School-Based Telepsychiatry in an Urban Setting:
Efficiency and Satisfaction with Care
Ashley M. Mayworm, PhD,1 Nancy Lever, PhD,2
Nicole Gloff, MD,2,* Jennifer Cox, LCSW-C,2
Kelly Willis, LCSW-C,2 and Sharon A. Hoover, PhD2
1
School of Education, Loyola University Chicago, Chicago, Illinois.
2
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Department of Psychiatry, University of Maryland School
O
of Medicine, Baltimore, Maryland.
*Current affiliation: The Maryland Centers for Psychiatry, P.A.,
Ellicott City and Annapolis, Maryland.
Abstract
Background and Introduction: Given the shortage of child
psychiatrists in most areas, telepsychiatry may increase acces-
sibility of psychiatric care in schools, in part by improving
psychiatrists’ efficiency and reach. The current study assessed
consumer and provider satisfaction with school-based tele-
psychiatry versus in-person sessions in 25 urban public schools
and compared the efficiency of these service delivery models.
Materials and Methods: In total, 714 satisfaction surveys were
completed by parents, students, school clinicians, and child
psychiatrists following initial (26.3%) and follow-up (67.2%)
visits (6.4% did not indicate type of visit). Most of these surveyed
visits were for medication management (69.9%) or initiation of
medication (22%). Efficiency analyses compared time saved via
telepsychiatry versus in-person care. Researchers also con-
ducted focus groups with providers to clarify preferences and
concerns about telepsychiatry versus in-person visits.
Results: Consumers were highly satisfied with both in-person
and telepsychiatry-provided school psychiatry services and
showed no significant differences in preference. Providers re-
ported both in-person and telepsychiatry were equally effective
and showed a slight preference for in-person sessions, citing
concerns about ease of video equipment use. Telepsychiatry
services were more efficient than in-person services, as commute/
setup occupied about 28 psychiatrist hours total per month.
Discussion and Conclusions: Findings suggest that students,
parents, and school clinicians perceive school-based tele-
psychiatry positively and equal to on-site care. Child psychia-
trists have apprehension about using equipment, so equipment
training/preparation and provision of technical support are
needed. Implications of study findings for telepsychiatry training
and implementation in schools are discussed.
DOI: 10.1089/tmj.2019.0038 ª M A R Y A N N L I E B E R T , I N C .  VOL. 00 NO. 00  MONTH 0000
Keywords: telepsychiatry, telemental health, school mental
health, satisfaction with care, telemedicine, telehealth
Introduction
ver the past two decades, there has been increase in
community and political support for the provision
of child and adolescent mental health services in
the school setting.1,2 School mental health (SMH)
services are advantageous because they bring mental health
care to a familiar, ecologically valid community setting where
youth are already located.3,4 Community-partnered SMH
programs, offering school-based services by community
mental health providers, have higher rates of service utiliza-
tion than traditional community health settings5 and have
demonstrated positive impacts on students’ academic and
social/emotional/behavioral functioning.6–9
Despite their growth, many SMH programs are unable to
provide psychiatry services because of a range of challenges,
including workforce shortages, cost, and limited training of
psychiatrists to work effectively with schools.10,11 As a result,
students and families are frequently required to obtain psy-
chiatry services at an off-site community outpatient mental
health center. Unfortunately, youth are often unsuccessful in
following through with referrals to outpatient psychiatric care
due to a variety of potential barriers (e.g., transportation, child
care, stigma, financial limitations).12 Access to child and ad-
olescent psychiatrists is particularly limited, including in both
rural and urban settings,13 suggesting a need for creative
solutions that will increase the number of youths that are able
to access psychiatric care when indicated.
TELEPSYCHIATRY IN SCHOOLS
SMH programs across the United States are increasingly
using technology to embed psychiatric care within their
programming.14 This trend parallels the increased im-
plementation of telehealth within schools to address the acute
physical health issues experienced by children during the
school day.15,16 Telehealth is defined as the ‘‘.. provision of
health care through long-distance telecommunications tech-
nology.’’16 Telemental health (TMH) refers to all mental health
services utilizing distance technology and includes the array
TELEMEDICINE and e-HEALTH 1
 MAYWORM ET AL.
of mental health service providers (e.g., social workers, coun-
selors, psychiatrists, and psychologists).17 Within the umbrella
of TMH is telepsychiatry, which specifically refers to the pro-
vision of psychiatric services through telehealth technologies.18
Telepsychiatry services are delivered over secure, Health In-
surance Portability and Accountability Act (HIPPA)-compliant
