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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

steven@berkeley.edu

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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