Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies

Telephone versus in-person intake assessment for bereavement intervention: Does efficiency come at a cost?

Standardized, evidence-based risk assessment is an important component in providing effective bereavement care. E-health intake assessments have been offered alongside or instead of in-person assessments, although evidence concerning the equivalence of assessment results is lacking. This article examines differences between a semistructured intake assessment for grief intervention conducted over the telephone (n = 330) and in-person (n = 115). Differences in scores and clinical implications were evaluated. Although composite assessment scores were lower in the telephone condition, further examination revealed this occurred in the semistructured assessment of risk of complications, not the structured grief symptom assessment. Implications for care provision are discussed.

The Diagnostic Validity and Reliability of an Internet-Based Clinical Assessment Program for Mental Disorders

Background

Internet-based assessment has the potential to assist with the diagnosis of mental health disorders and overcome the barriers associated with traditional services (eg, cost, stigma, distance). Further to existing online screening programs available, there is an opportunity to deliver more comprehensive and accurate diagnostic tools to supplement the assessment and treatment of mental health disorders.

Objective

The aim was to evaluate the diagnostic criterion validity and test-retest reliability of the electronic Psychological Assessment System (e-PASS), an online, self-report, multidisorder, clinical assessment and referral system.

Methods

Participants were 616 adults residing in Australia, recruited online, and representing prospective e-PASS users. Following e-PASS completion, 158 participants underwent a telephone-administered structured clinical interview and 39 participants repeated the e-PASS within 25 days of initial completion.

Results

With structured clinical interview results serving as the gold standard, diagnostic agreement with the e-PASS varied considerably from fair (eg, generalized anxiety disorder: κ=.37) to strong (eg, panic disorder: κ=.62). Although the e-PASS’ sensitivity also varied (0.43-0.86) the specificity was generally high (0.68-1.00). The e-PASS sensitivity generally improved when reducing the e-PASS threshold to a subclinical result. Test-retest reliability ranged from moderate (eg, specific phobia: κ=.54) to substantial (eg, bulimia nervosa: κ=.87).

Conclusions

The e-PASS produces reliable diagnostic results and performs generally well in excluding mental disorders, although at the expense of sensitivity. For screening purposes, the e-PASS subclinical result generally appears better than a clinical result as a diagnostic indicator. Further development and evaluation is needed to support the use of online diagnostic assessment programs for mental disorders.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

Trends in telemedicine use in addiction treatment

Introduction

Telemedicine use in addiction treatment and recovery services is limited. Yet, because it removes barriers of time and distance, telemedicine offers great potential for enhancing treatment and recovery for people with substance use disorders (SUDs). Telemedicine also offers clinicians ways to increase contact with SUD patients during and after treatment.

Case description

A project conducted from February 2013 to June 2014 investigated the adoption of telemedicine services among purchasers of addiction treatment in five states and one county. The project assessed purchasers’ interest in and perceived facilitators and barriers to implementing one or more of the following telemedicine modalities: telephone-based care, web-based screening, web-based treatment, videoconferencing, smartphone mobile applications (apps), and virtual worlds.

Discussion and evaluation

Purchasers expressed the most interest in implementing videoconferencing and smartphone mobile devices. The anticipated facilitators for implementing a telemedicine app included funding available to pay for the telemedicine service, local examples of success, influential champions at the payer and treatment agencies, and meeting a pressing need. The greatest barriers identified were: costs associated with implementation, lack of reimbursement for telemedicine services, providers’ unfamiliarity with technology, lack of implementation models, and confidentiality regulations. This paper discusses why the project participants selected or rejected different telemedicine modalities and the policy implications that purchasers and regulators of addiction treatment services should consider for expanding their use of telemedicine.

Conclusions

This analysis provides initial observations into how telemedicine is being implemented in addiction services in five states and one county. The project demonstrated that despite the considerable interest in telemedicine, implementation challenges exist. Future studies should broaden the sample analyzed and track technology implementation longitudinally to help the research and practitioner communities develop a greater understanding of technology implementation trends and practices.

Can Teleneuropsychology Help Meet the Neuropsychological Needs of Western Africans? The Case of Ghana

In Ghana, the services of psychologists, particularly clinical psychologists and neuropsychologists, remain largely inaccessible to a large proportion of those in need. Emphasis has been placed on "physical wellness" even among patients with cognitive and behavioral problems needing psychological attention. The small number of clinical psychologists and neuropsychologists, the deplorable nature of road networks and transport systems, geopolitical factors, and a reliance on the face-to-face method in providing neuropsychological services have further complicated the accessibility problem. One way of expanding and making neuropsychological services available and accessible is through the use of information communication technology to provide these services, and this is often termed teleneuropsychology. Drawing on relevant literature, this article discusses how computerized neurocognitive assessment and videoconferencing could help in rendering clinical neuropsychological services to patients, particularly those in rural, underserved, and disadvantaged areas in Ghana. The article further proposes recommendations on how teleneuropsychology could be made achievable and sustainable in Ghana.

