Telepsychiatry: an overview for psychiatrists

Digital technology and mental health during the COVID-19 pandemic: a narrative review with a focus on depression, anxiety, stress, and trauma

The sudden appearance and devastating effects of the COVID-19 pandemic resulted in the need for multiple adaptive changes in societies, business operations and healthcare systems across the world. This review describes the development and increased use of digital technologies such as chat bots, electronic diaries, online questionnaires and even video gameplay to maintain effective treatment standards for individuals with mental health conditions such as depression, anxiety and post-traumatic stress syndrome. We describe how these approaches have been applied to help meet the challenges of the pandemic in delivering mental healthcare solutions. The main focus of this narrative review is on describing how these digital platforms have been used in diagnostics, patient monitoring and as a treatment option for the general public, as well as for frontline medical staff suffering with mental health issues.

A Scoping Review of Adult Inpatient Satisfaction with Mental Health Services

Patient satisfaction with hospital services has been increasingly discussed as an important indicator of healthcare quality. It has been demonstrated that improving patient satisfaction is associated with better compliance with treatment plans and a decrease in patient complaints regarding doctors' and nurses' misconduct. This scoping review's objective is to investigate the pertinent literature on the experiences and satisfaction of patients with mental disorders receiving inpatient psychiatric care. Our goals are to highlight important ideas and explore the data that might serve as a guide to enhance the standard of treatment and patient satisfaction in acute mental health environments. This study is a scoping review that was designed in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) statement. A systematic search was conducted in the following databases: PubMed, MEDLINE, PsycINFO, CINAHL, and EMBASE. A comprehensive review was completed, including articles from January 2012 to June 2022. Qualitative and quantitative studies were included in this review based on our eligibility criteria, such as patient satisfaction as a primary outcome, adult psychiatric inpatients, and non-review studies published in the English language. Studies were considered ineligible if they included nonpsychiatric patients or patients with neurocognitive disorders, review studies, or study measure outcomes other than inpatient satisfaction. For the eligible studies, data extraction was conducted, information was summarized, and the findings were reported. A total of 31 studies representing almost all the world's continents were eligible for inclusion in this scoping review. Different assessment tools and instruments were used in the included studies to measure the level of patients' satisfaction. The majority of the studies either utilized a pre-existing or newly created inpatient satisfaction questionnaire that appeared to be reliable and of acceptable quality. This review has identified a variety of possible factors that affect patients' satisfaction and can be used as a guide for service improvement. More than half of the included studies revealed that the following factors were strongly recommended to enhance inpatient satisfaction with care: a clear discharge plan, less coercive treatment during the hospital stay, more individualized, higher quality information and teaching about the mental disorder to patients by staff, better therapeutic relationships with staff, and specific treatment components that patients enjoy, such as physical exercise sessions and music therapy. Patients also value staff who spend more time with them. The scope of patient satisfaction with inpatient mental health services is a growing source of concern. Patient satisfaction is associated with better adherence to treatment regimens and fewer complaints against health care professionals. This scoping review has identified several patient satisfaction research gaps as well as important determinants of satisfaction and how to measure and utilize patient satisfaction as a guide for service quality improvement. It would be useful for future research and reviews to consider broadening their scope to include the satisfaction of psychiatric patients with innovative services, like peer support groups and other technologically based interventions like text for support. Future research also could benefit from utilizing additional technological tools, such as electronic questionnaires.

Teleconsultations for mental health: Recommendations from a Delphi panel

Introduction

The use of teleconsultations for mental health has drastically increased since 2020 due to the Covid19 pandemic. In the present paper, we aimed to analyze the advantages and disadvantages of teleconsultations for mental health compared to face-to-face consultations, and to provide recommendations in this domain.

Methods

The recommendations were gathered using a Delphi methodology. The expert panel (N = 21) included professionals from the health and ICT domains. They answered questions via two rounds of web surveys, and then discussed the results in a plenary meeting. Some of the questions were also shared with non-experts (N = 104).

Results

Both the experts and the non-experts with teleconsultation experience reported a general satisfaction concerning teleconsultations. A SWOT analysis revealed several strengths and opportunities of teleconsultations for mental health, but also several weaknesses and threats. The experts provided a set of practical recommendations for the preparation and organization of teleconsultations for mental health.

Discussion

Teleconsultations for mental health have the potential to allow access to care for patients in remote and isolated areas. Thus, their use will unlikely be discontinued after the end of the pandemic. In this context, we suggest that the collaboration among clinicians, researchers, and interface designers is crucial to improve usability and user experience for both clinicians and patients. The importance of teaching teleconsultation skills and informing the public on the features of teleconsultations (e.g., data privacy/security) is also highlighted.

Family carer and professional perceptions of the potential use of telehealth for behavioural support

BACKGROUND

Telehealth (i.e. the use of technology across distance) is widespread in many fields. Although its use for behavioural support for people with intellectual or developmental disabilities (IDD) is emerging, there are no known studies examining stakeholder perceptions of this.

