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Guest Editorial
Psychiatry, Technology, and the Corn Fields of Iowa

Harry Karlinsky

(PDF)


In Review
The Internet’s Impact on the Practice of Psychiatry

Rima Styra

(PDF)

Clinical and Educational Telepsychiatry Applications: A Review
Donald M Hilty, Shayna L Marks, Doug Urness, Peter M Yellowlees, Thomas S Nesbitt

(PDF)

Portable Computing in Psychiatry
John Luo

(PDF)


Original Research
Assessing and Monitoring Antipsychotic-Induced Movement Disorders in Hospitalized Patients: A Cautionary Study

Leonardo Cortese, Mandar Jog, T Jeffrey McAuley, V Kotteda, Giuseppe Costa

(PDF)

Sociodemographic Factors Associated With Comorbid Major Depressive Episodes and Alcohol Dependence in the General Population
JianLi Wang, Nady El-Guebaly

(PDF)

Delineating the Population Served by a Mobile Crisis Team: Organizing Diversity
Janet Landeen, Julie Pawlick, Steven Rolfe, Ian Cottee, Melanie Holmes

(PDF)

Detecting Women at Risk for Postnatal Depression Using the Edinburgh Postnatal Depression Scale at 2 to 3 Days Postpartum
Frédérique Teissèdre, Henri Chabrol

(PDF)


Review Paper
Ethics in Psychiatric Research: Study Design Issues

Gordon DuVal

(PDF)


Brief Communication
The Prevalence of Psychological Morbidity in West Bank Palestinian Children

Tanya L Zakrison, Amira Shahen, Shaban Mortaja, Paul A Hamel

(PDF)


Book Reviews
(PDF)

Beyond Technique in Solution Focused Therapy.
Reviewed by
Llewellyn W Joseph, MD, FRCPC


The Epidemiology of Schizophrenia.
Reviewed by
Mary V Seeman, MD


The Private Self.
Reviewed by
Paul Ian Steinberg, MD, FRCPC


Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical Care.
Reviewed by
Gilbert Pinard, MD, FRCPC


Pharmacogenetics of Psychotropic Drugs.
Reviewed by
Gustavo Turecki MD PhD


Psychotherapy and Counselling in Practice. A Narrative Framework.
Reviewed by
Paul KB Dagg


Oedipus and Beyond: A Clinical Theory.
Reviewed by
Paul Ian Steinberg, MD, FRCPC


Letters to the Editor
(PDF)

Modafinil Treatment of Excessive Sedation Associated With Divalproex Sodium

Ziprasidone in Parkinson’s Disease Psychosis

Combined Oral Venlafaxine and Intravenous Clomipramine-A: Successful Temporary Response in a Patient With Extremely Refractory Depression

Doxepin Increases Serum Cholesterol Levels

Re: Suicide: The Persisting Challenge

Reply: Suicide: The Persisting Challenge

Depression and a History of Alcoholism

Gains in Speeded Information Processing Following Clozapine Treatment of Schizophrenia

Problems With Crystallizing Phenomenology and Nosology in Adolescent Psychiatry

Serotonin Syndrome With Prolonged Dysphagia

In Review

Clinical and Educational Telepsychiatry Applications: A Review

Donald M Hilty, MD1, Shayna L Marks, BA2, Doug Urness, MD3, Peter M Yellowlees, MD4, Thomas S Nesbitt, MD5

 

Objective: Telepsychiatry in the form of videoconferencing brings enormous opportunities for clinical care, education, research, and administration. Focusing on videoconferencing, we reviewed the telepsychiatry literature and compared telepsychiatry with services delivered in person or through other technologies.

Methods:We conducted a comprehensive review of telepsychiatry literature from January 1, 1965, to July 31, 2003, using the terms telepsychiatry, telemedicine, videoconferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empowerment, and costs. We selected studies for review if they discussed videoconferencing for clinical and educational applications.

Results: Telepsychiatry is successfully used for various clinical services and educational initiatives. Telepsychiatry is feasible, increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, facilitates education, and empowers parties using it. Data are limited with regard to clinical outcomes and cost-effectiveness.

Conclusion: Telepsychiatry is effective. More short- and long-term quantitative and qualitative research is warranted on clinical outcomes, predictors of satisfaction, costs, and educational outcomes.

(Can J Psychiatry 2004;49:12–23)

Click here for author affiliations.

Clinical Implications

  • Telepsychiatry has been used successfully for many types of patients in many settings.

  • Telepsychiatry has been well received by both patients and physicians.

  • Telepsychiatry appears to compare favourably with in-person care in terms of validity, reliability, and ability to communicate.

Limitations

  • Data are limited with regard to patient outcomes and cost-effectiveness.

  • More randomized controlled trials of telepsychiatry are needed.

  • Qualitative and quantitative descriptions of telepsychiatry’s impact on routine services are needed.


