Even before COVID-19, tele-health was becoming a big part of rural Virginia health care

HARRISONBURG — Meagan Thurston wasn’t sure what to expect when she walked into Strength in Peers in December of 2019 for her first tele-psychiatry session, but she was willing to do whatever it took to get her children back.

The previous summer, Virginia’s Child Protective Services had taken her five children, between the ages of 4 and 11, because she was struggling with an addiction to methamphetamine. The next day, Thurston, 30, began the journey to get them back, signing up for recovery programs. 

That path led Thurston to Strength in Peers, a nonprofit organization in the Shenandoah Valley comprised of individuals in recovery from substance abuse, mental health or trauma related challenges, who share the lessons learned from their own experiences with other people experiencing similar issues. She was assigned a peer, who suggested Thurston try tele-psychiatry.

That’s how Thurston wound up in a room with a monitor and webcam, and speaking with Adam Colbert, a fourth-year resident in psychiatry at the University of Virginia, on the other side of the Blue Ridge Mountains in Charlottesville.

About four months later, the COVID-19 pandemic has turned the process of communicating through streaming video into a commonplace practice, used for classes, meetings and hang-out sessions during this time of social distancing. Over the last few years, the technology has also become a staple of rural health care, used to assist doctors in serving an aging, geographically spread-out population with relatively high rates of hypertension, diabetes and other illnesses.

Tele-health is particularly good at connecting patients with specialists, for whom in-person visits often require hours-long drives and months-long waiting lists. Tele-psychiatry is becoming much more common in rural Virginia, as mental health care providers build a smarter, more nimble system. In addition to using tele-health to link patients, providers are also strategically deploying psychiatric nurse practitioners and training family doctors to be more confident in treating mental illness.

Southwestern Virginia Community Service Boards, which coordinate emergency and follow-up care for people in mental health crises, already are using tele-psychiatry on a regular basis. That includes not only connecting patients with psychiatrists located out of the region, but also to connect patients with psychiatric nurse practitioners who may be located at another facility in the next county. The technology allows the agencies more flexibility in staffing while still providing a nimble response in a pinch.

These practices are emerging at a time when Virginia ranks 27th in the nation for access to mental health care, according to the State of Mental Health in America 2020 report. In 2018, Virginia was 40th. This significant shift came in large part because lawmakers voted in 2018 to expand Medicaid, which brought more federal funding to the state and allowed more state investment in mental health services, including a guarantee of same-day service for people who walk into state-funded mental health clinics.

‘I was just living day to day’

When Thurston’s peer first suggested she try tele-health at Strength in Peers, she was skeptical.

“I knew that I had depression, and I began to treat it in January 2019, but I felt like I wasn’t getting anywhere with it,” she said. “I felt like I was getting worse rather than better.”

But after his initial evaluation, Colbert diagnosed Thurston not just with depression, but with post-traumatic stress disorder. She’d heard that before, but thought it was just a condition suffered by people in the military. Colbert corrected that perception and explained the condition.

“It was pretty clear after that, that’s exactly what I had,” Thurston said. “And my depression had gotten worse from not being treated correctly. I was on the right medication but the dosage wasn’t high enough for me.”

Colbert increased the dosage and discontinued other medications Thurston was on. Now, four months later, she’s doing better.

“I’m proud of myself, something I’ve never really felt before,” she said. “I feel comfortable in my future now. Before, I couldn’t even think into the future. I was just living day to day.”

Nicky Fadley, founder and executive director of Strength In Peers, said that other tele-health participants have found the service beneficial as well.

“I’ve heard from participants that they’ve never had psychiatrists listen this much,” Fadley said. “They have had breakthrough moments over the computer.”

Strength in Peers serves people who often are homeless or have recently been released from jail, facing circumstances that create instability — but “even thinking of all those barriers, we have very few no-shows or cancellations,” Fadley said. Often, the tele-psych sessions are important for connecting people recently released from jail with only a few days’ worth of their medication. 

“Mental illness plays a role in why they’re incarcerated, and they’re set up to go right back,” said Colbert. “The risk of relapse is so huge if depression and anxiety are untreated.”

Thurston said she actually finds it easier to open up to someone through a screen than in person. 

“You feel like they’re right there, but at the same time, it’s almost like a safety window,” Thurston said. “Being right there in the office with your counselor behind closed doors, especially with PTSD, you kind of feel trapped a little bit. You become comfortable over time. With tele-psych, if you need to take a minute, you can take a minute. It’s like an invisible safety window.”

Tele-psychiatry is working not only in small cities like Harrisonburg, but in more rural places like Mouth of Wilson, where 53-year-old David Dowell has been using tele-psychiatry for more than a decade to connect with UVA psychiatrist Richard “Larry” Merkel. 

Like Thurston, Dowell, who has been diagnosed with bipolar disorder, depression and manic depression, said the screen actually facilitates better communication.

“I was more free to say what I needed to say,” Dowell said. “I could communicate better for some reason than with someone right next to me.”

For a while, Dowell was traveling to a clinic in Troutdale, a 10-minute drive, for his tele-psychiatry appointments. Now he’s driving to a clinic in Konnarock, which takes a half-hour or more, but has been able to continue his relationship with Merkel. If it wasn’t for tele-psychiatry, he’d be driving much farther and waiting much longer between appointments.

Tele-psychiatry looks primed to expand even more with the General Assembly’s funding of Virginia Mental Health Access Program (VMAP) in the budget passed in the 2020 session.

Sandy Chung, a pediatrician in Northern Virginia, helped launch the VMAP in 2018 with the goal of filling gaps in care and educating more providers, including pediatricians and primary care providers. The pilot program included training sessions for family practitioners, a phone line staffed by psychiatrists to provide consultations, and a growing tele-health program in which child psychiatrists can consult, diagnose and treat over through streaming video screens. 

The budget passed by the 2020 General Assembly included $5.45 million to expand VMAP statewide, which will bring more access to more training and tele-psychiatry resources to doctors and patients across the commonwealth.

 In Harrisonburg, Thurston is continuing to benefit from her experience with tele-psychiatry at Strength in Peers. has secured stable housing and is working a new job that she finds rewarding. She’s continuing to work through recovery from meth, attend classes and programs at Strength in Peers and consult with Colbert on a regular basis. And she’s on track to win back custody of her children this summer. That progress is due to the network of care that Thurston has found at Strength in Peers, but she gives no small amount of credit to Colbert and her experience with tele-psychiatry.

“I’ve talked to him twice, for two hours, and I feel like I’ve already improved so much just from doing that,” Thurston said. “I want the world to be able to have access to that.”