by Carol Watkins, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
I read with interest Dr. Ruskin’s planned research on the use of telepsychiatry with depressed patients. Now that improved technology is available, the practice of medicine by remote connection is more practical. Already, psychologists, and other non-physician psychotherapists are doing ongoing psychotherapy using the Internet or telephone. It is important that psychiatrists take a careful look at this area and assume a leadership role in determining the uses and limitations of long distance psychiatry. A good first step will be carefully controlled studies.
It will be important that we proceed carefully and not generalize too much from the first studies. This study’s results might not apply to weekly dynamic or cognitive psychotherapy. Psychotic or demented patients might respond differently.
How will the physicians involved in the study deal with physical exams? If I am evaluating a child or adult for anxiety or depression, I need to see the person’s hands and legs to look for fidgeting. Bitten nails and bleeding cuticles are relevant. I may want to take a closer look at the neck to see if there is an enlarged thyroid. Are there needle tracks on the arms? Should this study require that a local physician check for specific physical findings?
Having the ability to control the camera and zoom in on specific parts of the patient may not be possible in many current telemedicine settings. During my residency training, I spent a lot of time doing family therapy with a one-way mirror and videotape. We had a cameraman who had been videotaping family therapy for almost a decade. His ability to zoom in on specific things made a big difference in the quality of information on the videotape. At times, the camera work seemed to follow his own interpretation of the therapy process.
Finally, there is concern that if the current telepsychiatry studies are successful, managed care companies will pressure psychiatrists to perform much of their work from remote locations. This is a real concern, but should not stand in the way of legitimate research. We will need to take an active role in determining how this data is applied or misapplied in clinical settings.
This study is a start, but there should be further work before this technique is applied in non-experimental settings. Future studies should consider having a psychiatrist determine whether patients meet criteria for inclusion. Psychiatrists should serve as their own controls. Specific psychotherapeutic techniques need to be standardized between control and telemedicine groups. It should be clear whether we expect telemedicine to apply to primary psychotherapy or just to medication management. We should be especially careful that it not be applied to crisis management until it has been extensively tested in that specific area.