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

Staff experiences with videoconferences during the COVID-19 pandemic in forensic psychiatry outpatients

AIM

To describe staff experiences with the use of videoconferences with forensic psychiatric outpatients during the COVID-19 pandemic.

METHOD

Semi-structured interviews with staff at forensic community services in the Region of Southern Denmark.

RESULTS

Nine semi-structured staff interviews were conducted. Two main themes were identified through thematic analysis: Challenges due to technical uncertainty and the Use of videoconferences as support in clinical assessment and treatment. The second main theme also included a number of subthemes: Lack of opportunity for observation of a patient's overall situation; Compromise of nurses' professionalism; Limitation of disturbing stimuli means more focus on the conversation; Telephone contact vs. video contact-pros and cons; Expectations reflect attitudes; and Will professionalism be changed based on organizational and political perspectives?

CONCLUSION

Staff opinions on use of videoconferences in psychiatric patients differed. The nurses in particular were concerned about whether professionalism could be maintained. Others experienced patients focusing more on the conversation when it took place via video because there were fewer disturbing elements. In general, expectations seem to influence attitudes toward using videoconferences.

Patient Perceptions of Audio-Only Versus Video Telehealth Visits: A Qualitative Study Among Patients in an Academic Medical Center Setting

Introduction

Telehealth utilization surged during the COVID-19 pandemic, offering expanded health care access. Audio-only visits emerged as a crucial tool for patients facing technology or connectivity barriers to still use telehealth. This qualitative study aims to better understand patient perceptions of audio-only versus video telehealth visits during the COVID-19 pandemic, and how patients perceive the role of each in their overall health care.

Methods

Semi-structured interviews were conducted with 14 adult patients seeking care at an academic medical center located in the Southeast region of the United States. Patients had experienced both an audio-only and video telehealth visit within the past 6 months. Topics covered in the interview included comfort, preference, quality, and communication during each type of visit. Interviews were transcribed verbatim, coded, and analyzed using a general inductive approach.

Results

Participants valued having both modalities available largely due to convenience and saw these visits as supplemental or supporting their in-person care. Preferences for visit types were varied among participants and were context-specific, influenced by visit purpose and provider rapport. Patients viewed audio-only visits favorably for informational follow-ups and highlighted their convenience, particularly for multitasking and caregiving duties. In contrast, video visits were seen as more effective for communication due to visual cues and better suited for demonstrating health conditions. Audio-only visits were also seen as less technology-dependent and served as a vital back-up to failed video encounters.

Discussion

Despite varied preferences, patients perceived both modalities as complementary to in-person care. Concerns around the quality of care were mitigated by patients' and providers' judicious use of visit types based on clinical appropriateness and existing rapport. The results emphasize the necessity and flexibility of audio-only visits in ensuring equitable access to telehealth, especially for those with technology limitations or demanding responsibilities. To maintain the access and convenience afforded by telehealth and ensure these benefits are offered equitably, policy makers and health care organizations must continue to provide flexible telehealth options, including audio-only visits.

Live two-way video versus face-to-face treatment for depression, anxiety, and obsessive-compulsive disorder: A 24-week randomized controlled trial

AIM

Live two-way video, easily accessible from home via smartphones and other devices, is becoming a new way of providing psychiatric treatment. However, lack of evidence for real-world clinical setting effectiveness hampers its approval by medical insurance in some countries. Here, we conducted the first large-scale pragmatic, randomized controlled trial to determine the effectiveness of long-term treatment for multiple psychiatric disorders via two-way video using smartphones and other devices, which are currently the primary means of telecommunication.

METHODS

This randomized controlled trial compared two-way video versus face-to-face treatment for depressive disorder, anxiety disorder, and obsessive-compulsive disorder in the subacute/maintenance phase during a 24-week period. Adult patients with the above-mentioned disorders were allocated to either a two-way video group (≥50% video sessions) or a face-to-face group (100% in-person sessions) and received standard treatment covered by public medical insurance. The primary outcome was the 36-Item Short-Form Health Survey Mental Component Summary (SF-36 MCS) score. Secondary outcomes included all-cause discontinuation, working alliance, adverse events, and the severity rating scales for each disorder.

RESULTS

A total of 199 patients participated in this study. After 24 weeks of treatment, two-way video treatment was found to be noninferior to face-to-face treatment regarding SF-36 MCS score (48.50 vs 46.68, respectively; p < 0.001). There were no significant differences between the groups regarding most secondary end points, including all-cause discontinuation, treatment efficacy, and satisfaction.

CONCLUSION

Two-way video treatment using smartphones and other devices, was noninferior to face-to-face treatment in real-world clinical settings. Modern telemedicine, easily accessible from home, can be used as a form of health care.

Lifestyles and Quality of Life of People with Mental Illness During the COVID-19 Pandemic

The COVID-19 pandemic has had a significant impact on the quality of life (QoL), daily lifestyle, and mental health of people suffering from a mental disorder. This study aimed to investigate the effects of the prolongation of the COVID-19 emergency on QoL and lifestyles in a sample of 100 outpatients at the Psychiatry Unit in Palermo University Hospital, Italy. QoL was measured through the 12-item Short Form Survey and the COV19-Impact on Quality of Life. Lifestyle changes during the pandemic were measured through the lifestyle change questionnaire. The majority of participants reported a great impact of COVID-19 on the QoL, and almost half reported worsened lifestyles. Worsened lifestyles were predictive of both poor mental and physical health related QoL. These results suggest that people with mental illness need interventions targeting lifestyles, and the mental health service in Italy should adjust to the ongoing pandemic, developing virtual treatments.

Cognitive pediatric tele-assessment: a scoping review

Cognitive tele-assessment (CTA) adoption has increased considerably recently, in parallel with the maturation of the digital technologies that enable it, and the push to move assessment to the online format during the COVID-19 pandemic in 2019. This mode of assessment stems from remote assessment applications that originated in general tele-medicine, where it was typically used for patient screening as part of an intervention. The development of remote tele-medicine was later adapted for CTA in adult populations in tele-neuropsychiatry and tele-psychology and is increasingly applied in experimental research in cognitive science research with adult and pediatric populations, and for remote academic assessment. Compared to in-person assessment, CTA offers advantages such as decreasing time and logistic costs and facilitating the assessment of remote or special needs populations. However, given the novelty of CTA, its technical, methodological, and ethical issues remain poorly understood, especially in cases where methods for assessment of adults are used in pediatric populations. In the current paper, we provide a scoping review on the evolution of remote tele-assessment from the years 2000 to 2021, to identify its main themes, methodologies, and applications, and then focus on the issues of assessment in pediatric populations. Finally, we present recommendations on how to address the challenges previously mentioned.

Clinician perspectives on providing telepsychiatry services to young adults with first-episode psychosis during COVID-19

BACKGROUND

Telepsychiatry has the potential to facilitate access to mental health services for young people with first-episode of psychosis (FEP); however, limited attention has been given regarding the perceptions of mental health providers in this regard.