technologies, with the psychiatrist in one location and the
patient and/or other mental health provider in a second loca-
tion. Advancements in multiway videoconferencing applica-
tions also make it possible for multiple parties, in different
locations, to be simultaneously involved in a telepsychiatry
session (e.g., multiple caregivers, teachers).
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Although telepsychiatry is often considered most relevant
to rural settings, where specialty child and adolescent psy-
chiatry services are most limited,19 urban settings can also
benefit from this modality of care.20 There are several com-
pelling reasons for introducing telepsychiatric care in urban
schools, including capacity and efficiency issues related to the
time involved to transport psychiatrists to multiple schools.14
For example, to provide in-person school-based services, a
psychiatrist needs to account for the time it takes to
travel from their main setting to various schools, whereas a
psychiatrist-providing telepsychiatry services can use that
saved travel time to see multiple students attending different
schools from their main office setting; this has the potential
to increase provider efficiency and access to psychiatric
services for youth and families.
CONSUMER AND PROVIDER SATISFACTION
WITH TELEPSYCHIATRY
One concern surrounding telepsychiatry is whether the care
will be equivalent to in-person care and if students and families
will be satisfied with the service delivery format. In the litera-
ture on telepsychiatry with adults, it is well established that
adult consumers are satisfied with psychiatric care delivered via
telecommunications.21–24 Additionally, research indicates that
diagnostic assessments25 and clinical care are equivalent across
telepsychiatry and traditional care settings.26,27 Telepsychiatry
programs focused on youth and families have been developing
rapidly over the past few years.28 Some argue that tele-
psychiatry may be preferable to in-person care for young
people, due to the novelty, potential for family authenticity,
and distance (physical and psychological).29 Myers et al.17
found that parents were satisfied with their child’s tele-
psychiatric care through an outpatient clinic, and Pakyurek
et al.30 conclude that youth may find it superior to in-person
methods. Studies on the efficacy of telepsychiatry with children
and adolescents suggest that the care is equivalent to, if not
better than, traditional psychiatric services.31
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Less is known about consumer and provider satisfaction
with telepsychiatry services delivered to youth in the school
setting. Psychiatry services in schools, including medication
management, diagnostic evaluation, and consultation, have
increased over the past few decades, but still remain uncom-
mon.14 Without a comprehensive database of school-based
telepsychiatry programs, it is difficult to know how many
programs are being implemented.14 Those few studies that do
exist (N = 3) suggest promising results of school-based tele-
psychiatry, including increased access to care, acceptability
and feasibility of implementation, and high consumer and
provider satisfaction.4,14,32
CURRENT STUDY
Previous studies suggest that providers are generally satisfied
with school-based telepsychiatry, both consultation and direct
service-delivery models. However, no known studies to date
have examined both provider and consumer satisfaction with
telepsychiatry services compared with in-person care in
schools, nor have any looked at the impact of school-based
telepsychiatry on provider reach and efficiency. The current
study examines two key outcomes related to implementation of
a school-based telepsychiatry program within a community-
partnered SMH program: (1) the impact of the telepsychiatry
program on provider efficiency and (2) self-reported satisfac-
tion with services for students, parents, mental health clini-
cians, and psychiatrists when engaged in in-person versus
telepsychiatry sessions.
Materials and Methods
PARTICIPANTS
Data were collected from providers, students, and caregiv-
ers in 25 Baltimore City schools receiving services from child
and adolescent psychiatrists and SMH clinicians employed by
the University of Maryland School Mental Health Program
(SMHP) during the 2015–2016 academic year. See Stephan
et al.14 for a detailed description of the SMHP telepsychiatry
program and its history. Students received care via one of
three mechanisms—in-person only, telepsychiatry only, and
‘‘blended’’ (a hybrid model, combining the use of tele-
psychiatry and in-person services. Blended schools aimed to
have half of their sessions conducted via telepsychiatry and
half in-person33). Seven psychiatrists served these 25 schools,
with each delivering care in each arm of the model (i.e., tel-
epsychiatry only, in-person only, and blended). Within the 25
schools, a total of 270 students were served by the SMHP
(enrolled in billable services), 107 of whom received medi-
cation management from school-based psychiatrists during
that time frame. In total, the psychiatrists had 548 billable
ª MARY ANN LIEBERT, INC.

