Annotated Bibliograpgy

In Review

Clinical and Educational Telepsychiatry Applications: A Review

Donald M Hilty, MD 1 , Shayna L Marks, BA

2 , Doug Urness, MD

3 , Peter M Yellowlees, MD

4 ,

Thomas S Nesbitt, MD 5

T he National Library of Medicine defines telemedicine as

the use of electronic communication and information

technologies to provide or support clinical care at a distance

(1). Each new technology offers advantages and disadvan-

tages, compared with currently available technology.

Telemedicine in the form of videoconferencing has increased

access to psychiatric care in rural (2–5), suburban (5), and ur-

ban areas (6) by linking specialists at academic or regional

health centres with health care professionals in underserved

areas (7). Preliminary studies have demonstrated positive

12 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

Objective: Telepsychiatry in the form of videoconferencing brings enormous opportunities

for clinical care, education, research, and administration. Focusing on videoconferencing,

we reviewed the telepsychiatry literature and compared telepsychiatry with services deliv-

ered in person or through other technologies.

Methods: We conducted a comprehensive review of telepsychiatry literature from January

1, 1965, to July 31, 2003, using the terms telepsychiatry, telemedicine, videoconferencing,

effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empower-

ment, and costs. We selected studies for review if they discussed videoconferencing for

clinical and educational applications.

Results: Telepsychiatry is successfully used for various clinical services and educational

initiatives. Telepsychiatry is feasible, increases access to care, enables specialty consulta-

tion, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms

of communication, generally satisfies patients and providers, facilitates education, and em-

powers parties using it. Data are limited with regard to clinical outcomes and

cost-effectiveness.

Conclusions: Telepsychiatry is effective. More short- and long-term quantitative and qual-

itative research is warranted on clinical outcomes, predictors of satisfaction, costs, and edu-

cational outcomes.

(Can J Psychiatry 2004;49:12–23)

Information on author affiliations appears at the end of the article.

Clinical Implications

� Telepsychiatry has been used successfully for many types of patients in many settings.

� Telepsychiatry has been well received by both patients and physicians.

� Telepsychiatry appears to compare favourably with in-person care in terms of validity, reli - ability, and ability to communicate.

Limitations

� Data are limited with regard to patient outcomes and cost-effectiveness.

� More randomized controlled trials of telepsychiatry are needed.

� Qualitative and quantitative descriptions of telepsychiatry ’s impact on routine services are needed.

Key Words: telepsychiatry, mental health, outcomes, education, review, satisfaction, effectiveness, in-person, telephone, cost

outcomes and user satisfaction with telemedicine (8,9).

Information is still being sought in regard to how

telepsychiatry compares with previous services, what tech-

nology is used, and how it may be integrated with other ser-

vices (10–12). Information is also needed on its costs (10–14),

its outcomes (10–12), and its effects on communication and

interpersonal behaviour (15,16). Questions with regard to its

effectiveness persist because there are few clinical outcome

studies, cost data, and randomized trials.

This article reviews the clinical and educational applications

of telepsychiatry, focusing specifically on how it is used and

its effect on access to care, as well as on its reliability, its out-

comes, its effects on communication and interpersonal behav-

iour, and its costs. We also focus on patient and provider

satisfaction, education, empowerment, integration of data

streams, administrative planning, and overall effectiveness.

When applicable, we compare telepsychiatry with other tech-

nologies (for example, telephone and the Internet) and with

in-person service. Legal and reimbursement issues are

beyond the scope of this article but are discussed elsewhere

(1).

Methods We conducted a comprehensive review of the telepsychiatric

literature between January 1, 1965, and July 31, 2003, by

searching the following databases: Medline, PubMed,

PsycInfo, Embase, Science Citation Index, Social Sciences

Citation Index, and Telemedicine Information Exchange. The

Journal of Telemedicine and Telecare was also hand-

searched for the years in which it is not available on Medline.

W e used the following key words: telepsychiatry,

telemedicine, videoconferencing, effectiveness, efficacy,

access, outcomes, satisfaction, quality of care, education,

empowerment, and costs. The primary author reviewed article

titles and abstracts, selecting studies for review if they dis-

cussed videoconferencing for clinical and educational appli-

cations. Selected articles were pulled and references were

reviewed for additional potential articles.

Results

Technology Used for Telepsychiatry

Nearly all telepsychiatric services are conducted using inter-

active videoconferencing. Equipment selection is based on

software applications, ease of use, image and sound quality,

cost, and compatibility with other units to which one will link.

For example, clinics doing 2-way videoconferencing sessions

might use the following equipment: dial-up integrated service

digital network (ISDN) or T1 lines with a transmission speed

of 128 to 512 kilobits per second (KBS), pentium computers

with 128 to 512 megabytes of random access memory (RAM),

cameras with local and remote pan-tilt-zoom control, colour

monitors, and a CODEC (COder-DECoder) for converting

the audio and visual information into the binary code for

transmission.

Key variables in telepsychiatric videoconferencing are the

speed of transmission in KBS, the transmission method, audio

quality, and picture quality in frames per second (FPS). Most

services transmit between 128 KBS and 512 KBS, although

transmission at 768 KBS has been reported. It is important to

have adequate bandwidth for the task at hand or to have an

alternative clinical option (for example, a primary care pro-

vider who evaluates a tremor if it cannot be adequately seen).

Terrestrial transmission is most commonly used and is rela-

tively inexpensive; however, it is limited by the availability of

access to fiber optic lines in rural areas (2). It provides a good

picture when conducted at 128 KBS, although a 0.3 second

audio and visual delay may generally occur; transmission at

384 KBS to 512 KBS is virtually live. Satellite transmission

transcends geographic limitations, is 8 times as costly (2), and

almost always involves a 0.5- to 1.0-second delay (as occurs,

for example, in worldwide broadcasts). In addition to band-

width, frames per second (FPS) is a measure of how closely

videoconferencing approximates a real image (for example,

30 FPS is television quality). FPS depends on television tech-

nology that refreshes the pixels of the screen image. Its rele-

vance to videoconferencing is that a sudden flux of movement

can require a complete change of pixels and overwhelm the

available bandwidth, resulting in pixelization, distortion, and

freezing at low bandwidths.

The Internet has been used to a lesser degree for

videoconferencing. It has no cost (other than the costs of con-

necting or dialing in from long distance), offers many applica-

tions, and is highly accessible. There are 3 major challenges to

Internet-based telepsychiatry: insufficient bandwidth, quality

of service, and security. The term “quality of service”

describes the priority health care services receive, compared

with other services on the Internet. For example, if too many

users were on the Internet, would digital space for the health

care consultation be preserved?

Telemedicine for Psychiatry: Uses, Access to Care, and Programs

Review articles have described clinical applications (8),

research applications (9), effectiveness (17), and geriatric

telepsychiatry (18). Service points are theoretically limitless:

they include clinics, hospital emergency rooms, patients’

homes, group homes, nursing homes, homeless shelters, hos-

pices, schools, and forensic facilities. A full range of evalua-

tion, consultation, and management services have been

carried out by telemedicine, including case management;

decision support; disease prevention and management; legal

hearings; forensic evaluation; transplant evaluation;

� Can J Psychiatry, Vol 49, No 1, January 2004 13

Clinical and Educational Telepsychiatry Applications: A Review

neuropsychological evaluation; individual, family, and group

therapy; home, outpatient, nursing home, and inpatient care;

and personal and social support.

