Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service

Comparative effectiveness of in-person vs. remote delivery of the Common Elements Treatment Approach for addressing mental and behavioral health problems among adolescents and young adults in Zambia: protocol of a three-arm randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed.

METHODS

This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3-4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context.

DISCUSSION

Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 2021.

[Online psychotherapy in times of coronavirus disease 2019]

Theoretischer Hintergrund

In Reaktion auf die durch die „coronavirus disease 2019“ (COVID-19) verursachte Pandemie konnte Psychotherapie im Einzelsetting in Deutschland unbegrenzt online durchgeführt werden. Haltungen und Erfahrungen von Psychotherapeuten (PT) bezüglich Onlinetherapie (OT) wurden jedoch allgemein und besonders mit Blick auf die Pandemiesituation bislang wenig untersucht.

Ziel der Arbeit

Ziele der Studie waren, 1) die Nutzungshäufigkeit von OT während des ersten Lockdowns, 2) die Zufriedenheit mit OT vs. „Face-to-face“-Therapie sowie 3) die Technologieakzeptanz und -erfahrung insgesamt und in Abhängigkeit vom Richtlinienverfahren zu untersuchen.

Material und Methode

Deutsche PT (approbiert und in Ausbildung; verhaltenstherapeutisch [VT, 45,6 %], tiefenpsychologisch [TP, 34,5 %], analytisch [AP, 14 %], systemisch [SYS, 5,8 %]) wurden mithilfe einer Onlineerhebung zu demografischen und therapeutischen Daten, durchgeführter OT, Zufriedenheit mit OT vs. Face-to-face-Therapie (Zufriedenheitsfragebogens für Therapeuten, ZUF-THERA) und Technologieakzeptanz (Unified Theory of Acceptance and Use of Technology 2 Questionnaire, UTAUT) befragt.

Ergebnisse

Die 174 teilnehmenden Therapeuten (Alter M = 44,73 Jahre, SD ± 12,79; 81,6 % Frauen) gaben an, dass der durchschnittliche Anteil von OT an der gesamten therapeutischen Tätigkeit während des Lockdowns 43,09 % betrug, wobei sich signifikante Unterschiede zwischen den Richtlinienverfahren zeigten (TP, VT > AP). Die Zufriedenheit mit OT erwies sich als signifikant niedriger als mit Face-to-face-Therapien und unterschied sich zwischen den Verfahren nicht. Vorerfahrungen mit OT hatten insgesamt 23,6 % der Therapeuten und vermehrt systemisch arbeitende im Vergleich zu VT- oder AP-Therapeuten. Verhaltenstherapeuten gaben häufiger an, Spaß an der OT zu haben, als TP- und APler. Auch nahmen sie einen stärkeren sozialen Einfluss (beispielsweise durch Kollegen) bei der Nutzung von OT wahr als die TPler.

Schlussfolgerung

Die Nutzungshäufigkeit von OT nahm während des ersten Lockdowns (März bis Mai 2020) sprunghaft zu (43 %, zum Vergleich das frühere Abrechnungslimit der Krankenkassen: 20 %). Die Zufriedenheit mit der OT war prinzipiell hoch, jedoch signifikant niedriger als mit Face-to-face-Therapien. Weiterführende Untersuchungen, die die Gründe im Detail analysieren, werden dringend angeraten.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

A systematic review of providers' attitudes toward telemental health via videoconferencing

Telemental health conducted via videoconferencing (TMH-V) has the potential to improve access to care, and providers' attitudes toward this innovation play a crucial role in its uptake. This systematic review examined providers' attitudes toward TMH-V through the lens of the unified theory of acceptance and use of technology (UTAUT). Findings suggest that providers have positive overall attitudes toward TMH-V despite describing multiple drawbacks. Therefore, the relative advantages of TMH-V, such as its ability to increase access to care, may outweigh its disadvantages, including technological problems, increased hassle, and perceptions of impersonality. Providers' attitudes may also be related to their degree of prior TMH-V experience, and acceptance may increase with use. Limitations and implications of findings for implementation efforts are discussed.

