What About Telepsychiatry? A Systematic Review

Background: Mental illness has become a significant worldwide health issue in recent years. There is presently insufficient evidence to definitively determine the clinical effectiveness and cost-effectiveness of different health care models. The objective of this study was to evaluate the effectiveness of videoconferencing in mental illness.

Data Sources: Literature searches were performed in Medline, EMBASE, PsycINFO, Centre for Reviews and Dissemination, and The Cochrane Library Controlled Trial Registry databases (1997–May 2008). A search of the following terms was used: e-health, mental disorders (MeSH term), mental health (MeSH term), mental health services (MeSH term), telecare, teleconsultation, telehome, telemedical, telemedicine, telemental, telepsychiatric, telepsychiatry, televideo, videoconference, and videophone.

Study Selection: Type of disease, interventions, and clinical outcomes or patient satisfaction were identified. Exclusion criteria included studies that did not analyze intervention outcomes and studies with a sample size of fewer than 10 cases. Peer review and quality assessment according to Cochrane recommendations were required for inclusion.

Data Extraction/Synthesis: Of 620 identified articles, 10 randomized controlled trials are included (1,054 patients with various mental disorders). There were no statistically significant differences between study groups for symptoms, quality of life, and patient satisfaction.

Conclusions: There is insufficient scientific evidence regarding the effectiveness of telepsychiatry in the management of mental illness, and more research is needed to further evaluate its efficiency. However, there is a strong hypothesis that videoconference-based treatment obtains the same results as face-to-face therapy and that telepsychiatry is a useful alternative when face-to-face therapy is not possible.

Prim Care Companion J Clin Psychiatry 2010;12(2):e1–e5

Submitted: April 28, 2009; accepted June 18, 2009.

Published online: March 25, 2010 (doi:10.4088/PCC.09m00831whi).

Corresponding author: Francisca García-Lizana, MD, PhD, C/Sinesio Delgado 4, pab 4, 28029 Madrid, Spain (fglizana@hotmail.com).

Mental illness has become a significant worldwide health issue in recent years. By 2020, it is projected that the burden of mental and neurologic disorders will have increased to 15%.1 The widespread and pervasive nature of mental illness, and many nations’ limited ability to recognize and treat such conditions, has led the World Health Organization to attempt to increase international awareness of the dangers and prevalence of mental illness. Thus, it is clear that most people with mental disorders remain either untreated or poorly treated.2 It is therefore critical to develop more effective mental health service delivery systems to enhance treatment access and quality.3

There is presently insufficient evidence to definitively determine the clinical effectiveness and cost-effectiveness of different health care models.4 Nevertheless, there is a trend toward collaborative care models, including those incorporating a case management approach and/or using the services of a care manager or primary mental health care worker, showing some modest benefit, at least in the short term.4 In addition, telephone care management interventions appear to be of some benefit to patients with mild-to-moderate mental health problems; however, telehealth care may be a more effective model of service delivery if combined with delivering specific interventions of proven effectiveness, such as cognitive-behavioral therapy.4

Videoconferencing plays an important role in most telemedicine initiatives.5 Medical and mental health services often are inadequate in remote geographical areas with few specialist providers. Telepsychiatry provides clinical, consultative, and educational services to populations in remote regions and other isolated groups.6 Telepsychiatry, in the form of videoconferencing, has been well received in terms of increasing access to care and user satisfaction.7 Questions persist, however, about its effectiveness, because there are few clinical outcome studies8 and limited patient populations for whom telepsychiatry is most suitable.9

The objective of this review is to evaluate the effectiveness of telepsychiatric services delivered via videoconferencing techniques.

METHOD

Literature Search

Computerized literature searches were performed in Medline, EMBASE, PsycINFO, Centre for Reviews and Dissemination, and The Cochrane Library Controlled Trial Registry databases (1997–May 2008), in addition to a manual search of the identified meta-analyses and systematic reviews. A search of the following terms was used: e-health, mental disorders (MeSH term), mental health (MeSH term), mental health services (MeSH term), telecare, teleconsultation, telehome, telemedical, telemedicine, telemental, telepsychiatric, telepsychiatry, televideo, videoconference, and videophone.