One significant advantage of telepsychiatry has been

improved access to psychiatric care in rural (2,3,5,19,20),

suburban (5), and urban areas (6). With regard to patient care

and continuing education, its ability to link specialists at aca-

demic or regional health centres with health care profession-

als in underserved areas is particularly useful (5,19,20).

Moreover, this model supports primary care providers who

would rather physically locate psychiatrists in their clinics

than send their patients to a mental health clinic (5). This

model also reduces provider isolation and gives them a

hands-on way to learn how to treat patients (5), particularly if

they sit in on the telepsychiatric evaluation (21). Consultation

by telepsychiatry has been successful, with high initial and

longitudinal satisfaction on the part of consultees (22). By

avoiding travel to rural sites, it also uses specialist time

efficiently.

Currently, over 50 telepsychiatry programs exist in the US,

another 14 exist in Canada, and many others exist internation-

ally. The literature describes several telepsychiatry programs,

including those offered by Alberta’s Mental Health Board;

Australia’s Rural and Remote Mental Health Service; the US

Federal Bureau of Prisons; the Telemedicine Network; Ore-

gon’s RodeoNet; the South Carolina Department of Mental

Health’s Deaf Services Program; Ontario’s St Joseph’s

Health Centre; Texas’ Tech University; the University of

California, Davis; Ireland’s University College Hospital in

Galway; the University of Kansas Medical Center; the Uni-

versity of Kentucky; the University of Oulu, Finland; and pro-

g r a m s i n r u r a l A p p a l a c h i a a n d t h e H i g h l a n d s o f

Scotland (20,23,24).

Reliability Studies

There are several studies concerning the reliability of

telepsychiatric services (Table 1); they have been summarized

in detail elsewhere (8,9). Most studies compare telepsychiatry

with in-person care, although some compare it with telephone

care. Studies have been conducted for children, adults, and

geriatric patients. Nearly all have had good results, generally

at transmission speeds of 128 KBS to 384 KBS. A wide range

of psychiatric disorders were reliably diagnosed (for example,

anxiety, cognitive decline, depression, and psychosis). Over-

all, interrater reliability has been high (8,25), and in general,

diagnostic reliability appears to be excellent with

telepsychiatry, with only a few studies detecting minor

limitations.

Ratings are sometimes less reliable in adults and geriatric

patients when clinicians use the Brief Psychiatric Rating Scale

(BPRS) (4,26,27). We speculate that older patients with

dementia may have had difficulty responding to questions on

the BPRS, resulting in poor reliability. Cognitive examina-

tions with elderly patients using the Mini-Mental State Exam-

ination (MMSE) and the clock drawing test at 128 KBS have

sometimes, but not always, resulted in lower scores, perhaps

owing to patient difficulties with hearing and maintaining

attention (4,28–30). No problems have been noticed using the

MMSE in other studies.

Clinical Outcome Studies

The literature regarding outcomes for telepsychiatry is small,

but growing, and indicates that telepsychiatry may improve

outcomes or stabilize patients with chronic, deteriorating

courses (Table 2).

Telepsychiatry has enabled 2 opinions rather than 1 (that is, it

allows for both primary care provider and specialist opinions)

(5). Patients are referred mainly for diagnostic evaluation and

(or) treatment recommendations (20,22). In a study of spe-

cialty consultation including telepsychiatry, specialists

changed the diagnosis in 91% of cases and recommended

medication changes in 57% (31). According to clinical global

improvement measures, 56% of patients improved. Similarly,

nursing telecare to patients reduced depression and improved

mental health functioning and patient satisfaction (31). In a

comparison with in-person care, patients receiving tele-

psychiatric care did equally well on self-report and clinical

measurements over a 1-year follow-up (32). Similarly, an

8-week trial of cognitive-behavioural therapy delivered by

telepsychiatry at 128 KBS to children with depression was as

successful as in-person care (33). Positive outcomes may also

be defined by reduced transfers for emergencies (34), reduced

appointment waiting time (35), reduced use of the psychiatric

intensive care unit (36), and reduced hospital admissions (by

50%) (37).

Patient Satisfaction Studies

Assessment of patient and provider satisfaction becomes

increasingly important with rapid expansion of telemedicine

services (38,39). A systematic review of the satisfaction liter-

ature revealed limitations in the form of small sample sizes,

informal evaluation, and a lack of randomized trials (40).

Teleconsultation appears acceptable to patients, but further

exploration is needed. Key predictors of satisfaction with

telepsychiatry have not yet been delineated, although trans-

mission speed and equipment quality appear to play important

roles because of their impact on transmission quality (8).

Interestingly, although patients expected specialist–patient

interaction to be less satisfactory than that experienced in a

traditional specialist–patient encounter (41), overall satisfac-

tion has been very high (8,40). High satisfaction has been

reported in 17% of patients in one study, despite equipment

problems (35). Thus far, reduced time to travel (20,42,43),

14 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

reduced absence from work (20), reduced waiting time (44),

and more patient choice and control (20) have been reported

as positive predictors. Other predictors may include frame

speed (27); demographic factors (for example, age, sex, or

ethnicity) (8,45); state- and trait-dependent factors (for exam-

ple, acute depression vs depression in remission) (8,45); cost

(8); reduced waiting time, satisfaction with and availability of

local services, and familiarity with the local setting (that is, in

a remote site) (45); and provider qualities (46). Table 3

summarizes studies of telepsychiatry satisfaction. Several

interesting themes have emerged from the literature. First,

most patients speak freely when using telepsychiatry, rate

highly their preference for using it on subsequent visits, and

rate positively the experience with the specialist (47). Patients

prefer modes with visual cues rather than telephone services

alone. In an open prospective study, patient satisfaction with

telepsychiatric care was equal to other specialty care offered

via telemedicine (38). Another prospective study allowed

Clinical and Educational Telepsychiatry Applications: A Review

Can J Psychiatry, Vol 49, No 1, January 2004 � 15

Table 1 Summary of telepsychiatry reliability studies

Study n Patients KBS (FPS) Location Comments

Reliability

Baer and others (103) 10 Adult patients with OCD

128 (—) US Ratings of severity of OCD equal to in-person interview ratings

Baigent and others (26) 42 Adult state hospital inpatients

128 (—) Australia BPRS ratings similar, though difficulty with “overall concern” and affect

Ball and others (28) — Geriatric patients (review article)

Telephone US Compared the MMSE and its variants via telephone: good access, does not assess visuospatial and praxis ability, and possible confusion

Chae and others (104) 30 Adult outpatients 33 (—) Korea High interrater reliability between telemedicine and in-person interviews

Elford and others (25) 23 Child patients 336 (—) US Diagnosis and treatment recommendation: equal to usual, in-person care

Grob and others (4) 27 Nursing home residents

384 (—) US MMSE and Geriatric Depression Scale: telepsychiatric assessment equal to in-person assessment

Jones and others (27) 30 Geriatric nursing home patients

128 (—) US High reliability of ratings via videoconferencing

Kirkwood and others (105) 27 Adult patients in residential rehabilitation centres

128 (—) US Equal reliability for the National Adult Reading Test, the Quick Test, and the Adult Memory and Information Processing Battery

Malagodi and others (46) 4 Occupational evaluation of adult patients

128 video and 16.8 phone (—) US Video worked, but took more time and had motion artifact

McLaren and others (62) 7 Community mental health centre

128 (—) US Comparison of telepsychiatry (T) and in-person (IP): patient satisfaction higher with T and also higher than psychiatrist satisfaction