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination

BACKGROUND

Childhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam.

OBJECTIVE

To explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology.

PARTICIPANTS AND SETTING

Caregivers and adolescents who presented for a child sexual abuse medical evaluation at our county's child advocacy center.

METHODS

We completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached.

RESULTS

There was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system.

CONCLUSION

Telemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.

Clinical Update: Telepsychiatry With Children and Adolescents

This Clinical Update reviews the use of telepsychiatry to deliver psychiatric, mental health, and care coordination services to children and adolescents across settings as direct service and in collaboration with primary care providers or other clinicians. The update defines terms and presents the current status of telepsychiatry as a mode of health service delivery. The update presents procedures for conducting telepsychiatry services and optimizing the clinical experience.

From pilot to permanent service: ten years of paediatric telepsychiatry

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

Review of key telepsychiatry outcomes

AIM

To conduct a review of the telepsychiatry literature.

METHODS

We conducted a systematic search of the literature on telepsychiatry using the search terms, "telepsychiatry", "telemental health", "telecare", "telemedicine", "e-health", and "videoconferencing". To meet criteria for inclusion, studies had to: (1) be published in a peer-reviewed journal after the year 2000; (2) be written in English; (3) use videoconferencing technology for the provision of mental health assessment or treatment services; and (4) use an adequately-powered randomized controlled trial design in the case of treatment outcome studies. Out of 1976 studies identified by searches in PubMed (Medline database), Ovid medline, PsychInfo, Embase, and EBSCO PSYCH, 452 met inclusion criteria. Studies that met all inclusion criteria were organized into one of six categories: (1) satisfaction; (2) reliability; (3) treatment outcomes; (4) implementation outcomes; (5) cost effectiveness; and (6) and legal issues. All disagreements were resolved by reassessing study characteristics and discussion.

RESULTS

Overall, patients and providers are generally satisfied with telepsychiatry services. Providers, however, tend to express more concerns about the potentially adverse of effects of telepsychiatry on therapeutic rapport. Patients are less likely to endorse such concerns about impaired rapport with their provider. Although few studies appropriately employ non-inferiority designs, the evidence taken together suggests that telepsychiatry is comparable to face-to-face services in terms of reliability of clinical assessments and treatment outcomes. When non-inferiority designs were appropriately used, telepsychiatry performed as well as, if not better than face-to-face delivery of mental health services. Studies using both rudimentary and more sophisticated methods for evaluating cost-effectiveness indicate that telepsychiatry is not more expensive than face-to-face delivery of mental health services and that telepsychiatry is actually more cost-effective in the majority of studies reviewed. Notwithstanding legal concerns about loss of confidentiality and limited capacity to respond to psychiatric emergencies, we uncovered no published reports of these adverse events in the use of telepsychiatry.

CONCLUSION

A large evidence base supports telepsychiatry as a delivery method for mental health services. Future studies will inform optimal approaches to implementing and sustaining telepsychiatry services.

Comparing in-person to videoconference-based cognitive behavioral therapy for mood and anxiety disorders: randomized controlled trial

Background

Cognitive-behavioral therapy (CBT) has demonstrated efficacy and effectiveness for treating mood and anxiety disorders. Dissemination of CBT via videoconference may help improve access to treatment.

Objective

The present study aimed to compare the effectiveness of CBT administered via videoconference to in-person therapy for a mixed diagnostic cohort.

Methods

A total of 26 primarily Caucasian clients (mean age 30 years, SD 11) who had a primary Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) diagnosis of a mood or anxiety disorder were randomly assigned to receive 12 sessions of CBT either in-person or via videoconference. Treatment involved individualized CBT formulations specific to the presenting diagnosis; all sessions were provided by the same therapist. Participants were recruited through a university clinic. Symptoms of depression, anxiety, stress, and quality of life were assessed using questionnaires before, after, and 6 weeks following treatment. Secondary outcomes at posttreatment included working alliance and client satisfaction.

