Telepsychiatry: Thirty-Five Years' Experience

Elizabeth Liebson, MD

Disclosures

Medscape Psychiatry & Mental Health eJournal. 1997;2(4) 

In This Article

Historic Background

Telephone counseling has been used for decades in the form of suicide and crisis-intervention hotlines staffed by trained volunteers. This early experience with the new communication systems initially had an entrepreneurial basis; clinicians with tight schedules searched for ways to more efficiently use their time.[2] Exploration of possible military applications of these new techniques added further impetus.[3] However, the published accounts of these studies are largely descriptive and do not rigorously examine outcome.

The first telemedicine system was created in Nebraska in 1959. The Nebraska Psychiatric Institute in Omaha and the state mental hospital 112 miles away used 2-way, closed-circuit microwave television to transmit demonstrations with neurologic patients as part of the education of first-year medical students. Subsequent applications at Nebraska included group therapy, long-term therapy, consultation-liaison, and education. To supplement audiovisual information, telecopiers were available to transmit and receive printed matter such as patient charts, reports, and class materials.

Another early use of telepsychiatry was a system established in 1968 by Thomas Dwyer as part of Kenneth Bird's larger "telemedicine" project linking the Massachusetts General Hospital to a health station 2.7 miles away at Boston's Logan International Airport.[4] The program was inspired by the long drive time between the 2 locations due to heavy traffic. Dwyer and his colleagues used 2-way, interactive television for consultation with and evaluation of both adults and children.

A telepsychiatric network linking the Dartmouth-Hitchcock Mental Health Center to the Claremont General Hospital, 20 miles away in rural New Hampshire, was also established in 1968. This 2-way, closed-circuit television system, designed with the needs of family physicians in mind, was used only for consultation. The referring physician observed both the psychiatrist and the patient on a split-screen monitor. On completion of the interview, the referring physician and the psychiatrist discussed the findings, without the patient present, and collaborated on treatment plans.[5]

The state of Georgia has the most highly developed telemedicine network. Physicians at the Medical College of Georgia are using an interactive voice and color video telecommunication system transmitted by satellite, which they hope will eventually cover the entire state. Scientists in Georgia are also at the forefront of other types of technology in their use of virtual reality for the treatment of phobias. Graded exposure using computer-constructed views of elevators and bridges for treatment of 10 acrophobic college students was found to be successful. This technique allows graded exposure to be performed without the patient having to leave the office.[6]

Another application of the audiovisual record in psychiatry has been to establish the validity of psychiatric interviews and to identify sources of variance. For example, black and white films of diagnostic psychiatric interviews in cities in Britain and the US were used to clarify national differences in psychiatric diagnosis.[7] Videotaped interviews have also been used to study reliability in a multicenter study involving a large number of raters.[8] Even when structured interviews and predefined diagnostic criteria are used, there may be hidden biases that affect reliability; videotaping interviews is one practical way of attacking such a problem. They are also a good way to train raters and educate students.

The Internet has been used in providing support to caretakers of persons with Alzheimer's disease.[9] A communication system between clinicians and counselors has been designed that gives individual attention and anonymity to caretakers who may not be able to leave the home. It has not been determined whether caretakers, who are often elderly themselves, are able to overcome the challenges of getting online.

Although telepsychiatry has a long history, its practical consequences have been limited. Development and construction costs have been high in the past. These programs have not had to support themselves but have relied on federal and state grants. Perednia and Allen[1] noted that of the telemedicine programs begun before 1986, only 1 has survived. The others ended when external sources of funding were withdrawn. These investigators identified high cost as the single most important cause of the failure of these programs. Despite the rapid growth of telemedicine, only a small number of patients are being seen. In the first 6 months of 1994, electronic mental health consultation nationwide totaled approximately 500 patient-clinician interviews. The majority of online time has been used for medical education and administration.

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