sessions, 358 (65.3%) were completed in an in-person format
and 190 (34.7%) were completed through telecommunication.
PROCEDURE
Satisfaction surveys. Anonymous satisfaction surveys were
collected from consumers (students and caregivers) as well as
providers (psychiatrists and mental health clinicians), after
both telepsychiatry and in-person psychiatry sessions. To
reduce burden on consumers and providers, only one session
per day, per school was evaluated using the satisfaction sur-
vey. The mental health clinician used random.org to generate
a random number. Each visit was numbered chronologically
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and clinicians used the random number to determine the
session for which to respond. Students and caregiver(s) (if
present for the session) were asked to complete the anony-
mous survey at the conclusion of the session and placed the
survey in an envelope to maintain privacy; clinicians then
brought the completed surveys to the University of Maryland
evaluators on a weekly basis. Clinicians and psychiatrists also
completed the anonymous satisfaction survey about the ses-
sion and returned these to evaluators on a weekly basis.
Focus groups. At the end ( June 2016) of the academic school
year, focus groups were held with the SMHP mental health
clinicians and psychiatrists who were engaged in tele-
psychiatry services. Focus group sessions were facilitated by
the evaluation team. Responses to focus group questions were
transcribed, and names were not linked to responses.
INSTRUMENTATION
Participant and session information. In-person and tele-
psychiatry sessions were billed through fee-for-service mech-
anisms. Thus, internal program billing data were examined
retrospectively to gather information about student charac-
teristics, number and type of sessions conducted, and date and
length of sessions.
Satisfaction with services. Modified versions of the Parent
Satisfaction Survey17 were used to measure patient, caregiver,
and provider satisfaction with services. This survey measures
three domains of satisfaction important in telepsychiatry:
technical functioning, comfort with technology and privacy,
and access to care. The survey of Myers et al.17 was modified in
the current study to create four different versions for each
respondent type and modality. See Tables 1–4 for the list of
items and scaling of each survey. Previous versions of the
measure from which caregiver and student surveys were
modified showed strong internal consistency and strong
correlations with measures of global satisfaction.17 In the
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SCHOOL-BASED TELEPSYCHIATRY
current sample, after accounting for reverse-worded items, all
versions of the survey demonstrated moderate-to-strong in-
ternal consistency (Cronbach’s a range 0.67–0.99).
Efficiency of services. To understand the impact of tele-
psychiatry services on efficiency, both quantitative estimates of
provider time saved through utilization of telepsychiatry and
qualitative information gathered during focus groups with
providers were considered. To measure estimates of time sav-
ings, the following were considered: car travel time between
participating schools and the hospital using Google maps
mileage and estimates of time needed to park, check-in, and
organize materials. Additionally, themes in provider responses
to the following focus group questions were used to understand
the impact of telepsychiatry services on provider efficiency in
greater depth: (1) Were you able to accomplish more, less, or the
same in session by using telepsychiatry? and (2) What did you
like and dislike about doing telepsychiatry in schools?
Results
DESCRIPTIVE STATISTICS
In total, 714 surveys were completed and included in ana-
lyses. These included: 209 student, 125 parent, 181 clinician,
and 199 psychiatrist surveys. Of these surveys, 26.3% were
completed after an initial session with the psychiatrist and
67.2% were completed after a follow-up session (6.4% did not
report the type of session). Results of independent samples
t-tests did not change significantly when the 46 surveys
without session type reported were excluded from analyses, so
all surveys were included in the results reported below. The
survey response rate is unknown, as researchers were unable
to accurately track whether or not participants declined to
complete a survey, did not return a survey, or were not asked
to complete one after a session. Due to the applied nature of
this study, and fact that all surveys were anonymous, it is
unclear if the surveys collected reflect a representative sample
of the population served. Initiation of medication and/or
medication management was present in 76.6% of the psy-
chiatric sessions. The focus of sessions included: diagnostic/
intake sessions (4.5%), treatment planning (0.7%), case con-
ceptualization or case review (9.0%), initial medication con-
sultation (22.0%), ongoing medication consultation (69.9%),
and patient education (1.5%); percentages do not sum to
100%, as one session could address multiple topics.
SATISFACTION WITH TELEPSYCHIATRY IN SCHOOLS
Consumer satisfaction. Parent satisfaction was high, for both
telepsychiatry and in-person sessions (mean greater than 4.5
on 12 of the 13 items [on 1–5 point scale]; Table 1). The only
TELEMEDICINE and e-HEALTH 3
 MAYWORM ET AL.

