1. Implementation and Utilization of Telepsychiatry in West Texas: TWITR Project-Merits and Challenges
Dr. Ankit Chalia M.D., Manish Aligeti M.D.,
Ken Ritchie, PA-C Department of Psychiatry
Texas Tech Health Sciences Center

2. Introduction
Telepsychiatry has been employed since 1950s, but only past decade has it reached maturation and broad use a treatment modality (1). It is a gradually evolving treatment modality as it bridges the gap between the growing demand for mental health services and their shortage.
Over the last decade many large institutional programs (e.g., Department of Veteran Affairs) have been able to extend care utilizing telepsychiatry (2).
Continued technological advances, consumers increasing familiarity and comfortability with technology, and number of controlled trials demonstrating effectiveness and efficacy of telepsychiatry, allows the psychiatry specialty to reach those that would otherwise not have access to psychiatric care (3).
Among 1,253 rural counties in the nation with populations of 2,500 to 20,000, nearly three-fourths lack a psychiatrist, and 95 percent lack a child psychiatrists (4).
At TTUHSC, we use telepsychiatry to provide psychiatric care at underserved community clinics, such as CHCL, group homes, and school districts via TWITR project.

3. The TWITR Project
Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR) aims to promote school safety in rural areas of West Texas by providing psychiatric care to school-going children and adolescents. It is sponsored by Texas State Governor’s Office Criminal Justice Department.
Almost 70% of the two million children and adolescents arrested each year have mental illness and of these, at least 20% have serious illness making them vulnerable to commit suicide and violent crimes (5).
Most common psychiatric diagnoses in this population are Major Depression and other mood disorders (30%) and disruptive behavior disorders (30% to 50%) (5).
According to the Federal Bureau of Investigation’s Uniform Crime Report, in 2010 juvenile offenders were involved in nearly 15% of all murders when the victim was under the age of 18(6).
TWITR project was initiated to identify students at risk of criminal behavior secondary to mental illness.

4. Merits Strengthens the mental health screening process.
Promotes alliance of school educators and healthcare providers for efficient care.
Improves basic mental health training of school personnel.
At TTUHSC, this experience provides the psychiatric providers with a clear understanding of children and adolescents mental health state and the challenges they face by residing in rural areas.
Projects such as TWITTR, will not only help bridge the gap between the growing demand for mental health services and shortage of trained healthcare professionals, but will also provide unique rural exposure to physicians-in-training helping them become better community psychiatrists.
Can use this as a model to replicate the project nationwide.

5. Challenges
New providers are often intimidated by the technology and logistics concerning telepsychiatry.
Providers must be licensed in the state where the patient is located, providers must be credentialed in the health care system of the clinic the patient is being seen, meeting requisite equipment standards, additional regulations specific to state and payer of services.
Administrative issues.
How patient obtain labs, prescriptions, and make appointments.
Telepsychiatry have transmission delays and this can cause loss of flow of natural conversation.
Clinic flow and roles of on-site staff.
Patients in need of emergency services.
At TTUHSC, technological glitches were among the most noted challenges by 60% of the residents and maintenance of patient confidentiality was the second most common challenge, experienced by 20% of the residents.

6. Recommendations
Clinical training in telepsychiatry and clinical guidelines have been established from a number of different organizations and many offer online training.
Patient and on-site facility may discuss and arrange logistics prior to meeting with provider, an orientation visit prior to their appointment might alleviate anxiety and make for a more comfortable first visit.
Psychiatrist must work with the patient to optimize the environment (e.g., lighting, room configuration, privacy).
Psychiatrist will need to facilitate maintaining natural flow to conversation by increasing or decreasing pauses and rate of their speech.
Bringing staff in (social workers, nurses) at the end of a visit to review plan. Debriefing at the end of a patient visit.
Both patients and staff at point of care should be familiar with emergency procedures and techniques for managing emergencies.
Remote staff can support patient use of video system however they should receive basic training to improve ability to configure, use, and troubleshoot the system.

7. References
Baer L, Elford DR, Cukor P: Telepsychiatry at forty: what have we learned? Harv Rev Psychiatry 1997; 5:7–17
2. Luxton DD, Sirotin AP, Mishkind MC: Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review. Telemed J E Health 2010; 16:705–711
3. Yellowlees P, Marks S, Hilty D, Shore JH: Using e-health to enable culturally appropriate mental healthcare in rural areas. Telemed J E Health 2008; 14:486–492
4. Workforce Series: Rural Behavioral Health. (2008, October). Retrieved October 1, 2014, from National Rural Health Association Policy Position:
5. National Conference of State Legislators. (2007, June) Mental Health Needs of Juvenile Offenders. Retrieved April 19, 2014, from
6. Federal Bureau of Investigation. Crime in the United States Uniform Crime Reports. Retrieved April 22, 2014, u.s/2012/crime-in-the-u.s.-2012/offenses-known-to-law-enforcement/expanded- offense/expandedoffensemain.