Results

Retention was similar across treatment conditions; there was one more client in the videoconferencing condition at posttreatment and at follow-up. Statistical analysis using multilevel mixed effects linear regression indicated a significant reduction in client symptoms across time for symptoms of depression (P<.001, d=1.41), anxiety (P<.001, d=1.14), stress (P<.001, d=1.81), and quality of life (P<.001, d=1.17). There were no significant differences between treatment conditions regarding symptoms of depression (P=.165, d=0.37), anxiety (P=.41, d=0.22), stress (P=.15, d=0.38), or quality of life (P=.62, d=0.13). There were no significant differences in client rating of the working alliance (P=.53, one-tailed, d=–0.26), therapist ratings of the working alliance (P=.60, one-tailed, d=0.23), or client ratings of satisfaction (P=.77, one-tailed, d=–0.12). Fisher’s Exact P was not significant regarding differences in reliable change from pre- to posttreatment or from pretreatment to follow-up for symptoms of depression (P=.41, P=.26), anxiety (P=.60, P=.99), or quality of life (P=.65, P=.99) but was significant for symptoms of stress in favor of the videoconferencing condition (P=.03, P=.035). Difference between conditions regarding clinically significant change was also not observed from pre- to posttreatment or from pretreatment to follow-up for symptoms of depression (P=.67, P=.30), anxiety (P=.99, P=.99), stress (P=.19, P=.13), or quality of life (P=.99, P=.62).

Conclusions

The findings of this controlled trial indicate that CBT was effective in significantly reducing symptoms of depression, anxiety, and stress and increasing quality of life in both in-person and videoconferencing conditions, with no significant differences being observed between the two.

Trial Registration

Australian New Zealand Clinical Trials Registry ID: ACTRN12609000819224; http://www.anzctr.org.au/ACTRN12609000819224.aspx (Archived by WebCite at http://www.webcitation.org/6Kz5iBMiV).

Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review

Rural communities face tremendous challenges in accessing mental health and substance abuse treatment services. Some of the most promising advancements in the delivery of rural health care services have been in the area of telecommunication technology. These applications have the potential to reduce the disparities in the delivery of substance abuse and mental health services between urban and rural communities. The purpose of this inquiry was to explore the advances and uses of telecommunications technology, and related issues, in the delivery of mental health and substance abuse treatment services within rural areas. A review of the academic literature and other relevant works was conducted and the content was organized into four major themes: (a) advantages of telehealth and applications to rural practice, (b) barriers to implementation in rural practice, (c) utilization in rural areas, and (d) areas for further research.

Effectiveness and impact of networked communication interventions in young people with mental health conditions: a systematic review

OBJECTIVE

Examine the effectiveness and impacts of the networked communication technologies used by health care professionals for the treatment of adolescents/young adults with mental health disorders.

METHODS

Nine electronic databases were searched. Quantitative and qualitative study designs were included, technologies were described and a narrative synthesis of all included studies was undertaken.

RESULTS

20,925 papers were identified from which 12 interventions met the inclusion criteria. Three categories of networked communication were identified: email and/or web-based electronic diary (n=6); videoconference (n=5); and virtual reality (n=1). Three studies reported statistically significant improvements in symptoms post intervention; all involved email communication. Patients were willing to use networked communication in routine care in nine studies.

CONCLUSIONS

Networked communication technologies can increase the opportunity for communication between patient and health care professionals. Limited improvements in quality of life and continuity of care for patients were reported. Patients and health care professionals expressed some satisfaction with technologies. Further research exploring concerns over privacy and security is needed.

PRACTICE IMPLICATIONS

Networked communication technologies have the potential to be a useful addition to mental health services delivery, however the impact and effectiveness of these technologies is inconclusive.

Young people's views on the potential use of telemedicine consultations for sexual health: results of a national survey

BACKGROUND

Young people are disproportionately affected by sexually transmissible infections in Australia but face barriers to accessing sexual health services, including concerns over confidentiality and, for some, geographic remoteness. A possible innovation to increase access to services is the use of telemedicine.