Table 1. Caregiver-Reported Satisfaction with Telepsychiatry and In-Person Psychiatry Sessions

CAREGIVER-REPORTED SATISFACTION CAREGIVER-REPORTED SATISFACTION
WITH TELEPSYCHIATRY (N = 33) WITH IN-PERSON PSYCHIATRY (N = 92)
ITEM M (SD) ITEM M (SD) T-TEST, P-VALUE

I could talk comfortably with the telepsychiatrist on the screen. 4.73 (0.57) I could talk comfortably with the psychiatrist. 4.75 (0.82) t(123) = 0.13, p = 0.90

I could see the telepsychiatrist very well. 4.85 (0.44) — — —

I could hear the telepsychiatrist very well. 4.64 (0.60) — — —

I felt confident that my child’s information was not 4.85 (0.36) I felt confident that my child’s information was 4.80 (0.76) t(123) = 0.36, p = 0.72
overheard by others outside the room. not overheard by others outside the room.

I could understand the telepsychiatrist’s recommendations. 4.85 (0.39) I could understand the telepsychiatrist’s 4.78 (0.78) t(123) = 0.49, p = 0.63
recommendations.
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I felt the telepsychiatrist was comfortable with 4.85 (0.36) I felt the telepsychiatrist was comfortable 4.77 (0.81) t(123) = 0.55, p = 0.56
seeing my child over the screen. with seeing my child.

Telepsychiatry allowed my child to see a psychiatrist sooner. 4.59 (0.71) — — —

My child would not have received psychiatry services 3.82 (1.40) — — —

without telepsychiatry.

My child will receive the help he/she needs 4.67 (0.60) My child will receive the help he/she needs 4.78 (0.77) t(123) = 0.74, p = 0.46
because of our visit with the telepsychiatrist. because of our visit with the psychiatrist.

The telepsychiatrist visit was as good as a 4.64 (0.70) — — —

regular in-person visit.

I would be willing to have my child see a 4.70 (0.53) I would be willing to have my child see 4.79 (0.79) t(123) = 0.61, p = 0.55
telepsychiatrist again in the future. a psychiatrist again in the future.

Overall I am very satisfied with the quality of 4.70 (0.64) Overall I am very satisfied with the quality 4.77 (0.77) t(123) = 0.47, p = 0.64
services provided by the telepsychiatrist. of services provided by the psychiatrist.

My concerns were addressed today. 4.70 (0.64) My concerns were addressed today. 4.78 (0.78) t(123) = 0.53, p = 0.60
Response options on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).
M, Mean; SD, standard deviation.

item with a mean score below 4.5 was the telepsychiatry
survey item that reads ‘‘My child would not have received
psychiatry services without telepsychiatry,’’ with a mean score
of 3.82; parents were generally neutral about the impact of
telepsychiatry on the likelihood of their child receiving psy-
chiatry services. Independent samples t-tests revealed that
mean scores were not significantly different between tele-
psychiatry and in-person sessions ( p > 0.05) for all compa-
rable items.
Students were highly satisfied with telepsychiatry and in-
person sessions (Table 2). Scores were above 3.00 (‘‘somewhat’’
agree) for all positively worded items (on a 4-point scale). For
the negatively worded item, ‘‘I was worried about anyone else
hearing me,’’ the mean scores for telepsychiatry (M = 1.52) and
in-person (M = 1.42) sessions were below 2.00, indicating an
average response between ‘‘not at all’’ or ‘‘a little’’ worried. The
only item that showed some dissatisfaction was the tele-
psychiatry survey item stating, ‘‘The consultation would have
been better if it was performed in person. (The doctor was in
the room),’’ with a mean score of 2.83 (between ‘‘a little’’ and
‘‘somewhat’’ agree). Independent sample t-tests were con-
ducted to compare student responses for telepsychiatry versus
in-person sessions; none of the items were statistically
significantly different ( p > 0.05 for all item comparisons).
Students appear to be equally satisfied with telepsychiatry and
in-person psychiatry sessions.
Provider satisfaction. Mental health clinicians, overall,
showed a high level of satisfaction with both telepsychiatry
and in-person sessions (Table 3). Average scores for seven of
the eight telepsychiatry items and for all seven in-person
items are above 4.00 (satisfied). The only item with a mean
score below 4.00 was ‘‘ease of using video teleconferencing
equipment,’’ with a mean score of 3.66 (falling between