Prevention of anxiety and depression in Chinese: a randomized clinical trial testing the effectiveness of a stepped care program in primary care

BACKGROUND

Despite empirical evidence demonstrating the effectiveness of collaborative stepped care program (SCP) in Western countries, such programs have not been evaluated in the east, which has a different services system structure and cultural nuances in seeking help for mental illness. Furthermore, only a few studies have used SCP for depression and anxiety prevention. We conducted a trial to test its effectiveness in preventing major depressive disorder and generalized anxiety disorder among primary care patients with subthreshold depression and/or anxiety in Hong Kong.

METHODS

Subthreshold depression and/or anxiety patients were randomized into the SCP group (n=121) or care as usual (CAU) group (n=119). The SCP included watchful waiting, telephone counseling, problem solving therapy, and family doctor treatment within one year. The primary outcome was the onset of major depressive disorder or generalized anxiety disorder in 15 months. The secondary outcomes were depressive and anxiety symptoms, quality of life and time absent from work due to any illness.

RESULTS

Survival analysis showed no differences between the SCP and CAU groups (the cumulative probability of onset at 15 month was 23.1% in the SCP group and 20.5% in the CAU group; Hazard Ratio=1.62; 95% Confidence Interval: 0.82-3.18; p=0.16). No significant differences were found in secondary outcomes.

LIMITATIONS

Sample size might not have been large enough.

CONCLUSIONS

SCP did not show beneficial effect on depression/anxiety prevention compared with CAU in Hong Kong primary care. As a large majority of patients improved overtime without any intervention, we are not able to exclude the possibility that the intervention might be effective. Future studies would need to have a larger sample size and conduct on patients with more severe symptoms or perform a second screening.

Telehealth problem-solving therapy for depressed low-income homebound older adults

OBJECTIVE

To evaluate the acceptance and preliminary efficacy of in-home telehealth delivery of problem-solving therapy (tele-PST) among depressed low-income homebound older adults in a pilot randomized control trial designed to test its feasibility and preliminary efficacy.

METHODS

A total of 121 homebound individuals who were age 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD) participated in the three-arm randomized control trial, comparing tele-PST with in-person PST and telephone support calls. Six sessions of the PST-primary care were conducted for the PST participants. For tele-PST, sessions 2-6 were conducted via Skype video call. Acceptance of tele-PST or in-person PST was measured with the 11-item, 7-point scale modified Treatment Evaluation Inventory (TEI). A mixed-effect regression analysis was used to examine the effects of treatment group, time, and the interaction term between treatment group and time on the HAMD scores.

RESULTS

The TEI score was slightly higher among tele-PST participants than among in-person PST participants. The HAMD scores of tele-PST participants and in-person PST participants at a 12-week follow-up were significantly lower than those of telephone support call participants, and the treatment effects were maintained at a 24-week follow-up. The HAMD scores of tele-PST participants did not differ from those of in-person PST participants.

CONCLUSIONS

Despite their initial skepticism, almost all participants had extremely positive attitudes toward tele-PST at the 12-week followup. Tele-PST also appears to be an efficacious treatment modality for depressed homebound older adults and to have significant potential to facilitate their access to treatment.

Telemental health evaluations enhance access and efficiency in a critical access hospital emergency department

INTRODUCTION

Mentally ill patients in crisis presenting to critical access hospital emergency rooms often face exorbitant wait times to be evaluated by a trained mental health provider. Patients may be discharged from the hospital before receiving an evaluation or boarded in a hospital bed for observation, reducing quality and increasing costs. This study examined the effectiveness of an emergency telemental health evaluation service implemented in a rural hospital emergency room.

MATERIALS AND METHODS

Retrospective data collection was implemented to consider patients presenting to the emergency room for 212 days prior to telemedicine interventions and for 184 days after. The study compared measures of time to treatment, length of stay (regardless of inpatient or outpatient status), and door-to-consult time.

RESULTS

There were 24 patients seen before telemedicine was implemented and 38 seen using telemedicine. All patients had a mental health evaluation ordered by a physician and completed by a mental health specialist. Significant reductions in all three time measures were observed. Mean and median times to consult were reduced from 16.2 h (standard deviation=13.2 h) and 14.2 h, respectively, to 5.4 h (standard deviation =6.4 h) and 2.6 h. Similar reductions in length of stay and door-to-consult times were observed. By t tests, use of telemedicine was associated with a statistically significant reduction in all three outcome measures.

CONCLUSIONS

Telemedicine appears to be an effective intervention for mentally ill patients by providing more timely access to mental health evaluations in rural hospital emergency departments.

Telehealth problem-solving therapy for depressed low-income homebound older adults

OBJECTIVE

To evaluate the acceptance and preliminary efficacy of in-home telehealth delivery of problem-solving therapy (tele-PST) among depressed low-income homebound older adults in a pilot randomized control trial designed to test its feasibility and preliminary efficacy.