OBJECTIVE

To assess service providers' perceptions on the use of telepsychiatry and changes over time.

METHODS

Longitudinal survey (conducted at two time points) of 26 service providers, including physicians, nurses, social workers, occupational therapists, and peer support workers, recruited from a specialized program for FEP providing telepsychiatry services through REACTS (videoconferencing platform).

RESULTS

Responses during the initial and the follow-up survey were similar. Most participants used REACTS nine times or more, with more than half reporting that sessions lasted more than 30 min. Over time, there was a trend towards higher frequency of use and lower duration of sessions. The majority perceived REACTS as safe and easy to use and indicated they would recommend REACTS to colleagues. Although participants reported some issues related to set-up and initial use, internet accessibility, and sound and image, most of these concerns decreased during follow-up. Participants appreciated the usability and utility of REACTS, and reported several benefits of telepsychiatry, including facilitating client engagement, assessment and continuity.

CONCLUSIONS

Service providers expressed positive perceptions regarding the use of telepsychiatry. Despite analysis being limited to a small sample, this study raises awareness of telepsychiatry's value and feasibility for offering services to young populations with FEP and the importance of conducting research on clinician perspectives in this regard.

Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Telemedicine has played a vital role in providing psychiatric treatment to patients during the rapid transition of services during the COVID-19 pandemic. Furthermore, the use of telemedicine is expected to expand within the psychiatric field. The efficacy of telemedicine is well described in scientific literature. However, there is a need for a comprehensive quantitative review that analyzes and considers the different clinical outcomes and psychiatric diagnoses.

OBJECTIVE

This paper aimed to assess whether individual psychiatric outpatient treatment for posttraumatic stress disorder, mood disorders, and anxiety disorders in adults using telemedicine is equivalent to in-person treatment.

METHODS

A systematic search of randomized controlled trials was conducted using recognized databases for this review. Overall, 4 outcomes were assessed: treatment efficacy, levels of patient satisfaction, working alliance, and attrition rate. The inverse-variance method was used to summarize the effect size for each outcome.

RESULTS

A total of 7414 records were identified, and 20 trials were included in the systematic review and meta-analysis. The trials included posttraumatic stress disorder (9 trials), depressive disorder (6 trials), a mix of different disorders (4 trials), and general anxiety disorder (1 trial). Overall, the analyses yielded evidence that telemedicine is comparable with in-person treatment regarding treatment efficacy (standardized mean difference -0.01, 95% CI -0.12 to 0.09; P=.84; I2=19%, 17 trials, n=1814), patient satisfaction mean difference (-0.66, 95% CI -1.60 to 0.28; P=.17; I2=44%, 6 trials, n=591), and attrition rates (risk ratio 1.07, 95% CI 0.94-1.21; P=.32; I2=0%, 20 trials, n=2804). The results also indicated that the working alliance between telemedicine and in-person modalities was comparable, but the heterogeneity was substantial to considerable (mean difference 0.95, 95% CI -0.47 to 2.38; P=.19; I2=75%, 6 trials, n=539).

CONCLUSIONS

This meta-analysis provided new knowledge on individual telemedicine interventions that were considered equivalent to in-person treatment regarding efficacy, patient satisfaction, working alliance, and attrition rates across diagnoses. The certainty of the evidence regarding efficacy was rated as moderate. Furthermore, high-quality randomized controlled trials are needed to strengthen the evidence base for treatment provided via telemedicine in psychiatry, particularly for personality disorders and a range of anxiety disorders where there is a lack of studies. Individual patient data meta-analysis is suggested for future studies to personalize telemedicine.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021256357; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256357.

Attitudes of Mental Health Professionals towards Telepsychology during the Pandemic: A Pilot Study

OBJECTIVE

This pilot study investigated mental health professionals' attitudes towards remote psychological consultations and internet-based interventions.

METHODS

An online survey in Italian and English was administered to a sample of 191 psychologists and psychotherapists to collect detailed information about their professional experience providing online psychological interventions a year and a half after the beginning of the SARS-CoV-2 pandemic.

RESULTS

The results did not reveal a statistically significant association between the participants' theoretical approaches and the number of patients treated via the online modality. Overall, most of the participants found advantages to the online setting but also noted critical issues regarding privacy and the ease of integrating new technology into their clinical practice.

CONCLUSIONS

According to the participants, despite the challenges that must be addressed, telehealth is a viable psychological therapeutic option that is destined to grow in importance in the near future.

The reliability of symptom assessment by telepsychiatry compared with face to face psychiatric interviews

INTRODUCTION

With the start of the COVID-19 pandemic, the various social distancing policies imposed have mandated psychiatrists to consider the option of using telepsychiatry as an alternative to face-to-face interview in Hong Kong. Limitations over sample size, methodology and information technology were found in previous studies and the reliability of symptoms assessment remained a concern.

AIM

To evaluate the reliability of assessment of psychiatric symptoms by telepsychiatry comparing with face-to-face psychiatric interview.

METHOD

This study recruited a sample of adult psychiatric patients in psychiatric wards in Queen Mary Hospital. Semi-structural interviews with the use of standardized psychiatric assessment scales were carried out in telepsychiatry and face-to-face interview respectively by two clinicians and the reliability of psychiatric symptoms elicited were assessed.

RESULTS

90 patients completed the assessments The inter-method reliability in Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Columbia Suicide Severity Rating Scale and Brief Psychiatric Rating Scale showed good agreement when compared with face-to-face interview.

CONCLUSION

Symptoms assessment by telepsychiatry is comparable to assessment conducted by face-to-face interview.

Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions' approaches to an evolving healthcare landscape

BACKGROUND

During the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.

METHODS

We used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.

RESULTS

Thirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.

CONCLUSIONS

Our results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

Psychiatric treatment conducted via telemedicine versus in-person consultations in mood, anxiety and personality disorders: a protocol for a systematic review and meta-analysis

INTRODUCTION

Major advancements in technology have led to considerations how telemedicine (TM) and other technology platforms can be meaningfully integrated in treatment for psychiatric disorders. The COVID-19 pandemic has placed a further focus on use of TM in psychiatry. Despite the widespread use of TM, little is known about its effect compared with traditional in-person (IP) consultation. The objective of this systematic review is to examine if individual psychiatric outpatient interventions for adults using TM are comparable to IP in terms of (1) psychopathology outcomes, (2) levels of patient satisfaction, (3) working alliance and (4) dropout from treatment.

