Donald M. Hilty

The Effectiveness of Telemental Health: A 2013 Review

INTRODUCTION The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed. MATERIALS AND METHODS The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international. RESULTS Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes. CONCLUSIONS Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

Clinical and Educational Telepsychiatry Applications: A Review

Objective: Telepsychiatry in the form of videoconferencing brings enormous opportunities for clinical care, education, research, and administration. Focusing on videoconferencing, we reviewed the telepsychiatry literature and compared telepsychiatry with services delivered in person or through other technologies. Methods: We conducted a comprehensive review of telepsychiatry literature from January 1, 1965, to July 31, 2003, using the terms telepsychiatry, telemedicine, videoconferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empowerment, and costs. We selected studies for review if they discussed videoconferencing for clinical and educational applications. Results: Telepsychiatry is successfully used for various clinical services and educational initiatives. Telepsychiatry is feasible, increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, facilitates education, and empowers parties using it. Data are limited with regard to clinical outcomes and cost-effectiveness. Conclusions: Telepsychiatry is effective. More short- and long-term quantitative and qualitative research is warranted on clinical outcomes, predictors of satisfaction, costs, and educational outcomes.

Telepsychiatry: an overview for psychiatrists.

Telepsychiatry, in the form of videoconferencing and other modalities, brings enormous opportunities for clinical care, education, research and administration to the field of medicine. A comprehensive review of the literature related to telepsychiatry - specifically videoconferencing - was conducted using the MEDLINE, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases (1965 to June 2001). The keywords used were telepsychiatry, telemedicine, videoconferencing, Internet, primary care, education, personal digital assistant and handheld computers. Studies were selected for review if they discussed videoconferencing for patient care, satisfaction, outcomes, education and costs, and provided models of facilitating clinical service delivery. Literature on other technologies was also assessed and compared with telepsychiatry to provide an idea of future applications of technology. Published data indicate that telepsychiatry is successfully used for a variety of clinical services and educational initiatives. Telepsychiatry is generally feasible, offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behaviour. More quantitative and qualitative research is warranted with regard to the use of telepsychiatry in clinical and educational programmes and interventions.

A retrospective analysis of a child and adolescent eMental health program

OBJECTIVE New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary care setting, particularly in rural areas of the United States and especially for children and adolescents. The aim of this study was to examine the diagnostic characteristics and outcomes for children referred for eMental Health consultations at UC Davis (videoconferencing, telephone, and secure e-mail) from 10 primary care clinics in rural northern California. METHOD : A retrospective analysis was conducted on the diagnostic and clinical outcomes of 139 referred children who received a full psychiatric diagnostic evaluation via videoconferencing. Within the group, a convenience sample of 58 initial and 41 three-month follow-up Child Behavior Checklists (CBCLs) was collected. RESULTS Comprehensive eMental Health programs appear to be effective for psychiatric diagnosis and assessment of children. Attention deficit (36.2%) and mood (28.1%) disorders were the most common diagnostic groupings overall. Most children were seen only once, but a statistically significant improvement between initial evaluation and 3-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the CBCL for girls and boys, respectively. CONCLUSIONS Versatile eMental Health programs, incorporating standardized checklists, may assist in diagnosis and treatment of rural children.

Discharge Against Medical Advice From Inpatient Psychiatric Treatment: A Literature Review

OBJECTIVE A comprehensive review of the literature examined discharge from inpatient psychiatric settings against medical advice (excluding elopements) over the past 50 years. Specifically, definitions, prevalence, predictors, temporal patterns, consequences, and interventions pertaining to such discharge were explored. METHODS The authors searched the PubMed and PsycINFO databases and selected articles for review if studies had been conducted in an inpatient setting or included discharge against medical advice as one of the aims or results and if findings were based on formal statistical analyses. RESULTS Sixty-one articles met the selection criteria. Prevalence of discharge against medical advice ranged from 3 to 51 percent and increased over time. Discharge against medical advice was most commonly predicted by patient factors, such as young age; single marital status; male gender; comorbid diagnosis of personality or substance use disorders; pessimistic attitudes toward treatment; antisocial, aggressive, or disruptive behavior; and history of numerous hospitalizations ending in discharges against medical advice. It was also predicted by provider variables, such as failure to orient patients to hospitalization and failure to establish a supportive provider-patient relationship, and by temporal variables, such as evening and night shifts. Outcomes of patients discharged against medical advice were characterized by poor outcomes in several domains of functioning and more frequent rehospitalizations. CONCLUSIONS Prediction of patients at risk of discharge against medical advice is possible with several defined variables. Awareness of the factors involved in discharge against medical advice should facilitate clinical decision making and the development of successful interventions for high-risk patients.

