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Current Telepsychiatry
Activity in the U.S., Australia, Canada, and Norway
Terry Wheeler and Ace
Allen
PHOTO – CECIL WITTSON’S PROGRAM –
COURTESY REBA BENSCHOTER
The Development of
Telepsychiatry
In a sense, telepsychiatry is the "native application"
for interactive-video telemedicine. Mental health interactions are
straightforward, and demand little other than that the participants see and
talk with one another. There is no need for sophisticated peripheral devices
such as video oto-ophthalmoscopes or electronic stethoscopes. Perhaps for this
reason, telepsychiatry was the first use of interactive video for medical
purposes. In 1961, Dr. Cecil Wittson at the U. of Nebraska Medical Center
(UNMC) in Omaha began pilot testing telepsychiatry on the campus-wide
tele-education system, which had been operating since the early 1950’s.
The trials, involving two psychiatrists and eight groups of four or five
patients, went well; the researchers found that the televideo sessions were
well accepted and appeared to be as effective as on-site sessions. In January,
1965 the first "production" telepsychiatry program was begun, a
microwave-mediated link between Omaha and Norfolk State Mental Hospital, 112
miles away. It was supported by a 6-year grant from the National Institutes of
Mental Health. During the period of the grant, over 300 hours of clinical
telepsychiatry sessions were logged. The program didn’t survive the end of
the grant period, probably because of the formidable transmission costs between
Omaha and Norfolk, which averaged about $48,000/ year (in 1960’s
dollars!).
Telemedicine Today’s last full survey of
telepsychiatry was in the summer of 1994 (Vol. 2, no. 2). At the time, we
identified 9 programs in the U.S. that were actively seeing patients, as well
as one in Canada and one in Norway. The five most active programs were Norfolk
(NE) Regional Medical Center (about 420 consultations/yr); U. of SC (about
288/yr); E. Montana (about 116/yr); E. OREGON (about 48/yr); and U. of KS
(40/yr). Total consultations in 1994 among the 9 U.S. programs: about 948.
A lot has happened in the ensuing years. Last
year’s Telemedicine Today survey of active telemedicine programs, done
cooperatively with the Association of Telemedicine Service Providers,
documented 25 programs in the U.S. doing 3,460 telemental health consultations
in 1996 (Vol. 5, no. 4). Among the 19 programs in the U.S. we were able to
interview for this current survey, we found that an aggregate total of about
720 consultations/month are being done – or about 8,640/year. This is
nearly a 10-fold increase since 1994. Furthermore, there are now at least 5
programs doing over 500 telepsychiatry consultations/year: Northern Arizona, U.
of KS, U. of TX Medical Branch, E. Montana, and S. Australia. The first three
of these are doing well over 1,000/year. As with all of our surveys, we caution
that these figures have not been independently verified.
Doing This Survey
This year, we identified 29 active telepsychiatry
programs - 25 in the United States, one in Canada, one in England, one in
Norway and one in Australia. We conducted telephone interviews with at least
one representative of 16 of these programs and sent a two-page survey by fax or
e-mail to the remaining thirteen. Eight of the latter group responded, making a
total of 24 responses out of 29 programs. We also spoke with Dr. Ellen
Rothchild, who chairs the Committee on Telemedical Services for the American
Psychiatric Association.
We had hoped to gather firm data on the total number
of clinical interactions among all these programs. While we were able to garner
complete information on them, there are some gaps. Nevertheless, we feel that
this survey represents a reasonably accurate "snapshot" of the state of
telepsychiatry today.
There are significant variations in the way the
programs are set up. Some are demonstration projects, some are research
studies, some provide support to other professionals and do not actually see
patients, and so forth. All of these factors make it difficult to derive secure
numbers. However, it is probably safe to say that among the programs we
reviewed there is an aggregate total of about 1000 clinician/patient
interactions each month.
Technology Changes and Bandwidth Issues
There is a marked shift in technologies since our
previous surveys, towards desktop units running over ISDN at 128 Kbps. Five
programs are even dipping into even lower bandwidth technologies, seeing
patients over POTS (Plain Old Telephone System) systems. These technologies are
quite inexpensive; an ISDN-based desktop can be bought for well under $5,000
(including the computer), and a complete POTS-based set-top system costs about
$500.
An important issue for telepsychiatrists is
determining what the technology breakpoints are for adequate motion handling
and resolution. At lower bandwidths – and especially over POTS –
there can be serious ‘tiling’ and ‘pixelation’ of the video
image, particularly with movement, and lip-synching can be way off. This may or
may not impact the quality of the clinical interaction. Each user must
determine what their image (and audio) quality requirements are. These
requirements may differ depending on the clinical condition and diagnosis of
the patient. The team of Cukor and Baer, at the Harvard Telepsychiatry Program,
has done the most work looking at these issues. Their research, and review of
peer-reviewed telepsychiatry literature, suggests that 128 Kbps transmission
rates, at 15 frames/sec and FCIF resolution (288 x 352 pixels) can be used
reliably for administering some psychiatric rating and screening scales. It is
not so clear, however, under what circumstances and for which psychiatric
conditions the lower (and higher) bandwidth technologies can be used to
substitute for on-site encounters.
The next two issues of Telemedicine Today will contain
the 5th Annual Program Survey, which will include additional
information about telepsychiatry activity relative to other specialties. Also,
the October ’98 issue will look specifically at cost-effectiveness studies
in telemedicine, including telepsychiatry.
SURVEY HIGHLIGHTS
(U.S. only)
Programs surveyed: 19
Average number of sites/program*: 8.1 (range:
2-15)
Total consultations*: 720/month (average:
48/month)
Most common diagnoses:
Adult: depression, schizophrenia
Child: attention deficit disorder (ADHD/ADD)
Length of average consult*:
New patient: 49.6 minutes (range: 40-90)
Follow-up: 20 minutes (range: 10-50)
Unspecified: 28.9 minutes (range: 10-60)
Transmission bandwidth: POTS** (5 programs); 128 Kbps
(5); 384 Kbps (9); 512-786 Kbps (4); 1.54 Mbps/T1 (3)
Interactive video vendors:
Rollabout/room units: VTEL (8 programs); PictureTel
(2); NEC (1)
Desktop units: PictureTel (4); Intel ProShare (3);
VTEL (1); VCON (1)
Set-top boxes: 8x8 (3)
*among programs reporting numbers
**Plain Old Telephone System
SUGGESTED READING
Baer L, Cukor P, Jenike MA, Leahy L, O’Laughlen
J, Coyle JT. Pilot studies of telemedicine for patients with
obsessive-compulsive disorder. Am J Psychiatry 152:1383-1385, 1995
Baer L, Elford R, Cukor P. Telepsychiatry at forty:
what have we learned? Harvard Rev Psychiatry 5:7-17, 1997 [superb literature
review]
Cukor P, Baer L. Human factors in telemedicine: a
practical guide with particular attention to psychiatry. Telemedicine Today
2,2:pp. 9, 16-18, 1994
Dwyer T. Telepsychiatry: psychiatric consultation by
interactive television. Am J Psychiatry 130:865-9, 1973
McClaren PM, Laws VJ, Ferreira AC, O’Flynn D,
Lipsedge ML, Watson JP. Telepsychiatry: outpatient psychiatry by videolink. J
Telemed Telecare 2 (suppl 1):59-62, 1996
Perednia DA. Evaluating the use of telemedicine for
mental health applications. Telemedicine Today 2,2:10-11, 1994
Wittson CL, Affleck DC, Johnson V. Two-way
television in group therapy. Mental Hospitals 2:22-23, 1961 [the first
peer-reviewed published article] |