METHODS AND ANALYSIS

This review will only include randomised controlled trials for adult participants with mood disorders, anxiety or personality disorders. The primary outcome is psychopathology, and secondary outcomes include patient satisfaction, treatment alliance and dropout rate. Systematic searches were conducted in MEDLINE, APA PsycINFO, Embase, Web of Science and CINAHL. The inverse-variance method will be used to conduct the meta-analysis. Effect sizes will be calculated as standardised mean difference (Hedges' g) for the primary outcome, mean difference for patient satisfaction and working alliance, and risk ratio for the dropout rate. Effect sizes will be supplemented with 95% CI. We will calculate the I² statistic to quantify heterogeneity and Chi-square statistic (χ²) to test for heterogeneity for the primary outcome. Potential clinical and methodological heterogeneity moderators will be assessed in subgroup and sensitivity analysis. The risk of bias will be assessed by Cochrane Risk of Bias Tool V.2, and confidence in cumulative evidence will be assessed by Grading of Recommendations Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No ethical approval is required for this systematic review protocol. Data sets will be deposited in the Zenodo repository. The findings of this study will be published in a peer-review scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42021256357.

Implementation of telepsychiatry in Kenya: acceptability study

BACKGROUND

COVID-19-related restrictions on in-person contact in healthcare, increasing psychiatric illness during the pandemic and pre-existing shortages of mental healthcare providers have led to the emergence of telepsychiatry as an attractive option for the delivery of care. Telepsychiatry has been promoted as economical and effective, but its acceptance in low- and middle-income countries is poorly understood.

AIMS

To explore the acceptance, experiences and perspectives of patients and healthcare providers in the uptake of telepsychiatry services in a middle-income country.

METHOD

Focus group discussions were conducted on the WhatsApp platform with patients and care providers who have engaged in telepsychiatry. Data were analysed using a thematic approach.

RESULTS

Three main themes emerged from the five focus groups: (a) technical access, (b) user experience and (c) perceived effectiveness compared with face-to-face (in-person) interactions. Care providers reported challenges establishing rapport with the patient, particularly for initial sessions, maintaining privacy during sessions and detecting non-verbal cues on video. Patients cited internet connectivity problems, difficulty finding private space to have their sessions and cost as major challenges. Patients also felt in-person sessions were better for initial visits. Both patients and providers reported difficulties making insurance payment claims for telepsychiatry services. Overall, participants were mostly positive about telepsychiatry, citing its convenience and overall perceived effectiveness compared with in-person sessions.

CONCLUSIONS

Telepsychiatry is an acceptable platform for delivery of out-patient psychiatric services in a middle-income country. Patients and providers appreciate the convenience it offers and would like it integrated as a routine mode of delivery of care.

Can the Rorschach be Administered Remotely? A Review of Options and a Pilot Study Using a Newly Developed R-PAS App

The ongoing COVID-19 pandemic has required psychologists to adopt measures like physical distancing and mask wearing, though other safety procedures such as travel restrictions or prohibitions on in-person practice and research have fostered the use of tele-health tools. In this article, we review options for using the Rorschach task via videoconference and provide preliminary data from using a new electronic app for remote R-PAS administration to determine whether the remote administration in an electronic form yields different information than in-person administration with the cards in hand. As a pilot study, our focus is on the "first factor" of all Rorschach scores, i.e., complexity. Data were collected from 60 adult Italian community volunteers, and statistical analyses evaluated the extent to which the average complexity score significantly departed from R-PAS normative expectations (SS = 100), accompanied by Bayesian likelihoods for supporting the null hypothesis. Results suggest that the general level of complexity shown by the test-takers when administered the Rorschach remotely with the new R-PAS app closely resembles that previously observed using "standard" in-person procedures. Tentative analyses of other R-PAS scores suggested normative departures that could be due to the effects of the app, testing at home, or responses to the pandemic. We offer recommendations for future research and discuss practical implications.

A scoping review of telehealth diagnosis of autism spectrum disorder

Background

Considering the COVID-19 pandemic, understanding the reliability, validity, social validity, and feasibility of using telehealth to diagnose ASD is a critical public health issue. This paper examines evidence supporting the use of telehealth methods to diagnose ASD and outlines the necessary modifications and adaptations to support telehealth diagnosis.

Methods and procedures

Studies were identified by searching PubMed and PsychInfo electronic databases and references lists of relevant articles. Only peer reviewed articles published in English with a focus on using telehealth for the purposes of diagnosing ASD were included. Searches were conducted through June 3^rd, 2021.

Outcomes and results

A total of 10 studies were identified as meeting inclusion criteria. Of the eight papers that reported on reliability (e.g., accuracy), telehealth methods to diagnose ASD were between 80–91% accurate when compared with traditional in-person diagnosis. Six studies reported on validity (i.e., sensitivity and/or specificity). All six studies calculated sensitivity, with values ranging from 75% and 100%. Five of the six studies calculated specificity, with values ranging from 68.75% and 100%. The seven papers that reported social validity indicated that caregivers, as well as adult participants and clinicians, were mostly satisfied with telehealth. Feasibility was reported by seven studies and suggests that telehealth methods appear largely viable, though some challenges were reported.

Conclusions and implications

Although findings reviewed here are promising, more research is needed to verify the accuracy, validity, and feasibility of utilizing telehealth to diagnose ASD. Studies with larger sample sizes and samples across sites will be critical, as these will allow clinicians to identify subjects most likely to benefit from telehealth as well as those more likely to require an in-person assessment. This research is important not only due to the current pandemic, but also due to increased prevalence rates of ASD and an insufficient number of diagnostic providers—particularly in rural and/or otherwise under-served communities.

Implementing Home Office Work at a Large Psychiatric University Hospital in Switzerland During the COVID-19 Pandemic: Field Report

BACKGROUND

During the COVID-19 pandemic in 2020, psychiatric hospitals all over the world had to adapt their services to the prevailing governmental regulations. As a consequence, home office use and telepsychiatry boomed.

OBJECTIVE

The purpose of this study was to evaluate the potential of home office use, its adoption, and the association of home office use with employees' mental health in a large psychiatric university hospital in Switzerland.

METHODS

We obtained and analyzed home office implementation and use data from the psychiatric university hospital's information technology services. We also conducted a cross-sectional web-based survey to assess the employees' attitudes toward the clinic's crisis management during the COVID-19 pandemic in early 2020. Part of this web-based survey consisted of questions about home office use between March and June 2020, attitudes toward home office implementation, and mental health. Three mental health measures assessed depressive symptoms (Patient Health Questionnaire [PHQ]-2), anxiety (General Anxiety Disorder [GAD]-2), and stress factors (stress module of the PHQ-D); a cut-off score ≥3 was used for the PHQ-2 and GAD-2.

RESULTS

Of the 200 participating employees, 69 reported that they had worked from home at least partially (34.5%). Home office use differed significantly across professional groups (χ₁₆²=72.72, P≤.001, n=200). Employees experienced neither depressive symptoms (mean 0.76, SD 1.14) nor anxiety (mean 0.70, SD 1.03). The employees reported minor psychosocial stressors (mean 2.83, SD 2.92). The number of reported stress factors varied significantly across groups with different levels of home office use (χ₄²=9.72, P=.04).

