TELEMEDICINE AND e-HEALTHVolume 11, Number 5, 2005© Mary Ann Liebert, Inc.

Rural Jail Telepsychiatry: A Pilot Feasibility Study

LUISA MANFREDI, J.D., M.P.H.,1 JOANN SHUPE,2 and STEVEN L. BATKI, M.D.1,3

ABSTRACT

New York State has a large rural population, and many of the jails in rural areas have mini-mal or no psychiatric services available on site. Cost of transport to off-site psychiatric ser-vices and the safety issues related to moving inmates from a secure building may limit in-mate access to appropriate psychiatric services. This feasibility study describes a project thatprovided telepsychiatric consultation to increase access to psychiatric treatment in an under-served rural jail in upstate New York. Subjects were consenting jail inmates who requestedor were found to be in need of psychiatric care. The project provided interactive two-way au-dio–video communication between the psychiatrist located in an urban university medicalcenter and subjects who were incarcerated 182 miles away. During the project period, 15 in-mates were assessed and treated in 37 consultations. Subjects were predominantly youngwhite males with anxiety, mood, and substance use disorders. Services were readily acceptedby inmates and staff. Telepsychiatric examination and treatment appears to be a feasiblemethod to increase access to mental health care in rural jails. Future advocacy for increasedmental health services in rural areas in criminal justice setting is likely to depend on furtherevidence of favorable cost benefit.

1Department of Psychiatry, and 2Department of Telemedicine, SUNY Upstate Medical University, Syracuse, NewYork.

3VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York.

INTRODUCTION

RURAL POPULATIONS have significant mentalhealth-care needs, but they face substantial

barriers to access to care. Distance, inadequatefunding, lack of available providers, and otherdifficulties frequently pose challenges to the de-livery of care in small or isolated communities.1Telepsychiatry has been an approach used inrural and frontier areas to provide mentalhealth services.2 In 1998, the American Psychi-atric Association (APA) published a resourcedocument on telepsychiatry via videoconfer-encing. Approved by APA Board of Trustees, itemphasized the broadening scope of telemedi-

cine in general—and by extension, telepsychia-try—as well as its widespread application anddecreasing costs. Rural telepsychiatry hasgained a great deal of attention, and generallyseems to be well accepted.3 Debate remains,however, regarding whether telepsychiatry canbe both clinically effective and cost effective.4–8

In contrast to prisons, jails provide short-term, generally pretrial incarceration for largenumbers of inmates in the United States. Somerural jails in New York State have been unableto deliver adequate mental health care, eventhough they are required by law to providesuch services.9 Inmates may go without ap-propriate assessments or treatment due to lim-

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itations imposed by funding shortages and bysecurity priorities. Jails may be unable to pro-vide consistent or timely mental health care toinmates because they may not always have ac-cess to staff adequately trained to assess in-mates for mental illness. Most jails do not havepsychiatrists on site, leading to the necessity offinding outside providers, such as local mentalhealth clinics, emergency departments, orforensic psychiatric centers. These facilities areoften situated at a distance from the jail and re-quire transport of inmates. Other concernswithin a jail setting include reduced staffingwhile corrections officers transport inmatesand the increased security risks during the timethe inmates are outside of locked facilities.Moreover, delayed or limited access to mentalhealth care in jails is likely to lead to behavioraland other problems because of inadequatetreatment of mental disorders.

Little precise data are available regarding ei-ther the prevalence of mental illness among jailinmate populations or the exact type of careprovided by individual jails. The Conferenceon Local Mental Hygiene Directors, in its re-port on forensic mental health in New YorkState,9 examined the delivery of jail-based men-tal health services in each of the counties inNew York State. It found that many county jailshad no beds dedicated to mentally ill inmates.Mental health services were often provided bylocal county mental health clinics, usually lo-cated at some distance from the jails.

Telepsychiatry projects have been imple-mented in prison settings as a way of provid-ing greater access to care.10 There is little pub-lished information, however, on the use oftelepsychiatry in jail settings. One study that isavailable found that the monthly demand formental health consultations was five timesgreater than projected in a local jail.11

In this paper, we describe a pilot feasibilitystudy of telepsychiatric consultation as amethod to increase access to mental health ser-vices in a rural jail in upstate New York.

MATERIALS AND METHODS

The Franklin County jail, located in Malone,New York, serves a population of approxi-

mately 46,000 people. Franklin County is oneof eight of the most rural counties in New YorkState. It is 182 miles from SUNY Upstate Med-ical University in Syracuse. The county jailhouses up to 119 inmates and has no dedicatedmental health beds. The average length of stayin jail is 4–6 months. Franklin County MentalHealth Clinic provides mental health servicesfor the jail inmates. It is located 2 miles fromthe jail. There is no substance abuse or alcoholtreatment available in the jail, although jail staffestimated that 70–80% of the inmates have a co-exiting substance abuse problem. The staff at thejail are responsible for screening inmates re-garding mental health needs. When an inmateis deemed to be in need of mental health care,the corrections department notifies the Com-munity Mental Health Clinic staff. Inmates arethen transported to the mental health clinic tobe seen by a psychiatrist. Such transport requirestwo corrections officers to accompany the in-mate, typically for several hours.

