Telepsychiatry and social psychiatry

The spread and acceptance of technological advances has led to changes in the way medicine is practised. In most low- and middle-income countries, such as Paraguay and India, the majority of the medical workforce is concentrated in urban areas. However, with recent innovative initiatives in many countries where clinicians are based in the cities but use mobile vans and webcams, clinical diagnoses can be made and appropriate interventions can be suggested.

Sood et al. (2007) remind us that there are no universally agreed-upon terms and definitions, and they found 104 terms to define the field of telepsychiatry. Shore (2015) defines telepsychiatry as the provision of psychiatric care at a distance through the use of technologies including telephone care, emails, web-based systems and mobile applications. Obviously, each of these methods will have a different emphasis and will be utilised in a different way. Telepsychiatry generally refers to psychiatric care provided by a psychiatrist, whereas tele-mental health refers to the provision of mental healthcare by mental health professionals (see Shore, 2015 for further discussion).

Telepsychiatry is not an entirely new phenomenon, but because of the advent and wide acceptance and usage of the internet, its applications have changed. Shore (2015) reminds us that video-conferencing and the use of technology dates back to the 1950s. Technical advances since then have led to the development of telemedicine, teleradiology and telepathology. So where does social psychiatry fit in? The use of technology through webcams and so on can mean that rather than making actual domiciliary visits, clinicians can see patients in their actual habitat and explore as well as understand functioning and also ascertain needs. This is particularly of interest to rural areas (Brown, 1998) where access to services and investigations may be problematic.

Shore (2015) points out that telepsychiatry can do several things. It can improve healthcare for individuals, advance public health (especially public mental health) and help reduce costs through quality improvement (Richardson et al., 2001). However, more importantly, telepsychiatry can improve access and potentially reduce the duration of untreated illnesses. Shore (2015) reminds us that, like technology, psychiatry is also in the midst of great transformation. Thus, more personalised care can be developed and delivered. Telepsychiatry can also help deliver more integrated and physical healthcare. It certainly offers opportunities for healthcare delivery using new models and also at the place where patients need it. Equally importantly, these technological advances can produce better public mental health and improve the quality of healthcare.

Ethical frameworks for developing and using telepsychiatry are critical developments. Specific issues related to privacy and confidentiality can be difficult under these circumstances and must be recognised and dealt with accordingly. Clinicians should be able to guarantee their patients’ security and confidentiality in the global network that the Internet offers. Sabin and Skimming (2015) remind us that the fundamental critical responsibilities remain the same and do not alter according to change in methods of practice. They offer six headings in the ethical framework which include competent, safe care; clear informed consent; promoting privacy and confidentiality; managing boundaries; encouraging continuity of care; and addressing health equity. Thus, any training in the use of eHealth and telepsychiatry must include an ethical framework. These authors emphasise that telepsychiatry patients need to be able to trust their doctors, who place their (the patients’) welfare above other interests and provide competent care within the context of patient privacy and confidentiality. In addition, patients need careful sharing of decision making based on accurate information.

Ethical guidelines for in-person practice have emerged from decades of clinical discussion and appropriate consultation. There is no doubt that ethical framework remains the same, but some aspects need careful re-negotiation and dissemination. Telepsychiatry and eMental health both need careful ethical frameworks and must involve patients, their carers and their families in this context. Training in the use of telepsychiatry is an absolute must. A study showed that only 21 out of 183 US resident training schemes offered any training in the field and that is not mandatory (Hoffman & Kane, 2014). It is important to recognise that, as the field develops, guidelines and ethical advice are critical next steps. There needs to be a global effort to develop these. There must be agreed standards of care available through ongoing training to ensure that ethically sound training is provided. Shore (2015) offers careful and well-thought-out recommendations for training. Telepsychiatry can be used in home-based and primary care–based settings. Hilty et al. (2015) and Saeed et al. (2016) provide a helpful framework for telepsychiatric training and point out that there is considerable overlap between eMental health and telepsychiatry. They emphasise that competencies in telepsychiatry are no longer optional and deserve better training.

Telepsychiatry has been initially used and tested in different settings.As was demonstrated in Thailand following the Asian tsunami in 2004, video-conferencing after the disaster proved to be an eminently successful method for supervisors of healthcare professionals, as well as for assessment of those who required assistance (Visanuyothin, Chakrabhand, & Bhugra, 2006). Tele mental health has been used with children and adolescents as well (Gloff, Le Noue, Novins, & Myers, 2015), and there are various opportunities for assessing offenders in different settings using telepsychiatry. Recently in the addiction field, Zheng et al. (2017) compared videoconference and face-to-face medication-assisted treatment for opioid dependents. No differences were found between the two groups.

In conclusion, these are really exciting times for psychiatric practice as well as for telepsychiatry. However, to ensure the best usage, it is important that telepsychiatry is used in a proper ethical framework and that psychiatrists as well as other mental health professionals are trained appropriately to use their skills.