Peter Yellowlees

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.

Towards a Framework for Evaluating Mobile Mental Health Apps

INTRODUCTIONnMobile phones are ubiquitous in society and owned by a majority of psychiatric patients, including those with severe mental illness. Their versatility as a platform can extend mental health services in the areas of communication, self-monitoring, self-management, diagnosis, and treatment. However, the efficacy and reliability of publicly available applications (apps) have yet to be demonstrated. Numerous articles have noted the need for rigorous evaluation of the efficacy and clinical utility of smartphone apps, which are largely unregulated. Professional clinical organizations do not provide guidelines for evaluating mobile apps.nnnMATERIALS AND METHODSnGuidelines and frameworks are needed to evaluate medical apps. Numerous frameworks and evaluation criteria exist from the engineering and informatics literature, as well as interdisciplinary organizations in similar fields such as telemedicine and healthcare informatics.nnnRESULTSnWe propose criteria for both patients and providers to use in assessing not just smartphone apps, but also wearable devices and smartwatch apps for mental health. Apps can be evaluated by their usefulness, usability, and integration and infrastructure. Apps can be categorized by their usability in one or more stages of a mental health providers workflow.nnnCONCLUSIONSnUltimately, leadership is needed to develop a framework for describing apps, and guidelines are needed for both patients and mental health providers.

The Empirical Evidence for Telemedicine Interventions in Mental Disorders

PROBLEM AND OBJECTIVEnThis research derives from the confluence of several factors, namely, the prevalence of a complex array of mental health issues across age, social, ethnic, and economic groups, an increasingly critical shortage of mental health professionals and the associated disability and productivity loss in the population, and the potential of telemental health (TMH) to ameliorate these problems. Definitive information regarding the true merit of telemedicine applications and intervention is now of paramount importance among policymakers, providers of care, researchers, payers, program developers, and the public at large. This is necessary for rational policymaking, prudent resource allocation decisions, and informed strategic planning. This article is aimed at assessing the state of scientific knowledge regarding the merit of telemedicine interventions in the treatment of mental disorders (TMH) in terms of feasibility/acceptance, effects on medication compliance, health outcomes, and cost.nnnMATERIALS AND METHODSnWe started by casting a wide net to identify the relevant studies and to examine in detail the content of studies that met the eligibility criteria for inclusion. Only studies that met rigorous methodological criteria were included. Necessary details include the specific nature and content of the intervention, the research methodology, clinical focus, technological configuration, and the modality of the intervention.nnnRESULTSnThe published scientific literature on TMH reveals strong and consistent evidence of the feasibility of this modality of care and its acceptance by its intended users, as well as uniform indication of improvement in symptomology and quality of life among patients across a broad range of demographic and diagnostic groups. Similarly, positive trends are shown in terms of cost savings.nnnCONCLUSIONnThere is substantial empirical evidence for supporting the use of telemedicine interventions in patients with mental disorders.

Telepsychiatry: Effective, Evidence-Based, and at a Tipping Point in Health Care Delivery?

Patient-centered health care questions how to deliver quality, affordable, and timely care in a variety of settings. Telemedicine empowers patients, increases administrative efficiency, and ensures expertise gets to the place it is most needed--the patient. Telepsychiatry or telemental health is effective, well accepted, and comparable to in-person care. E-models of care offer variety, flexibility, and positive outcomes in most settings, and clinicians are increasingly interested in using technology for care, so much so that telepsychiatry is now being widely introduced around the world.