CONCLUSIONS

In general, home office implementation appears to be feasible for large psychiatric hospitals, however, it is not equally feasible for all professional groups. Professional groups that require personal contact with patients and technical or manual tasks must work onsite. Further evaluation of home office use in psychiatric hospitals up to the development of clinics that function merely online will follow in future research. The situation created by the COVID-19 pandemic served as a stepping stone to promote home office use and should be used to improve employees' work-life balance, to save employers costs and foster other benefits.

Telepsychiatry for Patients with Post-traumatic Stress Disorder During the COVID-19 Outbreak

Purpose

The novel coronavirus, SARS-CoV-2, emerged from Wuhan, China, causing a pandemic. Access to outpatient psychiatric care was limited. We conducted a pilot study of telepsychiatry during a national shutdown. Adult patients with post-traumatic stress disorder (PTSD) participated via Zoom. Patient preference comparing televisits to face-to-face visits was assessed.

Recent findings

Telemedicine has emerged as new technological tool in the evolution of the patient-physician relationship, changing the way we interact. Physicians and patients now have access to the electronic medical record, remote point-of-care testing, and each other. The present epidemic allows us to test the limits of technology in combating limited access to care for patients with psychiatric illness.

Summary

Twenty (90% male) patients with PTSD participated. Most (90 %) were moderately to severely depressed, and 50% used medical cannabis and increased their dosage during the study period. Patients preferred face-to-face meetings for its ease of use (p < .01) and general satisfaction from therapy (p < .01). However, given continued outbreak-limiting access to care, most patients stated they would continue with telepsychiatry. While most patients preferred face-to-face visits, telepsychiatry can be used during times of outbreak-limiting access to care. Future research and development should be directed at improving technological ease of use.

Psychiatry in the Digital Age: A Blessing or a Curse?

Social distancing and the shortage of healthcare professionals during the COVID-19 pandemic, the impact of population aging on the healthcare system, as well as the rapid pace of digital innovation are catalyzing the development and implementation of new technologies and digital services in psychiatry. Is this transformation a blessing or a curse for psychiatry? To answer this question, we conducted a literature review covering a broad range of new technologies and eHealth services, including telepsychiatry; computer-, internet-, and app-based cognitive behavioral therapy; virtual reality; digital applied games; a digital medicine system; omics; neuroimaging; machine learning; precision psychiatry; clinical decision support; electronic health records; physician charting; digital language translators; and online mental health resources for patients. We found that eHealth services provide effective, scalable, and cost-efficient options for the treatment of people with limited or no access to mental health care. This review highlights innovative technologies spearheading the way to more effective and safer treatments. We identified artificially intelligent tools that relieve physicians from routine tasks, allowing them to focus on collaborative doctor-patient relationships. The transformation of traditional clinics into digital ones is outlined, and the challenges associated with the successful deployment of digitalization in psychiatry are highlighted.

Age and Social Disparities in the Use of Telemedicine During the COVID-19 Pandemic in Japan: Cross-sectional Study

Background

The use of telemedicine outpatient visits has increased dramatically during the COVID-19 pandemic in many countries. Although disparities in access to telemedicine by age and socioeconomic status (SES) have been well-documented, evidence is limited as to how these disparities changed during the COVID-19 pandemic. Moreover, the equity of patient access to telemedicine has been scarcely reported in Japan, despite the huge potential for telemedicine expansion.

Objective

We aimed to investigate changes due to age and SES disparities in telemedicine use during the COVID-19 pandemic in Japan.

Methods

Using data from a large internet survey conducted between August 25 and September 30, 2020, in Japan, we examined the associations of participant age and SES (educational attainment, urbanicity of residence, and income level) with their telemedicine use in the following two time periods during the pandemic: April 2020 and August-September 2020.

Results

Of the 24,526 participants aged 18 to 79 years (50.8% [n=12,446] women), the proportion of individuals who reported using telemedicine increased from 2.0% (n=497) in April 2020 to 4.7% (n=1159) in August-September 2020. After adjusting for potential confounders, younger individuals were more likely to use telemedicine than older individuals in April 2020. Although this pattern persisted in August-September 2020, we also observed a substantial increase in telemedicine use among individuals aged 70 to 79 years (adjusted rates, 0.2% in April 2020 vs 3.8% in August-September 2020; P<.001 after multiple comparisons). We found disparities in telemedicine use by SES in August-September 2020 that did not exist in April 2020. In August-September 2020, individuals with a university degree were more likely to use telemedicine than those with a high school diploma or less (adjusted rates, 6.6% vs 3.5%; P<.001). Individuals living in urban areas exhibited higher rates of telemedicine use than those living in rural areas only in August-September 2020 (adjusted rates, 5.2% vs 3.8%; P<.001). Disparities in telemedicine use by income level were not observed in either time period.

Conclusions

In general, younger individuals increased their use of telemedicine compared to older individuals during the pandemic, although individuals in their 70s also increased their use of telemedicine. Disparities in telemedicine use by educational attainment and urbanicity of residence widened during the COVID-19 pandemic.

Remote Forensic Psychological Assessment in Civil Cases: Considerations for Experts Assessing Harms from Early Life Abuse

The COVID-19 pandemic has brought to the fore the question of whether psycho-legal assessments can be executed remotely in a manner that adheres to the rigorous standards applied during in-person assessments. General guidelines have evolved, but to date, there are no explicit directives about whether and how to proceed. This paper reviews professional, ethical, and legal challenges that experts should consider before conducting such an evaluation remotely. Although the discussion is more widely applicable, remote forensic psychological assessment of adults alleging childhood abuse is used as an example throughout, due to the complexity of these cases, the ethical dilemmas they can present, and the need to carefully assess non-verbal trauma-related symptoms. The use of videoconferencing technology is considered in terms of potential benefits of this medium, as well as challenges this method could pose to aspects of interviewing and psychometric testing. The global pandemic is also considered with respect to its effects on functioning and mental health and the confounding impact such a crisis has on assessing the relationship between childhood abuse and current psychological functioning. Finally, for those evaluators who want to engage in remote assessment, practice considerations are discussed.

Pediatric behavioral telehealth in the age of COVID-19: Brief evidence review and practice considerations

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

A visual step-by-step guide for clinicians to use video consultations in mental health services: NHS examples of real-time practice in times of normal and pandemic healthcare delivery

Despite the increasingly widespread use of video consultations, there are very few documented descriptions of how to set up and implement video consultations in real-time practice. This step-by-step guide will describe the set-up process based on the authors' experience of two real-time National Health Service (NHS) examples: a single health board use (delivered in normal time), and an All-Wales National Video Consultation Service roll-out (delivered during an emergency pandemic as part of the COVID-19 response). This paper provides a simple visual step-by-step guide for using telepsychiatry via the remote use of video consultations in mental health services, and outlines the mandatory steps to achieving a safe, successful and sustainable use of video consultations in the NHS by ensuring that video consultations fit into existing and new NHS workflow systems and adhere to legal and ethical guidelines.