Key Words
: telepsychiatry, mental health, outcomes, education, review, satisfaction, effectiveness, in-person, telephone, cost

Résumé : Applications cliniques et éducationnelles de la télépsychiatrie : une étude

The National Library of Medicine defines telemedicine as the use of electronic communication and information technologies to provide or support clinical care at a distance (1). Each new technology offers advantages and disadvantages, compared with currently available technology. Telemedicine in the form of videoconferencing has increased access to psychiatric care in rural (2–5), suburban (5), and urban areas (6) by linking specialists at academic or regional health centres with health care professionals in underserved areas (7). Preliminary studies have demonstrated positive outcomes and user satisfaction with telemedicine (8,9). Information is still being sought in regard to how telepsychiatry compares with previous services, what technology is used, and how it may be integrated with other services (10–12). Information is also needed on its costs (10–14), its outcomes (10–12), and its effects on communication and interpersonal behaviour (15,16). Questions with regard to its effectiveness persist because there are few clinical outcome studies, cost data, and randomized trials.

This article reviews the clinical and educational applications of telepsychiatry, focusing specifically on how it is used and its effect on access to care, as well as on its reliability, its outcomes, its effects on communication and interpersonal behaviour, and its costs. We also focus on patient and provider satisfaction, education, empowerment, integration of data streams, administrative planning, and overall effectiveness. When applicable, we compare telepsychiatry with other technologies (for example, telephone and the Internet) and with in-person service. Legal and reimbursement issues are beyond the scope of this article but are discussed elsewhere (1).

Methods

We conducted a comprehensive review of the telepsychiatric literature between January 1, 1965, and July 31, 2003, by searching the following databases: Medline, PubMed, PsycInfo, Embase, Science Citation Index, Social Sciences Citation Index, and Telemedicine Information Exchange. The Journal of Telemedicine and Telecare was also hand- searched for the years in which it is not available on Medline. We used the following key words: telepsychiatry, telemedicine, videoconferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empowerment, and costs. The primary author reviewed article titles and abstracts, selecting studies for review if they discussed videoconferencing for clinical and educational applications. Selected articles were pulled and references were reviewed for additional potential articles.

Results

Technology Used for Telepsychiatry
Nearly all telepsychiatric services are conducted using interactive videoconferencing. Equipment selection is based on software applications, ease of use, image and sound quality, cost, and compatibility with other units to which one will link. For example, clinics doing 2-way videoconferencing sessions might use the following equipment: dial-up integrated service digital network (ISDN) or T1 lines with a transmission speed of 128 to 512 kilobits per second (KBS), pentium computers with 128 to 512 megabytes of random access memory (RAM), cameras with local and remote pan-tilt-zoom control, colour monitors, and a CODEC (COder-DECoder) for converting the audio and visual information into the binary code for transmission.

Key variables in telepsychiatric videoconferencing are the speed of transmission in KBS, the transmission method, audio quality, and picture quality in frames per second (FPS). Most services transmit between 128 KBS and 512 KBS, although transmission at 768 KBS has been reported. It is important to have adequate bandwidth for the task at hand or to have an alternative clinical option (for example, a primary care provider who evaluates a tremor if it cannot be adequately seen). Terrestrial transmission is most commonly used and is relatively inexpensive; however, it is limited by the availability of access to fiber optic lines in rural areas (2). It provides a good picture when conducted at 128 KBS, although a 0.3 second audio and visual delay may generally occur; transmission at 384 KBS to 512 KBS is virtually live. Satellite transmission transcends geographic limitations, is 8 times as costly (2), and almost always involves a 0.5- to 1.0-second delay (as occurs, for example, in worldwide broadcasts). In addition to bandwidth, frames per second (FPS) is a measure of how closely videoconferencing approximates a real image (for example, 30 FPS is television quality). FPS depends on television technology that refreshes the pixels of the screen image. Its relevance to videoconferencing is that a sudden flux of movement can require a complete change of pixels and overwhelm the available bandwidth, resulting in pixelization, distortion, and freezing at low bandwidths.

The Internet has been used to a lesser degree for videoconferencing. It has no cost (other than the costs of connecting or dialing in from long distance), offers many applications, and is highly accessible. There are 3 major challenges to Internet-based telepsychiatry: insufficient bandwidth, quality of service, and security. The term “quality of service” describes the priority health care services receive, compared with other services on the Internet. For example, if too many users were on the Internet, would digital space for the health care consultation be preserved?

Telemedicine for Psychiatry: Uses, Access to Care, and Programs
Review articles have described clinical applications (8), research applications (9), effectiveness (17), and geriatric telepsychiatry (18). Service points are theoretically limitless: they include clinics, hospital emergency rooms, patients’ homes, group homes, nursing homes, homeless shelters, hospices, schools, and forensic facilities. A full range of evaluation, consultation, and management services have been carried out by telemedicine, including case management; decision support; disease prevention and management; legal hearings; forensic evaluation; transplant evaluation; neuropsychological evaluation; individual, family, and group therapy; home, outpatient, nursing home, and inpatient care; and personal and social support.

