Telepsychiatry Today
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PSYCHIATRY IN THE DIGITAL AGE (JS LUO, SECTION EDITOR)
Telepsychiatry Today
Steven Chan1& Michelle Parish
1,2& Peter Yellowlees
1
# Springer Science+Business Media New York 2015
Abstract The use of video-based telepsychiatry is increasing
in response to consumer demand for convenient, inexpensive,and readily accessible services; improved financial reimburse-
ment; and a robust body of evidence-based literature.
Telepsychiatry leads to high patient and provider satisfaction
ratings, and outcomes equivalent to in-person care, while
younger generations often prefer telepsychiatry over face-to-
face encounters. The evidence base for telepsychiatry is espe-
cially strong with respect to the treatment of post-traumatic
stress disorder (PTSD), depression, and ADHD, while its use
in underserved ethnic groups is well described in the Ameri-
can Indian, Hispanic, and Asian populations. Despite this,
telepsychiatry barriers still persist. These include personal bi-
as — especially in leadership — and insufficient training; the
challenging business environment and legislative processes;
and inconsistent reimbursement, licensing, and prescription
policies. Technology is now less of a barrier, and it is clear
that telepsychiatry overall is flourishing and changing the way
that providers are working and patients are being treated.
Keywords Telepsychiatry . Telemedicine . Video
consultation . Technology . Innovation
Introduction
Telemedicine’ s definitions vary in scope. Some broadly define
it as the transfer of medical information from one site to an-
other by electronic communications, encompassing not just
two-way video, but also e-mail, smartphones, and other tele-
communications technology, with the ultimate goal of diag-
nosing and treating illnesses [1, 2]. This broad definition im-
plies the potential to shift medical care towards new models of
Bencounterless^ digital communication [3]. In a more focused
definition, the Centers for Medicare and Medicaid Services
define telemedicine as two-way, real-time interactive commu-
nication. This occurs between a patient and a practitioner at
distant sites [4]. This often is referred to as synchronous
telemedicine.
Telepsychiatry — interchangeably known as telemental
health — is the application of telemedicine to mental health.
Though telepsychiatry can encapsulate the aforementioned
broader definition of not just video but also smartphone apps,
mobile devices, and sensors [5 – 11], this paper will specifically
cover synchronous telepsychiatry as video-based health ser-
vices involving the transmission of video over distance, and
briefly discuss non-real-time — or asynchronous — methods of
video consults. Research from 2012 through 2015 will primar-
ily be discussed and reviewed.
Advantages of Telepsychiatry
A significant amount of research has demonstrated the advan-
tages of telepsychiatry beyond increasing access to care. Use
of telepsychiatry leads to high patient and provider satisfac-
tion ratings and achieves health outcomes equivalent to in-
person care [12••]. Younger generations — children and ado-
lescents — particularly prefer telepsychiatry over in-person
This article is part of the Topical Collection on Psychiatry in the Digital Age
* Steven Chan
1 Department of Psychiatry & Behavioral Sciences, University of
California, Davis School of Medicine & Health System, 2230
Stockton Boulevard, Sacramento, CA 95817, USA
2 Betty Irene Moore School of Nursing, University of California,
Davis, 2230 Stockton Boulevard, Sacramento, CA 95817, USA
Curr Psychiatry Rep (2015) 17:89
DOI 10.1007/s11920-015-0630-9
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face-to-face encounters, due to their familiarity with video
apps. In our experience, telepsychiatry encourages intimate
conversations and unique clinical observation opportunities
such as the patient ’s home environment; is often preferable
where patients have paranoia, anxiety, or PTSD; and works
in settings such as nursing home populations, where patients
have multiple disabilities.
Telepsychiatry is versatile and is already used in a vari-ety of settings. In outpatient clinics, the technology is used
for diagnosis and treatment, which can include medication
management, individual psychotherapy, and group psycho-
therapy. It can also be used for consultations in primary
care, to the home, and to specialist clinics, including pain,
obesity, and surgery clinics. Within hospitals and mental
health facilities, telepsychiatry is used for consultation and
emergencies, as well as widely in correctional, and sub-
stance use rehabilitation settings. The technology has been
implemented and used for all ages: children, adults, and the
elderly.
