Realizing the Promises of Telepsychiatry in Special Populations.

Telepsychiatry holds great potential as a treatment modality for patients who suffer from mental health issues, but lack access to traditional in-person clinic visits. Reasons for poor access may include disabling medical illness, residence in remote areas, lack of transportation, and cultural barriers like language proficiency or stigmatization of psychiatric disorders.1-3 As such, there are many specific populations that stand to benefit from telepsychiatric services – namely, the elderly, rural residents, recent immigrants, and deployed members of the military.3-5 An important consideration when implementing telepsychiatric care is the likely expectations and reactions of the patients being treated. For example, it is possible that patients experience a stronger therapeutic alliance with face-to-face sessions. They may also have different expectations depending on whether they have met with their psychiatrist in person before, or if all meetings including the initial evaluation have occurred remotely. Moreover, those with limited experience using videoconferencing technology (such as the elderly or culturally isolated patients) might prefer face-to-face sessions, and they could even experience telepsychiatry as a stressor. Campbell et al. address this last concern in their report, demonstrating that geographically and culturally isolated patients in Ontario, Canada, actually respond very positively to telepsychiatry. Despite the fact that some of the patients surveyed had no Internet access or computers, over 90% of patients were comfortable with their telepsychiatric care, and 84.5% found it as beneficial as a direct physical presence. Moreover, only one patient out of 84 surveyed found the telepsychiatry experience to be stressful, and no patients experienced adverse outcomes as a result of the intervention. A range of diagnoses was represented in the study’s sample, increasing its applicability to other populations (though survey responses were not linked with diagnosis, in order to preserve anonymity). Virtually all of the patients stated on the survey that they would want to use the telepsychiatric service again in the future.3 This bodes well for other populations that may benefit from telepsychiatry. Similarly to the isolated patients in the report, elderly patients are also less likely to have Internet access and computer proficiency. The suggestion that a lack of experience with technology does not reduce the acceptability of telepsychiatric intervention is encouraging. Lending further support to this idea is a recent study by Vahia et al., which demonstrated the reliability and acceptability of telepsychiatric evaluation of older Spanish-speaking Latino adults with mild cognitive impairment in the rural county of Imperial in California.4 This result is especially striking given the many potential barriers to effective care – culture, age, language, geography, and cognition – in the study’s participants. A limitation of Campbell’s study that should be considered is the fact that participants had the opportunity to meet with a psychiatrist prior to their telepsychiatry session. The patient’s strongly positive feelings about their experience may have been buoyed by a sense of familiarity during the interaction. Other groups, such as active members of the military deployed to remote locations, may not have this opportunity. Fortunately, Poropatich et al. suggest in their 2013 report that patient satisfaction in this population remains high despite this. Perhaps more importantly, they report that a full 70% of behavioral health sessions with military members in Afghanistan would not have occurred if not for the availability of telepsychiatry.5 Another encouraging result from Campbell’s report is the near-unanimous agreement among participants that they would want to continue with telepsychiatric care in the future. A limitation of the study is that the survey was administered after only a single session, so it is unknown whether patient satisfaction in this case actually reduced treatment drop-out rate. However, other more longitudinal studies corroborate the suggestion that the acceptability of telepsychiatry is associated with adherence to therapy, even in culturally isolated populations.1,6 For example, in 2010, Mucic showed that in a study of refugees and asylum seekers that there was a high level of satisfaction with telepsychiatric care, and that the participants completed an average of five sessions during the study period.6 Of course, after confirming acceptability to patients and likelihood of patient adherence, the next step in implementing telepsychiatry is analysis of long-term patient outcomes. A review of one useful metric, readmission rates, was recently conducted by Koblauch et al. It was demonstrated that results of studies measuring readmission after telepsychiatry compared to traditional modalities of care have been mixed; some report a reduction in rate, while others show no difference. However, there are few high-quality studies in this area thus far, and further research will be required to draw any conclusions.7 Whether telepsychiatry rises to these challenges and demonstrates measurable benefits in the lives of patients remains to be seen, but its future certainly appears bright. These services are poised to make a remarkable difference for patients who might otherwise be prevented from receiving regular psychiatric care. Campbell’s findings are encouraging, as they suggest that patients will be highly satisfied with telepsychiatry as it continues to be implemented and studied.