METHODS

A four-round Delphi consultation was conducted with 11 professionals and six family carers of children with IDD to generate consensus on what would influence participants' use of telehealth for behavioural support. Data were collected prior to the coronavirus pandemic.

RESULTS

Thirty-six items reached consensus for professionals (26 advantages and 10 disadvantages/barriers) and 22 for family carers (8 advantages and 14 disadvantages/barriers). A range of solutions were also identified for the disadvantages/barriers.

CONCLUSIONS

Participants were willing to use telehealth for behavioural support. However, disadvantages/barriers need to be addressed, and guidelines relating to the use of telehealth in this field are needed. We report a number of practice recommendations including combining telehealth with in-person supports where possible, incorporating video technologies, and considering client perspectives and confidence with telehealth methodologies.

Impact of a Psychiatric Consultation Program on COVID-19 Patients: An Experimental Study

OBJECTIVE

Following the coronavirus disease-2019 (COVID-19) outbreak, the importance of addressing acute stress induced by psychological burdens of diseases became apparent. This study attempted to evaluate the effectiveness of a new mode of psychiatric intervention designed to target similar psychological crises.

METHODS

Participants included 32 out of 114 COVID inpatients at a hospital in Daegu, Korea, who were assessed between March 30 and April 7, 2020. Multiple scales for screening psychological difficulties such as depressed mood, anxiety, insomnia, acute stress, and suicidality were done. Psychological problem evaluations and interventions were conducted in the form of consultations to alleviate participants' psychological challenges via telepsychiatry. The interventions' effects, as well as clinical improvements before and after the intervention, were analyzed.

RESULTS

As a result of screening, 21 patients were experiencing psychological difficulties beyond clinical thresholds after COVID-19 infection (screening positive group). The remaining 11 were screening negative groups. The two groups differed significantly in past psychiatric histories (p=0.034), with the former having a higher number of diagnoses. The effect of the intervention was analyzed, and clinical improvement before and after the intervention was observed. Our intervention was found to be effective in reducing the overall emotional difficulties.

CONCLUSION

This study highlighted the usefulness of new interventions required in the context of healthcare following the COVID-19 pandemic.

Implementing telepsychiatry in an early psychosis service during COVID-19: Experiences of young people and clinicians and changes in service utilization

AIM

In response to the COVID-19 pandemic, our early psychosis program rapidly transitioned to telepsychiatry. This study examined the change in health service utilization and experiences of young people and clinicians in response to the implementation of telepsychiatry.

METHODS

Mixed methodology and triangulation of evidence drawn from health service databases and survey data. Using a retrospective observational design, health service data from pre- (Time 1) and post-(Time 2) telepsychiatry periods were compared. Surveys were also conducted with representation from clinicians and young people.

RESULTS

The number of appointments increased between Time 1 and 2, although this was accompanied by a near-doubling in missed appointments (8% to 13%). Young people had mixed views about telepsychiatry. While convenience was a frequently cited benefit, clients reported technological issues, isolation and lack of human connection. A preference for face-to-face appointments was linked to younger age and anxiety when using telepsychiatry. Clinicians reported improved workplace satisfaction and efficiency but noted some limitations in the use of telepsychiatry including difficulty interviewing and managing unwell clients remotely and called for greater skill development.

CONCLUSIONS

The introduction of telepsychiatry in response to COVID-19 was associated with an increase in service activity; however, there was an increase missed appointments by young people. Although clinicians and clients reported positive experiences, telepsychiatry was not completely endorsed as a replacement for face-to-face interactions.

Embodiment in online psychotherapy: A qualitative study

As a result of the COVID-19 pandemic, many therapists and patients have been required to switch to online sessions in order to continue their treatments. Online psychotherapy has become increasingly popular, and although its efficacy seems to be similar to face-to-face encounters, its capacity to support the implicit nonverbal and embodied aspects of the therapeutic relationship has been questioned and remains understudied.

OBJECTIVES

To study how embodied and intersubjective processes are modified in online psychotherapy sessions.

DESIGN

Taking the enactive concept of participatory sense-making as a guiding thread, we designed an interpretative phenomenological analysis to examine the experiences of embodiment in online therapy.

METHODS

We conducted phenomenological semi-structured interviews with patients and therapists who have recently switched from face-to-face encounters to online modality.

RESULTS

Adjustments in verbal and nonverbal behavior, gaze behavior, management of silences, and displacements of non-intentional and pre-reflective patterns onto reflective ones are reported as necessary to compensate for changes introduced in the online modality.

CONCLUSIONS

From an enactive perspective, such adaptations manifest regulatory processes aimed at sustaining interactive dynamics and coordinating the primordial tension between relational and individual norms in social encounters.

PRACTITIONER POINTS

We examine different aspects of embodiment that practitioners should take into account when switching from face-to-face to online encounters with their clients. Online communication systems can alter aspects of the therapeutic relationship, such as its structure, its fragility, and its significance. Video calls afford new forms of intervention such as integrating the experience of patients with their self-image, incorporating information about their habitual environment into the process, and adopting less confrontational therapeutic styles.