Historical and Current Trends in Adopting
Telepsychiatry
Historically, video-based telepsychiatry first developed as
a way for mental health professionals to reach patients in
remote areas. The University of Nebraska ’s Nebraska Psy-
chiatric Institute hosted the first video-based psychiatric
consults in 1959 [13]. Renewed interest in telepsychiatry
occurred in the 1990s — along with interest in teleradiology
and teledermatology — with large networks built through-
out the USA [14••], Canada, and Australia, though its
adoption was still hampered by limited bandwidth. Since
the 2000s, telepsychiatry experienced another boost in
popularity due to increased network speeds and new reim-
bursement models.
More recently, telemedicine has shifted towards web
and mobile technologies, with a boom in commercial com-
panies and medical services. A variet y of fac tors have
fueled this trend: increased Internet access even in isolated
communities; consumer preferences for convenient, inex-
pensive on-demand services; and expectations and accep-
tance of telemedicine by Millennials. Federal reimburse-
ment is slowly gaining traction as the Centers for Medicare
and Medicaid have made recent moves towards telehealth
parity coverage and expanded reimbursement [15]. Busi-
nesses have also taken note, as the number of employers
offering telemedicine is predicted to expand from 22 % in
2014 to 37 % in 2015 [16]. The US government plans to
expand VA telemedicine services in FY 2016 by 11.5 %
[17]. Telepsychiatry, however, is still largely supported by
internal or grant funding — such as within the US Depart-
ment of Veterans Affairs (VA) — and then in decreasing
order, federal funding, private grants from foundations or
endowments, and — more infrequently — state or local
funding [18, 19], with relatively few mental health pro-
grams showing long-term commercial sustainability.
A shortage of psychiatrists, psychiatric services, and
funding nationwide has contributed to the enthusiasm for
telepsychiatry, with 55 % of US counties unable to recruit
mental health practitioners. Funding constraints have led tothe closure of hospital beds; now, only 27 % of community
hospitals have inpatient psychiatric units [20].
Health systems are adopting telepsychiatry as they per-
ceive telemedicine as a competitive advantage in attracting
patients [21•]. The largest health system in the USA, the
Veterans Health Administration (VHA), has embraced
telepsychiatry. Within VHA, telemental health experienced
rapid growth from 2006 through 2010 for individual psy-
chotherapy with medication management (218 %), follow-
ed by group psychotherapy (178 %), diagnostic assessment
(175 %), individual psychotherapy without medication
management (174 %), and medication management alone(140 %) [22] as shown in an analysis of 342,288 telemental
health encounters from national-level VHA data. A sepa-
rate study of 98,609 mental health patients before and after
enrollment in telemental health services demonstrated a
25 % average reduction of patient hospitalizations in this
same time period [23]. The VA has also piloted home-
based tel eps ychiatry using home webcams on vetera n-
owned computers and secure encrypted software [24]. In-
terestingly, the second largest health system in the USA,
Kaiser Permanente, uses telemedicine and virtual visits
[25], but has no published reporting of telepsychiatry ser-
vices. Telepsychiatry is also used internationally; within
Canada ’s Ontario Telemedicine Network, over one-half of
the 204,058 telemedicine consults in FY 2011 – 2012 were
for telepsychiatry [26].
Telepsychiatry is expanding beyond its historical roots as a
tool for rural underserved communities. Within the correctional
setting, more than 10,000 psychiatric consultations have taken
place annually in Texas since 2006, while at least eight other
states have implemented telepsychiatry programs within cor-
rectional facilities. This has resulted in increased access for
inmates to mental healthcare and decreased costs in provider
travel, inmate travel, and use of other medical services [27].
Telepsychiatry also has been used to augment limited mental
health clinic hours in urban settings as well, such as within the
Maryland VA health system [28] and Los Angeles county [29].
