Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, April 21, 2013

Tele Me More

I want to pick up where I left off with the telepsychiatry post by looking at evidence in the literature.

One study, The Effectiveness of Telemental Health Applications: A Review  
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.

Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.

Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.

A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.

The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.

So what do we know?

  • TMH seems to be helpful in treating some conditions, such as depression and PTSD.
  • In veterans, TMH has decreased admissions and length of stay by roughly 25%. 98,000 veterans-you can't ignore that number.
  • TMH was equivalent to face-to-face treatment for consultation with brief follow-up, and cost less.
  • Online CBT looked better than treatment by a GP in the UK.
  • Many Chinese who otherwise wouldn't have access to psychotherapy or psychoanalysis are eager to have TMH treatment.
Based on this information I'd like to see a more formal study of face-to-face vs. Skype treatment for  a more general population, and for, say, psychodynamic psychotherapy, before drawing any conclusions. But I certainly wouldn't dismiss the idea of TMH entirely. 

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