One significant advantage of telepsychiatry has been improved access to psychiatric care in rural (2,3,5,19,20), suburban (5), and urban areas (6). With regard to patient care and continuing education, its ability to link specialists at academic or regional health centres with health care professionals in underserved areas is particularly useful (5,19,20). Moreover, this model supports primary care providers who would rather physically locate psychiatrists in their clinics than send their patients to a mental health clinic (5). This model also reduces provider isolation and gives them a hands-on way to learn how to treat patients (5), particularly if they sit in on the telepsychiatric evaluation (21). Consultation by telepsychiatry has been successful, with high initial and longitudinal satisfaction on the part of consultees (22). By avoiding travel to rural sites, it also uses specialist time efficiently.

Currently, over 50 telepsychiatry programs exist in the US, another 14 exist in Canada, and many others exist internationally. The literature describes several telepsychiatry programs, including those offered by Alberta’s Mental Health Board; Australia’s Rural and Remote Mental Health Service; the US Federal Bureau of Prisons; the Telemedicine Network; Oregon’s RodeoNet; the South Carolina Department of Mental Health’s Deaf Services Program; Ontario’s St Joseph’s Health Centre; Texas’ Tech University; the University of California, Davis; Ireland’s University College Hospital in Galway; the University of Kansas Medical Center; the University of Kentucky; the University of Oulu, Finland; and programs in rural Appalachia and the Highlands of Scotland (20,23,24).

Reliability Studies
There are several studies concerning the reliability of telepsychiatric services (Table 1); they have been summarized in detail elsewhere (8,9). Most studies compare telepsychiatry with in-person care, although some compare it with telephone care. Studies have been conducted for children, adults, and geriatric patients. Nearly all have had good results, generally at transmission speeds of 128 KBS to 384 KBS. A wide range of psychiatric disorders were reliably diagnosed (for example, anxiety, cognitive decline, depression, and psychosis). Overall, interrater reliability has been high (8,25), and in general, diagnostic reliability appears to be excellent with telepsychiatry, with only a few studies detecting minor limitations.

Table 1  Summary of telepsychiatry reliability studies 

Study 

n 

Patients 

KBS (FPS) 

Location 

Comments 

Reliability 

         

Baer and others (103) 

10 

Adult patients with OCD 

128 (—) 

US 

Ratings of severity of OCD equal to in-person interview ratings 

Baigent and others (26) 

42 

Adult state hospital inpatients 

128 (—) 

Australia 

BPRS ratings similar, though difficulty with “overall concern” and affect 

Ball and others (28) 

— 

Geriatric patients (review article) 

Telephone 

US 

Compared the MMSE and its variants via telephone: good access, does not assess visuospatial and praxis ability, and possible confusion 

Chae and others (104) 

30 

Adult outpatients 

33 (—) 

Korea 

High interrater reliability between telemedicine and in-person interviews 

Elford and others (25) 

23 

Child patients 

336 (—) 

US 

Diagnosis and treatment recommendation: equal to usual, in-person care  

Grob and others (4) 

27 

Nursing home residents 

384 (—) 

US 

MMSE and Geriatric Depression Scale: telepsychiatric assessment equal to in-person assessment 

Jones and others (27) 

30 

Geriatric nursing home patients 

128 (—) 

US 

High reliability of ratings via videoconferencing 

Kirkwood and others (105) 

27 

Adult patients in residential rehabilitation centres 

128 (—) 

US 

Equal reliability for the National Adult Reading Test, the Quick Test, and  the Adult Memory and Information Processing Battery 

Malagodi and others (46) 

Occupational evaluation of adult patients 

128 video and 16.8 phone (—) 

US 

Video worked, but took more time and had motion artifact 

McLaren and others (62) 

Community mental health centre 

128 (—) 

US 

Comparison of telepsychiatry (T) and in-person (IP): patient satisfaction higher with T and also higher than psychiatrist satisfaction 

Montani and others (29,30) 

25 

Geriatric patients 

128 (—) 

US 

MMSE: overall good reliability if hearing is sufficient 

Ruskin and others (51) 

30 

Adult inpatients with depression 

 —  (—) 

US 

Reliability coefficients similar for in-person and telepsychiatry 

Zarate and others (106) 

45 

Adult schizophrenia patients 

128 and 384 (—) 

US 

Global severity and positive symptoms per BPRS and other scales were reliably rated; negative symptoms less so 

KBS = kilobits per second; FPS = frames per second; OCD = obsessive–compulsive disorder; BPRS = Brief Psychiatric Rating Scale;
MMSE = Mini-Mental State Examination 

Ratings are sometimes less reliable in adults and geriatric patients when clinicians use the Brief Psychiatric Rating Scale (BPRS) (4,26,27). We speculate that older patients with dementia may have had difficulty responding to questions on the BPRS, resulting in poor reliability. Cognitive examinations with elderly patients using the Mini-Mental State Examination (MMSE) and the clock drawing test at 128 KBS have sometimes, but not always, resulted in lower scores, perhaps owing to patient difficulties with hearing and maintaining attention (4,28–30). No problems have been noticed using the MMSE in other studies.

