Telepsychiatry Services Research Articles

Limitations in the routine use of telepsychiatry

Telepsychiatry is well established in many countries, but there is still little information about its use in routine health care. We reviewed the literature for information on the use of telepsychiatry in mental health services. From 1033 publications identified in the literature search and through references from a separate project, 16 studies or descriptions of the routine use of telepsychiatry services were selected for further review. Eleven of these articles dealt primarily with videoconferencing and five with telephone- based services. Clinical use of videoconferencing in the programmes described by the reviewed papers was modest, with an average of 16 consultations per month. Three of the telephone-based services had large numbers of clients. The papers we reviewed gave limited consideration to the healthcare systems in which telepsychiatry was provided and to the use of conventional mental health services. Telepsychiatry appears to still be a niche technology in many health systems. A lack of champions for the technology and reimbursement problems may contribute to the limited use of this area of telemedicine.

Ten-Year Experience of a Private Nonprofit Telepsychiatry Service

This paper reports the results of a satisfaction survey of telepsychiatry patients at a rural community mental health clinic that had been providing psychiatric services solely via telemedicine for 10 years. The survey examined the perceived telepsychiatric session quality over a relatively long period of time with patients who had been utilizing the services for a number of years or over multiple sessions. One-page optional anonymous surveys were distributed from December 1, 2006, through March 30, 2007, covering 230 telepsychiatry patients, approximately 90% of current telepsychiatry patients at the agency. Of these, 76 patients responded, a 33.0% return rate. Among the respondents, satisfaction was generally very high, with telemedicine services provided over a period of up to 10 years perceived to be of similar (no worse) quality than in-person services. Results were further analyzed by gender, age, and number of telemedicine sessions experienced. Female patients appeared more accepting of the quality of medical care via telemedicine than male patients. Patients aged 20-49 had much higher acceptance rates than patients younger than 20 or older than 49. The least positive responses toward telemedicine were from patients in their 50s. Patients who had experienced 5 to 10 telemedicine sessions were more likely than patients who had experienced fewer than 5 to report that their sessions now run more smoothly than their initial sessions. Patients in their 20s and 30s reported the least need to have a clinician in the room with them to make them feel comfortable during their telemedicine sessions. Eight percent of respondents reacted negatively to the presence of a clinician in the room with them during their telemedicine sessions.

International telepsychiatry: a study of patient acceptability

An international telepsychiatry service was established between Denmark and Sweden for cross-cultural patient groups, such as asylum seekers, refugees and migrants. Over an 18-month period starting in mid 2006, 30 patients were treated by telepsychiatry (21 men and 9 women). The patients received mental health care by videoconferencing from providers who spoke the patients' own language, i.e. without the assistance of interpreters. The total number of telepsychiatry sessions was 203 (range 1-22; average 6.8 sessions per patient). Patients completed a satisfaction questionnaire at the end of treatment. Seven patients (23%) were not able to complete a questionnaire, due to illiteracy and/or a psychotic condition. The rest of the patients (n=23) reported a high level of acceptance and satisfaction with telepsychiatry, as well as a willingness to use it again or recommend it to others. Any disadvantages of telemedicine were compensated by the fact that the doctor and patient spoke the same language and had similar cultural and/or national references. Mentally ill asylum seekers, refugees and migrants are under-served in their mother tongue and telepsychiatry can improve access to scarce health-care resources.

The use of videoconferencing for mental health services in Finland

The utilization of telemental health (TMH) services in Finland was surveyed in 2006. In total, 135 health-care units provided responses. Eighty-four responses were received from primary care units (health-care centres and clinics) and eight from other clinics, in all hospital districts. The overall rate of TMH consultations was 4 per 100,000 population. The highest TMH consultation per population ratio, 22 per 100,000, was in northern Finland. Most of the sites used telepsychiatry services for less than 10% of clinical outpatient services. The sites with over 20% utilization of clinical TMH services from all psychiatric consultations were all rural health centres. Compared with Finland, the utilization rates of TMH were higher in Canada; that might be due to differences between the countries in the organization of mental health services in primary and specialized care. In Finland TMH consultations made up only a very small proportion of all mental health services. The use of TMH was particularly common in remote areas; however, there were many rural centres that did not utilize clinical TMH. TMH was widely utilized for continuing and medical education.

