Telepsychiatry as a routine service--the perspective of the patient

Patient perspectives were examined as part of an assessment of a routine telepsychiatry service in rural Alberta. Information was gathered through self-report questionnaires and telephone interviews. Of 379 questionnaires distributed to patients, 230 (61%) were returned. Of the patients who completed questionnaires, 89% reported being satisfied with the service and 96-99% were satisfied with the equipment and the room. Twenty-nine of 31 patients who were interviewed by telephone preferred telepsychiatry to waiting for a consultation, were willing to use the service again and would recommend telepsychiatry to a friend. While 25 of these 31 patients preferred telepsychiatry to travelling to a consultation, 15 indicated that they would prefer a face-to-face interview to telepsychiatry and a further seven were unsure. Twenty-three of the 31 patients interviewed would have had to miss time from work or pay for child care in order to travel to a conventional psychiatric consultation. The availability of telepsychiatry led to an estimated cost saving of $210 per consultation for patients who would otherwise have had to travel. From the patient's perspective, telepsychiatry was an acceptable technique in the management of mental health difficulties that both increased access to services and produced cost savings.     

Evaluation of a routine telepsychiatry service

An assessment was undertaken of a routine telepsychiatry service in rural areas of a Canadian province as a follow-up to a pilot telepsychiatry project. Over two years, there were 546 consultations at the five participating general hospitals, although the level of use varied considerably between them. Health professionals expressed high satisfaction with the service. While there were equipment problems in 17% of all consultations in the second year, they did not seem to affect acceptance of the technique. A cost analysis comparing consultations provided by a visiting psychiatrist and telepsychiatry found a break-even point of 348 consultations a year. However, when use of the videoconferencing network for administrative meetings was considered, the break-even point was 224 consultations a year, substantially below the actual utilization of telepsychiatry. Telepsychiatry appeared to result in increased access to community mental health services, suggesting future increased demand for these. From the perspective of health authorities and health professionals, telepsychiatry proved to be a useful and sustainable addition to existing mental health services.     

Economic evaluation of a tertiary telepsychiatry service to an island

The island of Jersey is located 160 km south of Britain and 23 km from northwest France. The island has well-established primary and secondary mental health services, but tertiary services have to be purchased from UK mainland service providers. A pilot study of telepsychiatry was conducted, using videoconferencing to access tertiary mental health services from the UK. During a six-month study period, five patient consultations and six specialist presentations were carried out. The total cost of using videoconferencing to deliver tertiary mental health services not ordinarily available in Jersey was 3483.06 pounds. The costs of using the traditional model instead would have been 12,975.00 pounds. The threshold at which videoconferencing became cheaper than travel was between five and six telemedicine episodes per year; the actual workload during the pilot study was 22 episodes per year. The study suggests that telemedicine is cost-effective for providing tertiary mental health services not ordinarily available in Jersey.     

The North Lewisham telepsychiatry project: beyond the pilot phase

The integration of a telepsychiatry application into an inner-city community mental health service was evaluated over 10 months. ISDN videoconferencing at 128 kbit/s was employed for psychiatric consultation between a primary care centre and a community mental health centre. A convenience sample of patients and referrals seen by videoconferencing was compared with a sample seen face to face. During the study period 19 patients were managed by videoconferencing and 12 face to face. There were 162 consultations, comprising 81 prearranged teleconsultations and 81 prearranged face-to-face consultations. There was no significant difference in attendance between videoconferencing and face-to-face consultations. Nine of the videoconferencing new referrals had not completed their treatment at the end of the study period, compared with only three in the face-to-face group. This implies that it takes longer to complete treatment for new referrals managed by videoconferencing.     