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 Table 2. Student-Reported Satisfaction with Telepsychiatry and In-Person Psychiatry Sessions
STUDENT-REPORTED SATISFACTION STUDENT-REPORTED SATISFACTION WITH
WITH TELEPSYCHIATRY (N = 66) IN-PERSON PSYCHIATRY (N = 143)
ITEM M (SD) ITEM M (SD) T-TEST, P-VALUE

I could see the doctor on the screen really well. 3.68 (0.71) — — —

I could hear the doctor on the screen really well. 3.52 (0.81) — — —

I was worried about anyone else hearing me. 1.52 (0.95) I was worried about anyone else hearing me. 1.42 (0.94) t(207) = 0.71, p = 0.48

It was easy to talk with the doctor over the screen. 3.61 (0.84) It was easy to talk with the doctor. 3.74 (0.63) t(207) = 1.24, p = 0.22

I could talk about my problems easily. 3.50 (0.81) I could talk about my problems easily. 3.38 (1.01) t(207) = 0.85, p = 0.40

I understood what the doctor wants me to do. 3.67 (0.64) I understood what the doctor wants me to do. 3.70 (0.71) t(207) = 0.29, p = 0.77
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I feel OK about the doctor’s advice. 3.68 (0.71) I feel OK about the doctor’s advice.* 3.80 (0.54) t(204) = 1.34, p = 0.18

I think my friends and other kids would like the 3.12 (1.05) I think my friends and other kids would 3.33 (1.05) t(206) = 1.34, p = 0.18
doctor on the screen. like the doctor.**

I am willing to go back to this doctor on the screen. 3.58 (0.84) I am willing to go back to this doctor. 3.75 (0.64) t(207) = 1.61, p = 0.11

I think that getting help over the screen was as good 3.39 (0.99) — — —
as getting help in person.

The consultation would have been better if it was 2.83 (1.08) — — —

performed in person. (The doctor was in the room).
Response options on a 4-point Likert scale (1 = not at all, 4 = a lot).
*N = 140; **N = 142.
M, Mean; SD, standard deviation.

Table 3. Mental Health Clinician-Reported Satisfaction with Telepsychiatry and In-Person Psychiatry Sessions
CLINICIAN-REPORTED SATISFACTION CLINICIAN-REPORTED SATISFACTION
WITH TELEPSYCHIATRY (N = 77) WITH IN-PERSON PSYCHIATRY (N = 104)
ITEM M (SD) ITEM M (SD) T-TEST, P-VALUE

The guidance you received from the 4.52 (0.70) The guidance you received from the 4.77 (0.49) t(179) = 2.83, p < 0.01
telepsychiatry consultation. in-person consultation.

Knowledge of the psychiatrist who provided 4.56 (0.68) Knowledge of the psychiatrist who provided 4.91 (0.34) t(179) = 4.54, p < 0.001
telepsychiatry consultation. the in-person consultation.

Duration of telepsychiatry consultation. 4.36 (0.95) Duration of psychiatry consultation. 4.85 (0.39) t(179) = 4.75, p < 0.001

Timeliness of scheduling the telepsychiatry 4.35 (0.93) Timeliness of scheduling the psychiatry 4.83 (0.43) t(178) = 4.62, p < 0.001
consultation. consultation.***

Summary dispositions from telepsychiatry 4.55 (0.89) Documentation from psychiatrist from 4.85 (0.44) t(177) = 2.97, p < 0.01
consultation.* psychiatry consultation.

Overall clinician satisfaction with the consultation.** 4.28 (0.93) Overall clinician satisfaction with the consultation.*** 4.85 (0.45) t(177) = 5.42, p < 0.001

Ease of using video teleconferencing equipment. 3.66 (1.38) — — —

Patient appeared satisfied with the consultation. 4.31 (0.88) Patient appeared satisfied with the consultation. 4.69 (0.67) t(179) = 3.30, p < 0.01
Response options on a 5-point Likert scale (1 = not at all satisfied, 5 = very satisfied).
*N = 75, **N = 76, ***N = 103.
M, Mean; SD, standard deviation.