Clinical Points

  • Videoconference seems to be a useful tool for diagnosis, treatment, and follow-up of patients in remote areas.
  • Telepsychiatry improves symptoms in various mental disorders.
  • The main barrier to successful telepsychiatry implementation is professional acceptance.

Articles included in this review were selected on the basis of the following criteria: (1) design: randomized controlled trial (RCT) assessing any kind of intervention applying videoconferencing to manage mental illness versus face-to-face assessment; (2) participants: patients with mental disorders (according to DSM-IV definitions) who directly used the technology; (3) outcomes: studies must have included information on clinical outcomes (symptoms, quality of life, treatment adherence, laboratory data) or patient satisfaction; and (4) technology: use of videoconference or televideo. Exclusion criteria consisted of studies that did not analyze intervention outcomes in patients, studies with a sample size of fewer than 10 cases in each comparison group, and studies in which the intervention was only phone based or preventive.

Selection of Publications and Extraction of Data

Initial screening of identified articles was based on their abstracts. Articles lacking an electronic abstract were initially excluded. Studies satisfying the inclusion criteria were thoroughly and independently examined by 2 reviewers with experience in data extraction in order to avoid double publication or redundancies as well as to assess the study quality using accepted criteria.10,11 If disagreements arose, they were resolved by consensus.

RESULTS

Figure 1

Click figure to enlarge

Of the 620 references identified in the systematic search, 11 articles that met the inclusion and study quality criteria were selected, corresponding to 10 RCTs (Figure 1). Five of the trials were from the United States, 4 from Canada, and 1 from Spain. The main characteristics of these trials and their results can be found in Table 1.

The analyzed results originated from a total of 1,054 patients with various mental illnesses. The disorders studied by the 10 RCTs included multiple diseases (4), most often patients from general psychiatric services5,12–14; depression (2)15,16; panic disorder (1)17; posttraumatic stress disorder (1)18,19; bulimia nervosa (1)20; and schizophrenia (1).21

In general, the objective of each RCT was to assess the diagnosis and follow-up using videoconference versus face-to-face assessment. Five RCTs used cognitive-behavioral therapy, while the rest did not specify a psychotherapeutic approach.

Table 1

Click figure to enlarge

Seven studies5,13,15–18,20 with a total of 969 patients (474 from the telepsychiatry group and 495 from the control group) were considered in the evaluation of symptoms. As can be seen in Table 1, the intervention group’s symptoms did not show statistically significant differences compared to those of the control group.

Seven studies12–16,18,21 directly evaluated patient satisfaction with the conducted programs. There were no differences between the groups, although it is unclear if satisfaction was generated by the program or the technology. Only Nelson et al15 and Ruskin et al16 have published data on patient satisfaction with the utilized technology and its quality. In both cases, patients appeared satisfied. Professional satisfaction was evaluated in only 2 RCTs,14,21 and both found the lowest level of satisfaction to be in the videoconferencing group.

Three studies evaluated quality of life. The interventions analyzed in this study have not produced a significant difference in quality of life between study groups.13,16,20

Regarding treatment adherence, Frueh et al19 reported better outcomes in the control group (P < .04), and Ruskin et al16 showed a statistically insignificant difference from the control group.

DISCUSSION

Establishing systems for patient care in psychiatry using videoconferencing is feasible, but there is little evidence of clinical benefits. The studies provided positive results for outcomes such as symptoms, quality of life, patient satisfaction, and treatment adherence. However, the evidence regarding cost-effectiveness is poor. Videoconferencing seemed to improve accessibility to services, serve an educational function, and produce savings of time, costs, and travel.22 However, these findings should be clearly demonstrated in future research.

The results of this review show that the available evidence on the effectiveness of telepsychiatry programs is limited in general. However, in agreement with other authors,8,9,22–26 we believe all data point toward videoconferencing as feasible and effective. Patients reported high levels of satisfaction with the process. In addition, no RCT showed complications, so we think telepsychiatry is safe. Although these results need to be confirmed over the long term, we believe telepsychiatry should play a main role in redesigning health systems in order to improve the quality of care for patients with mental disorders.

Another aspect to consider in assessment of telepsychiatry effectiveness is the rapid advancement in technology, as image quality and bit rate are improving every day. It is probable that the same interventions with better technologies will improve the results.

