Special Feature
Telepsychiatry as a Method to Provide Psychiatric Care
By Donald M. Hilty, MD
Although not yet widely available, telemedicine technology is one strategy to improve the accessibility of mental health care and consultation to patients and physicians in underserved areas. The format most applicable to psychiatry is live, two-way audio, two-way video transmission (interactive television).
Our University of California-Davis Health System uses telemedicine to link the Medical Center with 16 of its primary care clinics, which are 20-120 miles away. Telepsychiatric consultation is generally provided in weekly to monthly three-hour blocks to six clinics, via a consultation care model (i.e. the primary care physician is the principal provider of mental health services and calls the psychiatrist for advice or requests a one-time consultation).
A survey of a rural population revealed that over two-thirds of patients expected a less satisfactory doctor-patient interaction via telemedicine care than a traditional patient-doctor encounter.1 To address this issue, we measured patients’ preference for care, adherence to appointments, and satisfaction.2 All patients received care at their primary care clinic, choosing between in-person care or telepsychiatric care. Respondents rated their ability to speak freely when using telemedicine, their preference for using telemedicine on subsequent visits, and their experience with the telemedicine physician on a 5-point Likert-like scale (1 = poor, 5 = excellent). A total of 42 patients made 118 visits consisting of a 60-minute evaluation (24 visits) or a 20-minute follow-up appointment (94 visits). The primary diagnosis for these patients was major depression, adjustment disorder with depressed mood, or panic disorder. For initial evaluations, 71% (17/24) chose in-person care and 29% (7/24) chose telepsychiatric care. For follow-up appointments, 65% chose in-person care and 35% chose telepsychiatric care. The appointment adherence rate for in-person evaluations was 71% and, for telepsychiatric evaluations, the rate was 86%. The appointment adherence rate for in-person follow-up appointments was 87% and for telepsychiatric follow-up appointments was 79%. Patient satisfaction data were collected on 22 in-person visits and 31 visits via telemedicine. There was no significant difference found by t-test analysis on patients’ rating between telepsychiatric care and in-person psychiatric care. These data indicate that when given an initial choice, patients’ prefer in-person psychiatric care, but patient satisfaction was equivalent for in-person mental health care and telepsychiatric care on direct (satisfaction survey) and indirect (adherence rate with appointments) measures in this small sample.
Telemedicine appears to be a viable way of increasing access to mental health care in rural settings. Some patients have reservations about telemedicine, which may not fit their overall concept of seeing a doctor or patients’ concerns about, or lack of familiarity with, technology in general. There are also subtle interactions that patients value in the doctor-patient relationship that are not possible via telemedicine (e.g., the significance of a handshake).
A potential pitfall to telemedicine consultation is that psychiatrists and primary care physicians do not develop a relationship by working "side-by-side" in the primary care clinic, even though joint sessions are possible. The importance of this can not be overstated, since referrals are usually made on the basis of the professional relationship. In addition, if psychiatrists are "present" only by telemedicine, they may not fully understand the complexities of primary care practice.
References
1. Brick JE, et al. Public knowledge, perception and expressed choice of telemedicine in West Virginia. Telemedicine Journal 1997;3:159-172.
2. Hilty DM, et al. The use of telemedicine by academic psychiatrists for the provision of care to the primary care setting. Medscape Mental Health, in press.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content