Rural telepsychiatry is economically unsupportable: the Concorde crashes in a cornfield

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.

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.

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.

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.

Telepsychiatry Program for Rural Victims of Domestic Violence

Domestic violence is a significant public health problem and is correlated with serious mental and physical disorders. Victims' fear and isolation seriously limit access to psychiatric evaluation and treatment. Telemedicine provides a means to overcome these obstacles. This article describes a telemedicine program that provides psychiatric screening, evaluation, treatment, and referral for ongoing care to clients of a rural women's crisis center. Psychiatric evaluation and treatment were provided to a rural women's shelter program using telepsychiatry. The shelter program had difficulty accessing traditional mental health service. All new clients entering the program were screened for mental health problems. Those requiring further evaluation received a physical examination with medical history and initial psychological interview on site, followed by psychiatric evaluation by videoconference. Appropriate treatment was initiated, and referral for ongoing psychiatric care through the local community mental health clinic was arranged. Of the 38 women referred for mental health services by clinic staff, 35 completed a psychiatric evaluation using telepsychiatry and 31 entered treatment. The most commonly identified disorders were anxiety and major affective disorders, followed by substance use disorders. Telepsychiatry can provide rapid crisis intervention and effective mental health services to victims of domestic violence in a rural setting.

Cost effectiveness of telemedicine for the delivery of outpatient pulmonary care to a rural population

The objective of this study was to determine the cost effectiveness of outpatient pulmonary subspecialty consultations via telemedicine. A decision-analytic model was used to compare the cost effectiveness of providing outpatient telemedicine pulmonary consultations with alternative treatment methods. Model options included: (1) telemedicine, (2) routine care (patients travel from a remote site to the hub site to receive care), and (3) on-site care (patients receive care at the remote site). Cost and effectiveness data from the Milwaukee and Iron Mountain Veterans Affairs Medical Centers (VAMC) telepulmonary program were collected for a period of 1 year. The cost-effectiveness analysis was conducted from a societal perspective. Average and incremental cost-effectiveness ratios were calculated together with sensitivity analysis. Telemedicine was found to be more cost effective ($335 per patient/year) compared to routine care ($585 per patient/year) and on-site care ($1,166 per patient/year). Sensitivity analysis revealed that cost effectiveness of telemedicine was sensitive to changes in the values for the number of patients, probability of successful telemedicine consultation, telemedicine equipment cost, utility of telemedicine, and percentage effort assigned to the on-site pulmonary physician. Telemedicine is a cost-effective alternative for the delivery of outpatient pulmonary care for rural populations with limited access to subspecialty services. Cost effectiveness of telemedicine is related to three major factors: cost sharing, i.e., adequate patient volume and sharing of telemedicine infrastructure amongst various clinical users; effectiveness of telemedicine in terms of patient utility and successful clinical consultations; and indirect cost savings accrued by decreasing cost of patients' lost productivity.

Telepsychiatry: an overview for psychiatrists

Telepsychiatry, in the form of videoconferencing and other modalities, brings enormous opportunities for clinical care, education, research and administration to the field of medicine. A comprehensive review of the literature related to telepsychiatry - specifically videoconferencing - was conducted using the MEDLINE, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases (1965 to June 2001). The keywords used were telepsychiatry, telemedicine, videoconferencing, Internet, primary care, education, personal digital assistant and handheld computers. Studies were selected for review if they discussed videoconferencing for patient care, satisfaction, outcomes, education and costs, and provided models of facilitating clinical service delivery. Literature on other technologies was also assessed and compared with telepsychiatry to provide an idea of future applications of technology. Published data indicate that telepsychiatry is successfully used for a variety of clinical services and educational initiatives. Telepsychiatry is generally feasible, offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behaviour. More quantitative and qualitative research is warranted with regard to the use of telepsychiatry in clinical and educational programmes and interventions.

A rural mental health research agenda: defining context and setting priorities

This article provides a brief overview of research perspectives on rural mental health services and suggests the importance of building an agenda to bring coherence to studies in this area. The need for sound theory and methodology to guide research is emphasized. The importance of better conceptualization of the rural context as a focus of research is addressed, and 14 propositions concerning issues the authors think will advance rural research are presented. This article is intended to stimulate discussion about a research agenda that will lead to better understanding of rural needs for mental health services as well as more responsive service models.

Telepsychiatry in the heartland: if we build it, will they come?

The quality of care provided by telemedicine and its acceptability to persons who live in rural areas is largely undetermined. In this study, service satisfaction and functional status in persons using telemedicine was compared to those receiving face-to-face services at two rural sites over a 2-year study period. Similar ratings of satisfaction and clinical status were observed in twelve patients who received services under both modalities. Although there are many obstacles to successful program implementation, telepsychiatry appears to offer an acceptable and adequate alternative mode of service delivery to persons who live in rural areas.

Telepsychiatry and geriatric care

The use of telecommunications--telephone, computer, videoconferencing equipment--to provide mental health services at a distance has grown rapidly. This review encompasses reports from programs that provide telepsychiatry services, including telephone- and computer- based education and support services, telephone screening for dementia, and the use of videoconferencing to provide psychiatric consultations, health education, and administrative support. The extensive experience to date supports the value of telepsychiatry. Applications in geriatric settings and research involving geriatric subjects are reviewed. Cost analyses and economic evaluations of telepsychiatry are preliminary at this time and need further refinement. There is great potential for using telecommunications to expand access to mental health services to underserved geriatric populations.

Telepsychiatry in psychogeriatric service: a pilot study

A pilot study on telepsychiatry was conducted in which a videoconferencing link was established between a regional hospital and a care and attention home. Using this system, a psychogeriatric outreach team provided 149 psychiatric assessments to 45 residents of the care and attention home over 11 months. Videoconferencing was found to be highly feasible. It was acceptable to staff and patients and more cost-effective than on-site visits.

What do we really know about the cost-effectiveness of telemedicine?

Telemedicine is still in its infancy, but undergoing rapid development. It is very difficult to evaluate telemedicine. We performed a literature survey (Medline). During the period 1990-8, over 1500 articles on telemedicine were published. Of these, 246 mentioned economic aspects in the abstract (16%). We selected 29 studies although few had demonstrated cost-effectiveness. Benefits for the patients in the form of reduced travel and waiting time must often be weighed against increased provider costs. Up to now, telemedicine in general has not had any significant effect on medical practice, or the structure and organization of health-care. In order to utilize the potential of telemedicine, its integration with traditional health-care is very important. There are country-specific variations in the health systems that make it difficult to generalize the results from one country to another.