Montani and others (29,30) 25 Geriatric patients 128 (—) US MMSE: overall good reliability if hearing is sufficient

Ruskin and others (51) 30 Adult inpatients with depression

— (—) US Reliability coefficients similar for in-person and telepsychiatry

Zarate and others (106) 45 Adult schizophrenia patients

128 and 384 (—) US Global severity and positive symptoms per BPRS and other scales were reliably rated; negative symptoms less so

KBS = kilobits per second; FPS = frames per second; OCD = obsessive–compulsive disorder; BPRS = Brief Psychiatric Rating Scale; MMSE = Mini-Mental State Examination

patients to select in-person or telepsychiatric care for evalua-

tion and follow-up care, if applicable (45). When length of

wait, insurance, demographic information, and diagnoses

were controlled, satisfaction and adherence to appointments

were equal for in-person and telepsychiatric care. Children

(48,49), adolescents (25), and adults appear to be equally sat-

isfied with telepsychiatry (8). Geriatric patients, too, have

reported high satisfaction in studies, including a study com-

paring in-person and telepsychiatric evaluation (30). Some

geriatric patients had trouble hearing (30,50) or felt uncom-

fortable or inhibited by the equipment, but 94% of patients did

not believe that these factors had a detrimental effect on the

relationship (50). Satisfaction among the elderly, including a

group of patients with depression, has also been reported to be

similar to that among younger adults (27,51). Rarely, patients

have thought telepsychiatry was impersonal or had greater

potential for decreased sensitivity (20).

Provider Satisfaction Studies

Provider satisfaction with telepsychiatry is less well evalu-

ated. In rural Arkansas, medical school graduates from the

1960s, 1970s, and 1980s believed that telemedicine could sig-

nificantly improve education, information exchange, patient

care quality, and the institution’s reputation; however, they

did not believe it would improve access to care, follow-up

care, or provider recruitment (52). Consultee (that is, nurse,

psychologist, or other) satisfaction with telepsychiatry was

lower than satisfaction with in-person consultation in terms of

ease with the process, ability to express oneself, and quality of

the interpersonal relationship (49). In another study, however,

satisfaction with a consultation-liaison service was high (that

is, 4.5 or greater on a scale of 1 = poor to 5 = excellent) and

increased after 2 or more consultations over a 1-year period

(22). Rural providers had significantly higher satisfaction

than suburban or urban providers.

Effect on Communication and Relationship

Three articles have discussed in detail the effects of

telemedicine on communication and relationships (8,15,16).

Telepsychiatry appears to have both positive and negative

effects on communication (8). It allows the establishment of a

“social presence” (15). One concern with telemedicine is that

the technology may adversely affect communication and the

development of a positive therapeutic alliance (53). We

review findings from the nonmedical, medical, and psychiat-

ric literature, including comparisons between telepsychiatry,

telephone, and in-person services.

16 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

Table 2 Summary of outcome studies

Study n Patients KBS (FPS) Location Comments

Doze and others (20) 90 Adult outpatients 128 to 384 (—) Canada Specialists assisted with diagnosis and treatment; no outcomes measured

Graham (107) 39 Adult outpatients 768 (—) US Reduced hospitalization

Haslam and McLaren (36) 69 Adult and geriatric outpatients 128 (—) US More appropriate use of inpatient services

Hunkeler and others (34) 302 Adult outpatients in primary care — (—) US Nurse telecare improved depressive symptoms, functioning, and satisfaction vs usual care

Johnston and others (19) 40 Nursing facility residents 128 (adjusted to 5-inch square )

US Elimination of travel and more contact between patients and staff

Kennedy and Yellowlees (32) 124 Adult outpatients 128 (—) Australia Clinical improvement at 1-year follow-up on self-report and primary care provider assessments; equal to in-person care

Lyketsos and others (37) — Geriatric dementia patients — (20) US Reduced psychiatric hospitalization

Nelson and others (33) 28 Child patients with depression 128 (—) US Substantial clinical change, equivalent to in-person care

Nesbitt and others (31) 164 Adult outpatients with specialty consultations including psychiatry

128 to 384 (—) US Change in diagnosis in 91% of cases and clinical improvement in 56% of cases

Zaylor (108) 49 Adult outpatients with depression or schizoaffective disorder

128 (—) US No difference in GAF scores at 6-month follow-up vs in-person

GAF = Global Assessment of Functioning

Clinical and Educational Telepsychiatry Applications: A Review

Can J Psychiatry, Vol 49, No 1, January 2004 � 17

Table 3 Summary of patient telepsychiatry satisfaction studies

Study n Patients KBS (FPS) Location Comments

Baer and others (103) 26 Adult patients with OCD 128 (—) US Average to better than in- person care

Baigent and others (26) 63 Adult state hospital inpatients 128 (—) Australia Many patients were satisfied and preferred it instead of in-person

Ball and others (28) 6 Adult inpatients Low-cost system (—) UK Also measured satisfaction with in-person, telephone, and hands-free telephone

Blackmon and others (48) 43 Child outpatients — (—) US Parent satisfaction was also very good

Bratton and others (50) 20 Geriatric patients in a retirement community

128 (—) US Satisfied despite hearing and poor image problems

Callahan and others (38) 93 Adult primary care outpatients 128 (15) US Satisfaction equal to a nonpsychiatric population

Chae and others (104) 30 Adult outpatients 33 (—) Korea Equal to usual, in-person care

Dongier and others (49) 50 Adult, child outpatients Closed circuit TV (—)

Canada Equal to usual, in-person care

Doze and others (20) 90 Adult outpatients 128 to 384 (—) Canada Positive because of less travel and less absence from work; negative perception

Elford and others (109) 23 Children 336 (—) US Diagnosis and treatment recommendation equal to usual, in-person care

Graham (107) 39 Adult outpatients 768 (—) US Positive patient acceptance of telepsychiatry aftercare

(90% positive ratings)

Hilty and others (45) 40 Adult primary care outpatients 384 (15) US Satisfaction equal for in-person and telepsychiatric care, if patient given the choice

Johnston and others (19) 40 Nursing facility

residents

128 (—) US Patients and families expressed appreciation for the service

Kirkwood and others (105) 27 Adult patients in residential rehabilitation centres

128 (—) US Patients expressed high satisfaction while doing reading and memory tests

McCloskey and others (43) 236 Adult outpatients 128 (—) US Rural Montana; would have had to travel significantly

McLaren and others (58) 3 Adult schizophrenia patients — (—) UK Patients felt comfortable and some preferred it to in-person

Mielonen and others (81) 14 Adult inpatients — (—) Finland High patient satisfaction (80% considered it to have been useful)

Ruskin and others (51) — Geriatric outpatients — (—) US Geriatric satisfaction similar to adult satisfaction

Simpson and others (35) 230 Adult outpatients 384 (—) Canada High level of satisfaction with the service and equipment

Simpson and others (44) 546 visits

Adult outpatients 384 (—) Canada High level of satisfaction with the service and equipment, despite equipment problems in 17% of cases

Trott and others (80) 50 Adult and child outpatients — (—) Australia High level of acceptance by patients and mental health professionals

A critical variable affecting communication is telemedicine’s

ability to simulate real-time experiences in terms of image and

interaction. Transmission speed has a profound affect on

audio and video quality. Terrestrial transmission at 384 KBS

to 768 KBS provides a good picture and no audio delay.