The status of telepsychiatry services in Canada: a national survey

A survey of Canadian telepsychiatry programmes was undertaken to provide information for future health services. Fourteen programmes were identified. They used a variety of service models and administrative arrangements. The average number of clinical consultations per programme per year was 238, which corresponds to 107 psychiatric teleconsultations per million persons served by the programmes. The rate for children's telepsychiatry services was higher, at 194 per million. Comparison with some telepsychiatry programmes in the USA revealed similar patterns of activity. While the development of telepsychiatry services in Canada is promising, there is nevertheless concern regarding the viability and activity levels of these programmes over the long term. This survey demonstrates that programmes from across a large country can respond to a standardized questionnaire and provide comparable information.     

A review of the first five years of the University of Arizona telepsychiatry programme

We performed a retrospective review of the first five years of activity in the University of Arizona Telepsychiatry Programme. The programme began in 1998 as part of a telemedicine service for underserved rural areas. Over the first five years, 1086 teleconsultations were carried out for a total of 206 patients. There were 159 adult (77%) and 47 paediatric patients (23%). During the study period, the racial/ethnic diversity of the paediatric patients increased, as did the number of follow-up visits for adult patients (average 5.3/patient). These trends suggested that telepsychiatry became an integral part of the mental health service system at the six referring sites. Adult patients completed 81 satisfaction surveys (51%) and psychiatrists completed 47 (23%). The responses showed that providers and patients found telepsychiatry services satisfactory, although in a minority of teleconsultations (18% for providers and 17% for patients) equipment problems were distracting. The continued use of the services suggests that the telepsychiatry programme fills a service gap in rural areas of the state.     

The use of videoconferencing for mental health services in Finland

The utilization of telemental health (TMH) services in Finland was surveyed in 2006. In total, 135 health-care units provided responses. Eighty-four responses were received from primary care units (health-care centres and clinics) and eight from other clinics, in all hospital districts. The overall rate of TMH consultations was 4 per 100,000 population. The highest TMH consultation per population ratio, 22 per 100,000, was in northern Finland. Most of the sites used telepsychiatry services for less than 10% of clinical outpatient services. The sites with over 20% utilization of clinical TMH services from all psychiatric consultations were all rural health centres. Compared with Finland, the utilization rates of TMH were higher in Canada; that might be due to differences between the countries in the organization of mental health services in primary and specialized care. In Finland TMH consultations made up only a very small proportion of all mental health services. The use of TMH was particularly common in remote areas; however, there were many rural centres that did not utilize clinical TMH. TMH was widely utilized for continuing and medical education.     

International telepsychiatry: a study of patient acceptability

An international telepsychiatry service was established between Denmark and Sweden for cross-cultural patient groups, such as asylum seekers, refugees and migrants. Over an 18-month period starting in mid 2006, 30 patients were treated by telepsychiatry (21 men and 9 women). The patients received mental health care by videoconferencing from providers who spoke the patients' own language, i.e. without the assistance of interpreters. The total number of telepsychiatry sessions was 203 (range 1-22; average 6.8 sessions per patient). Patients completed a satisfaction questionnaire at the end of treatment. Seven patients (23%) were not able to complete a questionnaire, due to illiteracy and/or a psychotic condition. The rest of the patients (n=23) reported a high level of acceptance and satisfaction with telepsychiatry, as well as a willingness to use it again or recommend it to others. Any disadvantages of telemedicine were compensated by the fact that the doctor and patient spoke the same language and had similar cultural and/or national references. Mentally ill asylum seekers, refugees and migrants are under-served in their mother tongue and telepsychiatry can improve access to scarce health-care resources.     