METHODS

Young people's (aged 16-24) pre-use views on telephone and webcam consultations for sexual health were investigated through a widely-advertised national online survey in Australia. Descriptive statistics were used to describe the study sample and chi-square, Mann-Whitney U test, or t-tests were used to assess associations. Multinomial logistic regression was used to explore the association between the three-level outcome variable (first preference in person, telephone or webcam, and demographic and behavioural variables); odds ratios and 95%CI were calculated using in person as the reference category. Free text responses were analysed thematically.

RESULTS

A total of 662 people completed the questionnaire. Overall, 85% of the sample indicated they would be willing to have an in-person consultation with a doctor, 63% a telephone consultation, and 29% a webcam consultation. Men, respondents with same-sex partners, and respondents reporting three or more partners in the previous year were more willing to have a webcam consultation. Imagining they lived 20 minutes from a doctor, 83% of respondents reported that their first preference would be an in-person consultation with a doctor; if imagining they lived two hours from a doctor, 51% preferred a telephone consultation. The main objections to webcam consultations in the free text responses were privacy and security concerns relating to the possibility of the webcam consultation being recorded, saved, and potentially searchable and retrievable online.

CONCLUSIONS

This study is the first we are aware of that seeks the views of young people on telemedicine and access to sexual health services. Although only 29% of respondents were willing to have a webcam consultation, such a service may benefit youth who may not otherwise access a sexual health service. The acceptability of webcam consultations may be increased if medical clinics provide clear and accessible privacy policies ensuring that consultations will not be recorded or saved.

Health information technology to facilitate communication involving health care providers, caregivers, and pediatric patients: a scoping review

BACKGROUND

Pediatric patients with health conditions requiring follow-up typically depend on a caregiver to mediate at least part of the necessary two-way communication with health care providers on their behalf. Health information technology (HIT) and its subset, information communication technology (ICT), are increasingly being applied to facilitate communication between health care provider and caregiver in these situations. Awareness of the extent and nature of published research involving HIT interventions used in this way is currently lacking.

OBJECTIVE

This scoping review was designed to map the health literature about HIT used to facilitate communication involving health care providers and caregivers (who are usually family members) of pediatric patients with health conditions requiring follow-up.

METHODS

Terms relating to care delivery, information technology, and pediatrics were combined to search MEDLINE, EMBASE, and CINAHL for the years 1996 to 2008. Eligible studies were selected after three rounds of duplicate screening in which all authors participated. Data regarding patient, caregiver, health care provider, HIT intervention, outcomes studied, and study design were extracted and maintained in a Microsoft Access database. Stage of research was categorized using the UK's Medical Research Council (MRC) framework for developing and evaluating complex interventions. Quantitative and qualitative descriptive summaries are presented.

RESULTS

We included 104 eligible studies (112 articles) conducted in 17 different countries and representing 30 different health conditions. The most common conditions were asthma, type 1 diabetes, special needs, and psychiatric disorder. Most studies (88, 85%) included children 2 to 12 years of age, and 73 (71%) involved home care settings. Health care providers operated in hospital settings in 96 (92%) of the studies. Interventions featured 12 modes of communication (eg, Internet, intranets, telephone, video conferencing, email, short message service [SMS], and manual downloading of information) used to facilitate 15 categories of functions (eg, support, medication management, education, and monitoring). Numerous patient, caregiver, and health care relevant outcomes have been measured. Most outcomes concerned satisfaction, use, usability, feasibility, and resource use, although behavior changes and quality of life were also reported. Most studies (57 studies, 55%) were pilot phase, with a lesser proportion of development phase (24 studies, 23%) and evaluation phase (11 studies, 11%) studies. HIT interventions addressed several recurring themes in this review: establishing continuity of care, addressing time constraints, and bridging geographical barriers.

CONCLUSIONS

HIT used in pediatric care involving caregivers has been implemented differently in a range of disease settings, with varying needs influencing the function, form and synchronicity of information transfer. Although some authors have followed a phased approach to development, evaluation and implementation, a greater emphasis on methodological standards such as the MRC guidance for complex interventions would produce more fruitful programs of development and more useful evaluations in the future. This review will be especially helpful to those deciding on areas where further development or research into HIT for this purpose may be warranted.

