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When Hind Benjelloun, a District of Columbia-based crisis psychiatrist with InSight Telepsychiatry, works an overnight shift, there's never a dull moment. Even when the emergency room empties out, Benjelloun still has patients waiting for her on her computer screen. Whether they're from the inner city or rural Virginia, they have to be seen remotely, and advances in technology have made it possible for them to get the help they need at all hours of the day.
Like telemedicine, telepsychiatry relies on technology to bring clinical medicine to patients, rather than the other way around. Patients typically videoconference with doctors using computers or videoconferencing equipment. Telepsychiatric services are growing, and the advantage is that such technology opens access to care, particularly for those in remote areas where there are fewer psychiatrists.
The disadvantage, Benjelloun says, is that the human touch is missing. "A caring touch or handing a patient a tissue can never be possible," she says, adding that this can also lead to missed cues on her part. "I am unable to clearly see self-inflicted wounds or tears."
But many experts agree that despite the challenges of delivering care remotely, the advantages of telepsychiatry far outweigh the disadvantages.
In South Carolina, a steady decline of hospital beds for psychiatric patients in the 1980s and 90s due to downsizing at hospitals led to waiting lists in the early 2000s, says Mark Binkley, general counsel at the South Carolina Department of Mental Health.
This hit the community hospitals particularly hard. "When somebody needs a hospital bed, they usually wind up in a hospital emergency room," Binkley says. And if you don't have a psychiatrist on staff, he adds, "the tendency for the small ER was to hold onto the patient." This led to prolonged hospital stays, which became a drain on already strapped hospital budgets.
In 2006, the state's new health director, John McGill, proposed a solution: technology. With funding from The Duke Endowment, one of the nation's largest private foundations, he was able to "deploy" psychiatrists to people living in underserved, rural areas via the Internet. This enabled psychiatrists, many of whom were (and still are) clustered in the state's capital, Charleston, to consult with patients in real-time, irrespective of location, Binkley adds.
The results of this pilot study have been promising. Since the program started in March of 2009, there have been 21,900 total consultations, an average of about 400 per month. While only available to those admitted to emergency departments, patients at participating hospitals have experienced shorter stays, yielding $1,400 in savings per episode of care, Binkley says. Furthermore, patients who came through the program are 200 percent more likely to show up for aftercare, he adds.
Although telepsychiatry has developed on the heels of telemedicine, which uses technology to do things such as take patients' vital signs and send the results remotely, studies have shown that telepsychiatry might actually benefit psychiatric patients more. That's because their propensity to use the ER may be greater, Binkley says, so helping them avoid that visit through remote care is particularly advantageous.
Also, psychiatric patients may be more willing to open up from the comfort of their home. "Very rarely do patients have a problem talking to a psychiatrist on a big video screen," Binkley says.
Jim Varrell, a New Jersey-based psychiatrist and medical director of Insight Telepsychiatry, which provides telepsychiatry services to clinics and private users of telepsychiatry services, adds that patients with behavioral problems are more often compliant with remote consultations. "They do better in response to this service, as opposed to being in a room with one to two adults who are pointing out what's wrong with them," Varrell says. "They open up more through this medium."
The profile of patients using telepsychiatry is wide-ranging and includes everyone from children to geriatric patients; English to foreign-language speakers; and people experiencing mild depression to those in the midst of a psychotic episode. "Ultimately people are absolutely able to do it," Varrell says. "We haven't had any group unable to do it."
Sound quality can be more important than picture quality, he adds, especially in older patients with hearing problems. And while the major disadvantage of remote services is the absence of personal contact, which limits a psychiatrist's ability to use all senses when evaluating the patient, the equipment (a computer and video camera) has a number of features that can help offset that limitation. For example, it can allow the camera to zoom in on the face to visualize the dilation of eyeballs and any tics, Binkley says. There are extensive security protocols for protecting patient privacy as well, Varrell adds.
While South Carolina is a leader in the nation's adoption of telepsychiatry, thousands of programs have been launched in all 50 states, says Geoffrey Boyce, executive director of InSight Telepsychiatry. More than 1 million consultations are estimated to occur in the United States this year, he adds – many of which will be in underserved populations that extend beyond just rural pockets. "When you're talking about the weekends and after hours, that's where it can make a lot of sense in the urban areas," he says.
"In a more rural area, nobody has access [to psychiatric care]," he says. Telepsychiatry is "enormously more affordable at that point," Boyce says, since people who otherwise might have had to take a whole day off work to travel to see a doctor can now be seen in the comfort of their community hospital or home.
So far, California, Texas and Colorado have been the biggest adopters of telepsychiatry, apart from South Carolina. Regulatory and insurance reimbursement issues have held other states back from wide adoption of these services, Boyce says.
Many psychiatrists have begun to embrace the concept of serving patients remotely, Varrell says.
Several, like Benjelloun, find it gratifying to reach patients who were once out of reach. "[Telepsychiatry] allows for patients to be examined by a psychiatrist within an hour, as opposed to waiting for days in an emergency room," she says.