METHODS

A total of 121 homebound individuals who were age 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD) participated in the three-arm randomized control trial, comparing tele-PST with in-person PST and telephone support calls. Six sessions of the PST-primary care were conducted for the PST participants. For tele-PST, sessions 2-6 were conducted via Skype video call. Acceptance of tele-PST or in-person PST was measured with the 11-item, 7-point scale modified Treatment Evaluation Inventory (TEI). A mixed-effect regression analysis was used to examine the effects of treatment group, time, and the interaction term between treatment group and time on the HAMD scores.

RESULTS

The TEI score was slightly higher among tele-PST participants than among in-person PST participants. The HAMD scores of tele-PST participants and in-person PST participants at a 12-week follow-up were significantly lower than those of telephone support call participants, and the treatment effects were maintained at a 24-week follow-up. The HAMD scores of tele-PST participants did not differ from those of in-person PST participants.

CONCLUSIONS

Despite their initial skepticism, almost all participants had extremely positive attitudes toward tele-PST at the 12-week followup. Tele-PST also appears to be an efficacious treatment modality for depressed homebound older adults and to have significant potential to facilitate their access to treatment.

Agreement between telepsychiatry assessment and face-to-face assessment for Emergency Department psychiatry patients

We compared psychiatrists' evaluations of Emergency Department (ED) mental health patients made face-to-face or by telemedicine. In a 39-month study, 73 patients presenting in the ED were enrolled after initial screening. Patients were interviewed by a psychiatrist either face-to-face in the ED or remotely by video. A second psychiatrist, acting as an observer, was in the room with the patient and independently completed the assessment. Based on the primary diagnosis of the interviewer, 48% of patients had a depressive disorder, 18% a substance use disorder, 14% a bipolar disorder, 11% a psychotic disorder, 6% an anxiety disorder and 4% other disorders. The raw agreement between the psychiatrists about disposition when both used face-to-face assessment was 84% and it was 86% when one used telemedicine. Using Cohen's kappa to evaluate agreement, there were no significant differences for disposition recommendation, strength of recommendation, diagnosis or the HCR-20 dangerousness scale. There was no significant difference for the intraclass correlation coefficients for the suicide scale. The results provide preliminary support for the safe use of telepsychiatry in the ED to determine the need for admission to inpatient care.

Three principles for determining the relevancy of store-and-forward and live interactive telemedicine: reinterpreting two telemedicine research reviews and other research

The Agency for Healthcare Research and Quality sponsored two telemedicine research reviews. The latest review concluded that telemedicine is most relevant to specialties, such as psychiatry and neurology, where high levels of patient interaction are crucial to assessment. Telemedicine research studies cited in the reviews having positive findings in the specialties of ophthalmology, otolaryngology, obstetrics and gynecology, gastroenterology, and cardiology and more recent research in these areas are reviewed to identify criteria other than degree of interaction for determining the appropriateness of telemedicine interventions. These criteria include congruity or the extent that procedures used in telemedicine are similar to those of in-person examination, fidelity or the degree to which the information used for assessment in remote examinations is of similar quality to that used in-person, and reliability or the consistency with which information can be gathered and transmitted.

Telepsychiatry: Promise, potential, and challenges

Despite the high prevalence and potentially disabling consequences of mental disorders, specialized mental health services are extremely deficient, leading to the so-called 'Mental Health Gap'. Moreover, the services are concentrated in the urban areas, further worsening the rural-urban and tertiary primary care divide. Strengthening of and expanding the existing human resources and infrastructure, and integrating mental health into primary care appear to be the two major solutions. However, both the strategies are riddled with logistic difficulties and have a long gestation period. In such a scenario, telepsychiatry or e-mental health, defined as the use of information and communication technology to provide or support psychiatric services across distances, appears to be a promising answer. Due to its enormous potential, a review of the existing literature becomes imperative. An extensive search of literature was carried out and has been presented to delineate the modes of communication, acceptability and satisfaction, reliability, outcomes, cost-effectiveness, and legal and ethical challenges related to telepsychiatry. Telepsychiatry has been applied for direct patient care (diagnosis and management), consultation, and training, education, and research purposes. Both real-time, live interaction (synchronous) and store-forward (asynchronous) types of technologies have been used for these purposes. A growing amount of literature shows that training, supervision, and consultation by specialists to primary care physicians through telepsychiatry has several advantages. In this background, we have further focused on the models of telepsychiatry best suited for India, considering that mental health care can be integrated into primary care and taken to the doorstep of patients in the community.

