Abstract
Telepsychiatry is well established in many countries, but there is still little information about its use in routine health care. We reviewed the literature for information on the use of telepsychiatry in mental health services. From 1033 publications identified in the literature search and through references from a separate project, 16 studies or descriptions of the routine use of telepsychiatry services were selected for further review. Eleven of these articles dealt primarily with videoconferencing and five with telephone- based services. Clinical use of videoconferencing in the programmes described by the reviewed papers was modest, with an average of 16 consultations per month. Three of the telephone-based services had large numbers of clients. The papers we reviewed gave limited consideration to the healthcare systems in which telepsychiatry was provided and to the use of conventional mental health services. Telepsychiatry appears to still be a niche technology in many health systems. A lack of champions for the technology and reimbursement problems may contribute to the limited use of this area of telemedicine.
Introduction
Telepsychiatry has been used for many years and is generally regarded as an area where the application of telehealth has been a success. However, although telepsychiatry has been introduced in many countries, there is still little information about the extent to which it is used in routine health services. As part of a project between the Institute of Health Economics (IHE), Edmonton, and the Finnish Office for Health Technology Assessment, Helsinki (FINOHTA), we surveyed the use of videoconferencing for psychiatric services in Finland and reviewed available data on telepsychiatry use in a Canadian province. 1,2
To provide additional context for the data from Finland and Canada, we also reviewed available literature that described the routine use of telepsychiatry.
Methods
Papers that described aspects of routine use of telepsychiatry were identified from computerized literature searches using the MEDLINE, HealthSTAR, EMBASE, PsycINFO and CINAHL databases to June 2006, with the MEDLINE search updated to February 2008. Search terms used in a comprehensive search strategy included ‘telepsychiatry’, ‘teleconferencing’, ‘mental health’, ‘videoconferencing’, ‘on-line health’, ‘teletherapy’, ‘telemental health’, ‘remote access to information’ and ‘satellite communication’. Further details are available from the authors.
We selected articles that included credible information on the extent of use of telepsychiatry services in routine practice. All types of telepsychiatry applications and methods of communication were considered. We excluded articles that considered only technical matters, duplicates of other publications, and articles concerned with medical and continuing education.
Initial screening of the identified articles was based on the information obtained from their abstracts. The abstracts were read independently by all the authors and the selection of relevant articles agreed upon in discussion. When an abstract did not give sufficiently precise information about the study, or such information was not available at all, the article was obtained for further review. Full-text articles obtained for closer inspection were evaluated independently by the authors, who then reached a consensus on whether or not an article should be included in the final review, with reference to the selection criteria.
Data were extracted from each selected paper about the location of the telepsychiatry service, the subspecialty of the programme, the target population and volume, the number of services provided and the type of communication technology.
Results
From 1033 publications identified in the literature search and through references from a separate project, 16 studies or descriptions of the routine use of telepsychiatry services were selected for further review. Nine papers considered single programmes with one hub and one or more satellite sites, 3–11 two were concerned with multiple centres and satellites within large geographical areas, 12,13 four papers described programmes based on single call centres 14–17 and one paper presented a national review of telepsychiatry, covering several programmes. 18 Four of the papers were from the USA, four from Australia, three from Canada, two from the UK, and one each from Finland, Norway and Spain.
Seven of the papers reported on established telepsychiatry programmes and eight on programmes that had operated for two years or less. The national review of telepsychiatry services included details on both established and developing programmes. Ten papers were concerned primarily with programmes offering general psychiatric services, five with child or adolescent psychiatry and one with smoking cessation. Ten papers dealt with clinical services only, three with a mixture of clinical services and training supervision, and three considered clinical, educational and administrative use of telepsychiatry services.
There was limited consideration of the relationship of telepsychiatry services to the overall context of the healthcare systems that they served. Six papers mentioned aspects of the health system and, other than a comment on the effect of telepsychiatry on referral patterns, none provided information on the use of conventional mental health services.