Clinical Outcome Studies
The literature regarding outcomes for telepsychiatry is small, but growing, and indicates that telepsychiatry may improve outcomes or stabilize patients with chronic, deteriorating courses (Table 2).

Table 2  Summary of outcome studies 

Study 

n 

Patients 

KBS (FPS) 

Location 

Comments 

Doze and others (20) 

90 

Adult outpatients 

128 to 384 (—) 

Canada 

Specialists assisted with diagnosis and treatment; no outcomes measured 

Graham (107) 

39 

Adult outpatients 

768 (—) 

US 

Reduced hospitalization 

Haslam and McLaren (36) 

69 

Adult and geriatric outpatients 

128 (—) 

US 

More appropriate use of inpatient services 

Hunkeler and others (34) 

302 

Adult outpatients in primary care 

— (—) 

US 

Nurse telecare improved depressive symptoms, functioning, and satisfaction vs usual care 

Johnston and others (19) 

40 

Nursing facility residents 

128 (adjusted to 5-inch square ) 

US 

Elimination of travel and more contact between patients and staff 

Kennedy and Yellowlees (32) 

124 

Adult outpatients 

128 (—) 

Australia 

Clinical improvement at 1-year follow-up on self-report and primary care provider assessments; equal to in-person care 

Lyketsos and others (37) 

— 

Geriatric dementia patients 

— (20) 

US 

Reduced psychiatric hospitalization 

Nelson and others (33) 

28 

Child patients with depression 

128 (—) 

US 

Substantial clinical change, equivalent to in-person care 

Nesbitt and others (31) 

164 

Adult outpatients with specialty consultations including psychiatry 

128 to 384 (—) 

US 

Change in diagnosis in 91% of cases and clinical improvement in 56% of cases 

Zaylor (108) 

49 

Adult outpatients with depression or schizoaffective disorder 

128 (—) 

US 

No difference in GAF scores at 6-month follow-up vs in-person 

GAF = Global Assessment of Functioning 

Telepsychiatry has enabled 2 opinions rather than 1 (that is, it allows for both primary care provider and specialist opinions) (5). Patients are referred mainly for diagnostic evaluation and (or) treatment recommendations (20,22). In a study of specialty consultation including telepsychiatry, specialists changed the diagnosis in 91% of cases and recommended medication changes in 57% (31). According to clinical global improvement measures, 56% of patients improved. Similarly, nursing telecare to patients reduced depression and improved mental health functioning and patient satisfaction (31). In a comparison with in-person care, patients receiving tele- psychiatric care did equally well on self-report and clinical measurements over a 1-year follow-up (32). Similarly, an 8-week trial of cognitive-behavioural therapy delivered by telepsychiatry at 128 KBS to children with depression was as successful as in-person care (33). Positive outcomes may also be defined by reduced transfers for emergencies (34), reduced appointment waiting time (35), reduced use of the psychiatric intensive care unit (36), and reduced hospital admissions (by 50%) (37).

Patient Satisfaction Studies
Assessment of patient and provider satisfaction becomes increasingly important with rapid expansion of telemedicine services (38,39). A systematic review of the satisfaction literature revealed limitations in the form of small sample sizes, informal evaluation, and a lack of randomized trials (40). Teleconsultation appears acceptable to patients, but further exploration is needed. Key predictors of satisfaction with telepsychiatry have not yet been delineated, although transmission speed and equipment quality appear to play important roles because of their impact on transmission quality (8).

Interestingly, although patients expected specialist–patient interaction to be less satisfactory than that experienced in a traditional specialist–patient encounter (41), overall satisfaction has been very high (8,40). High satisfaction has been reported in 17% of patients in one study, despite equipment problems (35). Thus far, reduced time to travel (20,42,43), reduced absence from work (20), reduced waiting time (44), and more patient choice and control (20) have been reported as positive predictors. Other predictors may include frame speed (27); demographic factors (for example, age, sex, or ethnicity) (8,45); state- and trait-dependent factors (for example, acute depression vs depression in remission) (8,45); cost (8); reduced waiting time, satisfaction with and availability of local services, and familiarity with the local setting (that is, in a remote site) (45); and provider qualities (46). Table 3 summarizes studies of telepsychiatry satisfaction. Several interesting themes have emerged from the literature. First, most patients speak freely when using telepsychiatry, rate highly their preference for using it on subsequent visits, and rate positively the experience with the specialist (47). Patients prefer modes with visual cues rather than telephone services alone. In an open prospective study, patient satisfaction with telepsychiatric care was equal to other specialty care offered via telemedicine (38). Another prospective study allowed patients to select in-person or telepsychiatric care for evaluation and follow-up care, if applicable (45). When length of wait, insurance, demographic information, and diagnoses were controlled, satisfaction and adherence to appointments were equal for in-person and telepsychiatric care. Children (48,49), adolescents (25), and adults appear to be equally satisfied with telepsychiatry (8). Geriatric patients, too, have reported high satisfaction in studies, including a study comparing in-person and telepsychiatric evaluation (30). Some geriatric patients had trouble hearing (30,50) or felt uncomfortable or inhibited by the equipment, but 94% of patients did not believe that these factors had a detrimental effect on the relationship (50). Satisfaction among the elderly, including a group of patients with depression, has also been reported to be similar to that among younger adults (27,51). Rarely, patients have thought telepsychiatry was impersonal or had greater potential for decreased sensitivity (20).