The virtual Clinical Assessment of Skills and Competence: the impact and challenges of a digitised final examination

The COVID-19 pandemic has affected how clinical examinations are conducted, resulting in the Royal College of Psychiatrists delivering the Clinical Assessment of Skills and Competence virtually. Although this pragmatic step has allowed for progression of training, it has come at the cost of a significantly altered examination experience. This article aims to explore the fairness of such an examination, the difference in trainee experience, and the use of telemedicine to consider what might be lost as well as gained at a time when medical education and delivery of healthcare are moving toward the digitised frontier.

Digital psychiatry and COVID-19: the Big Bang effect for the NHS?

The COVID-19 pandemic has brought untold tragedies. However, one outcome has been the dramatically rapid replacement of face-to-face consultations and other meetings, including clinical multidisciplinary team meetings, with telephone calls or videoconferencing. By and large this form of remote consultation has received a warm welcome from both patients and clinicians. To date, human, technological and institutional barriers may have held back the integration of such approaches in routine clinical practice, particularly in the UK. As we move into the post-pandemic phase, it is vital that academic, educational and clinical leadership builds on this positive legacy of the COVID crisis. Telepsychiatry may be but one component of 'digital psychiatry' but its seismic evolution in the pandemic offers a possible opportunity to embrace and develop 'digital psychiatry' as a whole.

Patients' Satisfaction With Telepsychiatry Services at a University Hospital in Riyadh During the COVID-19 Pandemic

Background and objective

Telepsychiatry uses electronic communication and various technologies to provide psychiatric care by a psychiatrist in one location to a patient in another location. It was originally created to meet the mental health needs of patients in rural, remote, and inaccessible areas. This study aimed to assess the satisfaction level with telepsychiatry from patients' perspectives and to study whether the satisfaction levels influence the patients' decision to use the service in the future.

Methodology

This was a cross-sectional survey study conducted at King Khalid University Hospital in Riyadh, Saudi Arabia. The study included psychiatric patients with complete medical records who were followed up through the telepsychiatry program over the phone due to the restriction and regulation implemented by the government in the wake of the coronavirus disease 2019 (COVID-19) pandemic. The data were collected via a questionnaire designed on a Google Form. Initially, the sample size was set at 337 psychiatric patients, but only 141 patients agreed to be included. The SPSS Statistics program (IBM, Armonk, NY) was used to analyze the data.

Results

Patients were generally satisfied with the telepsychiatry services; 80.1%, 95.7%, and 96.5% of the participants were satisfied with the structure, process, and outcome, respectively, and 94.3% of the patients reported a sense of overall satisfaction. The study did not find any relationship between satisfaction and demographic characteristics. Patients highly valued some aspects during the service use, such as comfort, privacy, easy access, carefulness, and skillfulness of the clinicians. Of the respondents, 24.1% agreed and 24.8% strongly agreed when asked if they would use the service in the future.

Conclusion

Patients had generally positive satisfaction levels toward telepsychiatry service, and many reported that they would like to continue using it in the future. However, further studies are needed to assess whether patient perception will change over time after the COVID-19 pandemic.

Service user experiences and views regarding telemental health during the COVID-19 pandemic: A co-produced framework analysis

BACKGROUND

The prominence of telemental health, including providing care by video call and telephone, has greatly increased during the COVID-19 pandemic. However, there are clear variations in uptake and acceptability, and concerns that digital exclusion may exacerbate previous inequalities in access to good quality care. Greater understanding is needed of how service users experience telemental health, and what determines whether they engage and find it acceptable.

METHODS

We conducted a collaborative framework analysis of data from semi-structured interviews with a sample of people already experiencing mental health problems prior to the pandemic. Data relevant to participants' experiences and views regarding telemental health during the pandemic were identified and extracted. Data collection and analysis used a participatory, coproduction approach where researchers with relevant lived experience, contributed to all stages of data collection, analysis and interpretation of findings alongside clinical and academic researchers.

FINDINGS

The experiences and preferences regarding telemental health care of the forty-four participants were dynamic and varied across time and settings, as well as between individuals. Participants' preferences were shaped by reasons for contacting services, their relationship with care providers, and both parties' access to technology and their individual preferences. While face-to-face care tended to be the preferred option, participants identified benefits of remote care including making care more accessible for some populations and improved efficiency for functional appointments such as prescription reviews. Participants highlighted important challenges related to safety and privacy in online settings, and gave examples of good remote care strategies they had experienced, including services scheduling regular phone calls and developing guidelines about how to access remote care tools.

DISCUSSION

Participants in our study have highlighted advantages of telemental health care, as well as significant limitations that risk hindering mental health support and exacerbate inequalities in access to services. Some of these limitations are seen as potentially removable, for example through staff training or better digital access for staff or service users. Others indicate a need to maintain traditional face-to-face contact at least for some appointments. There is a clear need for care to be flexible and individualised to service user circumstances and preferences. Further research is needed on ways of minimising digital exclusion and of supporting staff in making effective and collaborative use of relevant technologies.

Can we predict who will be more anxious and depressed in the COVID-19 ward?