Three Integrated Switched Digital Network(ISDN) lines were installed inside the jail for a384-Kps bandwidth connection. A PolycomViewstation 512 system (Pleasanton, CA)mounted on a 20-inch television monitor wasset up in one of the jail interview rooms. Inter-views were conducted during specified weeklytelepsychiatric “clinic” hours from SUNY Upstate Medical University, Department ofTelemedicine. Video conferencing equipmentat both locations allowed for a secured, “real-time” consultation.

Subjects were inmates at the Franklin Countyjail who had been screened for mental healthproblems by the local mental health clinic so-cial worker. The social worker obtained in-formed consent from all subjects. The consentwas approved by the SUNY Upstate MedicalUniversity Institutional Review Board prior tosubject recruitment. Subjects were then sched-uled for telepsychiatric consultation during the “clinic” times. Approximately 2 hours perweek of telepsychiatry clinic time was madeavailable to the jail. Before each session, the so-cial worker faxed a referral form to the psy-chiatrist. At each session, the mental healthclinic social worker introduced the patient tothe psychiatrist and then left the room. The du-ration of the telepsychiatric consultation de-

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pended on the clinical needs of the subject, andranged from 15 to 60 minutes. Consultationscovered diagnosis, treatment planning, andmedication prescribing and management. Allprescriptions were faxed to the jail nurse, andprogress notes were maintained at both sites.Inmates were excluded from this service if theyneeded emergent mental health care.

RESULTS

Eighteen inmates gave informed consent toparticipate, of whom 15 were seen by the psy-chiatrist in 37 sessions between July 1 to De-cember 21, 2001 (3 were transferred out of thefacility before they could be seen). Table 1 de-scribes the demographic and inmate character-istics.

The subjects were seen within 5–7 days of be-ing referred for a consultation. Of the 15 sub-jects, 6 (40.0%) were seen by the psychiatrist foradditional telepsychiatry consultation sessionsto confirm diagnoses and assess medication re-sponse. The most frequent primary diagnoseswere mood disorders in 5 patients (33.3%), ad-justment disorders in 4 (26.7%), and anxietydisorders in 3 (20.0%). Substance use disorderwas present in 13 (86.7%) of patients, but wasthe primary diagnosis in only 1 patient. Med-ication was prescribed in 13 (86.7%) of the

cases, and most often consisted of antidepres-sants in 11 (84.6%) of those who were med-icated. Nearly half (46.2%) of those medicatedwere prescribed more than one medication.

Anecdotal reports suggested a high level ofacceptance by the participants, as well as thejail staff. The psychiatrist and the social workerwere satisfied with the ease of using thetelemedicine equipment. To date, the equip-ment and service continues to be provided forthe jail. Inmates currently have the option ofscheduling a telepsychiatric appointment withthe psychiatrist at the local clinic. Costs are as-sumed by the county.

DISCUSSION/CONCLUSION

This pilot project demonstrated the feasibilityof providing telepsychiatric consultation froman urban university medical center to a rural jail.The local mental health clinic now providestelepsychiatric services to all inmates who pre-fer it. This is limited only by the willingness ofpsychiatrists to use the service, not its cost.

A benefit to the county jail continues to berealized through reduced need for inmatetransport. Further potential uses include morespecialized telepsychiatric services in areassuch as substance abuse, adolescent, and foren-sic psychiatry. Future research should assess

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TABLE 1. CHARACTERISTICS OF INMATE PARTICIPANTS TREATED THROUGH THE TELEPSYCHIATRY PROJECT (n � 15)

GenderMale 13 (86.7%)Female 2 (13.3%)

Mean age 21 yearsRace

White 14 (93.3%)African-American 1 (6.7%)

Criminal chargeCrimes against person 7 (47%)

Primary diagnosesMood disorders 5 (33.3%)Adjustment disorder with anxiety and depressed mood 4 (26.7%)Anxiety disorders 3 (33.3%)Substance use disorder 1 (6.7%)Sleep disorder 1 (6.7%)Attention deficit/hyperactivity disorder 1 (6.7%)

Medications prescribed 13 (87%)Antidepressants 11 (84.6% of those medicated)Mood stabilizer 1 (7.7%)Antipsychotic 1 (7.7%)Prescribed more than one medication 6 (46.2% of those medicated)

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cost-effectiveness of telepsychiatric services inrural jails in New York State to determine bet-ter the types of jail settings and mental healthproblems for which such services may be mostappropriate. Although some research has al-ready shown positive outcomes of telepsychi-atric applications, further careful evaluation ofcosts and benefits is indicated.12

ACKNOWLEDGMENTS

This research project was supported by anintramural support grant from SUNY UpstateMedical University Hendricks Foundation anda supplemental research support grant fromthe Department of Psychiatry. All telecommu-nication support was provided by the Depart-ment of Telemedicine.

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Address correspondence to:Luisa Manfredi, J.D., M.P.H.

Department of PsychiatrySUNY Upstate Medical University

750 East Adams StreetSyracuse, NY 13210

E-mail: manfredl@upstate.edu

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