Low-KBS terrestrial transmission (for example, < 128 KBS)

and satellite transmission provide good pictures, but with

0.3-second and 0.5-second signal delays, respectively. If

delays are too great, words are cancelled out when parties

speak simultaneously. Consequently, they may perceive the

other as interrupting, and a turn-taking conversation may

occur (54,55). Some of this may be caused by the presence of

others in the room or by the patients’ belief that they are being

videotaped or that information exchange takes place primarily

on a verbal channel, rather than a video channel, regardless of

how high-quality the video channel is (15,54,56).

Nevertheless, no differences in the development of rapport

were found in a small cohort comparing 0.0-second,

0.3-second, and 1.0-second signal delays (57).

Decreased ability to detect nonverbal cues in patient inter-

views has been reported during videoconferencing (58),

which may limit mutual connections and understanding (59).

In a physical environment, informational cues are incorpo-

rated without conscious awareness (for example, a patient is

seen walking in a reticent way). The virtual environment cre-

ated by telemedicine may differ, particularly when low-cost

systems are used (55), although it appears to provide enough

of the physical environment for good decision making (16).

Videoconferencing provides more cues than telephone

conferencing; however, it may require more time than does

the telephone to communicate the same ideas (56,60,61),

although this was not found in 2 studies (62).

Several papers comment on telepsychiatry’s effect on psycho-

therapy. In a report of psychoanalysis carried out by telephone,

no significant psychotheraupeutic differences were found

between office and telephone therapy (63). Nevertheless, such

sessions may have a distancing effect on the relationship and

may not allow detection of key physical cues. Most patients

make use of whatever method is available to bring material into

the transference, including strong affects (64). Some analysts

prefer listening with an averted gaze, actively blocking out

visual information to enhance processing of verbal information

(65,66). Basic indications and contraindications have been sug-

gested for using telephone and videoconferencing methods for

psychotherapy (65), but more rigorous evaluation is warranted

before drawing conclusions.

Some wonder whether it is necessary to have a preexisting

relationship (that is, to see the patient first in person) to mini-

mize telepsychiatry’s possible negative effects, if any, on the

specialist–patient relationship. A preexisting relationship has

been reported helpful for psychotherapy supervision (67) and

was required in a study that compared telepsychiatric inter-

ventions with in-person therapy or usual care populations

(68). Two studies using formal assessments revealed no diffi-

culty developing an alliance and no adverse events

noted (69,70).

Some of the barriers created by the telemedicine interface

(that is, the technology–human interface) may be dramatically

lessened in the future through virtual reality or 3-dimensional

technology. It may be as if the patient is in the room with

the specialist.

Cost Studies

This article reports cost studies briefly, because the quality of

data in the literature is suboptimal and little information has

been collected in a systematic, controlled, prospective fashion

(10). Ideally, direct and indirect costs should be collected for

patients, clinics, providers, and society at large. Direct costs

include equipment, installation of lines, and supplies. Fixed

costs also include the rental cost of lines, salary and wages,

and administrative expenses. Variable costs include data

transmission costs, fees for service, and equipment mainte-

nance and upgrades. Cost analysis is difficult for several rea-

sons. For example, technologies continue to evolve and

become dated rapidly (71), and costs depend on use. In addi-

tion, the cost may seem high, since usual care often amounts to

no care. New cost analyses are being completed, but the

heterogeneous methods skew the data. Cost-effectiveness and

cost–benefit analyses are recommended (17,72–74).

Several studies have reported cost data (Table 4). Usually,

telepsychiatry is less expensive for patients (35,42,75,76).

Telepsychiatry services have been estimated to be less expen-

sive (3,77,78), as expensive (10), or more expensive than out-

reach in-person services (20,50,79) Telepsychiatry appears

cost-effective in reducing costly transfers (for example, in the

case of forensic psychiatry; 77,80,81) and hospitalization

(36,37). Break-even cost analyses are often used, as is the case

with the telepsychiatry program in Alberta (with 7 consulta-

tions weekly; 20,44,75).

A metaanalysis of cost data found that only 38/551 articles

contained any quantifiable data. It is therefore premature to

conclude that telemedicine is cost-effective (82). Several

d e t a i l e d g u i d e l i n e s h a v e b e e n r e c e n t l y p u b l i s h e d

(10,11,83–85), as have recommendations for cost-

effectiveness (86) and cost–benefit (73) evaluations.

Integrating and Organizing Telepsychiatry into Daily Practice

The increased availability of broadband systems, whether

satellite-based, cable, fibre, or digital subscriber lines (DSLs),

has reduced their price. Consequently, there is more opportu-

n i t y t o p r o v i d e e f f e c t i v e t e l e p s y c h i a t r y s e r v i c e s ,

18 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

incorporating multiple data streams, to any place in the world,

any time, from the doctor’s desktop. Inevitably over time, we

will move to global health care systems wherein clinicians and

patients interact in electronically distributed worldwide envi-

ronments supported by broadband technologies, either wired

or wireless. These global delivery environments on the doc-

tor’s desktop will incorporate various features, including

technology to allow video consultations in real time or video

e-mail for store-and-forward programs as well as electronic

consumer-owned or provider-shared voice-driven health

records. Practice-management and communications software,

serviced from central servers or kept on doctors’ local net-

works, will allow them to link seamlessly, peer-to-peer, with

their colleagues. Many of telepsychiatry’s current organiza-

tional problems will be overcome through the use of

Web-based scheduling systems. Such systems will allow

patients to connect to their doctors in a manner similar to the

way in which we use the Internet to reserve, for example, a

hotel room (87). Specialists’ electronic desktops will have a

very strong educational focus, because doctors and other

health care professionals will be able to receive their continu-

ing health education via their desktops. Several commercial

companies are already starting to manufacture and distribute

these systems (88). The practice and practitioners of

telepsychiatry have to meet the challenges contained in the

recent crucially important report from the Committee of Qual-

ity Health Care in America of the Institute of Medicine, which

noted that “information technology must play a central role in

the redesign of the health care system” (89). Telepsychiatry is

not yet completely integrated into daily mental health service

delivery. Substantial further research is required, especially to

Clinical and Educational Telepsychiatry Applications: A Review

Can J Psychiatry, Vol 49, No 1, January 2004 � 19

Table 4 Summary of telepsychiatry cost studies

Study n Patients KBS (FPS) Location Comments

Alessi and others (77) — Adult forensic inpatients — ( —) US Telepsychiatry is cost-effective

Doze and others (20) 90 Adult patients 336 to 384 (—) Alberta Costs break even at approximately 390 consultations yearly; less if used for administration, too

Hailey and others (10) — Adult patients — US Reduced costs to rural patients

Hailey and others (42) — A review of 5 mental health studies; adult patients

— International Savings to health system and patients through less travel

Gammon and others (67) — — Norway Costs break even at 18 trips (800 km) or 34 trips (300 km)

Haslam and McLaren (36) 69 Adult and geriatric patients 128 (—) US Reduced cost by more appropriate use of inpatient services and cheaper case conferences and patient assessments

Lyketsos and others (37) See comments

Geriatric patients with dementia in long-term facility

— (20) US Admissions: 21 in 1997–1998 and 11 in 1999–2001; 100 fewer hospital days total

Mielonen and others (81) 14 Adult inpatients — Finland Savings in health care costs, reduction in travel and ease and speed of consultation

Simpson and others (35) 379 Adult outpatients 128 to 384 (—) Canada Savings of $210 per consultation for patients who would have had to travel

Simpson and others (44) 546 Adult outpatients 384 (—) Canada Costs break even at approximately 350 consultations yearly; less if used for administration, too

Trott and others (80) 50 Adult and child outpatients — Australia Substantial savings in health care costs from reduction in travelling and patient transfers

Werner and Anderson (79) — Theoretical analysis — US Not feasible: start-up costs; high cost per visit (for example, $322 for community mental health centre–rural site medication check-up; less for University–rural site)

examine the human- and change-management issues that

have to be overcome for this to occur (90).