OBJECTIVE

Hospitalized patients with COVID-19 are at high risk for anxiety and depression, but most studies about mental health during the pandemic included the general public, healthcare workers, and students. We aimed to explore the anxiety and depression levels, prevalence and predictors in patients hospitalized with COVID-19.

METHODS

In this cross-sectional, exploratory study, sociodemographic and clinical features of 281 patients with confirmed COVID-19 were explored. Patients underwent a comprehensive psychiatric assessment and the Hospital Anxiety and Depression Scale (HADS) was administered through a telephonic interview.

RESULTS

The mean age of the participants was 55.0 ± 14.9 years. One hundred forty-three (50.9%) patients were male, and 138 (49.1%) were female. Ninety-eight (34.9%) patients had significant levels of anxiety and 118 (42.0%) had significant levels of depression. Female gender, staying alone in a hospital room, early days of hospital stay, and any lifetime psychiatric disorder was associated with symptoms of anxiety. Being over 50 years of age, staying alone in a hospital room, and NSAID use before the week of hospital admission were associated with symptoms of depression. Anxiety and depression levels were lower when family members who tested positive for COVID-19 stayed in the same hospital room during treatment.

CONCLUSION

Women, patients >50 years, patients who used NSAIDs before hospital admission, and those with lifetime psychiatric disorders may be at risk for anxiety and depressive symptoms in the COVID-19 ward. Allowing family members with COVID-19 to stay in the same hospital room may be associated with lower anxiety and depression levels.

"You can't touch this": Delivery of inpatient neuropsychological assessment in the era of COVID-19 and beyond

Objective: The COVID-19 pandemic is a global health crisis that has created sudden and unique challenges within the field of clinical neuropsychology. Adapting neuropsychology services using teleneuropsychology models (e.g. video or telephone assessments) may not always be a viable option for all providers and settings. Based on the existing teleneuropsychology literature, we propose a "contactless" evidence-based inpatient test battery to be used for in-person assessments amenable to physical distancing. Method: In addition to the proposed test battery, we suggest a decision-making workflow process to help readers determine the appropriateness of the proposed methods given their patients' needs. Considerations for special populations (i.e. seniors, patients with brain injury, psychiatric patients), feedback, limitations of the proposed physical distancing approach, and future directions are also discussed. Conclusions: Our aim is that the suggested teleneuropsychology-informed battery and model may inform safe and practical neuropsychological inpatient assessments during the COVID-19 pandemic and other situations requiring contact precautions for infection prevention and control.

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.

Patients' Perspective on Mental Health Specialist Video Consultations in Primary Care: Qualitative Preimplementation Study of Anticipated Benefits and Barriers

Background

Due to limited access to specialist services, most patients with common mental disorders (depression or anxiety, or both) usually receive treatment in primary care. More recently, innovative technology-based care models (eg, video consultations) have been proposed to facilitate access to specialist services. Against this background, the PROVIDE (Improving Cross-Sectoral Collaboration Between Primary and Psychosocial Care: An Implementation Study on Video Consultations) project aims to improve the provision of psychosocial care through implementing video consultations integrated into routine primary care.

Objective

From the patients’ perspective, this qualitative preimplementation study explored (1) anticipated benefits from and (2) barriers to implementing mental health specialist video consultations embedded in primary care services and (3) prerequisites for interacting with therapists via video consultations.

Methods

Using a purposive (ie, stratified) sampling strategy, we recruited 13 patients from primary care practices and a tertiary care hospital (psychosomatic outpatient clinic) for one-off semistructured interviews. In a computer-assisted thematic analysis, we inductively (bottom-up) derived key themes concerning the practicability of mental health specialist video consultations. To validate our results, we discussed our findings with the interviewees as part of a systematic member checking.

Results

Overall, we derived 3 key themes and 10 subthemes. Participants identified specific benefits in 2 areas: the accessibility of mental health specialist care (shorter waiting times: 11/13, 85%; lower threshold for seeking specialist mental health care: 6/13, 46%; shorter travel distances: 3/13, 23%); and the environment in primary care (familiar travel modalities, premises, and employees: 5/13, 38%). The main barriers to the implementation of mental health video consultations from the patients’ perspective were the lack of face-to-face contact (13/13, 100%) and technical challenges (12/13, 92%). Notably, participants’ prerequisites for interacting with therapists (12/13, 92%) did not seem to differ much from those concerning face-to-face contacts.

Conclusions

Mental health service users mostly welcomed mental health specialist video consultations in primary care. Taking a pragmatic stance, service users, who are often frustrated about uncoordinated care, particularly valued the embedment of the consultations in the familiar environment of the primary care practice. With respect to interventional studies and implementation, our findings underscore the need to minimize technical disruptions during video consultations and to ensure optimal resemblance to face-to-face settings (eg, by training therapists in consistently reacting to nonverbal cues).

Trial Registration

German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one

Ethical Issues in Online Psychotherapy: A Narrative Review

BACKGROUND

The provision of psychotherapy over distance using technology is a growing market reaching many patients and therefore the risks and benefits need to be known by all psychotherapists whether they themselves practice online or not. This comprehensive review of the main ethical arguments for and against different forms of online psychotherapy aims to enhance discussion of ethical issues in this growing area.

