by Paul E. Ruskin, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
Telepsychiatry offers a novel means of providing expert psychiatric care to patients at a distance from the source of care. It can be used for the diagnosis and treatment of patients in remote locations, or in locations where psychiatric expertise is scarce.
Despite pilot studies in telepsychiatry conducted since the 1950s, the high cost of providing the needed technology has impeded its widespread use. In recent years, however, new technological advances and increasing affordability are making telepsychiatry more feasible to address maldistribution of psychiatric expertise. In order to use this new technology in psychiatry, we must demonstrate that psychiatric diagnosis and treatment conducted remotely via telecommunications is as reliable and effective as diagnosis and treatment conducted face-to-face.
The Veterans Administration Maryland Health Care System (VAMHCS) recently received a health services research and development (HSR&D) grant from the Veterans Administration to evaluate the efficacy of telepsychiatry in the treatment of depression. In this randomized trial, trained research assistants use the Structured Clinical Interview for DSM-IV (SCID-IV) and the 24-item Hamilton Depression Scale (Ham-D) to evaluate veterans who present to any of three mental hygiene clinics (Baltimore VA, Perry Point VA, Cambridge satellite clinic) within the VAMHCS for treatment of depression. Veterans with a DSM-IV diagnosis of major depression, dysthymic disorder, adjustment disorder with depressed mood, or depression not otherwise specified, as well as a Ham-D score of 16 or above are eligible for participation.
Eligible veterans are randomized to either face-to-face treatment, or remote treatment via telecommunication. Randomization is stratified within age (young: 50 and below, old: above 50), and severity of depressive symptoms (Mild: Ham-D below 24, Severe: Ham-D 24 and above). The study will include a total of 144 veterans.
The face-to-face treatment is conducted at the Baltimore Mental Hygiene Clinic (MHC), the Perry Point MHC, or the Cambridge MHC. Remote treatment occurs between the Baltimore and Perry Point clinics, and between the Baltimore and Cambridge clinics (the patient is located at one clinic and the treating psychiatrist at the other). Psychiatrists conduct treatment at each of the 3 clinics. Each psychiatrist treats some patients face-to-face and others remotely. Treatment involves at least 8 sessions lasting 30 minutes over the 26 week study period. Additional treatment sessions take place if clinically indicated. The treatment consists of psychotropic medication and psychological evaluation concerning the disease, medications, and side effects.
Outcomes include
Cost and cost-effectiveness of treatment will also be determined. For those treated remotely, comparisons will also be made between age groups (old and young) and severity of depression (mild and severe) to determine if these factors affect treatment outcome, patient compliance, or patient satisfaction.
The technology used for this study allows the patient and psychiatrist to see and hear each other during the course of the treatment session. The voice transmission is clear, and the video transmission is smooth and life-like, although not quite up the quality of a VCR. The video and voice are well synchronized with only a slight delay (less than a second) when waiting for a response. We have found that after using the equipment for a short period of time, the users become accustomed to this slight delay, and it does not interfere with communication.
The audio-visual system used for the study is personal computer (PC) based. Each unit, including the necessary software and the video camera, costs about $6,000. Voice and video are transmitted through ISDN lines from computer to computer, using 3 ISDN lines per connection to achieve a speed of 384 kilobytes per second. The technology continues to improve in quality and decrease in price.
For another planned pilot study, we will use a television-based technology, which runs over regular phone lines. One of these units costs only about $500. At this time, the quality is only fair although units such as these are apparently already in use clinically in under-served areas.
Other systems of audio-video transmission currently in development should improve quality and make telecommunication even less expensive. One of the most promising innovations involves transmission across the Internet. Thus, in the near future we should have inexpensive units requiring only minimal transmission costs, and providing high quality, real-time voice and video.
Developments in telepsychiatry could have a tremendous impact on the way psychiatric assessment and treatment is conducted. If it can be demonstrated that “remote” psychiatric treatment via telecommunication is as effective as “face-to-face” treatment, then many patients with psychiatric illness will have easy access to psychiatric care, even if they live in geographically remote areas or other locations where psychiatric treatment is unavailable, or expensive to maintain.
Dr. Ruskin, Clinical Manager, Geriatric Psychiatry, Veterans Administration Maryland Health Care System, is an associate professor of psychiatry at the University of Maryland.