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 MAYWORM ET AL.

Table 4. Psychiatrist-Reported Satisfaction with Telepsychiatry and In-Person Psychiatry Sessions

PSYCHIATRIST-REPORTED SATISFACTION PSYCHIATRIST-REPORTED SATISFACTION
WITH TELEPSYCHIATRY (N = 97) WITH IN-PERSON PSYCHIATRY (N = 102)
ITEM M (SD) ITEM M (SD) T-TEST, P-VALUE

I had access to as much of this patient’s pertinent medical 4.36 (1.17) — — —

record as I would for an in-person visit.

Using the video teleconferencing equipment, 4.42 (0.98) — — —

I was able to elicit a good history of the patient’s
health/medical condition.

I was able to identify the presenting concern of the school 4.87 (0.34) I was able to identify the presenting concern 4.85 (0.36) t(197) = 0.40, p = 0.69
mental health clinician today. of the school mental health clinician today.
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I was able to obtain pertinent mental 4.60 (0.83) I was able to obtain pertinent mental 4.81 (0.48) t(197) = 2.20, p < 0.05
health information. health information.

I felt confident in providing consultation for this patient’s 4.49 (0.89) I felt confident in providing consultation 4.84 (0.39) t(196) = 3.61, p < 0.001
problems using the video teleconferencing equipment. for this patient’s problems.**

The video teleconferencing equipment worked well 4.10 (1.38) — — —

today (e.g., no technical issues).

I was able to obtain pertinent physical health 4.28 (1.13) I was able to obtain pertinent physical health 4.74 (0.49) t(196) = 3.75, p < 0.001
information about the patient.* information about the patient.

The consultation would have been better if 4.29 (0.97) — — —

it was in person.

The patient appeared satisfied with this consultation.* 4.64 (0.67) The patient appeared satisfied with 4.76 (0.47) t(196) = 1.47, p = 0.14
this consultation.

Overall I was satisfied with today’s consultation. 4.38 (1.05) Overall I was satisfied with today’s consultation. 4.82 (0.38) t(197) = 3.97, p < 0.001
Values shown in bold indicate statistically significant findings.
Response options on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).
*N = 96, **N = 101.
M, Mean; SD, standard deviation.

‘‘neutral’’ and ‘‘satisfied’’). Unlike consumer satisfaction re-
sults, clinicians reported statistically significantly higher
levels of satisfaction for in-person sessions compared with
telepsychiatry sessions ( p < 0.01 for all item comparisons).
However, the practical significance of these findings is
questionable, as high levels of satisfaction (M > 4.00) were
seen across both types of sessions.
As shown in Table 4, psychiatrists had similar results to cli-
nicians. All positively worded items on both the psychiatrist
telepsychiatry and in-person satisfaction surveys had mean
scores above 4.00 (‘‘agree’’). On the negatively worded item,
‘‘The consultation would have been better if it was in person,’’
respondents had a mean score of 4.29, indicating that they agree
or strongly agree that an in-person session would have been
better than a telepsychiatry session. Independent samples t-tests
showed significantly higher satisfaction ratings for in-person
sessions on four of six compared items ( p < 0.05). However,
there was no difference in psychiatrist’s ratings of their ability to
identify the presenting concern or in their perception of patient
satisfaction across the two session types ( p > 0.05).
EFFICIENCY
Efficiency was calculated by estimating drive time based on
average distance from the outpatient setting to the schools. The
SMHP program included 7 psychiatry fellows who served 25
schools. If all services were to be provided in person, and each
school was to have the psychiatry fellow on staff at least once
per month, this means that each fellow would need to visit three
to four schools per month. For the purposes of this analysis, it is
assumed that each psychiatrist will visit one school each week
of the month with an average of 4 weeks in a month. The 25
schools served are an average of 3.2 miles from the medical
office building where the psychiatrists primarily work. SMHP
psychiatric services were all provided on Tuesday mornings. At
8:00 am on a Tuesday morning (estimates based on Google
maps calculations for October 6, 2015), this averages to 16 min