Education

Telemedicine has been used for several educational initia-

tives, including provider education (91,92), clinical consulta-

tion (5), and supervision (67). It has successfully linked

academic centres with rural areas for continuing medical edu-

cation, both in North America and internationally (7,92).

Clinical consultations also reduce provider isolation, provide

case-based learning (93), and help with decision support (94).

Empowerment

Patient travel time is reduced (20,42,43), as is time absent

from work (20) and waiting time (35). Further, patients have

more choice and control regarding treatment (20). Primary

care providers have access to specialists for patient care and

education, are able to keep their patients rather than referring

them (22), and feel good about their practice. Communities

also keep their patients, reduce the costs for transfers (80,81),

and retain dollars that would have otherwise been lost to sub-

urban centres upon referral (95). Communities presumably

also benefit from providing a higher quality of care and more

opportunities for staff education, as well as from greater ease

with recruitment and accreditation (17).

Effectiveness

The overall effectiveness of telepsychiatry has recently been

evaluated (17,32). According to its Latin root, effectiveness is

defined as “having the power to produce an effect . . . a deci-

sive effect; efficient; as, . . . an effective . . . remedy” (96).

Ideally, effectiveness should be considered for the patient,

provider, program, community, and society. With what

telepsychiatry’s effectiveness is being compared is another

key issue. If there is no service at all, then telepsychiatry will

be judged highly effective. Standard care in communities has

often not been completely evaluated, and without direct com-

parison, it is hard to judge telepsychiatry’s effectiveness. If

superior local services already exist, telepsychiatry is usually

not initiated. Effectiveness also depends on the experience

and skill of the consultant—even with limitations imposed by

technology, a good telespecialist may be better than a

local specialist.

Telepsychiatry’s effectiveness has been evaluated with regard

to access to care, quality of care (that is, outcomes, reliability,

satisfaction, and comparison with in-person care), costs, edu-

cation, empowerment, and other factors that influence effec-

tiveness (for example, technology and administrative

coordination) (17). According to preliminary data (17),

telepsychiatry appears effective, although it is premature to

claim it is cost-effective (22).

Telepsychiatry’s effectiveness needs to be further assessed

(8,9,42,75,76,97). Frameworks have been proposed (10–14)

and key aspects have been recently summarized (17). All

parameters could benefit from more assessment, particularly

in terms of outcomes and costs. Randomized controlled trials

of telemedicine are feasible, enable recruitment of patients,

and maintain enrollment (98).

Discussion

Telepsychiatry is being used successfully for various clinical,

educational, and research purposes. The technology, speed of

transmission, and program structure vary widely among many

clinical settings. One significant advantage of telepsychiatry

has been improved access to psychiatric care in rural, subur-

ban, and urban areas. Compared with in-person care, most

studies have shown it to reliably diagnose a wide range of con-

ditions in adults, children, and geriatric populations. It

appears to be generally acceptable to patients. Overall,

telepsychiatry appears to allow the building of relationships,

with clear advantages over the telephone and few disadvan-

tages, compared with in-person care. Educational use has

included didactic, case-based consultation and supervisory

initiatives. Telepsychiatry appears to have greatly empowered

patients, providers, programs, and communities.

More rigorous assessment of telepsychiatric service is needed

in various areas, and lessons learned may also be valuable for

elements of in-person psychiatric service (for example, out-

comes and costs) not commonly studied outside research set-

tings. More data are needed on patient outcomes for almost all

age groups and disorders. Measurement of satisfaction needs

to be more specific about several key variables: demographic

factors (for example, age, sex, or ethnicity), state- and

trait-dependent factors, cost, travel time for both patients or

specialists, waiting time, and quality and availability of local

services. More data are needed on referring and consulting

provider satisfaction, with attention to the variables listed

above as well as to training, specialty, years in practice, type

of practice, and other factors that affect practice. In addition,

the technology needs to be better described so that its effect on

the measurement of all parameters can be understood. Such

technology includes bandwidth, audio quality, FPS, size of

the transmitted video image (rather than the size of the moni-

tor), computer speed, and name or make of the CODEC and

other equipment (99). Information about the cost of

telepsychiatry services needs to be collected in a standard,

prospective fashion (10), preferably through cost-

effectiveness and cost–benefit analyses. Longitudinal evalua-

tion is needed throughout the telepsychiatry literature, and

studies need to report quantifiable data that can be pooled

when appropriate for metaanalysis (82).

20 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

Table 5 lists guidelines for program viability and delivering

quality clinical care (7,8). Programs should be based on

underlying patient and provider needs, with incentives for

each of the parties involved. Clinical guidelines and protocols

in telemedicine can significantly improve program quality

and efficiency. Training practitioners to practise tele-

psychiatry requires ensuring their comfort with the equip-

ment, adapting it to clinical practice, and being aware of its

limitations. Several factors have led to the downfall of

telemedicine programs. Many programs fail because of inade-

quate needs assessment and inadequate support from organi-

zation leaders. Inadequate technical support will alienate all

parties. Inadequate collection of outcome, satisfaction, and

other data jeopardizes the renewing of contracts or grants.

Specialist participation requires resolution of various issues,

including remuneration, clinical responsibility from a dis-

tance, impact on usual practice, credentialing, and medico-

legal coverage, as well as organizational support to supply

service to remote populations.

It appears that telepsychiatry use will continue to grow. Its

curve of growth or decline will depend on how well programs

are organized and adapt to potential pitfalls. Some obstacles

(for example, costs and access to broad bandwidth lines) will

recede as technology advances. Integration of video-

conferencing with other digital technologies appears particu-

larly promising in terms of clinical care, patient and provider

education, provider–specialist communication, and elec-

tronic medical records. The computer can significantly facili-

tate clinical care and education (100,101) if it fits with the

demands of clinical practice and the cognitive structures of

clinicians (102).

References

1. Canadian Psychiatric Association. Telepsychiatry guidelines and procedures for

clinical activities. University of Toronto Psychiatric Outreach Program. Discus -

sion paper. Ottawa: Canadian Psychiatric Association; 2003.

2. Preston J, Brown FW, Hartley B. Using telemedicine to improve health care in

distant areas. Hosp Community Psychiatry 1992;43:25–32.

3. Brown FW. Rural telepsychiatry. Psychiatr Serv 1998;49:963– 4.

4. Grob P, Weintraub D, Sayles D, Raskin A, Ruskin P. Psychiatric assessment of a

nursing home population using audiovisual telecommunication. J Geriatr Psychi -

atry Neurol 2001;14:62–5.

5. Hilty DM, Servis ME, Nesbitt TS, Hales R. The use of telemedicine to provide

consultation liaison service to the primary care setting. Psychiatr Ann

1999;29:421–7.

6. Straker N, Mostyn P, Marshall C. The use of two-way TV in bringing mental

health services to the inner city. Am J Psychiatry 1976;133:1202–5.

