BOCA RATON, FLA. — Telepsychiatry is a valid and reliable way to extend depression treatment to rural settings, according to a study from researchers at the University of California, Davis.
“Telepsychiatry has been hot and cold, hot and cold, and right now it's hot,” Dr. Donald M. Hilty said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.
Attention-deficit hyperactivity disorder, depression, developmental disorders, eating disorders, posttraumatic stress, and schizophrenia are among the disorders being treated via telemedicine.
“The bottom line is that telepsychiatry is reliable and valid. There is no question that telepsychiatry can be used for these diagnoses,” said Dr. Hilty of the university.
Early surveys of physicians and patients regarding telepsychiatry yielded less than satisfactory results, perhaps partly because of technical limitations, Dr. Hilty said. “A lot of studies were done at 128 [kilobytes per second], which might give you a negative view. With 384 and 512 kb connections, we'll find it is even more satisfying.” Signal delays at the slower connection speed sometimes stilted interaction between the patient and physician, leading to conversation “collisions,” turn taking, and numerous pauses.
The UC Davis telepsychiatry program has provided 2,500 consultations to primary care physicians and their patients since 1996. A broadband connection now provides “quite powerful resolution” for videoconferencing to a patient at one of 40–60 sites in California, Dr. Hilty said. Secure e-mail interaction is another feature.
Psychiatrists control cameras on both ends during a video conference, thus allowing a closer look at facial expressions or nonverbal clues. “You can zoom the camera on the patient end. Generally, they are not aware of changes to their camera unless you go side to side,” Dr. Hilty said.
“Most people doing telepsychiatry are not trying to replace in-person care,” he said. The goal is to provide physician-patient interaction in locations where in-person care is not available or quality is an issue. “It would be nice to see patients in person at least once, but it is not always possible in rural areas with cost and transportation issues.”
Critics of telepsychiatry suggest that a long-distance connection is dangerous if a patient is in crisis. Some situations require patient supervision by the primary care physician, Dr. Hilty said. Patients in imminent danger from suicide ideation or intoxication are examples, as are those with an inability to use equipment because of sensory deficits and those with significant anxiety about meeting people or using technology. “We have their primary care physician come in for a few minutes, and that usually works out.”
A study by Dr. Hilty and his colleagues (in press) assessed 104 depressed adults over 12 months using the Structured Clinical Interview for the DSM-IV (SCID-IV). Participants in this randomized, controlled trial received primary care in rural settings. At 3 months and 6 months, those managed via telepsychiatry experienced a 60% reduction in depression symptoms, compared with 40% of controls.
MediCal provides some reimbursement for telemedicine to qualified California residents, Dr. Hilty said in response to a question from a person attending the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology. “A model a lot of the academic programs use now is contracts with rural organizations. An organization can buy 20% of my time, salary, etc., and use the service or lose it.” The telemedicine program at UC Davis receives money from a variety of sources, including state funds, federal funds, and the National Institutes of Health.
Reduced time to travel for a consultation, reduced waiting time, and less time away from work are among advantages cited by patients. One benefit for psychiatrists is that sessions are recorded electronically, thus obviating the need for written chart documentation, Dr. Hilty said. Telepsychiatry consultations also can reduce nursing home admissions, use of emergency services, and misdiagnosis by primary care providers (J. Geriatr. Psychiatry Neurol. 2001;14:66–71).
Another study demonstrated equal outcomes for telemedicine vs. in-person care for adults with depression (Am. J. Psychiatry 2004;161:1471–6).