Depression Treatment Among Rural Older Adults: Preferences and Factors Influencing Future Service Use

The purpose of this study was to investigate depression treatment preferences and anticipated service use in a sample of adults aged 55 years or older who reside in rural Wyoming. Sixteen participants (mean age = 59) completed 30- to 60-minute, semi-structured interviews. Qualitative methods were used to characterize common themes. Social/provider support and community gatekeepers were perceived by participants as important potential facilitators for seeking depression treatment. In contrast, perceived stigma and the value placed on self-sufficiency emerged as key barriers to seeking treatment for depression in this rural, young-old sample. Participants anticipated presenting for treatment in the primary care sector and preferred a combination of medication and psychotherapy for treatment. Participants were, however, more willing to see mental health professionals if they were first referred by a clergy member or primary care physician.

Telepsychogeriatrics: a new horizon in the care of mental health problems in the elderly

BACKGROUND

The use of telemedicine for the care of mental health problems has developed significantly over the last decade thanks to the emergence of a number of stable telepsychiatry programs in many countries. Parallel to this development, this care modality has also targeted specific populations with higher difficulty in gaining access to mental health services such as the elderly. Telepsychogeriatrics is expected to have an increasing role in providing care to geographically isolated rural communities, with a particular focus on long-term care facilities, in light of the high prevalence of psychiatric disorders in these centers and the lack of available specialized care.

METHODS

A thorough search of the literature was conducted using Medline, Web of Science, and PsychINFO databases in order to gather available evidence on the applicability of telepsychiatry, specifically the use of videoconferencing for remote consultation, in the elderly population with mental disorders. A succinct description of the selected studies is given along with a general reflection on the state-of-the-art in the field of psychogeriatric clinical practice and research.

RESULTS

Research on the use of telemedicine in this age group has taken into account their special characteristics, and has focused on demonstrating its applicability, the acceptance and satisfaction of elderly users and their healthcare providers, the possibility of carrying out cognitive and diagnostic assessments, and the efficiency of these programs.

CONCLUSIONS

Despite limited experience, telepsychogeriatrics appears to be a viable option, well accepted by patients, including those having dementia. More systematized studies are needed in this new field based on larger sample sizes, including comparison with traditional consultations and assessment of the clinical outcomes.

Cost analysis of store-and-forward telepsychiatry as a consultation model for primary care

Store-and-forward telepsychiatry, or asynchronous telepsychiatry (ATP), which allows clinical data, including video to be collected to be reviewed at a later time by a specialist, has been described as a feasible alternative to real-time telepsychiatry, or synchronous telepsychiatry (STP), as a consultation model for primary care. In theory, ATP should be economically more cost-effective than STP due to the increased flexibility of patient data collection and the substitution of the time of specialists with that of lower-cost providers. The aim of this study was to conduct a retrospective cost-analysis comparing ATP with STP and traditional in-person psychiatric consultations in the primary care setting. One hundred and twenty five ATP consultations were performed and fixed and marginal costs were calculated for each model using inputs such as equipment costs, time spent by providers and support staff, and hourly salaries. The fixed costs were $7,000 and $20,000 for ATP and STP and marginal costs were $68.18, $107.50, and $96.36, respectively, for the three groups. STP was the most expensive of the three types of consultations. ATP became the most cost-effective of the three models beyond 249 consultations. The marginal cost savings of ATP were due to substitution of low-cost providers for specialists. ATP represents a potential disruptive healthcare process that could allow more affordable care to be delivered to a larger population of patients. A full accounting of ATP's efficiency will require further studies, including prospective cost-benefit analyses from the perspectives of the patient, provider, and society.

A telepsychiatry transition clinic: the first 12 months experience

To improve the management of soldiers with combat-related mental health problems, an interdisciplinary telepsychiatry service was established between a clinic at the Fort Bragg army base and the Veterans Affairs (VA) Medical Center in Salem. In the first 12 months of operation, 120 soldiers (105 males) were seen in a total of 394 telepsychiatry sessions. The time spent on telepsychiatry by the six VA psychiatrists increased from 13 hours in the first month to 41 hours in the twelfth month. The number of telepsychiatry sessions increased from nine in the first month to 56 in the twelfth month. The mean global assessment of function score (GAF) in the soldiers increased significantly ( P < 0.001) from 58.0 at intake to 62.3 at the last visit. Soldiers received VA telepsychiatry on average 22 days after the initial consultation with a primary care provider, a reduction of at least eight days compared to the previous delay. The majority of soldiers (89%) who were treated by VA psychiatrists enrolled in the VA within about six months of discharge. Similar VA-US Military collaborations may prove beneficial for other military bases that have returning combat soldiers.