7. Nesbitt TS, Hilty DM, Kuenneth T, Siefkin A. Development of a telemedicine

program: a review of 1,000 videoconferencing consultations. Western J Med

2000;173:169–74.

8. Hilty D, Luo JS, Morache C, Marcelo DA, Nesbitt TS. Telepsychiatry: what is it

and what are its advantages and disadvantages? CNS Drugs 2002;16:527– 48.

9. Frueh BC, Deitsch SE, Santos AB, Gold PB, Johnson MR, Meisler N, and oth-

ers. Procedural and methodological issues in telepsychiatry research and program

development. Psychiatr Serv 2000;51:1522–7.

10. Hailey D, Jacobs P, Simpson J, Doze S. An assessment framework for

telemedicine applications. J Telemed Telecare 1999;5:162–70.

11. Drummond MF, O’Brien BJ, Stoddart GL, Torrance GW. Critical assessment of

economic outcomes. Methods for economic evaluation of health care

programmes. Oxford: Oxford University Press; 1988. p 27–51.

12. Ohinmaa A, Hailey D, Roine R. Elements for assessment of telemedicine appli-

cations. Int J Technol Assess Health Care 2001;17:190–202.

13. Bashshur RL. Telemedicine effects: cost, quality, and access. J Med Syst

1995;19:81–91.

14. Grigsby J, Kaehny MM, Sandberg EJ, Schlenker RE, Shaughnessy PW. Effects

and effectiveness of telemedicine. Health Care Financ Rev 1995;17:115–31.

15. Cukor P, Baer L, Willis BS, Leahy L, O’Laughlen J, Murphy M, and others. Use

of videophones and low-cost standard telephone lines to provide a social pres -

ence in telepsychiatry. Telemed J 1998;4:313–21.

16. Hilty DM, Nesbitt TS, Marks SL, Callahan EJ. How telepsychiatry affects the

doctor–patient relationship: communication, satisfaction, and additional clini -

cally relevant issues. Primary Psychiatry 2002;9:29–34.

17. Hilty DM, Liu W, Marks SL, Callahan EJ. The effectiveness of telepsychiatry: a

brief review. CPA Bulletin 2003;35(5):10–7.

18. Jones BN III. Telepsychiatry and geriatric care. Curr Psychiatry Rep

2001;3:29–36.

19. Johnston D, Jones BN III. Telepsychiatry consultations to a rural nursing facil -

ity: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14:72–5.

20. Doze S, Simpson J, Hailey D, Jacobs P. Evaluation of a telepsychiatry pilot pro-

ject. J Telemed Telecare 1999;5:38–46.

21. Hawker FK, Kavanagh S, Yellowlees P, Kalucy RS. Telepsychiatry in South

Australia. J Telemed Telecare 1998;4:187–94.

Clinical and Educational Telepsychiatry Applications: A Review

Can J Psychiatry, Vol 49, No 1, January 2004 � 21

Table 5 Guidelines for program viability and for delivering quality service

1. Do a thorough needs assessment in the region that the program is planning to serve.

2. Obtain overall and financial support of the program from senior leadership of the organization.

3. Use clinically proven technology.

4. For each consult, be certain that the technical equipment is appropriately matched to the service and needs of the patient and their condition.

5. Evaluate options, implementation, and maintenance of telepsychiatry with a team of clinicians, technicians, and administrators in both the hub and the spoke sites.

6. Adequately train all site coordinators in the technical and procedural aspects of the service, including referral guidelines and transfer of patient medical information to the specialist and back to the referral site.

7. Obtain a telepsychiatric champion and provide adequate training for others with regard to the technology, adapt clinical practice to fit its use, and identify its limitations.

8. Provide regular technical maintenance and prompt trouble-shooting.

9. Coordinate timing of consults (that is, the patient is there at the right time, the telepsychiatrist has adequate time, and (or) referring providers or staff stop in if desired).

10. Adequately evaluate outcomes, satisfaction, and costs to the patient, the referring provider, and the specialist, as well as to the program

(coordinator, technical staff, and administration).

22. Hilty DM, Nesbitt TS, Kuenneth TA. Development of a successful telepsychiatry

program: a look at the first 200 consultations at UC Davis. Poster presented at

Academy of Psychosomatic Medicine; November 2000; Palm Springs (CA).

23. Brown F. A survey of telepsychiatry in the USA. J Telemed Telecare

1995;1:19–21.

24. Allen A, Wheeler T. Telepsychiatry background and activity survey. The devel-

opment of telepsychiatry. Telemed Today 1998;6:34–7.

25. Elford R, White H, Bowering R, Ghandi A, Maddiggan B, St John K, and others.

A randomized, controlled trial of child psychiatric assessments conducted using

videoconferencing. J Telemed Telecare 2000;6:73–82.

26. Baigent MF, Lloyd CJ, Kavanagh SJ, Ben-Tovim DI, Yellowlees PM, Kalucy

RS, and others. Telepsychiatry: ‘tele’ yes, but what about the ‘psychiatry’? J

Telemed Telecare 1997;3(Suppl 1):3–5.

27. Jones BI, Johnston D, Reboussin B, McCall W. Reliability of telepsychiatry as -

sessments: Subjective versus observational ratings. J Geriatr Psychiatry Neurol

2001;14:66–71.

28. Ball C, McLaren P. The tele-assessment of cognitive state: a review. J Telemed

Telecare 1997;3:126–31.

29. Montani C, Billaud N, Couturier P, Fluchaire I, Lemaire R, Malterre C, and oth-

ers. “Telepsychometry”: a remote psychometry consultation in clinical gerontol-

ogy: preliminary study. Telemed J 1996;2:145–50.

30. Montani C, Billaud N, Tyrrell J, Fluchaire I, Malterre C, Lauvernay N, and oth-

ers. Psychological impact of a remote psychometric consultation with hospital -

ized elderly people. J Telemed Telecare 1997;3:140–5.

31. Nesbitt TS, Marcin JP, Alexander RM, Hilty D, Prescott PT. Clinical outcomes:

the impact of telemedicine. Paper presented at the Annual Meeting of the Ameri-

can Telemedicine Association; 2002; San Francisco (CA).

32. Kennedy C, Yellowlees P. A community-based approach to evaluation of health

outcomes and costs for telepsychiatry in a rural population: preliminary results.

J Telemed Telecare 2000;6(Suppl 1):S155–S157.

33. Nelson EL, Barnard M, Cain S. Treating childhood depression over

videoconferencing. Telemed J E Health 2003;9:49–55.

34. Hunkeler EM, Meresman JF, Hargreaves WA, Fireman B, Berman WH, Kirsch

AJ, and others. Efficacy of nurse telehealth care and peer support in augmenting

treatment of depression in primary care. Arch Fam Med 2000;9:700–8.

35. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Telepsychiatry as a routine

service the perspective of the patient. J Telemed Telecare 2001;7:155–60.

36. Haslam R, McLaren P. Interactive television for an urban adult mental health

service: The Guy’s psychiatric Intensive Care Telepsychiatry Project. J Telemed

Telecare 2000;6:50–2.

37. Lyketsos C, Roques C, Hovanec L, Jones BN III. Telemedicine use and reduc-

tion of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry

Neurol 2001;14:76–9.

38. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine con -

sultation in primary care: comparison of ratings of medical and mental health ap-

plications. Telemed J 1998;4:363–9.

39. Bashshur RL. Critical issues in telemedicine. Telemed J 1997;3:113–26.

40. Mair F, Whitten P. Systematic review of studies of patient satisfaction with

telemedicine. BMJ 2000;320:1517–20.