Pediatric Telepsychiatry in Ontario: Caregiver and Service Provider Perspectives

Families in rural areas face significant geographic and economic obstacles to obtaining pediatric mental health services. Telepsychiatry promises the possibility of extending specialized expertise into areas that have no resident psychiatrists. In this study, user perspectives and experiences of a pediatric telepsychiatry program serving rural communities in Ontario, Canada, were explored. Qualitative, exploratory methods were utilized because of the complex nature of mental health services needs and provision in rural communities. Focus groups with rural mental health service providers and interviews with family caregivers of children receiving a telepsychiatry consultation were conducted. The purpose of this research was to evaluate the benefits and limitations of providing pediatric psychiatric services via video-technology to inform future program development and health policy. Whereas participants in the study indicated that their experiences with the telepsychiatry service had been positive, the need for additional local services to support treatment recommendations was emphasized. Natasha Greenberg, MA, Community Health Systems Resource Group, The Hospital for Sick Children, Department of Public Health Sciences, University of Toronto, 555 University Avenue, Toronto, ON M6G 1X8, Canada. Tiziana Volpe, MSc, Community Health Systems Resource Group, The Hospital for Sick Children, Department of Public Health Sciences, University of Toronto, 555 University Avenue, Toronto, ON M6G 1X8, Canada.     

Client acceptability and quality of life--telepsychiatry compared to in-person consultation

We evaluated client satisfaction and one-month mental health outcomes for telepsychiatry clients compared with those undergoing a face-to-face psychiatric consultation. Clients were asked to complete an SF-12 health survey before the consultation, a satisfaction survey after the consultation, and were contacted for a one-month follow-up SF-12 survey by telephone. Forty-eight of the 62 initial responders (77%) were available for contact by telephone after one month. Telepsychiatry clients demonstrated significant improvements on pre- and post-SF-12 mental health measures (t = 3.7; P = 0.001), while there was no change for the in-person group (t = 1.0; P = 0.35). Telepsychiatry clients felt that they could present the same information as in person (93%), were satisfied with their session (96%), and were comfortable in their ability to talk (85%); this was similar to the in-person clients. They reflected slightly lower levels of satisfaction regarding feeling supported and encouraged than did the in-person clients. Both telepsychiatry clients and traditional face-to-face psychiatry clients were satisfied with their experience of mental health care service provision, and mental health improvements were evident in the telepsychiatry patients.     

Telepsychiatry improves paediatric behavioural health care in rural communities

In the US, children with special health care needs are underserved by both the medical and educational systems. This problem is especially serious in rural states. Telemedicine is a technique that can reduce these gaps in service and help connect the two systems. The technology required has become cheaper and more accessible. Progress on reimbursement for such services has also been made. For some years, we have provided telepsychiatry for children in Washington State using videoconferencing. Interviews with families and service providers were conducted in Washington and Missouri. Some parents reported that their child actually preferred telepsychiatry to conventional consultation. The telepsychiatry service model was built on the existing system of outreach clinics, thus involving specialists who were familiar with the community and who were known and trusted by the community. Before starting, we ensured that all relevant service delivery agencies and providers were comfortable about using videoconferencing as a method of service delivery. In the 18-month period ending in March 2003, three providers in Seattle saw 159 patients by telepsychiatry and 210 patients face-to-face at the hospital clinic. The main barrier to further growth of the telepsychiatry service is the absence of reimbursement for telepsychiatry.     

Telemedicine services to a county jail

Local and county jails rarely offer telepsychiatry services to their inmates. We have established a telepsychiatry pilot project between the Kansas University Medical Center and the Lyon County Jail in Emporia, Kansas. A total of 264 telepsychiatry consultations were conducted with jail inmates. Of these, 70 were initial evaluations and 194 were follow-up visits; only one inmate refused to be seen. Approximately one-third of all inmates were seen for psychiatric consultation within one week of their incarceration and 68% were seen within one month of incarceration. Among lessons learned during the first year of service were: the monthly demand for consultations was five times greater than projected; moderately to severely ill inmates with a broad range of psychiatric illness can be seen and treated effectively using videoconferencing; and the technology was accepted by the jail personnel and the inmates alike and integrated into the jail's routine in terms of the delivery of psychiatric care.     