Teleconferencing model for forensic consultation, court testimony, and continuing education

A medical center-based forensic clinic that provides the necessary comprehensive consultation, continuing education, court testimony, and clinical services through an applied model of teleconferencing applications is addressed. Telemedicine technology and services have gained the attention of both legal and clinical practitioners, examining trends and models of health care for underserved populations, and identifying where consultation with a team of professionals may benefit service providers in rural communities. The contribution offered herein provides an understanding of the history of the development of the clinic, a theoretical model that has been applied to a clinical forensic program that employs telepsychiatry services, and the ethical and malpractice liability issues confronted in using teleconferencing services. This model is examined through a child and adolescent forensic evaluation clinic. The goals of this model are offered, as are a number of applications within the broad spectrum of services utilizing telemedicine. Finally, changing patterns are addressed in clinically based health-care delivery for criminal justice, social services, and forensic mental health.

New APA Resource Addresses Psychiatry in Underserved Areas

New APA Resource Addresses Psychiatry in Underserved Areas

Counseling Center-Based Tele-Mental Health for Students at a Rural University

Students attending rural academic institutions often have no immediate access to psychiatrists to supplement on-site Counseling Center (CC) services. Because the Medical College of Georgia (MCG) could not cost-effectively provide on-site psychiatry services to Georgia Southern University (GSU) students, the two institutions explored telehealth services delivered by supervised Psychiatry residents using Web-based videoconferencing on MCGs virtual private network. GSU counselors completed client severity rating forms. CC clients in ongoing therapy who were judged to be in need of psychiatric services were referred to the Tele-clinic (TC). CC counselors referred the most challenged students to TC according to total distress score on intake, clinician intake assessment of client difficulty, and client need for medications. After seeing the clients in TC, MCG residents also completed GSU CC client severity rating forms. Post-intake and satisfaction surveys already in use at the GSU CC were completed both by CC clients not in TC and by CC clients jointly enrolled in TC. TC and CC populations were compared by gender, race, past mental health treatment, past psychiatric hospitalization, and past and current use of psychotropic drugs. Telepsychiatry conducted using low bandwidth videoconferencing successfully supplemented GSU CC mental healthcare, especially for clients with the most serious problems, and did so without travel from campus and within the milieu of daily student life. Cost-effective telepsychiatry services can successfully supplement management of students with mental health issues who attend rural, smaller, and/or resource-challenged academic institutions.

Feasibility, Acceptability, and Sustainability of Telepsychiatry for Children and Adolescents

Feasibility, Acceptability, and Sustainability of Telepsychiatry for Children and Adolescents

Feasibility, Acceptability, and Sustainability of Telepsychiatry for Children and Adolescents

This study examined the feasibility, acceptability, and sustainability of a telepsychiatry service for children and adolescents living in nonmetropolitan communities. Using high-bandwidth interactive video teleconferencing, psychiatrists at a children's hospital provided care to patients of primary care physicians at four nonmetropolitan sites. Review of one-year utilization provided feasibility data. Surveys of referring physicians examined acceptability of telepsychiatry. Reimbursement records provided sustainability data. Overall, 387 sessions were provided to 172 youths (mean=2.25 sessions) whose clinical profiles were representative of national samples. Referring providers endorsed high satisfaction with telepsychiatric care, although pediatricians were consistently more satisfied than family physicians. Sustainability of telepsychiatry is challenged by infrastructure costs and low reimbursement by public payers. Telepsychiatry is a feasible and acceptable approach to providing psychiatric services to youths in underserved communities. Sustainability will depend on developing financial alternatives to fee-for-service, especially if caseloads emphasize publicly funded programs.

Rapid Eye Movements for Acute Stress Disorder Using Video Conference Communication

In order to effectively reduce the risk of developing long-lasting mental disorders in the aftermath of traumatic stress exposure, interventions must be offered early on. Therefore, access to expert assistance can have significant effects on prognosis. Rapid eye movements are part of the Eye Movement Desensitization and Reprocessing procedure that gained considerable attention in previous years. The authors present a patient suffering from an acute stress disorder, treated by rapid eye movements through telepsychiatry services.

Emergency management guidelines for telepsychiatry

Objective Telepsychiatry, in the form of live interactive videoconferencing, is an emerging application for emergency psychiatric assessment and treatment and can improve the quality and quantity of mental health services, particularly for rural, remote and isolated populations. Despite the potential of emergency telepsychiatry, the literature has been fairly limited in this area. Method Drawing on the combined clinical and administrative experiences of its authors, this article reviews the common administrative, legal/ethical and clinical issues that arise in emergency telepsychiatry. Results An initial set of guidelines for emergency telepsychiatry is presented to generate further discussion to assist those who are considering establishing general telepsychiatry and/or emergency telepsychiatry services. Conclusion The practices and techniques of emergency telepsychiatry are relatively new and require further examination, modification and refinement so that they may be fully utilized within comprehensive mental health service systems.