Are videoconferenced mental and behavioral health services just as good as in-person? A meta-analysis of a fast-growing practice

The use of videoconferencing technologies (VCT) is on the rise given its potential to close the gap between mental health care need and availability. Yet, little is known about the effectiveness of these services compared to those delivered in-person. A series of meta-analyses were conducted using 57 empirical studies (43 examining intervention outcomes; 14 examining assessment reliability) published over the past two decades that included a variety of populations and clinical settings. Using conventional and HLM3 meta-analytical approaches, VCT consistently produced treatment effects that were largely equivalent to in-person delivered interventions across 281 individual outcomes and 4336 clients, with female clients and those treated in medical facilities tending to respond more favorably to VCT than in-person. Results of an HLM3 model suggested assessments conducted using VCT did not appear to lead to differential decisions compared to those conducted in-person across 83 individual outcomes and 332 clients/examinees. Although aggregate findings support the use of VCT as a viable alternative to in-person service delivery of mental healthcare, several limitations in the current literature base were revealed. Most concerning was the relatively limited number of randomized controlled trials and the inconsistent (and often incomplete) reporting of methodological features and results. Recommendations for reporting the findings of telemental health research are provided.

"Telepsychiatry" in the time of COVID-19: Overcoming the challenges

Telepsychiatry, the application of telemedicine in the field of psychiatry is defined as the use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance. COVID 19 and its implications related to physical distancing for patients and service providers has made tele- psychiatry and e-consultations an attractive option. Psychiatry, more than any other field in medicine stands to benefit through tele-psychiatry as a physical examination may not be always necessary to arrive at a diagnosis. Some have gone on to suggest that tele psychiatry is likely to replace in person psychiatric assessments pertaining to certain clinical situations. The article reviews the existing evidence for tele-psychiatry and addresses the challenges and pitfalls in the South Asian context.

Economic evaluation and costs of telepsychiatry programmes: A systematic review

OBJECTIVE

Telepsychiatry involves use of telecommunications technology to deliver psychiatric care and offers promise to reduce costs and increase access to mental health services. This systematic review examined cost reporting of telepsychiatry programmes for mental healthcare.

METHODS

We systematically searched electronic databases for studies reporting costs, including economic evaluations such as cost-effectiveness analyses, or costs of developing telepsychiatry programmes for clinical care of mental disorders. Included studies enrolled participants with mental disorders and involved telepsychiatry for depression, anxiety disorders, serious mental illnesses including schizophrenia spectrum disorders and bipolar disorder, post-traumatic stress disorder, dementia or epilepsy.

RESULTS

Twenty-six unique studies met inclusion criteria (17,967 participants), with most targeting depression (n = 7; 27%), general mental disorders and screening (n = 7; 27%), child mental health (n = 4; 15%) and geriatric mental health (n = 4; 15%). Nearly all studies (n = 25; 96%) compared telepsychiatry programme costs with either standard in-person consultation or usual care, with 15 (60%) reporting that telepsychiatry programmes were less expensive, and 8 (32%) showing telepsychiatry programmes were more expensive. Three studies reported cost-effectiveness analyses, favouring telepsychiatry programmes, but at highly elevated cost-effectiveness thresholds. Few studies reported costs of developing or delivering telepsychiatry programmes.

CONCLUSION

Costs of telepsychiatry programmes varied widely, with substantial heterogeneity in how costs were defined and reported. Some programmes cost less than in-person services while others cost more. Therefore, rigorous cost-effectiveness studies following established standards in economic evaluation are needed to inform implementation and sustainability of these programmes in health systems.

Videoconferencing in psychiatry, a meta-analysis of assessment and treatment

Context

Videoconferencing in psychiatry allows psychiatric counseling to be dealt remotely. A number of human randomised clinical trials (RCTs) on this topic were conducted but not systematically analysed since 2005.

Objects

A meta-analysis was undertaken to test the hypothesis of non-inferiority of remote psychiatric counseling, including both assessment and treatment, compared to face-to-face setting. Focus of research was the general psychiatric approach, which includes pharmacotherapy, counseling and some not specific psychotherapeutic techniques such as listening, reformulation and clarification among others. Specific forms of psychotherapies were not included in this analysis.

Design

RCTs including ≥ 10 subjects per arm were identified in Medline, the Cochrane Library, Embase and the reference list of single papers. A random-effect and a mixed-effect model served for test the hypothesis under analysis.

Results

Twenty-six RCTs were included in the analysis, involving 765 (assessment) and 1585 patients (efficacy). The non-inferiority of remote psychiatric counseling was reported both for assessment and treatment. Heterogeneity could not be excluded for assessment, but was excluded for treatment while taking into account clinical and study related variables (P-values = 0.003 and 0.06, respectively).

Conclusion

High levels of consistency between remote and in vivo psychiatric assessment is reported. Efficacy of remote psychiatric counseling was shown to be not inferior compared to in vivo settings. Heterogeneity could not be excluded for assessment, and further analyses are mandatory. The presence of multiple diagnoses included in the analysis was a limit of the present investigation.

Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers

Telepsychiatry is effective and has generated hope and promise for improved access and enhanced quality of care with reasonable cost containment. Clinicians and organizations are informed about clinical, technological, and administrative telepsychiatric barriers via guidelines, but there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Literature describing barriers to use of telepsychiatry was reviewed. PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. Barriers are described from both patient and clinicians' perspectives. Patients and clinicians are largely satisfied with telepsychiatry, but concerns about establishing rapport, privacy, safety, and technology limitations have slowed acceptance of telepsychiatry. Clinicians are also concerned about reimbursement/financial, legal/regulatory, licensure/credentialing, and education/learning issues. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Although telepsychiatry service is convenient for patients, the many barriers from clinicians' perspectives are concerning, because they serve as gatekeepers for implementation and sustainability of telepsychiatry services. This suggests that solutions to overcome barriers must start by addressing the concerns of clinicians and enhancing clinical workflow.

The virtual physical exam in the 21st century

The modern Western medical encounter follows a strict framework that weaves subjective and objective components into a unifying diagnosis. As health care changes to incorporate new technology, such as virtual health care, the components that lead to diagnosis must likewise evolve. The virtual physical exam has limitations compared with the traditional exam. Despite this limitation, every year more patients are seen virtually with high satisfaction. Data have shown that supplementary real-time patient-provider video telemedicine increases access and extends established patient-physician relationships which will likely fuel increased telemedicine adoption even further. However, to date, there are limited data regarding the validity of the virtual examination compared with the traditional physical exam. In this paper, we review the use of developing technology related to the virtual physical exam.