Challenges in conducting psychiatry studies in India

A large number of psychiatry studies are conducted in India. Psychiatry studies are complex and present unique challenges in the Indian setting. Ethical issues pertaining to the risk of worsening of illness, use of placebo and validity of informed consents are commonly faced. Site selection can be difficult due to the relative paucity of ICH-GCP (International Conference on Harmonisation - Good Clinical Practice) trained psychiatry investigators in India. Recruitment can be challenging due to issues such as strict eligibility criteria, (lack of) availability of caregiver, illness-related considerations, etc. Assessment of the consent capacity of patients is not simple, while structured assessments are not commonly employed. As the illness fluctuates, the consent capacity may change, thus requiring continued assessment of consent capacity. Study patients run the risk of worsening of illness and suicide due to exposure to inactive treatments; this risk is counterbalanced by use of appropriate study designs, as well as the indirect psychotherapeutic support received. Psychiatry studies are associated with a high placebo response. This necessitates conduct of placebo-controlled studies despite the attendant difficulties. Also, the high placebo response is often the cause of failed trials. Rating scales are essential for assessment of drug response. Some rating instruments as well as some rater training procedures may not be suitable for the Indian setting. Technological advancements may increase the procedural complexity but improve the quality of ratings. Psychiatry studies present monitors and auditors with unique scenarios too. Utilization of psychiatry specific training and expertise is recommended to ensure successful conduct of these studies in India.

The use of videoconferencing with patients with psychosis: a review of the literature

Videoconferencing has become an increasingly viable tool in psychiatry, with a growing body of literature on its use with a range of patient populations. A number of factors make it particularly well suited for patients with psychosis. For example, patients living in remote or underserved areas can be seen by a specialist without need for travel. However, the hallmark symptoms of psychotic disorders might lead one to question the feasibility of videoconferencing with these patients. For example, does videoconferencing exacerbate delusions, such as paranoia or delusions of reference? Are acutely psychotic patients willing to be interviewed remotely by videoconferencing? To address these and other issues, we conducted an extensive review of Medline, PsychINFO, and the Telemedicine Information Exchange databases for literature on videoconferencing and psychosis. Findings generally indicated that assessment and treatment via videoconferencing is equivalent to in person and is tolerated and well accepted. There is little evidence that patients with psychosis have difficulty with videoconferencing or experience any exacerbation of symptoms; in fact, there is some evidence to suggest that the distance afforded can be a positive factor. The results of two large clinical trials support the reliability and effectiveness of centralized remote assessment of patients with schizophrenia.

Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues

BACKGROUND

The limited number of mental health specialists for children has led to an increased need for child and adolescent psychiatrists to provide primary care consultations and treatment recommendations. Psychiatric assessments and treatments provided via two-way videoconferencing (telepsychiatry) have been used to increase the availability of child psychiatrists. This article reviews the literature on telepsychiatry assessment of children and adolescents.

METHODS

Research on telepsychiatry has focused on the comparability of telepsychiatric treatments to in-person treatment for adult patients. Relatively little research has addressed the ability of telepsychiatric assessments to facilitate favorable treatment outcomes, particularly for child or adolescent patients. This was a literature search using Medline via Ovid. It focused on English-language material published between 1996 and 2009. A range of search terms relating to assessment, mental health, telemedicine, and children was used. Any studies focusing on child and adolescent psychiatric assessment were included.

RESULTS

The limited literature on children is usually related to project descriptions or case reports. The studies tend to find acceptance and the diagnoses and recommendations are not seen as different from in-person assessments. Practical considerations that arise in giving telepsychiatric assessments are discussed.

CONCLUSION

Although there are significant weaknesses in the research justifying telepsychiatric assessments in children and adolescents, there are no data that suggest that this process contributes to negative outcomes. Details on the setting for telepsychiatry assessments and camera view have not been studied.

What about telepsychiatry? A systematic review

BACKGROUND

Mental illness has become a significant worldwide health issue in recent years. There is presently insufficient evidence to definitively determine the clinical effectiveness and cost-effectiveness of different health care models. The objective of this study was to evaluate the effectiveness of videoconferencing in mental illness.

DATA SOURCES

Literature searches were performed in Medline, EMBASE, PsycINFO, Centre for Reviews and Dissemination, and The Cochrane Library Controlled Trial Registry databases (1997-May 2008). A search of the following terms was used: e-health, mental disorders (MeSH term), mental health (MeSH term), mental health services (MeSH term), telecare, teleconsultation, telehome, telemedical, telemedicine, telemental, telepsychiatric, telepsychiatry, televideo, videoconference, and videophone.

STUDY SELECTION

Type of disease, interventions, and clinical outcomes or patient satisfaction were identified. Exclusion criteria included studies that did not analyze intervention outcomes and studies with a sample size of fewer than 10 cases. Peer review and quality assessment according to Cochrane recommendations were required for inclusion.

DATA EXTRACTION/SYNTHESIS

Of 620 identified articles, 10 randomized controlled trials are included (1,054 patients with various mental disorders). There were no statistically significant differences between study groups for symptoms, quality of life, and patient satisfaction.

CONCLUSIONS

There is insufficient scientific evidence regarding the effectiveness of telepsychiatry in the management of mental illness, and more research is needed to further evaluate its efficiency. However, there is a strong hypothesis that videoconference-based treatment obtains the same results as face-to-face therapy and that telepsychiatry is a useful alternative when face-to-face therapy is not possible.