Hawaii Prescribing Bill Advances Despite Reduced Training Standards

Hawaii Prescribing Bill Advances Despite Reduced Training Standards

I'm only at the end of a video link

Younus Saleem and Paul Stankard discuss the only forensic telepsychiatry service in the United Kingdom

Setting up a telepsychiatry service

Telepsychiatry is the delivery of healthcare and the exchange of healthcare information for purposes of providing psychiatric services across distances (Yellowlees et al, 2003). In practice, this most often means an interaction between a patient and clinician who are in different sites, through the use of transmitted live sound and video images. The term telepsychiatry was first used by Dwyer in 1973 who described the use of closed-circuit television at Massachusetts General Hospital for consultations between psychiatrists and patients. However, telemedicine was pioneered at the Nebraska Psychiatric Institute nearly 20 years earlier (Wittson & Dutton, 1956).

From pilot to permanent service: ten years of paediatric telepsychiatry

The Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) in Sydney has been providing telepsychiatry services in New South Wales (NSW) for ten years. Services are provided to over 40 sites in remote and rural NSW. There are eight telepsychiatry clinics a week, providing almost 600 consultations a year. As well as telepsychiatry, three additional services are provided: professional supervision, education and training, and Aboriginal child and adolescent mental health traineeships. The service was re-evaluated in 2004 using a semi-structured interview to obtain information about service satisfaction and effectiveness from hub and rural clinicians. There continues to be a high level of satisfaction with the telepsychiatry service and with other telemedicine services, such as clinical supervision and teaching. Videoconferencing appears to be a highly effective and well accepted method of providing mental health care to remote and rural children, adolescents and families. CAPTOS has developed into an integral part of child and adolescent mental health services in remote and rural New South Wales.

Economic evaluation of a tertiary telepsychiatry service to an island

The island of Jersey is located 160 km south of Britain and 23 km from northwest France. The island has well-established primary and secondary mental health services, but tertiary services have to be purchased from UK mainland service providers. A pilot study of telepsychiatry was conducted, using videoconferencing to access tertiary mental health services from the UK. During a six-month study period, five patient consultations and six specialist presentations were carried out. The total cost of using videoconferencing to deliver tertiary mental health services not ordinarily available in Jersey was 3483.06 pounds. The costs of using the traditional model instead would have been 12,975.00 pounds. The threshold at which videoconferencing became cheaper than travel was between five and six telemedicine episodes per year; the actual workload during the pilot study was 22 episodes per year. The study suggests that telemedicine is cost-effective for providing tertiary mental health services not ordinarily available in Jersey.

Telepsychiatry improves paediatric behavioural health care in rural communities

In the US, children with special health care needs are underserved by both the medical and educational systems. This problem is especially serious in rural states. Telemedicine is a technique that can reduce these gaps in service and help connect the two systems. The technology required has become cheaper and more accessible. Progress on reimbursement for such services has also been made. For some years, we have provided telepsychiatry for children in Washington State using videoconferencing. Interviews with families and service providers were conducted in Washington and Missouri. Some parents reported that their child actually preferred telepsychiatry to conventional consultation. The telepsychiatry service model was built on the existing system of outreach clinics, thus involving specialists who were familiar with the community and who were known and trusted by the community. Before starting, we ensured that all relevant service delivery agencies and providers were comfortable about using videoconferencing as a method of service delivery. In the 18-month period ending in March 2003, three providers in Seattle saw 159 patients by telepsychiatry and 210 patients face-to-face at the hospital clinic. The main barrier to further growth of the telepsychiatry service is the absence of reimbursement for telepsychiatry.

Evolution of telepsychiatry to rural sites: changes over time in types of referral and in primary care providers' knowledge, skills and satisfaction

Introduction Rural populations remain underserved in terms of psychiatric services. This study assesses changes over time in the utilization of telepsychiatric services by individual primary care providers (PCPs) and clinics in rural areas, specifically: (a) types of referrals for telepsychiatry service; (b) PCPs' knowledge and skills related to medication dosing; and (c) PCPs' satisfaction with telepsychiatry. Methods Data with regard to patient demographics, diagnoses, reason for consultation, medication dosing and satisfaction were prospectively collected on the first 200 and the subsequent 200 telepsychiatric initial consultations. A number of educational interventions were implemented during the project. Results Adult patients were primarily referred for mood and anxiety disorders, particularly for diagnosis and medication treatment planning. Over time, PCPs significantly improved medication dosing and asked for more treatment planning help. PCPs' satisfaction also improved over time. Discussion Telepsychiatric consultation, in combination with specific educational interventions, appears to facilitate the enhancement of skills and knowledge of PCPs. “Developmental” steps in provider and clinic evolution, along with interventions specific to a given provider's and a given site's needs, ought to be further elucidated.