Disagreement in Satisfaction Between Patients and Providers in the Use of Videoconferences by Depressed Adults

Aim: To evaluate whether there was a difference in satisfaction scores between providers and patients in the use of videoconferences (VCs) by depressed adults. Method: This study was a subanalysis of the joint European project, MasterMind, and participants were recruited from 15 pilot studies in 11 different countries. The Client Satisfaction Questionnaire (CSQ)-3 was used as assessment tool, and scores were summed to give total scores. The questionnaire consists of three items evaluating general satisfaction, fulfillment of needs in treatment, and usability. Results: A total of 362 respondents, 201 patients and 161 providers, completed the questionnaire. Providers had a mean total CSQ-3 score of 9.17 (95% confidence interval [CI] = 8.90-9.45), whereas patients had a mean of 9.70 (95% CI = 9.44-9.98). Mean scores for item 1 (the extent to which VCs had met the needs of the participants): patients 3.19, providers 2.93 (p = 0.00048); for item 2 (general satisfaction): patients 3.22, providers 3.08 (p = 0.083); and item 3 (whether participants wanted to use VCs again): patients 3.28 providers 3.16 (p = 0.045). Conclusion: The results showed that total satisfaction scores were higher in patients than in providers. The differences between patients and providers were significant for items 1 and 3 (p < 0.05), but we did not find a significant difference regarding item 2.

Identifying and addressing mental health providers' perceived barriers to clinical video telehealth utilization

OBJECTIVE

Clinical video telehealth (CVT) is an innovative modality to provide care directly to Veterans' homes. Despite prior training initiatives, CVT remains underutilized. This project sought to better understand barriers to implementation and to compare responses of CVT utilizers versus nonutilizers.

METHOD

Mental health staff were invited to complete an online anonymous survey on their use of CVT in clinical practice.

RESULTS

A total of 159 mental health staff completed the survey. Although the majority of the sample endorsed personal use of a video chat program, less than half reported using CVT for patient care. Among nonutilizers, lack of training was the most frequently endorsed barrier to CVT use whereas administrative burden was the most frequently endorsed barrier by utilizers.

CONCLUSIONS

This study extends existing literature by determining barriers to CVT adoption. It identifies several barriers among utilizers versus nonutilizers. Discussion includes potential guidelines for overcoming barriers to CVT utilization.

Instances of online suicide, the law and potential solutions

To understand the social and legal issues posed by suicide-related communications over the Internet (messages of threatened suicide and advocated suicide), this article examines a selection of cases involving different types of online baiting and harassment that illustrate different legal and technological issues. The anonymity afforded by computer-mediated communication allows bullies to harass vulnerable individuals and leak (disclose) their personal information. Computer mediation of communication potentially diffuses responsibility; imposes a temporal asynchrony between signified intent and audience response; and reduces the empathy that might motivate observers or witnesses to intervene and render assistance, factors that make online baiting a serious social, legal and technological problem. Potential actions (both legal and technological) for addressing this problem are outlined.

Telemental Health in Low- and Middle-Income Countries: A Systematic Review

Introduction

The rising incidence of mental illness and its impact on individuals, families, and societies is becoming a major public health concern, especially in resource-constrained countries. Consequently, there is an increasing demand for mental health services in many middle- and low-income countries (LMIC). Challenges such as inequality in access, lack of staff and hospital beds, and underfunding, often present in the LMIC, might in part be addressed by telemental health services. However, little is known about telemental health in the LMIC.

Methods

A systematic review was performed, drawing on several electronic databases, including PubMed, PsycINFO, Web of Science, Springer Link, and Google Scholar. Original English language studies on the practice of telemental health in LMIC, involving patients and published between 1 January 2000 and 16 February 2017, were included.

Results

Nineteen studies met the inclusion criteria. Most of the articles were recent, which may reflect an increasing focus on telemental health in the LMIC. Eight of these studies were from Asia. Eight of the studies were interventional/randomized controlled trials, and 11 examined general mental health issues. Videoconferencing was the most frequently (6) studied telemental modality. Other modalities studied were online decision support systems (3), text messaging and bibliotherapy (1), e-chatting combined with videoconferencing (1), online therapy (2), e-counseling (1), store-and-forward technology (1), telephone follow-up (1), online discussion groups (1), audiovisual therapy and bibliotherapy (1), and computerized occupational therapy (1). Although many of the studies showed that telemental services had positive outcomes, some studies reported no postintervention improvements.

Conclusion

The review shows a rising trend in telemental activity in the LMIC. There is a greater need for telemental health in the LMIC, but more research is needed on empirical and theoretical aspects of telemental activity in the LMIC and on direct comparisons between telemental activity in the LMIC and the non-LMIC.

Patient Reaction to Telemedicine for Clinical Management of Hepatitis C Virus Integrated into an Opioid Treatment Program

Background and Introduction: Virtual integration of hepatitis C virus (HCV) infection management within the opioid treatment program (OTP) through telemedicine may overcome limited treatment uptake encountered when patients are referred offsite. To evaluate the diffusion of telemedicine within the OTP, we conducted a pilot study to assess acceptance of and satisfaction with telemedicine among 45 HCV-infected opioid use disorder (OUD) patients on methadone. Materials and Methods: We administered a modified 11-item telemedicine satisfaction questionnaire after the initial HCV telemedicine evaluation, when initiating HCV treatment, and 3 months post-HCV treatment completion. Among a patient subset, a semistructured interview further assessed issues of participant referral to the telemedicine program as well as convenience and confidentiality with the telemedicine encounters. Results: Patients demonstrated their acceptance of telemedicine-based encounters by referral of additional participants. They highlighted the convenience of on-site treatment with a liver specialist through recognition of the benefit of "one-stop shopping." They also expressed confidence in the privacy and confidentiality of telemedicine encounters. Discussion: In this pilot study, telemedicine appears to be well accepted as a modality for HCV management among OUD patients on methadone. Virtual integration of medical and behavioral therapy through telemedicine warrants further investigation for its use in this population. Conclusions: In this pilot study, we found that a largely racial minority population of substance users grew to accept telemedicine over time with diminished privacy and confidentiality concerns. Telemedicine was well accepted within the OTP community as reflected by participant referral to the program.

Using New and Innovative Technologies to Assess Clinical Stage in Early Intervention Youth Mental Health Services: Evaluation Study

Background

Globally there is increasing recognition that new strategies are required to reduce disability due to common mental health problems. As 75% of mental health and substance use disorders emerge during the teenage or early adulthood years, these strategies need to be readily accessible to young people. When considering how to provide such services at scale, new and innovative technologies show promise in augmenting traditional clinic-based services.

Objective

The aim of this study was to test new and innovative technologies to assess clinical stage in early intervention youth mental health services using a prototypic online system known as the Mental Health eClinic (MHeC).

