Telepsychiatry: Expanding our Scope

Dr. Greg SmithOctober 10, 2018
By Gregory E. Smith, MD
Gregory E. Smith, MD, serves as Chief of Psychiatric Services at Aiken Barnwell Mental Health Center. He has been practicing psychiatry for 30 years since he finished a residency in psychiatry at the Medical College of Georgia in Augusta.

One Case in 100,000

“He’s not acting right,” said his mother, sitting on a chair beside her son in the emergency department of a rural South Carolina hospital. “He gets all upset, he yells out, he hits at me, then he just gets real quiet-like. It’s been happening a lot more lately. He just stares off, he doesn’t move, he won’t say nothing to me. Then he kinda wakes up after a while.”

I observed the young man perched on the exam table, as his mother gave me more background information and medical history, then expressed her frustration that her concerns were not being heard.

“They say he’s got ADD or that he has bad behavior. I know my son. Something is not right. He’s not acting right. Can you help us?”

This was a routine telepsychiatry evaluation, one of the one hundred thousand patient visits that the South Carolina Department of Mental Health has provided since the inception of its award-winning telemedicine program in 2009. Only this routine encounter turned into something different. As I listened to the mother of this young man, I saw that he was sitting very still, not engaging or interacting with us at all, not clinging to his mother, and certainly not agitated or acting out in any way. He had a very far-off, vacant stare. I asked him simple, routine questions, and got absolutely no response. This is not the usual scenario when seeing a child in the emergency department.

“See, see. That’s the way he is when he gets like this,” his mother confirmed.

Using the remote control that allowed me to manipulate the camera in the emergency room, I panned away from mother toward son, then zoomed in on his face. There were minute twitches around his mouth, involuntary, so small that they would not even be noticeable unless you were looking for them. His eyes, though wide open, would blink every few seconds in an oddly rhythmical way. I knew what was going on with him, and he did not need primary psychiatric treatment.

The South Carolina Department of Mental Health is the largest provider of telemedicine services in the state. Telepsychiatry connects patients in emergency departments and community mental health centers to SCDMH psychiatrists in other locations. The program has been a lifeline for rural areas of the state, where there is a longstanding shortage of psychiatrists and other mental health professionals to provide high quality care.

The service uses high definition video to connect patient and mental health professionals. Private rooms provide confidentiality to those being seen. Real time communication is not recorded, further ensuring patient privacy. Telepsychiatry makes it possible for a patient to have a timely assessment with a psychiatrist who may be many miles away, but with the same quality as a personal, face-to-face meeting in the doctor’s office.

Telemedicine not only helps patients avoid unnecessary hospital admissions, but also provides the specialized treatment they need sooner and closer to home. It reduces expenses for providers and taxpayers, frees up space and services in local emergency rooms that are needed for other critical needs, and in general ensures quality, timely mental health evaluation and disposition.

This specialized connection between me, my young patient and his worried mother made it possible to see that he was not acting out as a result of a mental health condition, but that he was more than likely suffering from an acute neurological condition whose symptoms mimicked behavioral acting out or oppositional behavior in this child. The eye blinking and involuntary twitches around his mouth, seen more clearly by zooming in with the high definition camera on the telepsychiatry equipment, made it possible for me to make a provisional diagnosis of petit mal epilepsy, and to recommend further specialized neurological evaluation for this child in Charleston or another venue that could provide such services.

This consultation, which at first seemed so routine, was one of the most rewarding of my almost nine year tenure with the telepsychiatry team. The opportunity to provide services from afar to those patients who might otherwise never receive them is gratifying. The ability to combine two of my passions, working in the mental health field and using cutting edge technology in my everyday work, has made this period of my psychiatric career one of the most challenging and enjoyable so far. The South Carolina Department of Mental Health should be very proud indeed that it is truly a leader in the provision of quality mental health services to the thousands of citizens we serve.