Telepsychiatry for Treating Rural American Indian Youth

Of all of the medical specialties, child and adolescent psychiatry has the most severe shortage of practitioners. This shortage is even more pronounced in economically disadvantaged and rural areas (Clark et al., 1999; Pollitt, 2000; Satcher, 1999). The American Indian population is younger, more economically disadvantaged, and more rural than the general U.S. population (United States Census Bureau, 2000). Researchers and many American Indians believe that their traumatic history and current marginalization has made them more likely to experience mental health problems such as alcoholism and posttraumatic stress disorder (Beals et al., 2003, 2005; Spicer et al., 2003). The Surgeon General has made it a priority to improve mental health services, especially for children and adolescents (Satcher, 1999). American Indians should not be left out of this movement. Telepsychiatry, the use of real-time, interactive videoconferencing to deliver psychiatric services, is an exciting opportunity to ensure that they are not. There have been approximately 30 articles and papers regarding the use of telepsychiatry services to provide mental health services to children and adolescents (Pesamaa et al., 2004). This includes two randomized, controlled trials. One of these trials showed that diagnoses and treatment recommendations made by child psychiatrists by telemedicine and in faceto-face interviews were similar 96% of the time (Elford et al., 2000). The other showed that psychotherapeutic treatment of depressed children via telemedicine can be effective (Nelson, et al., 2003). The remaining studies are primarily descriptive and offer case examples or case series. These articles report that patients and providers were satisfied with the services offered and results obtained (Blackmon et al., 1997; Elford et al., 2000; Ermer, 1999a,b; Hilty et al., 2000; Miller et al., 2002). Although some clinicians expressed concern that it was more difficult for patients to convey emotions to providers via telepsychiatry, they concluded that their ability to provide effective, high-quality services was not significantly impaired by this. Furthermore, some clinicians have observed that the distance from the provider seemed to make it easier for some patients to relate sensitive information that could be important in treatment. The authors of these articles concluded that use of telepsychiatry can assist in providing child and adolescent psychiatric services to patients in remote and underserved areas while sparing patients and providers long, expensive, and life-disrupting journeys. One can expect that American Indians, a group that has been subjected to considerable trauma by the U.S. government, may be suspicious of initiatives by the government to try to help them. In fact, many American Indians have expressed distrust of the Indian Health Service (IHS) precisely because most of the providers are not Indian, come from outside communities, and often stay at their posts only long enough to complete their several-year commitments (Allen et al., 2004; Novins et al., 2004). Many American Indians have participated in research projects but have not Accepted September 1, 2005. Drs. Savin and Garry are with the Department of Psychiatry, University of Colorado Health Sciences Center, Denver; Dr. Garry and Ms. Zuccaro are with Rapid City Indian Health Service Hospital, Rapid City, SD; Dr. Novins is with the Division of American Indian and Alaska Native Programs, Department of Psychiatry, University of Colorado Health Sciences Center, Denver. This project was supported by grants from the National Center for Minority Health and Health Disparities (MD000507, Spero Manson, Ph.D., PI) and the Agency for Healthcare Research and Quality (HS10854, Spero Manson, Ph.D., PI). Correspondence to Dr. Daniel Savin, Department of Psychiatry, University of Colorado Health Sciences Center, University North Pavilion, Box A011-15, 4455 East 12th Avenue, Denver, CO 80220; e-mail: daniel.savin@uchsc.edu. 0890-8567/06/4504Y0484 2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000198594.68820.59 C L I N I C A L P E R S P E C T I V E S Associate Editor: Michael S. Jellinek, M.D.

Pediatric Telepsychiatry in Ontario: Caregiver and Service Provider Perspectives

Families in rural areas face significant geographic and economic obstacles to obtaining pediatric mental health services. Telepsychiatry promises the possibility of extending specialized expertise into areas that have no resident psychiatrists. In this study, user perspectives and experiences of a pediatric telepsychiatry program serving rural communities in Ontario, Canada, were explored. Qualitative, exploratory methods were utilized because of the complex nature of mental health services needs and provision in rural communities. Focus groups with rural mental health service providers and interviews with family caregivers of children receiving a telepsychiatry consultation were conducted. The purpose of this research was to evaluate the benefits and limitations of providing pediatric psychiatric services via video-technology to inform future program development and health policy. Whereas participants in the study indicated that their experiences with the telepsychiatry service had been positive, the need for additional local services to support treatment recommendations was emphasized.