This week we will be reviewing and discussing an article published in the Journal of Clinical Psychology in December of 2019. In this article, titled “Rural mental health service utilization in a Texas telepsychiatry clinic”, authors Tarlow, McCord, Du, Hammett, and Wills examined associations between telehealth service utilization and clients’ distance from nearby telehealth access points. The purpose of this study was to determine if service utilization varied based on the remoteness of clients in a predominantly rural health professional shortage area (HPSA) in Texas.


Why did they do it?

While geographic location (e.g., rural versus urban) does not necessarily impact rates of mental illness, it is well documented that rural communities have poorer access to mental health resources, which is often associated with poorer outcomes. As the authors of this article state, rural communities make up approximately 85% of all federally designated mental HPSA’s. Rural communities also have significantly higher rates of poverty compared to urban counterparts, which is another factor that appears to be associated with poorer mental health. 

Telehealth is a feasible option to improve mental health access; however, there are still many potential obstacles to health service utilization, including barriers related to an individuals’ location, demographic traits, and overall health status. To address these obstacles, the authors  examined two hypotheses about the utilization of free telepsychology services delivered via a hub and spoke model (explained below) to low‐income clients in a predominantly rural HPSA in Texas. 

How did they do it?

The authors of this study analyzed archival data from individuals who received telepsychology services between January 2014 and January 2017 from a clinic in Texas. The clinic provided free weekly individual psychotherapy via synchronous telehealth (i.e., video and phone call) and utilized a hub and spoke model. The hub and spoke model refers to a healthcare delivery system whereby clients in the five counties traveled to spoke sites located within their communities, with one spoke site in each of the five counties serviced.

The authors assessed four service utilization behaviors; the number of counseling sessions attended, the percentage of scheduled sessions attended (i.e., the scheduled sessions that were not canceled or no‐showed), the percentage of sessions conducted by phone (which, unlike video sessions, could be attended from the clients’ home), and  whether or not the client dropped out of treatment prematurely. Clients’ distance from telehealth services, demographic information, and depression severity was also collected from the archival data. 


What did they find?

The authors did not find any statistically significant differences in service utilization based on patient distance from the nearest service access point. They did find, however, that age was a significant predictor of service utilization, such that older clients attended more sessions on average and were less likely to drop out of services. Black and Latinx clients attended fewer sessions on average, and increased depression severity was associated with missing more scheduled appointments and higher dropout rates. 


Although there were urban–rural differences in distance traveled for services, there were not statistically significant urban-rural differences in service utilization behaviors. Clients in rural, micropolitan, and small metropolitan counties had similar treatment durations, attendance, phone session utilization, and dropout rates. For clients in the most distant, sparsely populated regions of the clinic's service area, the hub and spoke telepsychology model essentially decreased travel to the closest comparable in‐person mental health services by half, making service utilization much easier. 


What does it all mean (our take)?

What an outstanding study - we commend the authors for this great work. Minimizing treatment barriers and continuing to learn about the factors that impede access to care by those in HPSAs is crucial. As technology continues to become part of nearly all aspects of everyday life, we envision a [perhaps not so distant] future whereby limited accessibility to care and living in HPSAs will become less prohibitive for patients. We are excited to continue playing a role in using technology as a means to increase access and quality of care for all patients.

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