Site versus centralized raters in a clinical depression trial: impact on patient selection and placebo response

The use of centralized raters who are remotely linked to sites and interview patients via videoconferencing or teleconferencing has been suggested as a way to improve interrater reliability and interview quality. This study compared the effect of site-based and centralized ratings on patient selection and placebo response in subjects with major depressive disorder. Subjects in a 2-center placebo and active comparator controlled depression trial were interviewed twice at each of 3 time points: baseline, 1-week postbaseline, and end point--once by the site rater and once remotely via videoconference by a centralized rater. Raters were blind to each others' scores. A site-based score of greater than 17 on the 17-item Hamilton Depression Rating Scale (HDRS-17) was required for study entry. When examining all subjects entering the study, site-based raters' HDRS-17 scores were significantly higher than centralized raters' at baseline and postbaseline but not at end point. At baseline, 35% of subjects given an HDRS-17 total score of greater than 17 by a site rater were given an HDRS total score of lower than 17 by a centralized rater and would have been ineligible to enter the study if the centralized rater's score was used to determine study entry. The mean placebo change for site raters (7.52) was significantly greater than the mean placebo change for centralized raters (3.18, P < 0.001). Twenty-eight percent were placebo responders (>50% reduction in HDRS) based on site ratings versus 14% for central ratings (P < 0.001). When examining data only from those subjects whom site and centralized raters agreed were eligible for the study, there was no significant difference in the HDRS-17 scores. Findings suggest that the use of centralized raters could significantly change the study sample in a major depressive disorder trial and lead to significantly less change in mood ratings among those randomized to placebo.

Face-to-face versus telephone administration of the parent's version of the children's interview for psychiatric syndromes (P-ChIPS)

The aim of this study was to examine the acceptability and reliability of telephone administration of the parent's version of the Children's Interview for Psychiatric Syndromes (P-ChIPS), a diagnostic interview examining 21 separate psychiatric syndromes, compared with face-to-face administration. Parents of 12 participants-seven boys and five girls-completed this preliminary study. The mean age of the children was 12.2 years (SD, 3.9 years). In comparing telephone and face-to-face administrations of the P-ChIPS, the percent agreement for each diagnosis was 75% to 100%, with an average percent agreement of 93.8% across all disorders assessed. Results of the face-to-face and telephone administration of the P-ChIPS were comparable, but this needs to be confirmed using a larger sample.

Telepsychiatry and the meaning of in-person contact: a preliminary ethical appraisal

Pioneering researchers claim that telepsychiatry presents the possibility of improving both the quality and quantity of patient care for populations in general as well as for those in rural and remote locations. The prevalence of, and literature on telepsychiatry has increased dramatically in the last decade, covering all aspects of research endeavors. However, little can be found on the topic of ethics in telepsychiatry. Using various clinical scenarios we may provide insight into the moral challenge in telepsychiatry-the lack of in-person contact. The difficulty is to articulate what the significance of in-person contact is and further, its meaning in the therapeutic relationship between the patient and the physician. Using the personalist perspective and related philosophical approaches we may sketch an idea of the patient as person, existentially considered as a relational and bodily human being. By applying Brennan's model for health technology assessment we may evaluate the morally troubling aspect of telepsychiatry-a lack of in-person contact-on this philosophical sketch of the person. This consideration is crucial when developing policies to guide the use of telepsychiatry in order to maintain the quality of care.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Telehealth and the deaf: a comparison study

Within the deaf population, an extreme mental health professional shortage exists that may be alleviated with videoconferencing technology-also known as telehealth. Moreover, much needed mental health education within the deaf population remains largely inaccessible. Researchers have warned that the deaf population may remain underserved if significant changes do not take place with traditional service delivery methods. This article evaluated the efficacy of telehealth in teaching psychoeducational objectives, with special emphasis given to its application to the deaf population. Results indicate that telehealth can be regarded as an efficacious and cost-effective option in delivering health care to the deaf population. Participants also indicated satisfaction with the telehealth technology. The use of printed transcripts for educational purposes is encouraged given the significant findings in this article. The findings also have implications for the literature on single-session interventions.

Rationale and design: telepsychology service delivery for depressed elderly veterans

Background

Older adults who live in rural areas experience significant disparities in health status and access to mental health care. "Telepsychology," (also referred to as "telepsychiatry," or "telemental health") represents a potential strategy towards addressing this longstanding problem. Older adults may benefit from telepsychology due to its: (1) utility to address existing problematic access to care for rural residents; (2) capacity to reduce stigma associated with traditional mental health care; and (3) utility to overcome significant age-related problems in ambulation and transportation. Moreover, preliminary evidence indicates that telepsychiatry programs are often less expensive for patients, and reduce travel time, travel costs, and time off from work. Thus, telepsychology may provide a cost-efficient solution to access-to-care problems in rural areas.