METHODS

A search of three databases (PubMed, PsycINFO, Web of Science) was conducted in August 2019 using a specific search protocol yielding 249 publications.

RESULTS

Of 24 ethical arguments in favor of online psychotherapy and 32 against, the top five ethical arguments in favor of online psychotherapy were (1) increased access to psychotherapy and service availability and flexibility; (2) therapy benefits and enhanced communication; (3) advantages related to specific client characteristics (e.g. remote location); (4) convenience, satisfaction, acceptance, and increased demand; and (5) economic advantages. The top five ethical arguments against engagement in online psychotherapy were (1) privacy, confidentiality, and security issues; (2) therapist competence and need for special training; (3) communication issues specific to technology; (4) research gaps; and (5) emergency issues.

CONCLUSIONS

The findings may be of help to practitioners in deciding whether to engage in online psychotherapy, and in informing patients about risks and benefits, improving ethical guidelines, and stimulating further ethical discussion. The findings are argumentative and qualitative in nature, and further quantitative research is needed.

Telepsychiatry: Implications for Psychiatrist Burnout and Well-Being

Physician burnout and stress have reached alarming levels. Psychiatrists are at risk of experiencing burnout due to emotional stressors related to the nature of the clinical work, occupational hazards, changing nature of service delivery, and increasing administrative pressures. Currently, little is known about the impact of telepsychiatry on psychiatrist well-being and burnout. This Open Forum examines potential benefits and challenges of telepsychiatry with regard to psychiatrist stress and burnout. It also discusses the broader implications of telepsychiatry for psychiatrist well-being.

"Psychological Boarding" and Community-Based Behavioral Health Crisis Stabilization

This exploratory paper presents a case study where a community based mental health organization forging a partnership with a local hospital system to establish a crisis stabilization unit (CSU) to address behavioral health emergency care. The study takes a mixed methods case study approach to address two research questions; (a) did this approach reduce the overall length of stay in the hospital emergency departments? (b) What challenges did the taskforce face in implementing this CSU model? The paper shares recommendation from the findings.

Cost issues with telepsychiatry in the United States

Videoconferencing has increased patient access to psychiatric care by linking specialists at academic or regional health centres with primary health care professionals in shortage areas (Hilty et al, 1999, 2002). Preliminary studies have demonstrated positive outcomes and user satisfaction (Hilty et al, 2002). Information is still being sought regarding costs because of a paucity of clinical outcome studies, cost data and randomised trials.

Usefulness of videoconferencing in psychiatric emergencies -- a qualitative study

High quality health services for psychiatric emergencies are difficult to maintain 24 h a day in sparsely populated areas, where the availability of specialists are limited. To overcome this challenge, the University Hospital of North Norway implemented an on-call system in psychiatric emergencies, by which psychiatrists are accessible 24/7 for telephone and videoconferencing consultations with patients and nurses at three regional psychiatric centers. The purpose of this study was to explore the usefulness of videoconferencing consultations in psychiatric emergencies. The on-call psychiatrists and nurses at the regional psychiatric centers who participated in at least one videoconferencing consultation were recruited for semi-structured interviews: 5 psychiatrists and 19 nurses for a total of 24 participants. The interviews were performed from July of 2012 to June of 2013. The interviews were transcribed and analyzed using a stepwise-deductive-inductive approach supported by the HyperRESEARCH analysis software. After the introduction of the videoconferencing system, telephone consultations were still used for straightforward situations when further treatment or admission decisions were obvious. Videoconferencing consultations, during which patients were present, were useful for challenging situations when there was 1) uncertainty regarding the degree of illness or the level of treatment, 2) a need to clarify the severity of the patient condition, 3) a need to build an alliance with the patient, and 4) disagreement either between health personnel or between the patient and health personnel. Videoconferencing is useful for challenging and complex psychiatric emergencies and is a suitable tool for building high quality, decentralized psychiatric services.

Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review

Background and Objectives

Due to the high costs of conventional mental health care, there has been a rise in the application of web-based technologies in recent years, i.e., telemental health care. We conducted this systematic review in 2017, using high quality research articles on the applications, technologies, advantages and challenges associated with telemental health care published since year 2000.

Methods

We used a combination of relevant key words to search four major databases, such as "Web of Sciences, Embase, PubMed and Science Direct". From among 156 articles, which had been published since 2000, twenty five articles met all of the inclusion criteria and were selected for the final review. The information extracted from these articles were used to construct Tables 1 and 2. Also, the materials derived from 55 credible articles were used as further support and complementary facts to substantiate the information presented in the Discussion section.

Results

The findings revealed that telemental health care is an extended domain supportive of conventional mental health services. Currently, telemental health care has multiple capabilities and technologies for providing effective interventions to patients with various mental illnesses. It provides clinicians with a wide variety of innovative choices and strategies for mental interventions, in addition to significant future potentials.

