote-capability video camera and videoconferencing system. The clinic is located in a different state from the psychiatrist, who holds medical licenses in both his own state and that of the clinic. The psychiatrist has credentials in the health care system of which the clinic is a part, and he uses a remote electronic medical record for the clinic to document care provided via telepsychiatry.
History (Obtained During the Initial Telepsychiatry Assessment)
Ms. A is a 31-year-old single white woman who has a 13-year-old daughter. She and her daughter live at the home of her mother and stepfather, who help with child care. The patient’s family practice physician and the clinic social worker requested a telepsychiatric consultation on this patient after she presented to the local emergency department after an overdose attempt; the patient took aspirin and acetaminophen when she was intoxicated and experiencing overwhelming feelings of abandonment after breaking up with her boyfriend.
Ms. A grew up in the rural community where the clinic is located and where she currently lives. She experienced significant physical and emotional abuse by her biological father and witnessed him abusing her mother. Her parents separated when she was 6 years old, and her mother remarried when the patient was 9 years old and has remained with this husband since. Ms. A struggled with behavioral issues in her adolescence and became pregnant at age 17. She dropped out of school because of her pregnancy but completed a General Equivalency Diploma when she was in her early 20s. She then completed a 2-year degree in business administration at a community college and is currently an assistant manager at an auto parts store. During her 20s, she had a series of abusive relationships with men, and she was raped when she was in her mid-20s. She has been living with her mother and stepfather for the past 4 years.
Ms. A has had long-standing struggles with feelings of anxiety, hypervigilance, and chronic sleep problems, with intermittent nightmares. She was recently in a relationship whose breakup precipitated the suicide attempt. She reports that this was a nonabusive relationship and that the breakup was initiated by her boyfriend because of the patient’s temper and “moodiness.” Since the breakup she describes feelings of depression, low energy, and not wanting to leave the house. She denies current substance abuse or psychiatric treatment. She had a previous overdose in her early 20s, precipitated by similar circumstances.
Initial Telepsychiatry Session
The initial session with the psychiatrist was a 90-minute session conducted via videoconferencing. During the initial consent and orientation process, the psychiatrist asked whether Ms. A had any experience with videoconferencing. She reported that she had never had a medical appointment via videoconferencing but had participated in videoconferencing as part of some guest lectures she had attended while working on her degree at the community college. During the initial session, Ms. A described how she often feels nervous and uncomfortable with men whom she does not know. Although she denied regular alcohol use, she did concede that alcohol may have played a role in her suicide attempt. At that juncture, the psychiatrist noticed that the patient became quiet and slightly tearful. He zoomed the remote camera for a close-up of the patient’s face to ascertain whether she was in fact crying, and she was. The psychiatrist commented that the patient appeared to be upset and asked what she was thinking about. The patient responded that she felt that she did not deserve to be happy and that she was unlovable and that was why her boyfriend abandoned her.
At the conclusion of the session, the psychiatrist's initial diagnostic impression was a diagnosis of PTSD and the need to rule out major depression, alcohol abuse, and potential cluster B traits. The psychiatrist shared his general impression with Ms. A and discussed concern about her current safety. The patient denied suicidal ideation. The psychiatrist discussed safety concerns with her, including ideation, intent, and the role alcohol played in her current and past attempts. He then discussed a safety plan with Ms. A, and she agreed both to contact the local hospital in the event of returned suicidal ideation with intent and to contact the psychiatrist via telephone. The clinic social worker was then brought into the videoconferencing session, and the treatment recommendations were discussed with both the social worker and the patient. These recommendations included beginning sertraline and prazosin to address symptoms of PTSD (with the prescription filled by telephone at a local pharmacy), coordination with the medical team, and having the social worker initiate supportive therapy focused on psychoeducation about trauma and trauma coping skills, and education about the relationship between substance abuse and trauma. The psychiatrist suggested that Ms. A bring her mother to the next session for further family education and collateral history.
At the conclusion of the first encounter, the psychiatrist inquired how Ms. A felt using videoconferencing. She replied that it was “a little weird” but that she felt more comfortable toward the end of the session. The psychiatrist asked how Ms. A felt about working with him given her report of feeling uncomfortable around men she did not know. She reported that she felt a little nervous but that videoconferencing made her feel safer since the psychiatrist was not in the room with her. The psychiatrist attempted to validate the patient’s feelings by discussing with her the fact that most patients who are new to videoconferencing report initial feelings of awkwardness but rapidly become comfortable with the process as they gain experience with it. Once the patient left the session, the psychiatrist had the social worker remain in the room and gave a brief presentation of the case and discussed the next steps and the treatment plan.
Follow-Up Telepsychiatry Sessions
The psychiatrist continued to work with Ms. A, initially seeing her every 1–2 weeks by videoconference while initiating the medication regimen. The patient tolerated this regimen well and experienced a decrease in anxiety and improvement in mood and sleep. The psychiatrist invited Ms. A’s mother for a family session focused on psychoeducation. The psychiatrist performed the same basic orientation to telepsychiatry with the mother before reviewing signs, symptoms, and treatment for PTSD, depression, and alcohol abuse. During this session, the psychiatrist observed the patient’s mother blaming the patient for her symptoms. The psychiatrist attempted to frame the patient’s behavior in a medical model for the mother. After the session, the psychiatrist telephoned the clinic social worker, described the observed mother-daughter dynamic, and suggested family therapy along the model of family-focused therapy for chronic mental illness. In family-focused therapy, an evidenced-based therapy, the therapist meets the patient and a selected family member over a number of sessions focusing on relapse prevention training and skills training for communication and problem solving. The social worker provided ongoing supportive therapy with intermittent family sessions along these lines. The psychiatrist continued medication management and consultation with the social worker on the therapeutic aspects of the case.