Table 3  Summary of patient telepsychiatry satisfaction studies 

Study 

n 

Patients 

KBS (FPS) 

Location 

Comments 

Baer and others (103) 

26 

Adult patients with OCD 

128 (—) 

US 

Average to better than in- person care 

Baigent and others (26) 

63 

Adult state hospital inpatients 

128 (—) 

Australia 

Many patients were satisfied and preferred it instead of in-person 

Ball and others (28) 

Adult inpatients 

Low-cost system (—) 

UK 

Also measured satisfaction with in-person, telephone, and hands-free telephone 

Blackmon and others (48) 

43 

Child outpatients 

— (—) 

US 

Parent satisfaction was also very good 

Bratton and others (50) 

20 

Geriatric patients in a retirement community 

128 (—) 

US 

Satisfied despite hearing and poor image problems 

Callahan and others (38) 

93 

Adult primary care outpatients 

128 (15) 

US 

Satisfaction equal to a nonpsychiatric population 

Chae and others (104) 

30 

Adult outpatients 

33 (—) 

Korea 

Equal to usual, in-person care 

Dongier and others (49) 

50 

Adult, child outpatients 

Closed circuit TV (—) 

Canada 

Equal to usual, in-person care 

Doze and others (20) 

90 

Adult outpatients 

128 to 384 (—) 

Canada 

Positive because of less travel and less absence from work; negative perception 

Elford and others (109) 

23 

Children 

336 (—) 

US 

Diagnosis and treatment recommendation equal to usual, in-person care 

Graham (107) 

39 

Adult outpatients 

768 (—) 

US 

Positive patient acceptance of telepsychiatry aftercare 

(90% positive ratings) 

Hilty and others (45) 

40 

Adult primary care outpatients 

384 (15) 

US 

Satisfaction equal for in-person and telepsychiatric care, if patient given the choice 

Johnston and others  (19) 

40 

Nursing facility 

residents 

128 (—) 

US 

Patients and families expressed appreciation for the service 

Kirkwood and others (105) 

27 

Adult patients in residential rehabilitation centres 

128 (—) 

US 

Patients expressed high satisfaction while doing reading and memory tests 

McCloskey and others (43) 

236 

Adult outpatients 

128 (—) 

US 

Rural Montana; would have had to travel significantly 

McLaren and others (58) 

Adult schizophrenia patients 

— (—) 

UK 

 

Patients felt comfortable and some preferred it to in-person 

Mielonen and others (81) 

14 

Adult inpatients 

— (—) 

Finland 

High patient satisfaction (80% considered it to have been useful) 

Ruskin and others  (51) 

— 

Geriatric outpatients 

— (—) 

US 

Geriatric satisfaction similar to adult satisfaction 

Simpson and others (35) 

230 

Adult outpatients 

384 (—) 

Canada 

High level of satisfaction with the service and equipment 

Simpson and others (44) 

546 visits 

Adult outpatients 

384 (—) 

Canada 

High level of satisfaction with the service and equipment, despite equipment problems in 17% of cases 

Trott and others (80) 

50 

Adult and child outpatients 

— (—) 

Australia 

High level of acceptance by patients and mental health professionals 

Provider Satisfaction Studies
Provider satisfaction with telepsychiatry is less well evaluated. In rural Arkansas, medical school graduates from the 1960s, 1970s, and 1980s believed that telemedicine could significantly improve education, information exchange, patient care quality, and the institution’s reputation; however, they did not believe it would improve access to care, follow-up care, or provider recruitment (52). Consultee (that is, nurse, psychologist, or other) satisfaction with telepsychiatry was lower than satisfaction with in-person consultation in terms of ease with the process, ability to express oneself, and quality of the interpersonal relationship (49). In another study, however, satisfaction with a consultation-liaison service was high (that is, 4.5 or greater on a scale of 1 = poor to 5 = excellent) and increased after 2 or more consultations over a 1-year period (22). Rural providers had significantly higher satisfaction than suburban or urban providers.

Effect on Communication and Relationship
Three articles have discussed in detail the effects of telemedicine on communication and relationships (8,15,16). Telepsychiatry appears to have both positive and negative effects on communication (8). It allows the establishment of a “social presence” (15). One concern with telemedicine is that the technology may adversely affect communication and the development of a positive therapeutic alliance (53). We review findings from the nonmedical, medical, and psychiatric literature, including comparisons between telepsychiatry, telephone, and in-person services.