Telepsychiatry in the Canary Islands: user acceptance and satisfaction

A telepsychiatry service, using ISDN videoconferencing, was established to provide psychiatric consultations for the population of El Hierro, the most westerly of the Canary Islands. During the first year of routine operation, a total of 40 patients had 40 initial and 126 follow-up teleconsultations. The main reason for the consultation identified in the general practitioner's referral form was to establish a diagnosis (60% of patients); the second most common reason was the management of a patient previously diagnosed (20% of patients). According to the results of a questionnaire survey, patients' acceptance of and satisfaction with the technology were high. In their first teleconsultation, about a third of them said that they experienced some initial inconvenience, but this disappeared after a few minutes. Ninety per cent of the patients considered that they received the follow-up care they required. Telepsychiatry was considered by physicians and patients as an adequate vehicle for mental health-care.     

A review of Medicare expenditure in Australia for psychiatric consultations delivered in person and via videoconference

We examined the activity (services recorded) and cost (benefits paid) of reimbursement associated with telepsychiatry services in the Australian public health-care sector. We reviewed the activity and costs administered through the government's Medicare Benefits Schedule (MBS) from July 2002 to June 2011. During this nine-year-period, almost 14 million psychiatric consultations were funded through Medicare at a cost of $1.6 billion. Of these, 8003 were telepsychiatry consultations which cost $934,000, i.e. the video consultations subgroup represented 0.06% of all psychiatric consultations provided and 0.06% of the total cost to the government for these services. Despite telepsychiatry being a widely reported and successful example of telehealth internationally, the uptake of telepsychiatry in Australia has been slow.     

Using health production functions to evaluate treatment effectiveness: an application to a community mental health service

The randomized controlled trial (RCT) is the recommended means of evaluating health care effectiveness and cost-effectiveness. Whilst representing a 'gold-standard' in health services research, RCT evidence on the clinical and economic desirability of services and treatments is often absent. Where RCT evidence is lacking, or where it is infeasible to implement randomized controlled comparisons, longitudinal observational and naturalistic data sources when analysed appropriately can yield useful insights regarding the clinical effectiveness and economic efficiency of treatments. In this paper we demonstrate the utility of applying panel estimation methods to data from an Italian psychiatric case register as a means of modelling the mental health outcomes of patients referred to a community-based mental health service. Emphasis is placed on quantifying the clinical effectiveness of consultations with different mental health professionals (including in-patient days) and whether service outcomes are affected by psychiatric diagnosis. The impact of service consultations and their interaction with different types of psychiatric diagnosis on a measure of patient mental health are found to be statistically significant, although the size of these effects are not substantial from a clinical perspective.     

The Impact of a Primary Care Telepsychiatry Program on Outcomes of Managed Care Older Adults

ObjectiveThe goal of this study was to assess the outcomes of a primary-based telepsychiatry intervention program for older managed care enrollees with depression/anxiety and with limited access to in-person psychiatric care.DesignA pre-post design was used to examine service use (n = 218) and severity of depression (n = 204). Enrollment, claims, and depression and anxiety score data were obtained from the medical group. The implementation process and self-reported outcomes were examined.Setting and ParticipantsThe program was funded by the Senior Care Action Network (SCAN) group and implemented by a large medical group serving older adults who were identified as needing outpatient psychiatric care, including those with psychiatric hospitalizations, depression/anxiety disorders, comorbid substance use disorders, or other multiple comorbidities.MethodsPoisson regressions were used to examine changes in predicted rates of outpatient services, emergency department visits, and hospitalizations up to 24 months prior and 24 months following the first telepsychiatry visit. Changes in predicted severity of depression up to 2 quarters prior and 3 quarters following the first telepsychiatry visit were examined.ResultsThe number of outpatient services declined significantly by 0.24 per patient per 6-month time frame following the first telepsychiatry visit. The number of emergency department visits and hospitalizations also declined after the first visit (0.07 and 0.03 per patient per 6-month time frame, respectively). Depression severity scores also declined in the quarters following the first visit (1.52). The medical group reported improvements in both wait time for appointments and no-show rates with the integration of telepsychiatry in primary care.Conclusions and ImplicationsThe telepsychiatry program lowered service use, depression severity, and increased better access to psychiatry care. The findings highlight the potential benefits of sustaining and expanding the telepsychiatry program by SCAN and other plans facing a limited supply of psychiatrists.     