Methods

We describe an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of an empirically supported treatment for major depressive disorder, Behavioral Activation, delivered either via in-home videoconferencing technology ("Telepsychology") or traditional face-to-face services ("Same-Room"). Our hypothesis is that in-homeTelepsychology service delivery will be equally effective as the traditional mode (Same-Room). Two-hundred twenty-four (224) male and female elderly participants will be administered protocol-driven individual Behavioral Activation therapy for depression over an 8-week period; and subjects will be followed for 12-months to ascertain longer-term effects of the treatment on three outcomes domains: (1) clinical outcomes (symptom severity, social functioning); (2) process variables (patient satisfaction, treatment credibility, attendance, adherence, dropout); and (3) economic outcomes (cost and resource use).

Discussion

Results from the proposed study will provide important insight into whether telepsychology service delivery is as effective as the traditional mode of service delivery, defined in terms of clinical, process, and economic outcomes, for elderly patients with depression residing in rural areas without adequate access to mental health services.

Trial registration

National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701).

Face-to-face versus remote administration of the Montgomery-Asberg Depression Rating Scale using videoconference and telephone

Although the use of telemedicine in psychiatry has a long history in providing clinical care to patients, its use in clinical trials research has not yet been commonly employed. Telemedicine allows for the remote assessment of study patients, which could be done by a centralized, highly calibrated, and impartial cohort of raters independent of the study site. This study examined the comparability of remote administration of the Montgomery-Asberg Depression Rating Scale (MADRS) by videoconference and by telephone to traditional face-to-face administration. Two parallel studies were conducted: one compared face-to-face with videoconference administration (N=35), and the other compared face-to-face with telephone administration (N=35). In each study, depressed patients were interviewed independently twice: once in the traditional face-to-face manner, and the second time by either videoconference or teleconference. A counterbalanced order was used. The mean MADRS score for interviews conducted remotely by videoconference was not significantly different from the mean MADRS scores conducted by face-to-face administration (mean difference=0.51 points), P=.388, intraclass correlation (ICC)=.94, P<0001. Similarly, the mean MADRS score for interviews conducted by telephone was not significantly different from the mean MADRS score conducted by face-to-face administration (mean difference=0.74 points), P=.270, ICC=.93, P<0001. Results of the study support the comparability of remote administration of the MADRS, by both telephone and videoconference, to face-to-face administration. Comparability of the administration mode allows for remote assessment of patients in both research and clinical applications.

Practice parameter for telepsychiatry with children and adolescents

This practice parameter discusses the use of telepsychiatry to provide services to children and adolescents. The parameter defines terms and reviews the status of telepsychiatry as a mode of health service delivery. Because many of the issues addressed are unique to telepsychiatry, the parameter presents principles for establishing a telepsychiatry service and optimizing clinical practice within that service. The principles presented are based on existing scientific evidence and clinical consensus. Telepsychiatry is still evolving, and this parameter represents a first approach to determining "best practices." The parameter emphasizes the integration of telepsychiatry within other practice parameters of the American Academy of Child and Adolescent Psychiatry.

CTN-194 (PICCO): design of a trial of citalopram for the prevention of depression and its consequences in HIV-hepatitis C co-infected individuals initiating pegylated interferon/ribavirin therapy

Hepatitis C (HCV)-related end stage liver disease is a primary cause of morbidity and mortality in people with HIV. Despite this, co-infected patients have low rates of HCV treatment initiation and completion. This is in large part due to the risk of pegylated-interferon alpha (PEG-IFN-alpha)-related neuropsychiatric complications. We describe the design of a multicentre randomized, placebo-controlled trial that evaluates whether antidepressant prophylaxis is superior to early detection and treatment of depression in increasing the successful completion of HCV therapy. Seventy-six HIV+ adults with chronic HCV infection requiring therapy and with no contraindications to PEG-IFN-alpha/ribavirin will be randomized in a 1:1 ratio to receive citalopram or placebo starting three weeks prior to HCV treatment. A novel aspect of the trial design is the built-in management of emergent depression while maintaining the blinded treatment assignment. This will permit the comparison of prophylactic versus therapeutic use of citalopram. The primary outcome is the average proportion of prescribed PEG-IFN-alpha and ribavirin doses taken per month at weeks 12 and 24, and will be compared between treatment arms. The study will also compare the development of moderate-to-severe depression between treatment arms. A unique feature of this trial will be the use of Telepsychiatry to standardize observer-administered neuropsychiatric evaluations. Assessments of anxiety, quality of life, and adherence to therapy, as well as pathogenetic studies of neuropsychiatric side effects, will be conducted. Intention-to-treat analyses using random regression modeling will be employed to analyze longitudinal data on prescribed PEG-IFN-alpha and ribavirin doses. Survival analyses will be used to compare the time to the development of depression between the two arms. Effective prevention of a broad range of neuropsychiatric symptoms by citalopram has the potential to diminish PEG-IFN-alpha associated morbidity and consequently, allow a greater number of patients to complete full therapy.

Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio-video communication-videoconferencing-is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.