A critical variable affecting communication is telemedicine’s ability to simulate real-time experiences in terms of image and interaction. Transmission speed has a profound affect on audio and video quality. Terrestrial transmission at 384 KBS to 768 KBS provides a good picture and no audio delay. Low-KBS terrestrial transmission (for example, < 128 KBS) and satellite transmission provide good pictures, but with 0.3-second and 0.5-second signal delays, respectively. If delays are too great, words are cancelled out when parties speak simultaneously. Consequently, they may perceive the other as interrupting, and a turn-taking conversation may occur (54,55). Some of this may be caused by the presence of others in the room or by the patients’ belief that they are being videotaped or that information exchange takes place primarily on a verbal channel, rather than a video channel, regardless of how high-quality the video channel is (15,54,56). Nevertheless, no differences in the development of rapport were found in a small cohort comparing 0.0-second, 0.3-second, and 1.0-second signal delays (57).

Decreased ability to detect nonverbal cues in patient interviews has been reported during videoconferencing (58), which may limit mutual connections and understanding (59). In a physical environment, informational cues are incorporated without conscious awareness (for example, a patient is seen walking in a reticent way). The virtual environment created by telemedicine may differ, particularly when low-cost systems are used (55), although it appears to provide enough of the physical environment for good decision making (16). Videoconferencing provides more cues than telephone conferencing; however, it may require more time than does the telephone to communicate the same ideas (56,60,61), although this was not found in 2 studies (62).

Several papers comment on telepsychiatry’s effect on psychotherapy. In a report of psychoanalysis carried out by telephone, no significant psychotheraupeutic differences were found between office and telephone therapy (63). Nevertheless, such sessions may have a distancing effect on the relationship and may not allow detection of key physical cues. Most patients make use of whatever method is available to bring material into the transference, including strong affects (64). Some analysts prefer listening with an averted gaze, actively blocking out visual information to enhance processing of verbal information (65,66). Basic indications and contraindications have been suggested for using telephone and videoconferencing methods for psychotherapy (65), but more rigorous evaluation is warranted before drawing conclusions.

Some wonder whether it is necessary to have a preexisting relationship (that is, to see the patient first in person) to minimize telepsychiatry’s possible negative effects, if any, on the specialist–patient relationship. A preexisting relationship has been reported helpful for psychotherapy supervision (67) and was required in a study that compared telepsychiatric interventions with in-person therapy or usual care populations (68). Two studies using formal assessments revealed no difficulty developing an alliance and no adverse events noted (69,70).

Some of the barriers created by the telemedicine interface (that is, the technology–human interface) may be dramatically lessened in the future through virtual reality or 3-dimensional technology. It may be as if the patient is in the room with the specialist.

Cost Studies
This article reports cost studies briefly, because the quality of data in the literature is suboptimal and little information has been collected in a systematic, controlled, prospective fashion (10). Ideally, direct and indirect costs should be collected for patients, clinics, providers, and society at large. Direct costs include equipment, installation of lines, and supplies. Fixed costs also include the rental cost of lines, salary and wages, and administrative expenses. Variable costs include data transmission costs, fees for service, and equipment maintenance and upgrades. Cost analysis is difficult for several reasons. For example, technologies continue to evolve and become dated rapidly (71), and costs depend on use. In addition, the cost may seem high, since usual care often amounts to no care. New cost analyses are being completed, but the heterogeneous methods skew the data. Cost-effectiveness and cost–benefit analyses are recommended (17,72–74).

Several studies have reported cost data (Table 4). Usually, telepsychiatry is less expensive for patients (35,42,75,76). Telepsychiatry services have been estimated to be less expensive (3,77,78), as expensive (10), or more expensive than outreach in-person services (20,50,79) Telepsychiatry appears cost-effective in reducing costly transfers (for example, in the case of forensic psychiatry; 77,80,81) and hospitalization (36,37). Break-even cost analyses are often used, as is the case with the telepsychiatry program in Alberta (with 7 consultations weekly; 20,44,75).

Table 4  Summary of telepsychiatry cost studies 

Study 

n 

Patients 

KBS (FPS) 

Location 

Comments 

Alessi and others (77) 

— 

Adult forensic inpatients 

 

— ( —) 

US 

Telepsychiatry is cost-effective 

Doze and others (20) 

90 

Adult patients 

336 to 384 (—) 

Alberta 

Costs break even at approximately 390 consultations yearly; less if used for administration, too 

Hailey and others (10) 

— 

Adult patients 

— 

US 

Reduced costs to rural patients 

Hailey and others (42) 

— 

A review of 5 mental health studies; adult patients 

— 

International 

Savings to health system and patients through less travel 

Gammon and others (67) 

— 

 

— 

Norway 

Costs break even at 18 trips (800 km) or 34 trips (300 km) 

Haslam and McLaren (36) 

69 

Adult and geriatric patients 

128 (—) 

US 

Reduced cost by more appropriate use of inpatient services and cheaper case conferences and patient assessments 

Lyketsos and others (37) 

See comments 

Geriatric patients with dementia in long-term facility 

— (20) 

US 

Admissions: 21 in 1997–1998 and 11 in 1999–2001; 100 fewer hospital days total 

Mielonen and others (81) 

14 

Adult inpatients 

— 

Finland 

Savings in health care costs, reduction in travel and ease and speed of consultation 