Details on the clinical use of videoconferencing-based telepsychiatry services described in nine papers are shown in Table 1. Organizational arrangements and the health systems served varied, but overall, the level of use of telepsychiatry for clinical purposes was modest.
Clinical use of primarily videoconferencing-based telepsychiatry services
*Review of 17 programmes
†Range for established provincial telepsychiatry programmes
Information on the use of established telephone-based services is given in Table 2. Three of the programmes handled large numbers of clients, an indication of the usefulness of telephone-based approaches.
Use of established telephone-based telepsychiatry services
Use of videoconferencing for tele-education services was mentioned in three papers. The Canadian review referred to 388 sessions in 13 programmes in 2001 (30 sessions per programme, range 2 to 105). 18 On average, there were 8.3 sites per session. In the study by Mielonen et al. 7 , 45% of videoconferencing time was used for teaching. Two of 28 consultations in the study by Hockey et al. 4 were for education.
Three of the selected papers were concerned with the use made of telepsychiatry services by health professionals, rather than with number of services. Gammon et al. found that types of videoconferencing use most frequently identified by health professionals in Northern Norway were training and supervision, clinical consultations and distance education. 12 In the Australian study by Gelber, 92% of those surveyed had used videoconferencing for clinical support and 36% for teaching. 13 The description by Kates et al. of telephone support for general practices by a psychiatrist noted that 63% of calls were from physicians and the remainder from counsellors. 5
Other information on routine use of telepsychiatry
Other information on routine use of telepsychiatry was available from reports and websites. The US Veterans Health Administration (VHA) operates a large telepsychiatry network. In 2003, 13,840 telepsychiatry encounters were delivered to 8370 veterans from 73 hospitals to 143 satellite clinics and 12 home health programmes. 19
A 1998 survey of 19 telepsychiatry programmes in the US found that they performed an aggregate of about 720 consultations per month (38 per programme per month). 20
Over the six years from February 1995, the Appal-Link Network in Virginia, USA, provided telepsychiatry services to 853 consumers (14.2 per month), involving 5173 separate activities (86 per month). 21 More than 350 patients participated in psychotropic medication management clinics.
The telepsychiatry programme in South Australia undertook 2219 clinically related sessions from May 1994 to February 1998 (49 per month), of which 1947 directly involved patient assessments. 22
Discussion
Our review of the literature indicates that there are still few publications that describe the utilization of telepsychiatry in routine health care. Most of the telepsychiatry programmes in our review that used videoconferencing offered clinical services to relatively small patient populations and had low utilization with few client sites (Table 1). Some telephone-based programmes had higher utilization. Our survey of videoconferencing for mental health services in Finland also found low utilization, with an annual rate of four consultations per 100,000 population. 1
The papers in the present review gave limited consideration to the health-care systems in which telepsychiatry was provided and to the use of conventional mental health services. Since the conclusion of our review, a paper has been published on a survey of videoconferencing in Norwegian mental health care. Fifty-one of 113 institutions had used videoconferencing in the previous year, mostly for meetings, supervision and lectures, and to a lesser degree for clinical work. The authors concluded that there was a gap between the potential of videoconferencing and its actual utilization in Norway's mental health sector. 23
The publications that we located may not provide an accurate reflection of the number and level of activity of telepsychiatry programmes. However, our review suggests that telepsychiatry is still not widely used in the delivery of mental health services. Absence of local champions to encourage routine use of telepsychiatry 24 and difficulties with reimbursement arrangements 25,26 may be among the reasons for the limited application of what is now a proven means of health-care delivery. There may also be concerns from some health professionals about possible changes to referral patterns and practice routine as a result of the introduction of telepsychiatry. On the other hand, our contact with telepsychiatry programmes in Canada and Finland suggests that telehealth services are well accepted by clients. There appears to be scope for a considerable growth in telepsychiatry services.