Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to those living in underserved areas. FQHCs provide services to 27 million Americans, 44% of whom live in rural areas, 90% of whom live in poverty, and 56% of whom are racial/ethnic minorities. The Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT) pragmatic comparative effectiveness trial led by John Fortney, PhD, and Jürgen Unützer, MD, MPH, MA, compared two approaches to managing PTSD and bipolar disorder in FQHCs without on-site psychiatrists or psychologists: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. In both arms, telepsychiatrists and telepsychologists from state medical schools were credentialed and privileged to practice as FQHC providers and charted in the FQHCs medical record.

The trial recruited 1,004 patients screening positive for PTSD and/or Bipolar Disorder from twenty-four FQHC clinics. The sample was middle aged, mostly (71%) female and a third (34%) were racial/ethnic minorities. Nearly a quarter (23%) did not graduate from high school, two thirds (67%) were unmarried, 82% were not employed full time, 7% were uninsured, 68% were Medicaid enrollees, 24.0% were Medicare enrollees, and 62% lived below 100% of the 2016 Federal Poverty Level (e.g., $11,880 for household size of one). The Short-Form 12 Mental Health Component Summary (SF-12 MCS) was the primary outcome. At baseline, patients were more than 2.5 standard deviations below the national mean on the SF-12 MCS and reported moderately severe symptoms on the disorder specific scales. By 12 months, patients in both arms of the trial demonstrated clinically substantial and statistically significant improvement in all outcome domains measured (PTSD symptoms, manic symptoms, mood state, depression symptoms, anxiety symptoms). There was no clinically meaningful or statistically significant difference in outcomes between arms.

The findings indicate that Telepsychiatry Collaborative Care can generate equally good outcomes for complex patients as Telepsychiatry Referral while using substantially less psychiatrist and psychologist time, and may help rural community health centers make decisions about how to provide mental health services to patients with PTSD or bipolar disorder.