Finally, telepsychiatry is expanding beyond synchronous
communication and into asynchronous communication. Most
published research in telepsychiatry is in the area of synchro-
nous telepsychiatry, with real-time, two-way video communi-
cation of a provider and a patient. However, a newer modality,
asynchronous telepsychiatry, involves recording a patient-
clinician interview to a video file and forwarding the file to a
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psychiatrist for assessment and treatment recommendations.
The psychiatrist then writes a consult note for the patient ’s
primary care provider. This method is similar to store-and-
forward teledermatology and teleradiology [30 , 31 ],
representing a disruptive innovation in mental healthcare that
has demonstrated feasible outcomes plus clinical and econom-
ic efficiency [32]. Cost analyses show that, with sufficient
patient volume, asynchronous telepsychiatry is more cost-effective compared to both synchronous telepsychiatry and
in-person psychiatric consultations [33]. Current work in-
cludes demonstrating widescale efficacy in a randomized clin-
ical trial [34], adopting new techniques using cross-language
methods and machine translation technologies in Hispanic
communities [35, 36], and demonstrating feasibility for elder-
ly patients in skilled nursing facilities [37].
How to Get Started in Telepsychiatry
Numerous commercial companies and entrepreneurial start-up organizations are providing telepsychiatry services and
other augmented models of care, particularly in camera-
equipped smartphone apps. Consumers can download apps
to their mobile devices to speak with a psychiatrist or psycho-
therapist over secure video chat channels.
How can one measure and classify all of these services and
projects? A 2012 expert consensus found four key factors to
be important: process and acceptability, clinical outcomes,
access, and cost [38]. Considerations for process and
acceptability include patient satisfaction, provider satisfac-
tion, coordination of care, integration of care, usability, rap-
port, stigma, and motivational readiness. Clinical outcomes
include measurement of percent of no shows (e.g., for failed
technology or other logistical causes), accuracy of assessment,
symptom outcomes, completion of treatment, quality of care
(e.g., through HEDIS system performance measures and con-
cordance with treatment guidelines), and treatment utilization.
Access includes the number of additional services that can be
accessed, numbers served (e.g., through relative value units),
wait times, length of session, distance to service, the likeli-
hood of using telemental health versus traditional care, and
cultural access. Finally, cost outcome considerations include
value proposition; direct and indirect costs for travel and tech-
nology; whether the project uses private or public funding;
societal burden on social network; personnel costs; supply
costs; and costs for training, facilities, and maintenance [39•].
Professional guidelines do exist. Telemental health guide-
lines written by the American Telemedicine Association cover
evidence-based practice for video-based online mental health
services [40••, 41••]. Practice parameters have also been pub-
lished for child and adolescent populations [42], with a 2015
revision in progress. The American Psychiatric Association’s
website curates resources on telepsychiatry [ 43]. The
American Psychological Association publishes telemental
health guidelines; though geared towards psychologists, these
include important topics such as data security and informed
consent [44].
With this information available, how does an individual
provider start their own solo direct-to-consumer telepsychiatry
practice? As of 2015, the process is complicated: providers
must follow multiple steps, including determining the type of telepsychiatry they want to practice, ensuring legal and tech-
nical requirements are met, getting the proper licenses, ad-
dressing in-person examination (i.e., face-to-face visit) re-
quirements, determining prescribing requirements, addressing
fraud and abuse issues, addressing reimbursement issues, and
considering all care issues such as handling of emergent situ-
ations like suicidal threats [14••]. Taking a locum tenens
telepsychiatry position — in which a psychiatrist takes a tem-
porary position to address a psychiatrist workforce shortage —
can be another pathway to starting a telepsychiatry career, as
these positions are increasingly being filled using
telepsychiatry [45]. Alternatively, increasing numbers of psy-chiatrists are signing on with commercial telepsychiatry com-
panies either to work for them, usually as independent con-
tractors, or to use the commercial technology platform to see
their own patients just as if they were renting physical space.