The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health System

ObjectiveThe authors replicated a program developed by UC San Diego, identified medical staff at risk for depression and suicide using a confidential online survey, and studied aspects of that program for 1 year.MethodsThe authors used a 35-item, online assessment of stress and depression depression developed and licensed by the American Foundation for Suicide Prevention that aims to identify and suicide risk and facilitate access to mental health services.ResultsDuring 2013/2014, all 1864 UC Davis residents/fellows and faculty physicians received an invitation to take the survey and 158 responded (8xa0% response rate). Most respondents were classified at either moderate (86 [59xa0%]) or high risk for depression or suicide (54 [37xa0%]). Seventeen individuals (11xa0%) were referred for further evaluation or mental health treatment. Ten respondents consented to participate in the follow-up portion of the program. Five of the six who completed follow-up surveys reported symptom improvement and indicated the program should continue.ConclusionsThis program has led to continued funding and a plan to repeat the Wellness Survey annually. Medical staff will be regularly reminded of its existence through educational interventions, as the institutional and professional culture gradually changes to promptly recognize and seek help for physicians’ psychological distress.

Need for and Steps Toward a Clinical Guideline for the Telemental Healthcare of Children and Adolescents

OBJECTIVEnThis article identifies and describes key considerations toward the development of a clinical guideline intended to optimize telemental healthcare (TMH) of children and adolescents.nnnMETHODSnThe literature was searched with key terms and title words. Of 2824 articles that met primary or secondary key word search criteria, 326 met both criteria, and 118 thematically related directly to child and adolescent TMH. Only 44 studies met levels of evidence I-III and expert recommendation criteria used in clinical guidelines; review of their references found 8 additional studies (52 total). Data from adult, child, and adolescent in-person psychiatric care and adult TMH were applied to provide context in developing the key considerations.nnnRESULTSnTMH guidelines for adults are well delineated, and TMH guidelines for children and adolescents are likely to closely overlap in terms of general clinical, technical, and administrative issues. However, for a child and adolescent focus, modifications of existing general guidelines appear necessary; for example, based on developmental status, family involvement, and patient-site modifications for space and sound. Additional clinical issues include specify who, exactly, is the patient (i.e., the patient, family, and /or other stakeholders), modalities of care (i.e., age-related psychotherapies such as play therapy or behavior management), and psychopharmacology.nnnCONCLUSIONSnSpecific clinical, administrative, and technical issues are key considerations - based on the nuances of established child and adolescent mental healthcare - and must be considered in developing a clinical guideline for TMH of these patients. Developing such guidance should proceed from a careful review of the growing evidence base, and through expert consensus processes.

The hybrid doctor–patient relationship in the age of technology – Telepsychiatry consultations and the use of virtual space

Abstract The doctor–patient relationship is evolving and changing through the impact of many technological, social and environmental factors. These factors will be examined, especially the impact of changing attitudes among younger generations of physicians and patients who live in an information-driven networked world. Telepsychiatry is already over 50 years old and has a strong evidence base which suggests that it is a better form of practice compared with the traditional in-person consultation for certain patient groups. In particular, telepsychiatry encourages intimacy in relationships through the use of the ‘virtual space’ in the consultation, better collaboration between psychiatrists and primary care physicians, and improved patient satisfaction. The practice of psychiatry will change through the use of mobile devices, asynchronous consultations, and the opportunities that automated interpretation and translation bring to work across cultures. The future will likely bring many psychiatrists working increasingly in a hybrid model, both in-person, and online, using the strengths of both approaches to improve patient care.

Mobile mental health care--an opportunity for India.