Professional opinions of the use of telemedicine in child & adolescent psychiatry

The Telemedicine project at Yorkhill Hospital, Glasgow was set up in 2004 to aid in the rapid diagnosis of children at a distant location. The Child and Adolescent Mental Health Services (CAMHS) are now the largest users. CAMHS use this service for clinical work, service development and to aid research. Twenty four CAMHS professionals with experience of the telemedicine facility were asked to complete questionnaires outlining their opinions on the strengths and weaknesses of the facility; 19 responded. The results showed a wide variety of professionals use the facility and that clinical work makes up the majority of the use. An advantage to rural populations in Scotland was considered the most important benefit. Saving time and an improved method of communication were also highlighted as important. Failure of technology and problems with sound quality were highlighted as drawbacks. Seventy nine percent of subjects stated that they preferred Telemedicine to Telephone conferencing. The results show the Telemedicine facility is perceived as a positive addition to CAMHS in Scotland. Therefore, its use should be encouraged in other areas of medicine and surgery.

Telemedicine in children and adolescents

Psychiatric care for children and adolescents is limited in remote and underserved areas because of the shortage of child and adolescent psychiatrists. Telepsychiatry has the potential to alleviate this problem. This article reviews the procedures used to develop telepsychiatry, equipment needed for videoconferencing in telepsychiatry, benefits and limitations of telepsychiatry, and confidentiality issues in telepsychiatry. Many questions regarding confidentiality, legality, reimbursement, cost-effectiveness, and technology still need to be resolved. However, telepsychiatry has the potential to be a useful treatment alternative.

Practice parameter for telepsychiatry with children and adolescents

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

A retrospective analysis of a child and adolescent eMental Health program

OBJECTIVE

New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary care setting, particularly in rural areas of the United States and especially for children and adolescents. The aim of this study was to examine the diagnostic characteristics and outcomes for children referred for eMental Health consultations at UC Davis (videoconferencing, telephone, and secure e-mail) from 10 primary care clinics in rural northern California.

METHOD

: A retrospective analysis was conducted on the diagnostic and clinical outcomes of 139 referred children who received a full psychiatric diagnostic evaluation via videoconferencing. Within the group, a convenience sample of 58 initial and 41 three-month follow-up Child Behavior Checklists (CBCLs) was collected.

RESULTS

Comprehensive eMental Health programs appear to be effective for psychiatric diagnosis and assessment of children. Attention deficit (36.2%) and mood (28.1%) disorders were the most common diagnostic groupings overall. Most children were seen only once, but a statistically significant improvement between initial evaluation and 3-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the CBCL for girls and boys, respectively.

CONCLUSIONS

Versatile eMental Health programs, incorporating standardized checklists, may assist in diagnosis and treatment of rural children.

Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment

Although telepsychiatry in the form of videoconferencing has been well received in terms of increasing access to care and user satisfaction, few data on treatment outcomes and efficacy from telepsychiatry applications are available at the present time. This paper evaluates the efficacy of telepsychiatry through videoconference in the treatment of mental disorders by comparing to face-to-face conventional (F2FC) treatment. We carried out a randomized clinical trial where 140 psychiatric outpatients were randomized to either F2FC treatment or videoconference telepsychiatry (VCTP) treatment. Patients were diagnosed according to International Classification of Diseases, 10th edition (ICD-10) criteria using the Composite International Diagnostic Interview. Treatment involves eight consultations lasting 30 minutes over the 24-week study period. Patients received pertinent psychotropic medication plus cognitive- behavioral therapy during sessions. The same psychiatrist diagnosed and treated all the patients that were recruited from the Community Mental Health Centre of San Sebastian de la Gomera, in the Canary Islands. Change in psychiatric test scores served as the primary efficacy criterion. Efficacy was determined by comparing baseline (visit 1) Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales as well as Global Indexes (GSI, PSDI, and PST) from SCL-90R with scores obtained at the end of the study period (week 24). Response was defined as a CGI-I score of 1 or 2. Reliable Change Indexes were computed in SCL-90R Global Indexes scores. Of 140 patients randomized, 130 completed 24 weeks of treatment. Only 4 patients dropped out prematurely from the study in VCTP and 6 in F2FC. The study involves 534 teleconsultations, 522 F2FC consultations, and more than 500 hours of clinical practice. Significant improvements were found on the CGI and SCL-90- R Global Indexes scores of both treatment groups, showing clear clinical state improvement. No statistically significant differences were observed when the efficacy of VCTP treatment was compared to F2FC psychiatric treatment efficacy. This study demonstrated that telepsychiatry treatment through videoconference has equivalent efficacy to F2FC psychiatric treatment. Telepsychiatry showed to be an effective mean of delivering mental health services to psychiatric outpatients living in remote areas with limited resources.