Conclusions

Telemental health care can provide effective and adaptable solutions to the care of mental illnesses universally. While being comparable to in-person services, telemental health care is particularly advantageous and inexpensive through the use of current technologies and adaptable designs, especially in isolated communities.

Developing a measure of engagement with telehealth systems: The mHealth Technology Engagement Index

Introduction Telehealth systems and mobile health (mHealth) devices allow for the exchange of both physical and mental healthcare data, as well as information from a patient to a practitioner, or care recipient to caregiver; but there has been little research on why users are motivated to engage with telehealth systems. Given this, we sought to create a measure that satisfactorily assesses human motivation to use telehealth devices. Methods 532 survey responses were used in an exploratory factor analysis and confirmatory factor analysis, which tested and retested the feasibility of this new measure. Convergent and divergent validity analyses indicated that the mHealth Technology Engagement Index (mTEI) is a unique measure of motivation. Results The results indicated that autonomy, competence, relatedness, goal attainment, and goal setting underpin motivation to use telehealth systems. Discussion The mTEI shows promise in indexing human motivation to use telehealth technologies. We also discuss the importance of developing measurement tools based on theory and how practitioners can best utilize the mTEI.

[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.

A randomized waitlist-controlled pilot trial of voice over Internet protocol-delivered behavior therapy for youth with chronic tic disorders

INTRODUCTION

Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients' homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP).

METHODS

Twenty youth (8-16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions - Improvement Scale), assessed using ratings of 'very much improved' or 'much improved' indicating positive treatment response.

RESULTS

Intention-to-treat analyses with the last observation carried forward were performed. At post-treatment (10-weeks), significantly greater reductions in clinician-rated, (F(1,18) = 3.05, p < 0.05, partial η(2 )= 0.15), and parent-reported tic severity, (F(1,18) = 6.37, p < 0.05, partial η(2 )= 0.26) were found in CBIT-VoIP relative to waitlist. One-third (n = 4) of those in CBIT-VoIP were considered treatment responders. Treatment satisfaction and therapeutic alliance were high.

DISCUSSION

CBIT can be delivered via VoIP with high patient satisfaction, using accessible, low-cost equipment. CBIT-VoIP was generally feasible to implement, with some audio and visual challenges. Modifications to enhance treatment delivery are suggested.

Telemental Health: Digital Disruption and the Opportunity to Expand Care

Telemental health, which involves clinicians connecting remotely to patients via teleconferencing, has seen growing interest. In addition to providing in-home treatment, this technology allows specialists to provide care in remote and underserved areas. Current research suggests that both patients and clinicians are satisfied with telemental health services and that it is comparable in terms of quality to in-person care. Nonetheless, concerns still exist regarding its effects on the role of clinicians and the care they provide.

A Telephone- and Text Message-Based Telemedicine Concept for Patients with Mental Health Disorders: Results of a Randomized Controlled Trial

Background: A telemedicine care concept based on telephone contacts and individualized text messages was developed for patients with mental disorders to continue treatment after therapy in a psychiatric day hospital. The primary objective of this study was to evaluate the effectiveness of the telemedicine interventions. Methods: The study had a 3-armed, randomized design with 2 intervention arms (intervention 1: telephone contacts; intervention 2: telephone contacts and short text messages; both took place over a period of 6 months and in addition to usual care), and a control group with usual care. Primary outcomes were 18-item Brief Symptom Inventory (BSI-18) scores for anxiety, depression and somatization. All participants were recruited from psychiatric day hospitals. The study was registered in the German Clinical Trials Register (DRKS00000662). Results: 113 participants were analyzed 6 months after starting the intervention. The average BSI-18 anxiety score after 6 months was -2.04 points lower in intervention group 2 than in the control group (p value: 0.042). The difference in BSI depression score between these two groups was marginally significant (p value: 0.1), with an average treatment effect of -1.73. In an exploratory sensitivity analysis restricted to the 75% of patients with the highest symptom scores at baseline, intervention group 1 yielded a significant effect for anxiety and depression compared to the control group (p = 0.036 and 0.046, respectively). Conclusions: Telemedicine provides a novel option in psychiatric ambulatory care with statistically significant effects on anxiety. A positive tendency was observed for depression, especially in cases with higher symptom load at baseline. © 2015 S. Karger AG, Basel.

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

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

Telepsychiatry: new perspectives and open issues

Telepsychiatry, thanks to the continuous advance of technologies, is an area with excellent prospects to become an effective tool for assistance in psychiatry. Many studies evaluated the effectiveness of telepsychiatry in different psychiatric disorders like anxiety disorders, psychotic disorders and depression. Results showed that telepsychiatry seems to be promising in anxiety and depressive disorders, especially in the maintenance phase, and also for psychotic disorders, especially for these cases with a poor compliance. We reviewed the literature to evaluate the feasibility of telepsychiatry in Italy in terms of satisfaction, costs and cultural acceptability and considering ethical and legal aspects. In Italy the development of telemedicine still presents a high level of fragmentation. A potential integration of these new types of services with the health care system is a very challenging task and poses many legal and ethical challenges. Therefore the creation of legal instruments and formal professional ethical guidelines are needed.

Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies

Background

In psychiatric emergencies in rural areas the availability of psychiatrists are limited. Therefore, tele-psychiatry, via real-time videoconferencing (VC), has been developed to provide advanced consultative services to areas that lack psychiatrists. However, there is limited research on the use of VC for psychiatric emergencies. The University Hospital of North Norway has been the first hospital in Norway to implement this type of service by developing a new on-call system for psychiatric emergency practice through which psychiatrists are accessible by telephone and VC 24 hours a day for consultations with patients and nurses at three regional psychiatric centres. This study explores patients’, psychiatrists’ and nurses’ experiences of using VC for psychiatric emergencies, as well as how the technology influenced their confidence.

Methods

In this study, we used a qualitative explorative research design. With a particular focus on users’ experiences of VC, we conducted 29 semi-structured interviews with patients, psychiatrists and nurses who had participated in a VC consultation in at least one psychiatric emergency.

Results

Our findings show that access to the VC system increased the experience of confidence in challenging psychiatric emergencies in four ways: (1) by strengthening patient involvement during the psychiatric specialist’s assessment, (2) by reducing uncertainty, (3) by sharing responsibility for decisions and (4) by functioning as a safety net even when VC was not used.

Conclusions

This study has demonstrated that an emergency psychiatric service delivered by VC may improve the confidence of psychiatrists, nurses and patients in challenging psychiatric emergencies. VC can serve as an effective tool for ensuring decentralised high-quality psychiatric services for emergency care.

Pilot Open Case Series of Voice over Internet Protocol-delivered Assessment and Behavior Therapy for Chronic Tic Disorders

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with Chronic Tic Disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and VoIP administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of Voice over Internet Protocol (VoIP)-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, four children received 8-weekly sessions of CBIT via VoIP and were assessed at pre- and post-treatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre to post-assessment on the YGTSS. Two of the four patients were considered treatment responders at post treatment, using Clinical Global Impressions-Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.

Methodology for conducting the children's attention-deficit hyperactivity disorder telemental health treatment study in multiple underserved communities

BACKGROUND

Children living in nonmetropolitan communities are underserved by evidence-based mental health care and are underrepresented in clinical trials.

PURPOSE

In this article, we describe lessons learned in conducting the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health (TMH) Treatment Study (CATTS), a randomized controlled trial testing the effectiveness of TMH in improving outcomes of children with ADHD living in underserved communities.

METHODS

Children were referred by primary care providers (PCPs). The test intervention group received six telepsychiatry sessions with each session followed by an caregiver behavior training session delivered in-person by a local therapist. A secure website was used to support decision making by the telepsychiatrists and to facilitate real-time collaboration between the telepsychiatrists and community therapists. The control group received a single telepsychiatry consultation. Questionnaires tapping ADHD symptoms and other outcomes were administered to parents and teachers online through a secure portal from personal computers.

RESULTS

total of 88 PCPs in seven communities referred the 223 children who participated in the trial. Attrition in treatment sessions and research assessments was very low. Lessons learned TMH proved to be a viable means of providing evidence-based pharmacological services to children and training to local therapists. Recruitment was enhanced by offering the control group a telepsychiatry consultation. Site-specific strategies were needed to meet recruitment targets.

CONCLUSIONS

The CATTS trial used methods designed to optimize inclusion of children living in multiple dispersed and underserved areas. The study will serve as a model for other research projects aiming at reducing geographic disparities in access to quality mental health care.

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.

VIDEOCARE: decentralised psychiatric emergency care through videoconferencing

BACKGROUND

Today the availability of specialists is limited for psychiatric patients in rural areas, especially during psychiatric emergencies. To overcome this challenge, the University Hospital of North Norway has implemented a new decentralised on-call system in psychiatric emergencies, by which psychiatrists are accessible by videoconference 24/7. In September 2011, the new on-call system was established in clinical practice for patients and health staff at three regional psychiatric centres in Northern Norway. Although a wide variety of therapies have been successfully delivered by videoconference, there is limited research on the use of videoconferenced consultations with patients in psychiatric emergencies. The aim of this study is to explore the use of videoconference in psychiatric emergencies based on the implementation of this first Norwegian tele-psychiatric service in emergency care.

METHODS/DESIGN

The research project is an exploratory case study of a new videoconference service in operation. By applying in-depth interviews with patients, specialists and local health-care staff, we will identify factors that facilitate and hinder use of videoconferencing in psychiatric emergencies, and explore how videoconferenced consultations matter for patients, professional practice and cooperation between levels in psychiatric care. By using an on-going project as the site of research, the case is especially well-suited for generating reliable and valid empirical data.

DISCUSSION

Results from the study will be of importance for understanding of how videoconferencing may support proper treatment and high-quality health care services in rural areas for patients in psychiatric emergencies.

Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review

OBJECTIVE

To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.

METHODS

MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.

FINDINGS

Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.

CONCLUSION

The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.

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.

Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review

OBJECTIVE

Studies involving the use of telepractice in the delivery of services to individuals with autism spectrum disorders (ASD) were reviewed with the intent to inform practice and identify areas for future research.

METHODS

Systematic searches of electronic databases, reference lists and journals identified eight studies that met pre-determined inclusion criteria. These studies were analysed and summarized in terms of the: (a) characteristics of the participants, (b) technology utilized, (c) services delivered via telepractice, (d) research methodology and (e) results of the study.

RESULTS

Telepractice was used by university-based researchers, behaviour analysts, psychiatrists and psychologists to assist caretakers and educators in the delivery of services to 46 participants with ASD. The services delivered included behavioural and diagnostic assessments, educational consulting, guidance and supervision of behavioural interventions and coaching/training in the implementation of a comprehensive early intervention programme.

CONCLUSIONS

Results suggests telepractice is a promising service delivery approach in the treatment of individuals with ASD that warrants additional research. Guidelines for practitioners and potential directions for future research are discussed.

A telephone- and text-message based telemedical care concept for patients with mental health disorders--study protocol for a randomized, controlled study design

BACKGROUND

As in other countries worldwide, the prevalence of mental disorders in Germany is high. Although numerically a dense network of in- and outpatient psychiatric health services exists, the availability in rural and remote regions is insufficient.In rural regions, telemedical concepts can be a chance to unburden and complement the existing healthcare system. Telemedical concepts consisting of video or telephone consulting show first positive results, but there are only a few studies with a randomized controlled design.To improve the treatment of patients with mental disorders in rural regions, we developed a telemedical care concept based on telephone contacts and text-messages. The primary objective of this study is to evaluate the effects of the telemedical interventions on psychopathological outcomes, e. g. anxiety, depressive symptoms, and somatisation. Secondary objective of the study is the analysis of intervention effects on the frequency of medical contacts with healthcare services. Furthermore, the frequency of patients' crises and the frequency and kind of interventions, initiated by the project nurses will be evaluated. We will also evaluate the acceptance of the telemedical care concept by the patients.

METHODS/DESIGN

In this paper we describe a three-armed, randomized, controlled study. All participants are recruited from psychiatric day hospitals. The inclusion criteria are a specialist-diagnosed depression, anxiety disorder, adjustment disorder or a somatoform disorder and eligibility to participate in the study. Exclusion criteria are ongoing outpatient psychotherapy, planned interval treatment at the day clinic and expected recurrent suicidality and self-injuring behaviour.The interventions consist of regular patient-individual telephone consultations or telephone consultations with complementing text-messages on the patients' mobile phone. The interventions will be conducted during a time period of 6 months.

TRIAL REGISTRATION

This study is registered in the German Clinical Trials Register (DRKS00000662).

What about telepsychiatry? A systematic review

BACKGROUND

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION/SYNTHESIS

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

CONCLUSIONS

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

Telemedicine for depression: a systematic review

PURPOSE

More than 14% of the population has a mood disorder, and more than 50% do not receive treatment. Information and communication technology (ICT) could improve health care. A systematic review was considered in order to know the programs that apply ICT in the management of depression and to assess their effectiveness.

CONCLUSION

There is insufficient scientific evidence regarding the effectiveness of ICT use in the management of depression. However, there is a well-founded hypothesis that videoconference produces the same results as face-to-face treatment and that self-help Internet programs could improve symptoms.

PRACTICE IMPLICATIONS

More research is needed; nevertheless, when traditional care is not possible, telemedicine could be used.

Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows

We reviewed the appointment data for a psychiatry service in California that provided consultations and also therapy through telepsychiatry. Over an 18-month period, there were 7523 telepsychiatry appointments and 115,148 conventional (face-to-face) appointments. A higher proportion of the telepsychiatry appointments was kept (92% telepsychiatry vs. 87% non-telepsychiatry). Also, telepsychiatry appointments were significantly less likely to be cancelled by patients (3.5% vs. 4.8%) and significantly less likely to be no-shows (4.2% vs. 7.8%). These findings were similar in three of the four counties where the service was delivered. However, one county was different, and further examination suggested that the morale of the staff and patients may have contributed to the unenthusiastic acceptance of telepsychiatry. We conclude that telepsychiatry can be used effectively in continuing care settings as well as in evaluation settings, and that staff and patient morale are important factors in successful telepsychiatry.

Emergency telepsychiatry

Telepsychiatry can be used in two kinds of psychiatric emergencies: one-time clinical events and public health situations associated with mass disaster. Emergency telepsychiatry delivered by videoconferencing has the potential to improve patient care in many settings. Although experience is limited, it has been found to be safe and effective, as well as satisfactory to both emergency department staff and the psychiatric patients treated. The development of comprehensive and standardized guidelines is necessary. There has been little use of acute telemedicine in disaster situations to date. However, telemedicine is becoming part of routine emergency medical response planning in many jurisdictions. Emergency telepsychiatry has the potential to reduce emergency department overcrowding, provide much needed care in rural areas and improve access to psychiatric care in the event of a natural or man-made disaster.