Simpson and others (35) 

379 

Adult outpatients 

128 to 384 (—) 

Canada 

Savings of $210 per consultation for patients who would have had to travel 

Simpson and others (44) 

546 

Adult outpatients 

384 (—) 

Canada 

Costs break even at approximately 350 consultations yearly; less if used for administration, too 

Trott and others (80) 

50 

Adult and child outpatients 

 — 

Australia 

Substantial savings in health care costs from reduction in travelling and patient transfers 

Werner and Anderson (79) 

— 

Theoretical analysis 

— 

US 

Not feasible: start-up costs; high cost per visit (for example, $322 for community mental health centre–rural site medication check-up; less for University–rural site) 

A metaanalysis of cost data found that only 38/551 articles contained any quantifiable data. It is therefore premature to conclude that telemedicine is cost-effective (82). Several detailed guidelines have been recently published (10,11,83–85), as have recommendations for cost- effectiveness (86) and cost–benefit (73) evaluations.

Integrating and Organizing Telepsychiatry into Daily Practice
The increased availability of broadband systems, whether satellite-based, cable, fibre, or digital subscriber lines (DSLs), has reduced their price. Consequently, there is more opportunity to provide effective telepsychiatry services, incorporating multiple data streams, to any place in the world, any time, from the doctor’s desktop. Inevitably over time, we will move to global health care systems wherein clinicians and patients interact in electronically distributed worldwide environments supported by broadband technologies, either wired or wireless. These global delivery environments on the doctor’s desktop will incorporate various features, including technology to allow video consultations in real time or video e-mail for store-and-forward programs as well as electronic consumer-owned or provider-shared voice-driven health records. Practice-management and communications software, serviced from central servers or kept on doctors’ local networks, will allow them to link seamlessly, peer-to-peer, with their colleagues. Many of telepsychiatry’s current organizational problems will be overcome through the use of Web-based scheduling systems. Such systems will allow patients to connect to their doctors in a manner similar to the way in which we use the Internet to reserve, for example, a hotel room (87). Specialists’ electronic desktops will have a very strong educational focus, because doctors and other health care professionals will be able to receive their continuing health education via their desktops. Several commercial companies are already starting to manufacture and distribute these systems (88). The practice and practitioners of telepsychiatry have to meet the challenges contained in the recent crucially important report from the Committee of Quality Health Care in America of the Institute of Medicine, which noted that “information technology must play a central role in the redesign of the health care system” (89). Telepsychiatry is not yet completely integrated into daily mental health service delivery. Substantial further research is required, especially to examine the human- and change-management issues that have to be overcome for this to occur (90).

Education
Telemedicine has been used for several educational initiatives, including provider education (91,92), clinical consultation (5), and supervision (67). It has successfully linked academic centres with rural areas for continuing medical education, both in North America and internationally (7,92). Clinical consultations also reduce provider isolation, provide case-based learning (93), and help with decision support (94).

Empowerment
Patient travel time is reduced (20,42,43), as is time absent from work (20) and waiting time (35). Further, patients have more choice and control regarding treatment (20). Primary care providers have access to specialists for patient care and education, are able to keep their patients rather than referring them (22), and feel good about their practice. Communities also keep their patients, reduce the costs for transfers (80,81), and retain dollars that would have otherwise been lost to suburban centres upon referral (95). Communities presumably also benefit from providing a higher quality of care and more opportunities for staff education, as well as from greater ease with recruitment and accreditation (17).

Effectiveness
The overall effectiveness of telepsychiatry has recently been evaluated (17,32). According to its Latin root, effectiveness is defined as “having the power to produce an effect . . . a decisive effect; efficient; as, . . . an effective . . . remedy” (96). Ideally, effectiveness should be considered for the patient, provider, program, community, and society. With what telepsychiatry’s effectiveness is being compared is another key issue. If there is no service at all, then telepsychiatry will be judged highly effective. Standard care in communities has often not been completely evaluated, and without direct comparison, it is hard to judge telepsychiatry’s effectiveness. If superior local services already exist, telepsychiatry is usually not initiated. Effectiveness also depends on the experience and skill of the consultant—even with limitations imposed by technology, a good telespecialist may be better than a local specialist.

Telepsychiatry’s effectiveness has been evaluated with regard to access to care, quality of care (that is, outcomes, reliability, satisfaction, and comparison with in-person care), costs, education, empowerment, and other factors that influence effectiveness (for example, technology and administrative coordination) (17). According to preliminary data (17), telepsychiatry appears effective, although it is premature to claim it is cost-effective (22).

Telepsychiatry’s effectiveness needs to be further assessed (8,9,42,75,76,97). Frameworks have been proposed (10–14) and key aspects have been recently summarized (17). All parameters could benefit from more assessment, particularly in terms of outcomes and costs. Randomized controlled trials of telemedicine are feasible, enable recruitment of patients, and maintain enrollment (98).