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of drive time from office to school; at 12:00 pm, this return trip
takes on average 14 min. If we estimate that parking takes on
average 10 min at each site (the school and on return to the
hospital) and checking into the school and setting-up for visits
takes another 10 min, this equates to 60 min of travel/parking/
setup time per week per psychiatrist. With seven psychiatrists
on staff and 4 weeks in a month, this totals 1,680 min (or 28 h)
per month spent traveling to serve schools on-site.
Qualitative data collected during focus group sessions
with psychiatrists and clinicians also provided important in-
formation about the impact of telepsychiatry services on
efficiency. Several themes emerged: (1) a strength of tele-
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psychiatry was the ability to provide services to more schools;
(2) telepsychiatry allowed more flexibility in switching ap-
pointment times or seeing a different client if someone did not
show up for their appointment; and (3) although it helped with
psychiatrist efficiency, some clinicians felt less efficient. Both
clinicians and psychiatrists stated that telepsychiatry in-
creased their ability to serve more schools. One psychiatrist
stated, ‘‘It allows us to reach schools that we would not have
been able to because of driving. We can cover multiple sites in
a few hours.’’ Additionally, clinicians and psychiatrists stated
that the flexibility that telepsychiatry allows for also increases
efficiency. If a client does not show up for their telepsychiatry
appointment, it is very easy for the psychiatrist to spend that
time consulting with another school clinician or seeing an-
other client who is available at that time at another school.
One clinician said that she liked, ‘‘. the flexibility and the
opportunity to switch times for appointments and clients, it
was more so than if she was at my school in-person.’’ Finally,
although psychiatrists reported a positive impact of tele-
psychiatry on efficiency of care, clinicians indicated a nega-
tive impact on their own efficiency related to the addition of
tasks. As an example, if a prescription for a client was needed
right away, and it could not be sent electronically or called
into the pharmacy (e.g., stimulant medications), the clinicians
sometimes drove to pick up the prescription from the psy-
chiatrist’s office to bring it to the client.
Discussion
Results of the current study suggest that consumers (care-
givers and students) and providers (psychiatrists and mental
health clinicians) were generally satisfied with both in-person
and telepsychiatry care in school and that it offered a more
efficient model of care than in-person treatment. Consumers
do not show significant differences in satisfaction between in-
person and telepsychiatry care. Providers show high rates of
satisfaction across both types of sessions, although they re-
ported greater satisfaction with in-person sessions than tele-
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SCHOOL-BASED TELEPSYCHIATRY
psychiatry sessions. Findings also suggest that in an urban
setting, like Baltimore, up to 28 psychiatrist hours per month
(4 h per psychiatrist) were saved by using telepsychiatry, ra-
ther than in-person visits.
Findings that consumers were equally, and highly, satisfied
with both telepsychiatry and in-person school-based sessions
suggest that school-based telepsychiatry was an acceptable
model of service delivery for students and caregivers. These
findings align with previous research that has been conducted
outside the school setting, showing that both parents17,34 and
children and adolescents30,34 are as satisfied with tele-
psychiatry as in-person sessions. Thus, as has been found in a
large body of research on adults in multiple settings and tele-
psychiatry formats, telepsychiatry delivered within the context
of comprehensive SMH appears to be acceptable to both chil-
dren and their caregivers.
Providers were also highly satisfied with both formats of
service delivery, although they show some preference for in-
person sessions over telepsychiatry sessions. Specifically, psy-
chiatrists tended to have lower confidence in their abilities and
less perceived ability to obtain pertinent mental and physical
health information in telepsychiatry sessions compared with in-
person sessions. Some of the aspects of service delivery that
clinicians viewed less favorably in telepsychiatry sessions were
ease of scheduling and duration of sessions; in addition, they
rated their overall satisfaction with telepsychiatry as lower.
However, as previously noted, the mean satisfaction scores
for telepsychiatry and in-person sessions were high, and dif-
ferences were small, suggesting a potential lack of practical
significance in these findings. Nonetheless, psychiatrists’ ar-
eas of concern are similar to those noted in previous studies.
For example, Wagnild et al.35 found that psychiatrists who
were engaged in both in-person and telepsychiatry services
with a range of patients not only recognized the benefits of
telepsychiatry (e.g., reduced travel burden on psychiatrist and
patient) but also noted several technical barriers (scheduling
difficulties, audio lag and echoing, poor video quality, diffi-