Telemedicine and neurosciences

It is well known that in most countries there is a perennial shortage of specialists in neurosciences. The available neurologists and neurosurgeons are clustered in the metropolitan, urban areas. Those living in suburban and rural areas may have limited or no access to neurological care. Concurrently, there has been an unprecedented growth in information and communication technology (ICT). In this article, the author will demonstrate how the practice of neurosciences will change, with increasing use of telemedicine and ICT. In addition to presenting the author's personal experience, the literature on telemedicine in neurosciences is reviewed.

Willingness to use telemedicine for psychiatric care

The aim of this study was to assess potential users' willingness to use telepsychiatry and its correlates within a theoretical framework guided by the principles of social-cognitive models. The conceptual model proposed willingness to use telepsychiatry to be associated directly to attitudes toward telemedicine, attitudes toward the patient-physician relationship, and satisfaction with current medical care, and indirectly to anxiety to technology. Phone interviews were conducted with a representative sample of 1,204 Jewish, noninstitutionalized adults in Israel (mean age = 58; 51% female). Structural equation modeling was used to examine hypothesized relationships. Willingness to use telepsychiatry was relatively high and was affected by the participants' attitudes toward telemedicine, the patient-physician relationship, and by the level of anxiety toward technology. Efforts aimed at encouraging the use of telemedicine for psychiatric care should target potential users' attitudes, as well as feelings of uneasiness and anxiety regarding technology.

Treating childhood depression over videoconferencing

Effective cognitive-behavioral treatments for childhood depression have developed over the last decade, but many families face barriers to such care. Telemedicine increases access to psychological interventions by linking the child and the clinician using videoconferencing (VC). The current study evaluated an 8-week, cognitive-behavioral therapy (CBT) intervention for childhood depression either face-to-face (F2F) or over VC. The telemedicine setup included two PC-based PictureTel systems at 128 kilibits per second (kbps). Success was defined by (1) decreasing depressive symptoms at similar rates in both the VC group and the F2F group and (2) demonstrating the feasibility of a randomized controlled trial in telemental health. Children were assessed for childhood depression using the mood section of the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present Episode (K-SADS-P). Twenty-eight children were randomized to either F2F or VC treatment. The participants completed the K-SADS-P and the Children's Depression Inventory (CDI) at pre- and post-treatment. The CBT treatment across the two conditions was effective. The overall response rate based on post-evaluation with the K-SADS-P was 82%. For the CDI total score, both the Time and the Group by Time effects were significant (p < 0.05). The interaction effect reflected a faster rate of decline in the CDI total score for the VC group. The study serves as a model for building on past research to implement a randomized controlled trial. This information provides persuasive research data concerning treatment effectiveness for clinicians, families, and funders.

Telenursing: clinical nurse consultancy for rural paediatric nurses

Videoconferencing is increasingly being accepted as a medium for health-care. Telenursing is in its infancy in Australia but has enormous potential for nursing care in remote areas. The Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) began in 1997 and in its first evaluation recommended more support for paediatric nurses. CAPTOS telenursing began as a new initiative in late 2001. The telenursing project aims to link ward nurses to CAPTOS and local community teams, and to provide both clinical consultancy on nursing and interdisciplinary issues and locally based professional development. Telenursing supports nurses via site visits, videoconferencing sessions, an interactive Website and sabbatical opportunities. Telehealth works with existing services to enhance the nursing care of young people with a complex mixture of psychological and physical health problems.