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).
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.
Technology Used for Telepsychiatry
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
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).
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
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
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).
Provider Satisfaction Studies
Effect on Communication and Relationship
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.
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).
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
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).
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.
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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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
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