Unfortunately, telepsychiatry education and assistance with
developing the resources and knowledge to build a practice
are still in their infancy, with little teaching or experience
available on telepsychiatry in most medical schools and resi-
dency training programs. Residency training in telepsychiatry
thus far has mainly consisted of supervised clinical care, with
some didactics around transcultural, medicolegal, and health
system issues on telepsychiatry [46]. The American Psychiat-
ric Association has recognized this gap: a workgroup is devel-
oping a telepsychiatry Btoolkit for practicing psychiatrists. A
series of courses have been run by the American Telemedicine
Association on BTelemental Health 101, both at annual con-
ferences [47] and online [48].
Current Telepsychiatry Research by Diagnosis
Though telepsychiatry has been used clinically for most diag-
noses, research studies have emphasized certain diagnoses
more than others. A recent study of mental health encounters
in FY 2012 — comparing 176,246 telemental health to 11.8M
in-person visits — showed that post-traumatic stress disorder
(PTSD), depression, and anxiety were more likely to be ad-
dressed using telepsychiatry than alcohol use disorders, sub-
stance use disorders, and psychotic disorders. The research
base is now well established for PTSD and depression, where-
as less research is available for other diagnoses [49]. This
section covers the most recent telepsychiatry studies from
2011 through 2015.
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Post-traumatic Stress Disorder
There is robust literature for telepsychiatry applications in
PTSD, given the high prevalence of this diagnosis in veteran
populations where much of the research on telepsychiatry has
occurred. Recent published telepsychiatry research has dem-
onstrated its effectiveness in PTSD in American Indian vet-
erans and Pacific Islander populations, as well as it being a medium for exposure therapy, group psychotherapy, and cog-
nitive processing therapy. The Telemedicine Outreach for
PTSD randomized clinical trial involved 11 VA community
outpatient clinics and showed significantly larger decreases in
Posttraumatic Diagnostic Scale scores in PTSD patients who
r e c e i v e d t e l e m e n t a l h e a l t h s e r v i c e s — i n c l u d i n g
telepsychologists providing cognitive processing therapy and
telepsychiatrists providing medication management — com-
pared to usual care at 12 months [50]. The authors suggested
that this was likely due to the increased engagement of remote
rural patients.
Researchers at the University of Colorado in Denver havelaunched projects to serve the American Indian population,
creating new models of care. The PTSD treatment model for
American Indian Veteran Telemental Health Clinics involves
a spectrum of PTSD services, from community engagement
with tribal/telehealth outreach workers, Tribal Veterans Rep-
resentatives, education, and outreach; patient education and
system navigation; family education and support; skills build-
ing, including cognitive behavioral therapy (CBT) for PTSD
and coping skills; insight-oriented psychotherapies; and dy-
namic and process-oriented therapies with cognitive process-
ing therapy and group sessions [51].
A particular type of trauma-focused psychotherapy, cogni-
tive processing therapy-cognitive only (CPT-C, which ex-
cludes the written trauma narrative), has also been delivered
in a rural Hawaiian area sample of 61 ethnically diverse vet-
erans with PTSD through video-based telepsychiatry. The
study found that video encounters provided a reduction in
PTSD symptoms — similar to the 64-person control group that
received face-to-face therapy — with high levels of therapeutic
alliance, treatment compliance, and satisfaction. The modality
did not negatively impact therapeutic process measures
[52 – 54]. In this parent study, different cohorts in two different
treatment conditions took anger management group CBT ei-
th e r with v id e o o r with in -p e rs o n c a re ; th e g ro u p
telepsychotherapy condition was shown to have significantly
lower total costs for providing this care to veterans who could
not normally be able to access such treatments, due to costly
air transport between the Hawaiian islands [55].
Exposure therapy has also been delivered in a non-
randomized controlled trial to veterans and found to reduce
PTSD, anxiety, depression, stress, and general impairment
symptoms, though the lack of randomization precludes
b e t w e e n - g r o up e ffe c t c o n c lu s i o ns [5 6 ] . O v e r a l l ,
telepsychiatry has increased the engagement of veterans with
PTSD in care, has especially benefited rural PTSD patients,
and generally has led to reduced symptoms and increased
access, compared with usual care.