Telepsychiatry in Chennai, India: the SCARF experience

India, with its huge population and limited mental health resources, must find alternative ways of delivering its mental healthcare services. Telepsychiatry seems to be a promising option even with no regulatory authority in place or specific laws in India that deal with telemedicine practice, there has been a mushrooming of telemedicine services in India. Healthy cooperation between government organizations such as the Indian Space Research Organization (ISRO) and institutions in the non-government and private sectors is another key feature in India. The experience of the Schizophrenia Research Foundation (SCARF), at Chennai, in South India, in running and establishing a telepsychiatry network is presented in this article. We identified the following tasks as essential to ensure an efficient intervention using telemedicine: identifying a suitable technology, a suitable location, and a local collaborator; providing training and creating awareness; establishing peripheral telepsychiatry centers and ensuring case documentation; and accountability.

Primary care patients in psychiatric clinical trials: a pilot study using videoconferencing

BACKGROUND

While primary care physicians play a pivotal role in the treatment of depression, collaboration between primary care and psychiatry in clinical research has been limited. Primary care settings provide unique opportunities to improve the methodology of psychiatric clinical trials, by providing more generalizable and less treatment-resistant patients. We examined the feasibility of identifying, recruiting, screening and assessing primary care patients for psychiatric clinical trials using high-quality videoconferencing in a mock clinical trial.

METHODS

1329 patients at two primary care clinics completed a self-report questionnaire. Those screening positive for major depression, panic, or generalized anxiety were given a diagnostic interview via videoconference. Those eligible were provided treatment as usual by their primary care physician, and had 6 weekly assessments by the off-site clinician via videoconferencing.

RESULTS

45 patients were enrolled over 22 weeks, with 36 (80%) completing the six-week study with no more than two missed appointments. All diagnostic groups improved significantly; 94% reported they would participate again, 87% would recommend participation to others, 96% felt comfortable communicating via videoconference, and 94% were able to satisfactorily communicate their feelings via video.

CONCLUSION

Results showed that primary care patients will enroll, participate in and complete psychiatric research protocols using remote interviews conducted via videoconference.

The e-Mental Health Consultation Service: providing enhanced primary-care mental health services through telemedicine

This article describes the University of California, Davis Medical Center eMental Health Consultation Service, a program designed to integrate tele-mental health clinical services, provider-to-provider consultation, and provider distance education. During the first year of operation, consultations were provided for 289 cases. The most common diagnoses among children were for attention-deficit hyperactivity disorder-spectrum problems. Among the adult patients, mood disorders were most common. A convenience sample of 33 adult patients who completed the SF-12 health status measure showed significant improvements in mental health status at 3-6 months of follow-up. This model of comprehensive rural outpatient primary mental health care delivered at a distance shows promise for wider application and deserves further study.

Psychiatrists' satisfaction with telepsychiatry

The purpose of this evaluation study was to learn more about psychiatrists' satisfaction with telepsychiatry. Telepsychiatry will succeed only if psychiatrists are satisfied with this service delivery method and offer it to their patients. While telepsychiatry appears to be effective and most patients report that they are satisfied with it, less information is available about factors that lead to psychiatrists' satisfaction. We interviewed psychiatrists who treat rural/frontier patients and asked them to describe factors that encouraged or discouraged their use of telepsychiatry. Only 4 were mostly satisfied with telepsychiatry and all offered suggestions for improving this delivery method. Most agreed that it was a hardship for many of their patients to travel 100 to 750 roundtrip miles over a 1-3 day period for a 20-minute consultation and that telepsychiatry could be a lifeline to many of them. Nevertheless, they identified significant technical and interpersonal barriers that discouraged their use of telepsychiatry.

The use of telemedicine in psychiatry

This paper examines the potential effects of using video-conferencing within the field of mental health in the UK. In order to assess the usefulness of telepsychiatric services, an electronic search was conducted for articles published between August 1998 and July 2006 using the MEDLINE, EMBASE, PsychINFO and Telemedicine and Information Exchange (TIE) databases. The search was carried out using the following terms: telepsychiatry, videoconferencing and telepsychology. A total of 178 articles were identified and based on review of the abstracts 72 were identified as being specific to efficacy, cost-effectiveness and satisfaction with psychiatric services delivered via videoconferencing. This paper concludes that the use of video conferencing can enhance psychiatric services within the UK especially for those patients who live in rural areas. Current advances in technology make this an increasingly more reliable and cost-effective method for assessing patients. The limitations of telemedicine are discussed and it is clear that this type of care is not suitable for all patients. Further research is required to assess the types of patients that telepsychiatry is most suitable for.

Consultation-liaison psychiatry: how far have we come?

This article takes stock of how far the field of consultation-liaison psychiatry has come since its inception in the 20th century. In order to do this, we review its past in terms of its knowledge base in psychosomatic medicine and in terms of its practice at the bedside in the general hospital setting. We also offer a contemporary account of the field and finish with a subjective view of the opportunities and pitfalls faced during the next phase of consultation-liaison psychiatry in the 21st century.