Discussion

Telepsychiatry is being used successfully for various clinical, educational, and research purposes. The technology, speed of transmission, and program structure vary widely among many clinical settings. One significant advantage of telepsychiatry has been improved access to psychiatric care in rural, suburban, and urban areas. Compared with in-person care, most studies have shown it to reliably diagnose a wide range of conditions in adults, children, and geriatric populations. It appears to be generally acceptable to patients. Overall, telepsychiatry appears to allow the building of relationships, with clear advantages over the telephone and few disadvantages, compared with in-person care. Educational use has included didactic, case-based consultation and supervisory initiatives. Telepsychiatry appears to have greatly empowered patients, providers, programs, and communities.

More rigorous assessment of telepsychiatric service is needed in various areas, and lessons learned may also be valuable for elements of in-person psychiatric service (for example, outcomes and costs) not commonly studied outside research settings. More data are needed on patient outcomes for almost all age groups and disorders. Measurement of satisfaction needs to be more specific about several key variables: demographic factors (for example, age, sex, or ethnicity), state- and trait-dependent factors, cost, travel time for both patients or specialists, waiting time, and quality and availability of local services. More data are needed on referring and consulting provider satisfaction, with attention to the variables listed above as well as to training, specialty, years in practice, type of practice, and other factors that affect practice. In addition, the technology needs to be better described so that its effect on the measurement of all parameters can be understood. Such technology includes bandwidth, audio quality, FPS, size of the transmitted video image (rather than the size of the monitor), computer speed, and name or make of the CODEC and other equipment (99). Information about the cost of telepsychiatry services needs to be collected in a standard, prospective fashion (10), preferably through cost- effectiveness and cost–benefit analyses. Longitudinal evaluation is needed throughout the telepsychiatry literature, and studies need to report quantifiable data that can be pooled when appropriate for metaanalysis (82).

Table 5 lists guidelines for program viability and delivering quality clinical care (7,8). Programs should be based on underlying patient and provider needs, with incentives for each of the parties involved. Clinical guidelines and protocols in telemedicine can significantly improve program quality and efficiency. Training practitioners to practise tele- psychiatry requires ensuring their comfort with the equipment, adapting it to clinical practice, and being aware of its limitations. Several factors have led to the downfall of telemedicine programs. Many programs fail because of inadequate needs assessment and inadequate support from organization leaders. Inadequate technical support will alienate all parties. Inadequate collection of outcome, satisfaction, and other data jeopardizes the renewing of contracts or grants. Specialist participation requires resolution of various issues, including remuneration, clinical responsibility from a distance, impact on usual practice, credentialing, and medico- legal coverage, as well as organizational support to supply service to remote populations.

Table 5 Guidelines for program viability and for delivering quality service 

  1. Do a thorough needs assessment in the region that the program is planning to serve. 

  2. Obtain overall and financial support of the program from senior leadership of the organization. 

  3. Use clinically proven technology. 

  4. For each consult, be certain that the technical equipment is appropriately matched to the service and needs of the patient and their condition. 

  5. Evaluate options, implementation, and maintenance of telepsychiatry with a team of clinicians, technicians, and administrators in both the hub and the spoke sites. 

  6. Adequately train all site coordinators in the technical and procedural aspects of the service, including referral guidelines and transfer of patient medical information to the specialist and back to the referral site. 

  7. Obtain a telepsychiatric champion and provide adequate training for others with regard to the technology, adapt clinical practice to fit its use, and identify its limitations. 

  8. Provide regular technical maintenance and prompt trouble-shooting.  

  9. Coordinate timing of consults (that is, the patient is there at the right time, the telepsychiatrist has adequate time, and (or) referring providers or staff stop in if desired). 

10. Adequately evaluate outcomes, satisfaction, and costs  to the patient, the referring provider, and the specialist, as well as to the program (coordinator,  technical staff, and administration). 

It appears that telepsychiatry use will continue to grow. Its curve of growth or decline will depend on how well programs are organized and adapt to potential pitfalls. Some obstacles (for example, costs and access to broad bandwidth lines) will recede as technology advances. Integration of video- conferencing with other digital technologies appears particularly promising in terms of clinical care, patient and provider education, provider–specialist communication, and electronic medical records. The computer can significantly facilitate clinical care and education (100,101) if it fits with the demands of clinical practice and the cognitive structures of clinicians (102).


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Author(s)

Manuscript received and accepted September 2003.

1. Associate Professor of Clinical Psychiatry, Director of Telepsychiatry, University of California Davis, Sacramento, California.

2. Research Assistant, Mood Disorders and Health Services Research Program, University of California Davis, Sacramento, California.

3. Director, Telemental Health Service, Alberta Mental Health Board, Ponoka, Alberta.

4. Director of Online Health, Professor of Community Mental Health, Department of Psychiatry, University of Queensland, Brisbane, Queensland, Australia

5. Professor of Family and Community Medicine, Associate Dean, Regional Outreach and Telehealth, University of California Davis, Sacramento, California.

Address for correspondence: Dr DM Hilty, University of California, Davis, 2230 Stockton Boulevard, Sacramento, CA 95817

e-mail: dmhilty@ucdavis.edu

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