Depression
Telepsychiatry has long been shown to benefit patients withdepression [12••], with a number of studies showing greater
symptom improvement in the telemental health group com-
pared with the in-person groups. A recent 2015 study showed
that patients taking antidepressants reported fewer
antidepressant-related side effects in a high-intensity telemed-
icine-based collaborative care model, compared with low-
intensity practice-based collaborative care [57]. A 2012 study
of 167 patients in a community clinic demonstrated that pa-
tients had improved access to depression-specific care using
telepsychiatry [58].
Telepsychiatry can also augment collaborative care models
when these are used for depression treatment. A 2013 non- blinded randomized comparative effectiveness trial in a Fed-
erally Qualified Health Center compared two groups of pa-
tients who, on average, had moderately severe depression.
The control group received the standard model of care at
the time: in-person nurse care manager depression treatment.
The intervention group used telepsychiatry, with access to an
off-site nurse care manager, pharmacist, psychologist, and
psychiatrist available by videoconferencing. Both groups
had access to an on-site primary care provider. The interven-
tion group showed greater reductions in depression symptom
severity over time [59] despite patient attendance, engage-
ment, and utilization of telepsychotherapy being relatively
low. The authors surmised that the main difference between
the groups was that the fidelity of nurse care manager-
delivered depression treatment was better by telemedicine
than in-person, and it was thought that the low use of psy-
chotherapy was due to the traditional referral process used in
the intervention group [60].
One caveat about the use of telepsychiatry for depression
relates to cost. The VA collaborative care project showed in-
creased costs in the short term due to an intended increase in
depression-related encounters [61]. However, most other re-
search studies have shown that telepsychiatry can realize long-
term cost savings [12••, 27, 33, 55].
Child and Adolescent Populations
Not surprisingly, children, brought up in the era of the Internet
and mobile videoconferencing, find telepsychiatry to be a
fairly natural way to meet with a physician. A 2014 review
of e-health solutions for youth, including telepsychiatry, de-
scribed numerous case studies with successful outcomes that
used telepsychiatry. The authors also noted the high
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concordance of child psychiatrist diagnoses and treatment rec-
ommendations between videoconferencing and face-to-face
modes [62].
A recent randomized controlled trial used a hybrid ap-
proach to care for children with ADHD living in underserved
communities. The trial combined synchronous, asynchronous,
and in-person modes of interaction, as well as web-based ed-
ucational approaches and the involvement of teachers, par-ents, and primary care physicians, all supported by an elec-
tronically enabled treatment team from the University of
Washington. The results in 224 children were significant with
improvement in both inattention and hyperactivity symptoms
[63 – 66]. This novel telepsychiatry service model of hybrid
collaborative mental health services using multiple technolo-
gies has already been described as not only being a new way
to practice but also demonstrating a new standard of practice
that is potentially significantly better than the traditional in-
person gold standard level of care [62].
Current Cultural Telepsychiatry Research
Telepsychiatry has the potential to bridge ethnic disparities in
mental health, providing care for underserved ethnic or demo-
graphic groups and bridging language gaps. Research from
2011 through 2015 has addressed primarily American Indian,
Hispanic, and Asian populations. No known studies within
this time frame have been performed with a focus on African
American populations, or specifically on women, where there
are in particularly substantial needs in veteran groups as a
consequence of sexual trauma.
American Indian Populations
Telepsychiatry has been extensively studied in American In-
d ia n p o p u la tio n s . T h e o v e ra ll p ro c e s s o f a d a p tin g
telepsychiatry for American Indian cultures has been de-
scribed as part of the cultural adaptation model for remote
monitoring. This process includes gathering information;
adapting processes; testing; and gathering feedback and data,
such as satisfaction interviews, adherence data, patient re-
sponse patterns, adverse events, and outcome data [67].
