•  Clinical Outcomes
•  Donald M. Hilty, M.D.

Telepsychiatry’s evidence base is substantial and outcomes have been measured in the following areas: feasibility, validity, reliability, satisfaction, costs, and clinical outcomes.

Pre-requisites for good outcomes include:

• Excellent clinicians
• Program fitness in terms of organization, function, leadership, and the “right” members/workforce. Clinical, technical, and administrative teamwork makes this possible
• Technology which allows good engagement, clarity, and is reliable; options for the clinician to have far end camera control also provides options

Outcome areas (rated from: extremely poor; somewhat acceptable; similar to in-person care; good; outstanding):

• Feasibility rating: outstanding. The TMH evidence-base related to feasibility is related to satisfaction and usability and there are now only rare technical issues (e.g., poor visual images, pixilation, “drops” of conversations, turn taking in discussion) – those were all due to low bandwidth.
• Validity rating: outstanding. The TMH evidence-base related to validity has largely focused on TMH in comparison to in-person. You can do everything as you do in person with only minor exceptions (e.g., smell alcohol on a patient, check for extrapyramidal side effects or tremor – need to train a nurse on the other end).
• Reliability rating: outstanding. Diagnoses have been made reliably, with good inter-rater reliability, for a wide range of psychiatric disorders in all ages of patients. TMH overcomes limitations in hearing, and appears to facilitate language and cultural matching by accessing others.
• Satisfaction rating: outstanding. It is extremely high among patients, psychiatrists and other professionals. This extends to all clinical services, populations, and contexts.
• Cost and cost-effectiveness rating: similar to good. Robust studies have not been completed, but descriptive studies clearly indicate savings in time, travel, and money to patients and providers
• Clinical measures rating: individually assessed below.
  • Interviewing, assessment, cognitive testing, and others: outstanding. Dozens of clinician scales have been shown as reliable and valid.
  • Disorders include depression, anxiety, psychosis (counters myth that patients would get paranoid), substance, cognitive/attentional/behavioral (assistance for those with mental retardation or dementia), personality/behavioral, and many others: outstanding.
  • Settings well studied include outpatient, primary care/medical: outstanding. Settings less well studied include emergency rooms, jails, inpatient units and schools: somewhat acceptable – similar to in-person care.

Interesting and preliminary findings:

• For children and adolescents on the autism spectrum, it may be preferable to in-person.
• For adults with disabling anxiety (e.g., panic or posttraumatic stress disorder; veterans), it is preferred (and often coupled with telephone and e-mail options)
• Preliminary studies in geriatric patients and across cultures are positive. Indeed, it may facilitate cultural, ethnic and language matching between patients and providers.
• The experience with therapies is trending very positively, with surprisingly few problems.
• Care models that have good evidence include direct care, consultation to primary care and collaborative care.

References

• Hilty DM, Ferrer DC, Parish MB, et al. The Effectiveness of telemental health: A 2013 review. Telemed J E Health 2013;(19):444-454.
• Shore JH, Mishkind MC, Bernard J, et al. A Lexicon of Assessment and Outcome Measures for Telemental Health. ATA, 2013, at (no longer working link) http://www.americantelemed.org/practice/standards/ata-standards-guidelines/a-lexicon-of-assessment-and-outcome-measurements-for-telemental-health#.UwF5Dv0_3-Y. Last accessed: 1 February 2014
• Nelson EL, Duncan AB, Lillis T. Special considerations for conducting psychotherapy via videoconferencing. In Telemental Health: Clinical, Technical and Administrative Foundations for Evidenced-based Practice. Eds. Myers K, Turvey CL, Elsevier, San Francisco, CA, pp. 295-314, 2013.