41. Brick JE, Bashshur RL, Brick JF, D’Alessandri RM. Public knowledge, percep-

tion, and expressed choice of telemedicine in rural West Virginia. Telemed J

1997;3:159–71.

42. Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits

of telemedicine. J Telemed Telecare 2002;8 Suppl 1:1–30.

43. McCloskey AT. Rural psychiatric collaborative care via telemedicine. Syllabus

of the 150th Annual Meeting of the American Psychiatric Association. Washing -

ton (DC): American Psychiatric Association; 1997. p 106.

44. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Evaluation of a routine

telepsychiatry service. J Telemed Telecare 2001;7:90–8.

45. Hilty DM, Nesbitt TS, Hales RE, Anders TF, Callahan EJ. The use of

telemedicine by academic psychiatrists for the provision of care in the primary

care setting. Medscape Mental Health 2000;5:1–11.

46. Malagodi M, Smith S.. Prospective role for telemedicine as a communication

tool for rural rehabilitation practice. Work 1999;12:245–59.

47. Ball CJ, McLaren PM, Summerfield AB, Lipsedge MS, Watson JP. A compari-

son of communication modes in adult psychiatry. J Telemed Telecare

1995;1:22–6.

48. Blackmon LA, Kaak HO, Ranseen J. Consumer satisfaction with telemedicine

child psychiatry consultation in rural Kentucky. Psychiatr Serv 1997;48:1464–6.

49. Dongier M, Tempier R, Lalinec-Michaud M, Meunier D. Telepsychiatry: psychi-

atric consultation through two-way television. A controlled study. Can J Psychia -

try 1986;31:32–4.

50. Bratton RL, Cody C. Telemedicine applications in primary care: a geriatric pa-

tient pilot project. Mayo Clin Proc 2000;75:365–8.

51. Ruskin PE. Efficacy of telepsychiatry in treatment of depression [abstract].Vet-

erans Administration HSR&D Service 18th Annual Meeting; March 22, 2000;

Washington (DC).

52. Tilford JM, Garner WE, Strode SW, Bynum AB. Rural Arkansas physicians and

telemedicine technology: attitudes in communities receiving equipment. Telemed

J 1997;3:257–63.

53. Kavanagh SJ, Yellowlees PM. Telemedicine clinical applications in mental

health. Aust Fam Physician 1995;24:1242–7.

54. O’Malley C, Langston S, Anderson A, Doherty-Sneddon G, Bruce V. Compari-

son of in-person and video-mediated interaction. Interactive Computers

1996;8:177–92.

55. Kim T, Biocca F. Telepresence via television: two dimensions of telepresence

may have connections to memory and persuasion. Journal of Computer Mediated

Communication 1997 [on-line];3(2). http://jcmc.juji.ac.il/vol3/issue2/kim.html.

56. Ochsman RB, Chapanis A. The effects of 10 communication modes on the be-

havior of teams during co-operative problem-solving. International Journal of

Man-Machine Studies 1974;6:579–619.

57. Manning TR, Goetz ET, Street RL. Signal delay effects on rapport in

telepsychiatry. CyberPsychol Behav 2000;3:119–27.

58. McLaren P, Ball CJ, Summerfield AB, Watson JP, Lipsedge M. An evaluation of

the use of interactive television in an acute psychiatric service. J Telemed

Telecare 1995;1:79–85.

59. Short J, Williams E, Christie B. The social psychology of telecommunications.

London, New York: Wiley; 1976. p ix, 195.

60. Jameson DC, Hobsley M, O’Hanlon P, Buckton S. Real-time interactivity on the

superJANET network. Interacting with Computers 1996;8:285–95.

61. Gale S. Adding audio and video to an office environment. In: Bowers JM,

Benford S, editors. Studies in computer supported cooperative work. Amsterdam,

New York: North-Holland; 1991. p xiii, 355.

62. McLaren P, Laws V, Ferreira A, O’Flynn D, Lipsedge M, Watson JP.

Telepsychiatry: outpatient psychiatry by videolink. J Telemed Telecare

1996;2:59 –2.

63. Lindon JA. Psychoanalysis by telephone. Bull Menninger Clin 1988;52:521–8.

64. Freud S. Recommendations to physicians practicing psychoanalysis. In: Strachey

J, editor. The complete psychological works of Sigmund Freud. London:

Hogarth Press; 1958. p 15.

65. Kaplan EH. Telepsychotherapy: psychotherapy by telephone, videotelephone,

and computer videoconferencing. J Psychother Pract Res 1997;6:227–37.

66. Ogden TH. Reconsidering three aspects of psychoanalytic technique. Int J

Psychoanal 1996;77:883–99.

67. Gammon D, Sorlie T, Bergvik S, Hoifodt TS. Psychotherapy supervision con-

ducted by videoconferencing: a qualitative study of users ’ experiences. J

Telemed Telecare 1998;4:33–5.

68. Nakamura K, Takano T, Akao C. The effectiveness of videophones in home

healthcare for the elderly. Med Care 1999;37:117–25.

69. Manchanda M, McLaren P. Cognitive behaviour therapy via interactive video. J

Telemed Telecare 1998;4:53–5.

70. Stevens A, Doidge N, Goldbloom D, Voore P, Farewell J. Pilot study of

televideo psychiatric assessments in an underserviced community. Am J Psychia-

try 1999;156:783–5.

71. Reid J. A telemedicine primer: understanding the issues. Billings (MT): Innova -

tive Medical Communication; 1999.

72. Katon W, Von Korff M, Lin E, Walker E, Simon G, Bush T . Collaborative man-

agement to achieve treatment guidelines. JAMA 1995;273:1026–31.

73. Weinstein MC, Stason WB. Foundations of cost-effectiveness analysis for health

and medical practices. N Engl J Med 1977;296:716–21.

74. Torrance GW, Feeny D. Utilities and quality-adjusted life years. Int J Technol

Assess Health Care 1989;5:559–75.

75. Håkansson S, Gavelin C. What do we really know about the cost-effectiveness of

telemedicine? J Telemed Telecare 2000;6:133–6.

76. Roine R, Ohinmaa A, Hailey D. Assessing telemedicine: a systematic review of

the literature. CMAJ 2001;165:765–71.

77. Alessi N, Rome L, Bennett J. . Cost-effectiveness analysis in forensic

telepsychiatry: prisoner involuntary treatment evaluations. Telemed J 1999;5:17.

78. Hilty DM, Ingraham R, Yang S, Anders TF. Psychiatric consultation to primary

care physicians by phone and email for the care of persons with developmental

disabilities in rural California. Poster presented at Annual Meeting of the Ameri -

can Psychiatric Association; May 2001; New Orleans (LA).

79. Werner A. Unanswered questions about telepsychiatry. Psychiatr Serv

2001;52:689–90.

80. Trott P, Blignault I. Cost evaluation of a telepsychiatry service in northern

Queensland. J Telemed Telecare 1998;4(Suppl 1):66–8.

81. Mielonen ML, Ohinmaa A, Moring J, Isohanni M. The use of videoconferencing

for telepsychiatry in Finland. J Telemed Telecare 1998;4:125–31.

82. Whitten P, Kingsley C, Grigsby J. Results of a meta-analysis of cost benefit re-

search: is this a question worth asking? J Telemed Telecare 2000;6(Suppl

1):S4–S6.