In a descriptive, retrospective chart review of 85 patients
with 1631 telemental health clinic visits, Shore et al. found a
high rate of comorbid general medical conditions and mental
disorders, as well as significant increases in prescriptions of
psychotropic medications across drug classes [68]. Supporting
this population with culturally appropriate care is critical, with
on-site tribal outreach workers, collaboration with community
services, and providers knowledgeable of tribe customs. A
pilot clinic, initially established by the University of Colorado
Denver ’s Centers for American Indian and Alaska, has since
expanded to serve tribes in Idaho, Montana, South Dakota,
and Wyoming [51] as described in a decade-long series of
more than 15 publications. What makes these programs par-
ticularly unique is the emphasis on a local facilitator — the
tribal/telehealth outreach worker — based with tribal organiza-
tions, which values tribal culture, including traditional healers,
and building trust and rapport with Tribal Veteran
Representatives.
An analysis of all 2008 VA outpatient encounters for Amer-ican Indian or Alaska Native patients found that they were
more likely to be from rural or Bhighly rural^ regions (with a
population density fewer than seven persons per square mile)
compared to non-Native veterans (49 versus 37 %). This pop-
ulation had higher-than-average levels of service-connected
disability (27 versus 17 %) [69].
Hispanic Populations
Telepsychiatry has also been researched in Hispanic popula-
tions, demonstrating acceptability but with varying results for
feasibility. One study of low-income un-acculturated Hispan-ic patients with depression incorporated culturally compatible
telepsychiatry components. The patients rated the program
high in satisfaction, but the program faced uncertain feasibil-
ity due to difficulties in scheduling around the patients’ job
demands and their inability to pay for services [70]. Another
study using consumer webcams and computers with 167
Hispanic patients showed improvement in depression symp-
toms and good satisfaction rates with monthly depression-
specific telepsychiatry encounters, held in a community
health center [58].
As a result of the difficulty some Hispanic field workers
had attending consultations, asynchronous telepsychiatry con-
sultations have been tested in this population, with both
Spanish- and English-speaking psychiatrists providing the
asynchronous consultations [71]. This innovative approach
has been shown to be feasible with broad diagnostic reliability
demonstrated across languages following translation [32].
These asynchronous, or store-and-forward, encounters that
are amenable to translation could potentially be used across
many ethnic groups and languages and may well be a model
for future telepsychiatry directions and innovations. [72].
Asian and Pacific Islander Populations
Studies in Asian populations have been limited despite the fact
that the Chinese American population tends to underutilize
psychiatric services due to high cultural stigma, even though
they have a high burden of depression [73]. In a pilot study,
Korean mental health patients in Georgia connected with a
culturally and linguistically competent psychiatrist based in
California, demonstrating high level of acceptance [74]. As
part of this study, a protocol for a collaborative care study
wa s p u b lis h e d in v o lv in g a n in it ia l a s s e s s me n t b y
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telepsychiatry; scheduled phone visits; and collaboration with
a primary care provider, psychiatrist, and case manager, all
geared towards depressed Chinese Americans in primary care.
PTSD treatment has been given to Pacific Islanders on the
Hawaiian islands, as previously described above [55].
Challenges and Barriers in Adopting Telepsychiatry
It is certainly the case that the Btipping point for telepsychiatry
in the USAhas passed and that telepsychiatry is, almost 60 years
after the first video consultations at the University of Nebraska,
finally becoming accepted as a part of routine mental healthcare.
Significant barriers still persist however. These concern the busi-
ness environment, personal and leadership reasons, and technol-
ogy and clinical workflow issues [75•].
Business Environment
The business environment, though improving, has not beenhistorically conducive towards telemedicine. Reimbursement
remains an issue with payers, such as the Centers for Medicare
and Medicaid Services, placing constraints on how telemedi-
cine services can be used. Inconsistent laws across states also
play a role, though as of May 2015, 27 states and the District of
Columbia had legislated B parity in the reimbursement of tele-
medicine services. Other states still do not reimburse telemed-
icine visits at the level of an in-person visit [76]. Licensure
requirements, prescription rules, and documentation require-
ments also vary by state [14••, 77]. The VA has legislation
supporting national licensing to their own facilities for all their
providers, and it is likely that this will be extended to the US
Department of Defense and possibly all federal programs soon,
but a national licensing process for all physicians practicing
telemedicine is still likely some years away. Summary analysis
reports of these constantly changing policies and legislative
activities are freely available online [78, 79]. Finally, there are
logistical and financial challenges for anyone setting up
telepsychiatry programs, such as telemedicine infrastructure
costs and high turnover rates for rural healthcare workers [80].