According to the World Health Organization, India had the highest number of suicides in the world in 2012 with 258,000 of 804,000 suicides worldwide. Indian youths between the ages of 15 and 29 years committed suicide with 35.5 deaths per 100,000, while suicide became the leading cause of death of young Indian women also1,2. Other mental health problems noted to be specific to India are depression related to economic insecurity, anxiety among youths over educational success, and distress among young women caught between the opportunities of a changing India and pressure from traditionally minded families to marry. n nIndias first-ever National Mental Health Policy3, announced in 2014, aims to provide universal psychiatric care to the population by 2020, despite a relatively small health care budget per capita compared with other developing nations. The Policy describes how care should be provided through integrated care services which “should espouse the principles of universal access, equitable distribution, community participation, inter-sectoral coordination and use of appropriate technology”3. In India, with 75 per cent of the population living in rural areas, only 0.7 physicians per 1000 population and only one psychiatrist for every 343,000 Indians, access to quality mental health care is limited and traditional approaches to care are highly unlikely to reduce the high national suicide rate or reach the 20 per cent of the population who have mental disorders2,3. n nIndia, however, has one major advantage when it comes to delivering future mental health services and has the opportunity to deliver services just as described in the National Mental Health Policy, through the use of appropriate technology, especially mobile wireless technologies. Much of the population is young, technologically sophisticated and equipped with wireless smartphones that have become an integral part of their lives. Smartphone penetrance in India is rapidly increasing and the country will have more smartphone users than the USA by 2016, with over 200 million being used nationally already4. This is effectively an already paid for and developed health communications technology infrastructure through which a substantial proportion of Indias future mental health services may be delivered. This could, if it is taken advantage of strategically, form the core of national preventive and patient centered mental health services for the country in future years. n nIndia has considerable internal experience using conventional telemedicine, especially through the partnership between the Indian Space Research Organization and the Apollo Telemedicine Networking Foundation which links more than 100 hospitals and provides tele-education to medical colleges and mobile telemedicine units in disaster relief camps5. Indian clinics and hospitals, especially in isolated areas, have long been the recipient of mobile email consultations and second opinions in many medical specialties, including psychiatry, from charities such as the Swinfen Foundation6, which accesses psychiatrist volunteers from the USA, UK and Australia. n nThis early telemedicine and electronic health care experience, and the young wirelessly enabled population, lay the foundations for India, if it so decides, to take the leap into “mobile mental health” and to set up a series of preventive, assessment and treatment platforms that can be delivered to smartphones nationally, and which can support and supplement the current government and privately run mental health services efficiently and effectively.

The Technology-Enabled Patient Advocate: A Valuable Emerging Healthcare Partner

The U.S. healthcare system is changing and is becoming more patient-centered and technology-supported, with greater emphasis on population health outcomes and team-based care. The roles of healthcare providers are changing, and new healthcare roles are developing such as that of the patient advocate. This article reviews the history of this type of role, the changes that have taken place over time, the technological innovations in service delivery that further enable the role, and how the role could increasingly be developed in the future. Logical future extensions of the current typical patient advocate are the appearance of a virtual or avatar-driven care navigator, using telemedicine and related information technologies, as healthcare provision moves increasingly in a hybrid direction, with care being given both in-person and online.

Antipsychotic-Induced Movement Disorder: Screening via Telemental Health

BACKGROUNDnThe purpose of this brief report is to make clinical and research recommendations to advance current knowledge and practices related to the assessment of antipsychotic drug-induced movement disorders (DIMDs) via live interactive videoconferencing.nnnMATERIALS AND METHODSnThe authors provide an overview of the frequent neurological side effects of antipsychotic drugs and review relevant telemedicine research. DIMD prevention is critical, but these disorders remain underdetected and under-reported. Although there are not yet formal recommendations for specific screening tools or screening frequency, baseline and annual assessments are generally agreed-upon minimums. As DIMD awareness increases and more specific guidelines are developed to steer assessments, telemental health may aid practitioners in efficiently and regularly monitoring onset and severity. Research shows that videoconferencing can be used for effective psychiatric treatments and assessment, with at least one study validating the use of videoconference assessment for a subset of movement disorders.nnnRESULTS AND CONCLUSIONSnClinical recommendations include developing practice-level protocols and procedures that include regular DIMD assessment (either in-person or via telemedicine) for the full spectrum of possible movement disorders for all patients taking antipsychotic medications. Research and evaluation recommendations include replicating and expanding upon the existing study using videoconferencing to assess movement disorder symptoms, using asynchronous telemental health assessments of DIMDs, and pilot-testing facial and movement recognition software to allow for clinical comparison of patients movement patterns over time.