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

anagement of behavioral disturbances Mand psychosis associated with dementia is a clinical and, in some cases, a medicolegal and ethical challenge for clinicians, caregivers, and health care settings. These medications are associated with multiple adverse outcomes, including serious adverse effects, such as increased risk for cerebrovascular events and mortality. At the same time, clinicians feel pressure from caregivers, acute inpatient staff, and long-term care settings to safely manage psychotic and aggressive behaviors in this population. The incidence and prevalence of dementia and associated behavioral disturbances in the adult population is on the rise. There is a lack of consistent practices and guidance to manage these behaviors as well as an upto-date review of the existing effectiveness literature, and these are much needed. Thus, the recent publication of the American Psychiatric Associations (APAs) practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia comes at a most opportune time. Practice guidelines are unique in that they have the potential to positively impact behavior of practicing clinicians. They are also likely to be used as standard of care by insurance companies and in lawsuits or other litigation. It is thus important that practice guidelines provide a thorough, balanced, accurate, and current review of available treatments based on medical and scientific literature. The APAs most recent practice guideline on antipsychotic treatment in patients with dementia appears to have done just that. The practice guideline is organized into two main sections. The first section is broken up into four main categories: an introduction and overview of the guidelines, the guidelines themselves and how they were implemented based on current evidence in literature, quality measurement considerations, and the guideline development process. The second section is an appendix that provides a comprehensive review of available evidence and the results of expert opinion survey data. The authors also included a list of acronyms and abbreviations used in the guidelines, glossary of terms, list

Posttraumatic concerns: a patient-centered approach to outcome assessment after traumatic physical injury.

Background.Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients’ perspectives regarding posttraumatic outcomes. Objective.To identify and categorize physically injured trauma survivors’ posttraumatic concerns. Research Design.Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma. Subjects.Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults. Measures.At the end of each interview patients were asked, “Of all the things that have happened to you since you were injured, what concerns you the most?” Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning. Results.Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients e-pressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (&kgr; = 0.72). The mean number of concerns e-pressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations. Conclusions.The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.

The child and adolescent telepsychiatry consultation: can it be a more effective clinical process for certain patients than conventional practice?

The literature on the efficacy of telepsychiatry for assessing and treating children and adolescents with mental health problems is still developing, but there is evidence that telepsychiatry is diagnostically valid, and that there is high patient and provider satisfaction. Outcome studies are awaited, with the assumption that telepsychiatry has to demonstrate at least as good outcomes and reliability as face-to-face psychiatric care. In this article we suggest, by reviewing the process of telepsychiatry with children, and illustrating relevant issues with five case studies of patients we have seen, that there is a valid case for arguing that in certain children and adolescents, telepsychiatry, as a consultation process, might actually be a superior method of psychiatric assessment to face-to-face consultation. Four factors stand out supporting this view. These are the novelty of the consultation, the capacity to provide direction, the extra distance involved (both psychological and physical), and the authenticity of the interaction. More research in child and adolescent telepsychiatry is indicated.

A Feasibility Study of the Use of Asynchronous Telepsychiatry for Psychiatric Consultations

OBJECTIVE This study examined the feasibility of conducting psychiatric consultations using asynchronous, or store-and-forward, video-based telepsychiatry. METHODS Video-recorded 20- to 30-minute assessments of 60 nonemergency, English-speaking adult patients in a medically underserved county in California were uploaded along with other patient data to a Web-based record. Two psychiatrists then used the record to provide psychiatric consultations to the referring primary care providers. RESULTS Eighty-five percent of patients received diagnoses of mood disorders, 32% diagnoses of substance use disorders, 53% diagnoses of anxiety disorders, and 5% other axis I diagnoses. Psychiatrists recommended short-term medication changes for 95% of the patients and provided guidelines for possible future changes. CONCLUSIONS This study-the first study of asynchronous telepsychiatry to be published-demonstrated the feasibility of this approach. This type of assessment should not replace the face-to-face psychiatric interview, but it may be a very helpful additional process that improves access to care and expertise.

A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications

Abstract Telepsychiatry (TP; video; synchronous) is effective, well received and a standard way to practice. Best practices in TP education, but not its desired outcomes, have been published. This paper proposes competencies for trainees and clinicians, with TP situated within the broader landscape of e-mental health (e-MH) care. TP competencies are organized using the US Accreditation Council of Graduate Medical Education framework, with input from the CanMEDS framework. Teaching and assessment methods are aligned with target competencies, learning contexts, and evaluation options. Case examples help to apply concepts to clinical and institutional contexts. Competencies can be identified, measured and evaluated. Novice or advanced beginner, competent/proficient, and expert levels were outlined. Andragogical (i.e. pedagogical) methods are used in clinical care, seminar, and other educational contexts. Cross-sectional and longitudinal evaluation using quantitative and qualitative measures promotes skills development via iterative feedback from patients, trainees, and faculty staff. TP and e-MH care significantly overlap, such that institutional leaders may use a common approach for change management and an e-platform to prioritize resources. TP training and assessment methods need to be implemented and evaluated. Institutional approaches to patient care, education, faculty development, and funding also need to be studied.