Methods

The online assessment within the MHeC was compared directly against traditional clinician assessment within 2 Sydney-based youth-specific mental health services (headspace Camperdown and headspace Campbelltown). A total of 204 young people were recruited to the study. Eligible participants completed both face-to-face and online assessments, which were randomly allocated and counterbalanced at a 1-to-3 ratio. These assessments were (1) a traditional 45- to 60-minute headspace face-to-face assessment performed by a Youth Access Clinician and (2) an approximate 60-minute online assessment (including a self-report Web-based survey, immediate dashboard of results, and a video visit with a clinician). All assessments were completed within a 2-week timeframe from initial presentation.

Results

Of the 72 participants who completed the study, 71% (51/72) were female and the mean age was 20.4 years (aged 16 to 25 years); 68% (49/72) of participants were recruited from headspace Camperdown and the remaining 32% (23/72) from headspace Campbelltown. Interrater agreement of participants’ stage, as determined after face-to-face assessment or online assessment, demonstrated fair agreement (kappa=.39, P<.001) with concordance in 68% of cases (49/72). Among the discordant cases, those who were allocated to a higher stage by online raters were more likely to report a past history of mental health disorders (P=.001), previous suicide planning (P=.002), and current cannabis misuse (P=.03) compared to those allocated to a lower stage.

Conclusions

The MHeC presents a new and innovative method for determining key clinical service parameters. It has the potential to be adapted to varied settings in which young people are connected with traditional clinical services and assist in providing the right care at the right time.

Rural Assertive Community Treatment and Telepsychiatry

Assertive community treatment (ACT) is an evidence-based treatment for patients with severe and persistent mental illness. ACT has been shown to reduce inpatient hospitalization and is increasingly being used as a mainstay of evidence-based psychiatric practice for these clinical populations. The increasing implementation of evidence-based practices has led to the expansion of ACT in rural areas. Variability in the adaptation of ACT in rural areas has included accommodation by teams to multiple barriers. One way to increase psychiatric professional efficiency in rural areas is with telepsychiatry and possibly with rural ACT, but with unknown effects on fidelity and outcomes. Telepsychiatry has been considered a means of expanding the reach of and access to ACT. Concerns about the use of telepsychiatry by ACT teams include the psychiatrist's ability to develop a relationship with patients and staff and difficulties observing the patient's entire living environment via telemedicine. The Piedmont Community Services Board (CSB) Program for Assertive Community Treatment (PACT) serves patients in southwestern Virginia in collaboration with the Virginia Tech Carilion School of Medicine. The Piedmont CSB PACT uses telemedicine to expand the treating psychiatrist's reach and contact with PACT patients, increasing the efficiency of the psychiatrist's PACT time. Telemedicine is used for crisis intervention and augmentation of regular ongoing visits. The goals of this project were to measure patient, staff, and psychiatrist comfort and satisfaction with the use of telepsychiatry in ACT in addition to monitoring routine outcome measures.

Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

WHAT IS KNOWN ON THE SUBJECT

There is a move towards the use of new ways of delivering mental health care, particularly via an increased use of telephone therapies. Although some studies have noted the advantages of telephone-delivered therapies (e.g., removing access barriers) and reported on equivalent therapeutic effects when compared to face-to-face, there are concerns about how telephone-based therapy adversely affects the therapeutic relationship.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

It contributes new knowledge regarding psychological practitioners' experience and views about using telephone-based therapies and how this affects the therapeutic relationship.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper provides data about the new practitioner workforce (IAPT Psychological Wellbeing Practitioners) and adds to a growing area of research regarding their clinical role. It has relevance for mental health nursing, because health services internationally and across the professions are exploring how telehealth can improve health care. This paper suggests that mental health services need to focus on what type of therapeutic relationship their practice facilitates and on offering transparency to service users. It concludes that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to focus on what facilitates and inhibits deeper therapeutic closeness and connection.

ABSTRACT

Introduction Over-the-telephone (OTT)-delivered psychological therapies as an alternative method to face-to-face (F2F) are becoming more prevalent in mental health care. Research suggests a range of benefits of OTT use in therapy, but there are growing concerns about its consequences for the therapeutic relationship. This paper presents new knowledge regarding psychological practitioners' experience and views of OTT work and its potential effects on the therapeutic relationship in the context of the UK's Increasing Access to Psychological Therapy (IAPT) programme. Aim This paper presents IAPT practitioners' experiences and views of OTT work and its potential effects on the therapeutic relationship. Methods Completed questionnaires (exploring OTT versus F2F work) which were distributed to IAPT practitioners revealed a concern about the therapeutic relationship in OTT. To explore this further, nine in-depth semi-structured interviews with PWPs were conducted and the findings from this qualitative study are reported here. Results Practitioners noted OTT use facilitated access and flexibility for service users; however, they expressed some concern over the adverse effect of OTT on the therapeutic relationship. Discussion Although a working alliance was possible OTT, this research suggests the type of therapeutic relationship formed OTT in a "low contact-high volume" service such as IAPT needs to be better defined. By addressing this, dissonance which might arise between practitioner aims and the aims of IAPT can be reduced. This research also contributes to wider debates regarding mental health care and its provision in the UK. Implications for practice This paper concludes that mental health services need to focus on what type of therapeutic relationship their practice facilitates and to offer transparency to service users. The findings suggest that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to offer a more nuanced understanding of the concept of a therapeutic relationship and focus on what facilitates and inhibits deeper therapeutic closeness and connection.

Telepsychiatry in Integrated Care Settings

The objective of this article is to inform psychiatrists and other mental health professionals and primary care providers about the role of telepsychiatry in facilitating integrated care models, particularly in remote primary care practices. A narrative literature review was conducted to highlight the evidence and challenges of using telepsychiatry for integrated care. Telepsychiatry uses communication technologies to facilitate audiovisual interaction between patients and care teams to deliver services and expertise across distances and practice settings. It is particularly suited for integrated care settings, if business model innovations such as collaborative care models are implemented alongside to improve the access and delivery of care to patients. Telepsychiatry has been shown to be equivalent to face-to-face evaluations and, in certain instances, may lead to better outcomes in integrated care settings. Several challenges of adopting telepsychiatry in real practice are highlighted, including reimbursement and licensing across states, which continue to be an important barrier. It is critical to use an established framework to understand the potential users of telepsychiatry and develop and promote competency-based telepsychiatry training for novice, competent, and expert users. Psychiatrists who want to extend their expertise to distant sites, improve access to care, and partake in the new business models of collaborative care will need to consider these benefits and challenges.

A comparison of problem identification interviews conducted face-to-face and via videoconferencing using the consultation analysis record

School psychologists who experience challenges delivering face-to-face consultation may utilize videoconferencing to facilitate their consultation activities. Videoconferencing has been found to be an effective method of service delivery in related fields and emerging research suggests that it may be effective for providing teacher training and support in school settings. In this exploratory investigation, we used the Consultation Analysis Record (Bergan & Tombari, 1975) and its four indices to assess the effectiveness of conducting problem identification interviews via videoconferencing versus face-to-face. Overall, findings indicated significant differences across these two conditions, with videoconference interviews coded as having higher indices of content relevance, process effectiveness, and message control, but lower content focus, compared to face-to-face interviews. As these indices have been positively associated with favorable consultation outcomes, the results provide initial support for the effectiveness of consultation delivered via videoconferencing.