Challenges to HIV prevention in psychiatric settings: perceptions of South African mental health care providers

Mental health services in South Africa increasingly feel the brunt of the AIDS epidemic. Despite the high prevalence of infection in the psychiatric setting, HIV risk reduction interventions targeting South Africans with psychiatric illness remain few and far between. The attitudes of mental health care providers about sexual relations and HIV among people with mental illness continue to influence the extent to which these issues are addressed in care settings. This study examines these attitudes through the use of a semi-structured interview administered to 46 mental health care providers in four provinces of South Africa. I found that personal, contextual and political factors in the clinic and the hospital create barriers to integrating prevention activities. In particular, providers face at least three challenges to intervening in the epidemic among their patients: their own views of psychiatric illness, the transitions occurring in the mental health care system, and shifting social attitudes toward sexuality. Barriers operate at the individual level, the institutional level, and the societal level. At the individual level providers' perceptions of psychiatric symptoms shape their outlook on intervention with psychiatric patients. At the institutional level disruptive transitions in service delivery relegate HIV services to lesser importance. At the societal level, personal beliefs about sexuality and mental illness have remained slow to change despite major political changes. Minimizing barriers to implementing HIV prevention services requires institutional and health care policies that ensure adequate resources for treating people with mental illness and for staff development and support.     

A review of the outcomes of the recommendations made during paediatric telepsychiatry consultations

Little is known about whether the recommendations made during telepsychiatry are actually implemented. We reviewed 100 telepsychiatry consultations, chosen randomly from a paediatric telepsychiatry programme serving rural communities in Ontario. Treatment recommendations had been made for each case reviewed and up to nine recommendations had been made for a single case. Twenty-seven percent of recommendations revolved around monitoring (10%), changing (9%), starting (4%), continuing (3%) and stopping (1%) medication. Case managers associated with 54 of the cases were interviewed to determine whether the recommendations had been implemented and to examine the barriers and facilitators to implementation. The results indicated that cooperation of both child and parent, clear communication of recommendations, involvement of the school and local health providers, stability of the agencies and availability of services were key components in the successful implementation of recommendations. The matter of technology or technological difficulties acting as a barrier to telepsychiatric consultations was not mentioned by case managers, suggesting that it was not a problem.     

Collaboration and local networks for rural and remote primary mental healthcare in South Australia

This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.     

A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland

We evaluated user satisfaction with a PC-based videoconferencing system used for child psychiatry assessments and performed a cost analysis. Thirty patients (aged 5-16 years), accompanied by a parent, completed a psychiatric assessment using the videoconferencing system. One of five child psychiatrists was randomly assigned to each assessment. Satisfaction questionnaires were completed after each assessment by the psychiatrist, patient and parent. Parents also completed a cost questionnaire. The telecommunications bandwidth was 336 kbit/s. The psychiatrists stated that they were either 'very satisfied' or 'satisfied' with the telepsychiatry assessments. On a five-point Likert scale (1 = lowest, 5 = highest), 28 of the 30 parents (93%) rated their satisfaction level as 5; the other two rated it 4. All 30 parents (100%) stated that they 'liked' the telepsychiatry assessment and would use the system again. Twenty-nine parents (97%) indicated that they would prefer to use the telepsychiatry system to travelling to see a child psychiatrist in person. Eleven children (aged 5-12) participated and all (100%) said they 'liked' using the telepsychiatry system. Five out of nine children (56%) stated they liked the 'television doctor' better than the 'real' doctor; four said they had no preference. Nineteen adolescents (aged 13-16 years) participated and most were very satisfied or satisfied with the system. Seventeen of the 19 adolescents (89%) said they would prefer to see the psychiatrist on the videoconferencing system to travelling for an assessment, and the same number said that they would use telepsychiatry again. The estimated total travel cost for the 30 patients was $12,849, an average of $428 per patient. The total cost of the telepsychiatry service for the three-month pilot was $12,575, or $419 per patient.