To the Editor: Telemedicine technology is one strategy for improving the accessibility of mental health care in the rural setting (1,2), which is the main point of contact for more than half of those suffering from mental disorders (3). This option may be particularly important for Mexican Americans, who infrequently use mental health services (4) and have a significantly more negative view of mental health treatment than other patients (5). We found no reports of telemedicine used for specific ethnic populations. In the case below, telemedicine allowed a patient to receive care in the office of her primary care physician and facilitated culturally sensitive care.
Mrs. R, a 56-year-old Mexican American woman, tearfully presented to her bilingual Caucasian primary care physician with somatic complaints nine months after the sudden death of her husband of 30 years. The physician diagnosed major depression and started Mrs. R on paroxetine 10 mg at nighttime, later increased to 20 mg. Despite four months of treatment, Mrs. R's depression persisted because she failed to consistently take the nightly dose.
No local psychiatrist spoke Spanish, and the patient was concerned about seeing a mental health professional in her community for fear of being stigmatized. Thus she was referred to the University of California, Davis, for a telepsychiatric evaluation.
The psychiatric evaluation lasted 90 minutes and was conducted by a telemedicine link with the UC Davis department of psychiatry and the UC Davis primary care clinic in Chico 60 miles away. The technology included dial-up integrated service digital network (ISDN) lines at 384 kilobits per second, Ascend Communications Multiband VSX multiplexors, PictureTel Live 100 color monitors, standard Pentium computers with 32 megabits of random access memory, and Canon VCC-1 cameras with pan-tilt-zoom local and remote control.
The interview was conducted in Spanish by a UC Davis psychiatrist introduced to Mrs. R by her primary care physician, who then left the room. Mrs. R had worked in California as a migrant field worker for 33 years, had no formal education, and spoke only Spanish. She did not drive. She described her husband's death as a great loss, resulting in many symptoms of depression. When asked about adherence to medication, she expressed concern about the safety of taking medication, but felt that her doctor's orders should not be openly questioned.
The primary care physician returned to the room for the last ten minutes of the session, and Mrs. R's concerns were discussed. Although unaccustomed to the technology, she acknowledged that talking with a psychiatrist had not been as difficult as she had imagined, and she even felt comfortable crying freely.
One month later, Mrs. R was still depressed despite taking her medication. The primary care physician was advised to increase the paroxetine to 30 mg at nighttime. Two months later, the patient was much less depressed and was free of somatic complaints for the first time since her husband's death. The frequency of visits for medical appointments decreased from once or twice a month during the year before the telepsychiatric consultation to only a single visit in the two months after the consultation.
Dr. Cerda is assistant clinical professor of psychiatry at the University of California, Davis, where Dr. Hilty is assistant professor of clinical psychiatry and Dr. Hales is professor and chair of the department of psychiatry. Dr. Nesbitt is associate professor of family and community medicine at UC Davis.