culty in controlling the patient environment) and interper-
sonal barriers (feels less personal, difficulty in reading feeling
states) when using telecommunications. Technical barriers
(ease of scheduling, duration of sessions) and interpersonal
barriers (confidence, ability to obtain pertinent physical and
health information) reported by psychiatrists in the current
study may be addressed through system improvement and
increased provider training, discussed below.
One of the most compelling potential benefits of tele-
psychiatry is its impact on increasing provider efficiency—
enabling more individuals to access and receive needed
services. Issues of access are often seen as only affecting rural
TELEMEDICINE and e-HEALTH 7
 MAYWORM ET AL.
areas, but the current study results suggest that they are also
critical in urban areas. Psychiatrists serving children in schools,
the most common site for receiving mental health services, must
drive to numerous different schools to provide care. Estimates of
travel and setup time saved using telepsychiatry rather than in-
person sessions in schools for a program of 25 schools in an
urban setting suggest that *28 psychiatrist hours could be
saved per month. Baltimore is a relatively small geographic
region for an urban setting, and therefore, the potential time
savings in more sprawling urban regions would conceivably be
higher. Psychiatrist and clinician focus group responses related
to efficiency also suggested that providers experienced a posi-
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tive impact of telepsychiatry on their efficiency and ability to
serve more youth. SMH programs, which have not yet broadly
capitalized on the benefits of telepsychiatry services, are en-
couraged to consider adopting this approach.
There are several limitations to the current evaluation study
that should be noted. First, this study only considers the
opinions of consumers and providers who participated in one
specific school-based telepsychiatry program. Depending on
program implementation, policies, and other varying factors, it
is plausible that other school telepsychiatry programs will
achieve different results. Second, because all surveys were
anonymous, our data do not capture the percentage of students
and parents served by our program who completed satisfaction
surveys, or how many times one individual completed a survey
(i.e., one parent could have completed many surveys, whereas
another parent could have completed none). Furthermore,
some parents did not attend sessions (or attended fewer ses-
sions). This is an important limitation, as we do not know how
representative our study sample is of all youth/caregivers
served by the program. However, because survey respondents
were selected using a random number generator, this likely
helped to increase the representativeness of the sample. Third,
the study only examined satisfaction using a self-report survey
format, and respondents may have felt pressure to provide
positive responses out of fear of harming the therapeutic re-
lationship or offending their providers (even though ano-
nymity was provided). Last, youth and parents were embedded
within schools, meaning that the data were nested, with stu-
dents in the same school receiving services from the same
psychiatrist and clinician. The current study did not have a
large enough sample or school data to control for the nonin-
dependence of observations. Furthermore, how appointment
type (i.e., intake vs. follow-up), diagnosis, symptom severity, or
other demographic variables may have impacted responses was
not considered due to sample size. Future research should be
conducted with a more rigorous research design that will ac-
count for these important, potentially confounding, variables.
8 TELEMEDICINE and e-HEALTH M O N T H 0 0 0 0
Conclusion
The current study establishes that an urban, school-based
telepsychiatry program was perceived as being equally satis-
factory as in-person psychiatry sessions by caregivers and stu-
dents. Providers were also highly satisfied with both the
telepsychiatry and in-person format of sessions, although they
show higher satisfaction when conducting in-person sessions.
This study aligns with previous findings suggesting that tele-
psychiatry is an acceptable form of service delivery but extends
these results to the school context. There is still much to learn
about school-based telepsychiatry programs and their accept-
ability, feasibility, and impact on outcomes. Therefore, future
studies should be conducted that expand upon the current study
by examining how school-based telepsychiatry services com-
pare with in-person sessions in regard to patient outcomes,
including social-emotional wellness, psychiatric symptomatol-
ogy, treatment adherence, therapeutic alliance, and school
outcomes (e.g., grades, attendance, discipline). Additionally, it
will be important to examine the most effective model of tele-
psychiatry in schools, including whether a hybrid model where
students and caregivers receive some in-person and some tele-
psychiatry sessions is preferable to only telepsychiatry sessions.
Acknowledgment
This research was made possible in part by funding from the
Betty Huse M D Charity Foundation.
Disclosure Statement
No competing financial interests exist.
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