In spite of the fact that only 2 RCTs14,15 studied children, the results indicated that cooperation of both child and parent, clear communication of treatment recommendations, involvement of the school and local health providers, stability of the agencies, and availability of services were key components of successful implementation of recommendations.22,27

Telepsychiatry appears to be a reasonable alternative for situations in which it is difficult or impractical to arrange face-to-face assessments. Whether telepsychiatry can replace face-to-face assessment for ongoing therapy requires more study. If telepsychiatry and face-to-face assessments are found to be similar, then there is no a priori reason to dismiss the idea that telepsychiatry may serve as a replacement for face-to-face assessment for ongoing therapy in certain situations. We may see the development of a hybrid model in which continuing treatment might be conducted via telepsychiatry. Rigorous studies are needed to perform complete economic evaluations, to further describe the interventions, to carry out cost calculations, and to establish a sufficient follow-up period to verify treatment results over time. Potential benefits of telepsychiatry in this area are clear: the possibility of permanently providing educational and orientation programs for patients and an obvious improvement in accessibility to health care services.28

The limitations of this study are due partly to the quality of the included RCTs, the variability of the interventions, and the heterogeneity of the follow-up periods, including the loss of follow-up in several of the analyzed RCTs.

In conclusion, there is insufficient scientific evidence regarding the effectiveness of telepsychiatry in the management of mental illness, and more research is needed to further evaluate its efficiency. However, health care providers, health care managers, and politicians have a big challenge: provide medical and mental health care in remote geographical areas or without dangerous delays, as per the ethical principle of equality and universal rights for all citizens. In our opinion, there is a strong hypothesis that videoconference-based treatment produces the same results as face-to-face therapy and that telepsychiatry is a useful alternative when face-to-face therapy is not available.

Author affiliations: Health Technology Assessment Agency, Instituto de Salud Carlos III, Science and Innovation Ministry, Madrid, Spain (Dr García-Lizana and Ms Muñoz-Mayorga).

Author contributions: Dr García-Lizana was responsible for project conception and design, analysis, and interpretation of data and provided final approval of the article. Ms Muñoz-Mayorga was responsible for analysis and interpretation of data and provided final approval of the article.

Potential conflicts of interest: The authors report no financial or other affiliations relevant to the subject of this article.

Funding/support: This work was supported by the Quality Plan for National Health Service, Health Ministry of Spain, Madrid.

Acknowledgment: The authors thank Raimundo Alcázar, BS, for his collaboration in the literature search and Andrew Blakely (medical student and scholarship holder) for English review (both from Health Technology Assessment Agency, Madrid, Spain). Mssr Alcázar and Blakely have no financial or other affiliations relevant to the subject of this article.

REFERENCES

1. World Health Organization. The World Health Report: Mental Health: New Understanding, New Hope. Geneva, Switzerland: World Health Organization; 2001.

2. Kao SC, Lin CE, Chiu NY. A proposed e-care center for mental health interventions. J Psychiatr Pract. 2006;12(3):180–186. PubMed doi:10.1097/00131746-200605000-00009

3. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–640. PubMed doi:10.1001/archpsyc.62.6.629

4. Doughty C. Effective models of mental health service provision and workforce configuration in the primary care setting. New Zealand Health Technology Assessment (NZHTA) Technical Brief Series; 2006. Available at: http://nzhta.chmeds.ac.nz/publications/mental_healthpc.pdf.

5. De Las Cuevas C, Arredondo MT, Cabrera MF, et al. Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment. Telemed J E Health. 2006;12(3):341–350. PubMed doi:10.1089/tmj.2006.12.341

6. McLaren P, Ball CJ, Summerfield AB, et al. An evaluation of the use of interactive television in an acute psychiatric service. J Telemed Telecare. 1995;1(2):79–85. PubMed

7. De Las Cuevas C, Artiles J, De La Fuente J, et al. Telepsychiatry in the Canary Islands: user acceptance and satisfaction. J Telemed Telecare. 2003;9(4):221–224. PubMed doi:10.1258/135763303322225553

8. Hilty DM, Marks SL, Urness D, et al. Clinical and educational telepsychiatry applications: a review. Can J Psychiatry. 2004;49(1):12–23. PubMed

9. Norman S. The use of telemedicine in psychiatry. J Psychiatr Ment Health Nurs. 2006;13(6):771–777. PubMed doi:10.1111/j.1365-2850.2006.01033.x

10. Imaz I, González E, Alcaide JF. Guía para la elaboración de Informes de Evaluación de Tecnologías Sanitarias. 19. Madrid, Spain: Agencia de Evaluación de Tecnologías Sanitarias, Instituto de Salud Carlos III; 1999.

11. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12. PubMed doi:10.1016/0197-2456(95)00134-4

12. Bishop JE, O’Reilly RL, Maddox K, et al. Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. J Telemed Telecare. 2002;8(4):217–221. PubMed doi:10.1258/135763302320272185

13. O’Reilly R, Bishop J, Maddox K, et al. Is telepsychiatry equivalent to face-to-face psychiatry? results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58(6):836–843. PubMed doi:10.1176/appi.ps.58.6.836

14. Stevens A, Doidge N, Goldbloom D, et al. Pilot study of televideo psychiatric assessments in an underserviced community. Am J Psychiatry. 1999;156(5):783–785. PubMed

15. Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E Health. 2003;9(1):49–55. PubMed doi:10.1089/153056203763317648

16. Ruskin PE, Silver-Aylaian M, Kling MA, et al. Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. Am J Psychiatry. 2004;161(8):1471–1476. PubMed doi:10.1176/appi.ajp.161.8.1471

17. Bouchard S, Paquin B, Payeur R, et al. Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemed J E Health. 2004;10(1):13–25. PubMed doi:10.1089/153056204773644535

18. Frueh BC, Monnier J, Yim E, et al. A randomized trial of telepsychiatry for post-traumatic stress disorder. J Telemed Telecare. 2007;13(3):142–147. PubMed doi:10.1258/135763307780677604

19. Frueh BC, Monnier J, Grubaugh AL, et al. Therapist adherence and competence with manualized cognitive-behavioral therapy for PTSD delivered via videoconferencing technology. Behav Modif. 2007;31(6):856–866. PubMed doi:10.1177/0145445507302125

20. Mitchell JE, Crosby RD, Wonderlich SA, et al. A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behav Res Ther. 2008;46(5):581–592. PubMed doi:10.1016/j.brat.2008.02.004

21. Manguno-Mire GM, Thompson J Jr, Shore JH, et al. The use of telemedicine to evaluate competency to stand trial: a preliminary randomized controlled study. J Am Acad Psychiatry Law. 2007;35(4):481–489.

22. Pesämaa L, Ebeling H, Kuusimäki ML, et al. Videoconferencing in child and adolescent telepsychiatry: a systematic review of the literature. J Telemed Telecare. 2004;10(4):187–192. PubMed doi:10.1258/1357633041424458

23. Hyler SE, Gangure DP, Batchelder ST. Can telepsychiatry replace in-person psychiatric assessments? a review and meta-analysis of comparison studies. CNS Spectr. 2005;10(5):403–413. PubMed

24. Frueh BC, Deitsch SE, Santos AB, et al. Procedural and methodological issues in telepsychiatry research and program development. Psychiatr Serv. 2000;51(12):1522–1527. PubMed doi:10.1176/appi.ps.51.12.1522

25. Hilty DM, Luo JS, Morache C, et al. Telepsychiatry: an overview for psychiatrists. CNS Drugs. 2002;16(8):527–548. PubMed doi:10.2165/00023210-200216080-00003

26. Monnier J, Knapp RG, Frueh BC. Recent advances in telepsychiatry: an updated review. Psychiatr Serv. 2003;54(12):1604–1609. PubMed doi:10.1176/appi.ps.54.12.1604

27. Boydell KM, Volpe T, Kertes A, et al. A review of the outcomes of the recommendations made during pediatric telepsychiatry consultations. J Telemed Telecare. 2007;13(6):277–281. PubMed doi:10.1258/135763307781644889

28. García-Lizana F, Sarría-Santamera A. New technologies for chronic disease management and control: a systematic review. J Telemed Telecare. 2007;13(2):62–68. PubMed doi:10.1258/135763307780096140