Telepsychiatry in India - Where Do We Stand? A Comparative Review between Global and Indian Telepsychiatry Programs

A wide discrepancy exists in India between the existing mental healthcare repertoire and the alarmingly high burden of individuals requiring immediate attention from requisite mental healthcare services. Providing equitable mental healthcare across a vast country characterized by profound cultural variations and territorial caveats has remained a major public health concern. Against this gloomy backdrop, the emergence of distant communications technology offers solace and optimism as an ingenious approach to bridge the existing gap between clients and mental health professionals. Using inexpensive equipment and basic technical knowhow, telepsychiatry expands the scope of the discipline to distant and hazy suburbs and villages from its urban centers of excellence. The current academic endeavor intends to perform a systematic review of relevant literature from India as well as from other countries. The various models of telepsychiatry-both asynchronous and synchronous models-in practice have been elaborated on with a focus on effectiveness, feasibility and acceptability of this latest modality. A sincere attempt to chronicle the remarkable journey of telepsychiatry in India, beginning in the dawn of the 21^st century to the current Indian scenario, has been made. The legal and ethical issues, along with a few words of caution and contemplation, have been briefly touched on. A set of recommendations has been provided with the hope that policy makers and administrators in the domain of mental health may benefit from them. It is anticipated that telepsychiatry will be adequately utilized in India to tackle the raging menace of inadequate mental healthcare services.

Telepsychiatry as an Economically Better Model for Reaching the Unreached: A Retrospective Report from South India

AIM

In a resource-poor country such as India, telepsychiatry could be an economical method to expand health-care services. This study was planned to compare the costing and feasibility of three different service delivery models. The end user was a state-funded long-stay Rehabilitation Center (RC) for the homeless.

METHODOLOGY

Model A comprised patients going to a tertiary care center for clinical care, Model B was community outreach service, and Model C comprised telepsychiatry services. The costing included expenses incurred by the health system to complete a single consultation for a patient on an outpatient basis. It specifically excluded the cost borne by the care-receiver. No patients were interviewed for the study.

RESULTS

The RC had 736 inmates, of which 341 had mental illness of very long duration. On comparing the costing, Model A costed 6047.5 INR (100$), Model B costed 577.1 INR (9.1$), and Model C costed 137.2 INR (2.2$). Model C was found fifty times more economical when compared to Model A and four times more economical when compared to Model B.

CONCLUSION

Telepsychiatry services connecting tertiary center and a primary health-care center have potential to be an economical model of service delivery compared to other traditional ones. This resource needs to be tapped in a better fashion to reach the unreached.

A Systematic Review of the Economic Evaluation of Telemedicine in Japan

Objectives:

There is no systematic review on economic evaluations of telemedicine in Japan, despite over 1000 trials implemented. Our systematic review aims to examine whether Japan’s telemedicine is cost-saving or cost-effective, examine the methodological rigorousness of the economic evaluations, and discuss future studies needed to improve telemedicine’s financial sustainability.

Methods:

We searched five databases, including two Japanese databases, to find peer-reviewed articles published between January 1, 2000 and December 31, 2014 in English and Japanese that performed economic evaluations of Japan’s telemedicine programs. The methodological rigorousness of the economic analyses was assessed with a well-established checklist. We calculated the benefit-to-cost ratio (BCR) when a reviewed study reported related data but did not report the BCR. All cost values were adjusted to 2014 US dollars.

Results:

Among the 17 articles identified, six studies reported on settings connecting physicians for specialist consultations, and eleven studies on settings connecting healthcare providers and patients at home. There are three cost-benefit analyses and three cost-minimization analyses. The remaining studies measured the benefit of telemedicine only, using medical expenditure saved or users’ willingness-to-pay. There was substantial diversity in the methodological rigorousness. Studies on teledermatology and teleradiology indicated a favorable level of economic efficiency. Studies on telehomecare gave mixed results. One cost-benefit analysis on telehomecare indicated a low economic efficiency, partly due to public subsidy rules, e.g., a too short budget period.

Conclusions:

Overall, telemedicine programs in Japan were indicated to have a favorable level of economic efficiency. However, the scarcity of the economic literature indicates the need for further rigorous economic evaluation studies.

Home-based clinical video teleconferencing care: Clinical considerations and future directions

Clinical video teleconferencing (CVT) is a treatment delivery modality that can be used to provide services to clinical populations that experience barriers to accessing mental health care. Recently, home-based CVT (HBCVT) has been developed in order to deliver treatment via CVT to patients in their homes. A number of clinical considerations, including the appropriate clinical population and individual patient factors, need to be taken into account when delivering CVT. Particular challenges can exist when setting up the home environment for HBCVT. Concerns about maintaining patient privacy while living in shared spaces, ensuring adequate CVT technology in the patient's home, and conducting risk management remotely are important to consider when delivering treatment via CVT. Since treatments delivered via CVT are often conducted across state lines, novel ethical and legal issues such as privacy laws, licensing of providers, prescribing practices, and insurance reimbursements need to be addressed when conducting services via these modalities. Future research on HBCVT will provide researchers and clinicians with information regarding which patients are most appropriate for treatment delivered via this modality and help further develop evidence for the cost-effectiveness of CVT and HBCVT clinical practice guidelines.

[Cost-effectiveness of Synchronous vs. Asynchronous Telepsychiatry in Prison Inmates With Depression]

INTRODUCTION

Telepsychiatry is defined as the use of information and communication technology (ICT) in providing remote psychiatric services. Telepsychiatry is applied using two types of communication: synchronous (real time) and asynchronous (store and forward).

OBJECTIVE

To determine the cost-effectiveness of a synchronous and an asynchronous telepsychiatric model in prison inmate patients with symptoms of depression.

METHODS

A cost-effectiveness study was performed on a population consisting of 157 patients from the Establecimiento Penitenciario y Carcelario de Mediana Seguridad de Manizales, Colombia. The sample was determined by applying Zung self-administered surveys for depression (1965) and the Hamilton Depression Rating Scale (HDRS), the latter being the tool used for the comparison.

RESULTS

Initial Hamilton score, arrival time, duration of system downtime, and clinical effectiveness variables had normal distributions (P>.05). There were significant differences (P<.001) between care costs for the different models, showing that the mean cost of the asynchronous model is less than synchronous model, and making the asynchronous model more cost-effective.

CONCLUSIONS

The asynchronous model is the most cost-effective model of telepsychiatry care for patients with depression admitted to a detention centre, according to the results of clinical effectiveness, cost measurement, and patient satisfaction.