Personal Biases and Lack of Training
Attitudinal change is still a problem at both health system
leadership and provider levels. Most health system leaders in
the USA are still from a generation that has not fully adopted
technology and are wary of the sorts of changes that technol-
ogy can bring. Their gold standard is still the in-person con-
sultation, despite the massive changes in some medical disci-
plines — namely pathology, radiology, cardiology, and derma-
tology — enabled by information technologies. Many are un-
able to envision the sorts of changes that might occur in men-
tal health if technologies were adopted more aggressively.
Younger generations of leaders are mid-way through their
careers and are not yet able to influence traditionally conser-
vative health environments to change and to adopt innovations
like telepsychiatry more extensively.
At a provider level, personal reasons can prevent psychia-
trists from confidently handling a telepsychiatry encounter.
These include concern about establishing rapport, detecting
nonverbal cues like poor hygiene or alcohol use, and not hav-ing formal instruction in telepsychiatry [75•]. This is changing
and employers, such as the VA, provide more formal instruc-
tion and organizations, such as the American Telemedicine
Association, offer accreditation [81] and webinars. Many au-
thors have written training handbooks and book chapters on
the subject [14••], while a number of online courses [48, 82,
83] exist to train clinicians.
Clinical and Technology Issues
The clinical workflow and business case for telepsychiatry must
be in synchrony to ensure the right tools are being used for theright purposes. A follow-up survey of researchers who pub-
lished on telepsychiatry and telemental health projects from
2008 to 2014 found that telepsychiatry projects often
discontinued because of one of three reasons: lack of funding,
changing telepsychiatry needs, and a lack of long-term planning
[19]. Technical barriers included a lack of data interoperability,
inconsistent electronic medical record systems, and changes in
bandwidth demand [75•]. Some rural communities may also
lack videoconferencing equipment and network capacity [84].
Conclusion
The field of telepsychiatry is an exciting area within which to
work. Compared with the past, there is now a rapidly chang-
ing and much more hospitable legislative and business cli-
mate, a solid evidence base, and enthusiasm for the approach
from both psychiatrists and patients. Telemedicine, with
telepsychiatry at the forefront, will continue to be actively
promoted by patients and increasingly by younger generations
o f p rov ide rs a n d h e alth le ad e rs. At a p o lic y le v el,
telepsychiatry is increasingly being promoted by health in-
surers, given increasing efforts for telemedicine reimburse-
ment parity, a new telemedicine accreditation program for
telemedicine medical service companies from the American
Telemedicine Association [81], and telemedicine’s move be-
yond national borders [14••].
Eventually, there will be hybrid models of care that com-
bine both in-person and technology-driven care, the latter of
which can include e-mail, instant messaging, asynchronous
telemedicine, and more. We envision seeing telepsychiatry
taught routinely in medical schools, residency training, and
continuing medical education programs [66].
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Demand for mental health services will continue to be
higher than the supply of providers in the near future. There
is still a vast amount of untreated mental illness nationally and
internationally; thus, there is an urgent need for the expedient
integration of technology into innovative models of mental
healthcare [85]. More research into the most effective models
and ways of providing technology-enabled mental healthcare,
while making the best use of our expert mental health work-force to treat the largest number of patients, is sorely needed.
Compliance with Ethics Guidelines
Conflict of Interest Michelle Parish declares that she has no conflict of
interest.
Steven Chan’s work on translation technologies is supported by the
APA/SAMHSA Minority Fellowship Program and a UC Davis Behav-
ioral Center of Excellence grant. Steven Chan serves as an Associate
Editor for iMedicalApps.
Peter Yellowlees is a co-founder and Chair of the Board of the com-
mercial telepsychiatry company, HealthLinkNow.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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