83. Institute of Medicine. Telemedicine: a guide to assessing telecommunication in

health. Washington (DC): National Academy Press; 1996.

84. Lobley D. The economics of telemedicine. J Telemed Telecare 1997;3:117–25.

85. Mair FS, Haycox A, May C, Williams T. A review of telemedicine

cost-effectiveness studies. J Telemed Telecare 2000;6(Suppl 1):S38–S40.

86. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations

of the Panel on Cost-effectiveness in Health and Medicine. JAMA

1996;276:1253–8.

87. Healthshare Secure E-Health Network. www.healthshare.com.au. Accessed 1

December 2003.

88. Yellowlees P. E-mental health in the future. In: Wooten R, Yellowlees P, Mc-

Laren P, editors. Telepsychiatry and E-mental health. London: Royal Society of

Medicine; 2003. p 305–16.

22 � Can J Psychiatry, Vol 49, No 1, January 2004

The Canadian Journal of Psychiatry—In Review

89. Ross MD, Twombly IA, Buyns C, Cheng R, Sengers S. Crossing the quality

chasm: a new health system for the twenty-first century. Albuquerque (NM): In-

stitute of Medicine; 2001.

90. McLaren P, Yellowlees P, Wooten R. Conclusion. In: Wooten R, Yellowlees P,

McLaren P, editors. Telepsychiatry and E-mental health. London: Royal Society

of Medicine; 2003.

91. Craig JLM, Wootton R. Does telemedicine have a role to play in disease man-

agement? Dis Manage Health Outcomes 1999;6:121–30.

92. D’Souza R. A pilot study of an educational service for rural mental health practi -

tioners in South Australia using telemedicine. J Telemed Telecare

2000;6(Suppl):187–9.

93. Greenberg WE, Paulsen RH. Moving into the neighborhood: preparing residents

to participate in a primary care environment. Harv Rev Psychiatry 1996;4:107–9.

94. Armstrong IJ, Haston WS. Medical decision support for remote general practitio -

ners using telemedicine. J Telemed Telecare 1997;3:27–34.

95. Dimand RJ, Marcin JP, Struve S, Traugott C, Nesbitt TS. Financial benefits of a

pediatric care unit based telemedicine program to a rural adult intensive care

unit: impact of keeping acutely ill and injured children in their local community.

Tel J E-Health. Forthcoming.

96. Webster’s revised unabridged dictionary. Volume 2003 [on-line]. Plainfield

(MA): MICRA, Inc; 1998. http://dictionary.reference.com

97. Currell R, Urquhart C, Wainwright P, Lewis R. Telemedicine versus in-person

patient care: effects on professional practice and health care outcomes. Cochrane

Database System Rev 2. CD002098; 2000.

98. Wallace PG, Haines A, Harrison R, Barber J, Thompson S, Jacklin P, and others.

Design and performance of a multicentre, randomized controlled trial of

teleconsulting. J Telemed Telecare 2002;8 Suppl 2:94–5.

99. Alessi N. Geriatric telepsychiatry: no matter the population, the questions remain

the same a commentary. J Geriatr Psychiatry Neurol 2001;14:88–90.

100. Griest J. Treatment for all: the computer as patient assistant. Psychiatr Serv

1998;49:887–9.

101. Sturges J. Practical use of technology in professional practice. Professional Psy-

chology: Research and Practice 1998;29:183–8.

102. Murphy M. Computer technology for office-based psychological practice: applica-

tions and factors affecting adoption. Computers in Practice 2000;6:83–90.

103. Baer L, Cukor P, Jenike MA, Leahy L, O’Laughlen J, Coyle JT. Pilot studies of

telemedicine for patients with obsessive compulsive disorder. Am J Psychiatry

1995;152:1383–5.

104. Chae YM, Park HJ, Cho JG, Hong GD, Cheon KA. The reliability and acceptability

of telemedicine for patients with schizophrenia in Korea. J Telemed Telecare

2000;6:83–90.

105. Kirkwood K, Peck D, Bennie L. The consistency of neuropsychological assess-

ments performed by telecommunication and face to face. J Telemed Telecare

2000;6:147–51.

106. Zarate C, Weinstock L, Cukor P, Morabito C, Leahy L, Burns C . Applicability of

telemedicine for assessing patients with schizophrenia: acceptance and reliability. J

Clin Psychiatry 1997;58:22–5.

107. Graham MA. Telepsychiatry in Appalachia. American Behavioral Scientist

1996;39:602–15.

108. Zaylor C. Clinical outcomes in telepsychiatry. J Telemed Telecare 1999;5:5– 60.

109. Elford DR, White H, St John K, Maddigan B, Ghandi M, Bowering R. A prospec-

tive satisfaction study and cost analysis of a pilot child telepsychiatry service in

Newfoundland. J Telemed Telecare 2001;7:73–81.

110. Darkins A. Program management of telemental health care services. J Geriatr Psy-

chiatry Neurol 2001;14:80–7.

Manuscript received and accepted September 2003. 1 Associate Professor of Clinical Psychiatry, Director of Telepsychiatry, Uni-

versity of California Davis, Sacramento, California. 2 Research Assistant, Mood Disorders and Health Services Research Pro-

gram, University of California Davis, Sacramento, California. 3 Director, Telemental Health Service, Alberta Mental Health Board, Ponoka,

Alberta. 4 Director of Online Health, Professor of Community Mental Health, Depart-

ment of Psychiatry, University of Queensland, Brisbane, Queensland, Aus- tralia 5 Professor of Family and Community Medicine, Associate Dean, Regional

Outreach and Telehealth, University of California Davis, Sacramento, Cali- fornia. Address for correspondence: Dr DM Hilty, University of California, Davis, 2230 Stockton Boulevard, Sacramento, CA 95817 e-mail: [email protected]

Clinical and Educational Telepsychiatry Applications: A Review

Can J Psychiatry, Vol 49, No 1, January 2004 � 23

Résumé : Applications cliniques et éducationnelles de la télépsychiatrie : une étude

Objectif : La télépsychiatrie, sous forme de vidéoconférence, comporte d’énormes possibilités pour

les soins cliniques, l’éducation, la recherche et l’administration. Ciblant la vidéoconférence, nous

avons examiné la documentation sur la télépsychiatrie et comparé celle-ci avec les services fournis en

personne ou par l’entremise d’autres technologies.

Méthodes : Nous avons mené un examen exhaustif de la documentation sur la télépsychiatrie de

1965 à 2003, à l’aide des mots clés télépsychiatrie, télémédecine, vidéoconférence, efficience,

efficacité, accès, résultats, satisfaction, qualité des soins, éducation, habilitation et coûts. Nous avons

choisi d’examiner les études qui traitaient de vidéoconférence pour des applications cliniques et

éducationnelles.

Résultats : La télépsychiatrie est employée avec succès pour divers projets de services cliniques et

éducationnels. La télépsychiatrie est faisable, élargit l’accès aux soins, permet la consultation de

spécialistes, donne des résultats positifs, permet une évaluation fiable, a peu d’aspects négatifs en ce

qui concerne la communication, satisfait généralement les patients et les fournisseurs de soins, facilite

la formation, et habilite les parties qui s’en servent. Les données sont limitées relativement aux

résultats cliniques et à la rentabilité.

Conclusions : La télépsychiatrie est efficace. Il faut davantage de recherche quantitative et qualitative

à court et à long terme sur les résultats cliniques, les prédicteurs de satisfaction, les coûts et les

résultats en matière d’éducation.