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Telepsychiatry': Keeping a Link with an Island

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Telepsychiatry': Keeping a Link with an Island BRIEFINGS 'Telepsychiatry': keeping a link with an island L Mannion, T.J. Fahy, C. Duffy, M, Broderick and E. Gethins quality. We report on the pilot phase of a video conferencing link between a psychiatric depart ment and an island located within its catchment area. The study The three Aran Islands, Inishmore, Inisheer, and Inishmean, located off the west coast of Ireland, are included as part of a sector area of the West Galway Psychiatric Service. The population of these islands have been greatly affected by emigration. We have estimated that there are 53 psychiatric patients permanently resident on the three islands. The majority of this group suffer from major psychiatric disorders requiring continual monitoring. The population of the Figure 1. Aran Islands. islands increases enormously during the sum mer months due to the influx of tourists. Medical care is provided by one general practitioner (GP). with a public health nurse resident on each Telemedicine' has been defined as the delivery of island. Psychiatric care is provided by periodic health care where the patient and health profes visits by the community services team of the sional are at different locations (McLaren & Ball, West Galway service. An out-patient clinic is held 1995), and in recent years has come to be on the main island, Inishmore, every two months regarded as the use of telecommunications and every three to four months on the smaller technology for medical applications. Telepsy- islands. A community psychiatric nurse (CPN) chiatry' is the branch of 'telemedicine' that visits Inishmore every month and each of the focuses on mental health applications. Video other islands on alternate months. Because of conferencing systems, as described by Kavanagh the shortage of medical and nursing staff, &Yellowlees(1995), provide effectivelyreal-time, psychiatric emergencies on the islands can be interactive audio and visual communication difficult to contain, and often necessitate im through ISDN (Integrated Services Digital Net mediate admission, unlike emergencies on the work) telephone lines. With personal computer- mainland that can often be managed without based video-conferencing units the requirements resort to admission. If patients need to be include a camera to capture the video image, a reviewed urgently by the psychiatric services microphone to capture the sound, a television they must travel by sea or air to the mainland. monitor to see and hear what is happening at This can often result in hospital admission each end, a coder and decoder to compress and because of the difficulties and uncertainties of decompress the data, and ISDN lines at both return transport. Admission rates from the ends of the link. The quality of the received image island are thus high in comparison to other is a function of the bandwidth of ISDNlines, with similar sector areas. the quality of the image improving as the number The concept of an audiovisual link between the of ISDN lines increases. However, the cost of Aran Islands and University College Hospital transmission also increases with broadening of Galway was proposed following discussions bandwidth; thus the consequence of this qual between the GP Unit of the Western Health ity/cost relationship is that a balance needs to be Board and the Department of Psychiatry at the met between sustainable cost and required University College Hospital, Galway (UCHG).We Psychiatric Bulletin (1998), 22, 47-49 47 BRIEFINGS sourced the equipment required, and set up a who gave a history of significant depressive one-day link between the GP's surgery and the symptoms post-partum. She was originally from mainland, as a feasibility exercise. Participants the mainland and felt quite isolated living on the in this initial link included psychiatrists, nursing island. She had a past history of untreated staff, management and technical staff, and the depression following the birth of her second island GP. Four patients agreed to be interviewed child. She was diagnosed as having a post- via the link. Following this it was agreed that a partum depressive episode and was commenced link could be potentially beneficial to the service on paroxetine. She was reviewed twice via and thus the audiovisual link between Inishmore videolink over the next month and showed and the Department of Psychiatry in UCHG was significant improvement each time. She did not established, as a pilot project. The system used want to attend the out-patient clinic on the is a six-line ISDN network linked with a island, and so attended for subsequent review computer-based video-conferencing system. at the hospital clinic. At that stage her symptoms Each link-up costs nine times the price of an had resolved completely and she was discharged ordinary telephone call for an equivalent length to the care of her GP. of time. Minimal training is required to operate Another patient, a single 26-year-old woman, the unit, which consists of a Window-based was referred for emergency assessment as a new system with a remote control camera. The patient. She had presented to her GP with a six camera can be controlled by the user to produce months' history of depressed mood. At interview a full length image of the patient or focused to she admitted having a death-wish and described allow for 'face-to-face' interaction. The quality of fleeting suicidal ideation. At videolink assess audio and visual reception has been good. ment she was diagnosed as having a depressive The link has been used by the sector psychia illness. She did not wish to be admitted to trists, social worker, psychologist and commu hospital. She was reviewed via the link three nity nurse. The link has mainly been used to days later and subsequently on two other facilitate emergency consultations between pa occasions. She was then seen at the island out tients on the island and the duty psychiatrist, patient clinic, and following further improvement always at the request of the island GP. If the GP was discharged to GP care. Further information requires a psychiatric opinion on a patient, she as to the patients seen is shown in Table 1. None telephones the duty doctor at the hospital, who of the patients referred was admitted to hospital arranges to set up the link at a time convenient following video assessment. It is feasible to say for both parties. The practice nurse explains the that in-patient admission was avoided for at least procedure to the patient and places them in front three patients. The issue of certification or of the television monitor and camera. The patient sectioning to hospital did not arise in any case. is interviewed on their own. but if they wish they Each session lasted an average of 30-45 min can have a family member or a nurse present. utes. When initiation or adjustment of medica Nine patients were referred for assessment in tion was required this was communicated to the this manner over a period of eight months. Three patient and followed up by a phone call to the GP. patients had their first psychiatric contact and The majority of the patients interviewed so far assessment through videolink, and were followed have had a diagnosis of depressive illness. up as out-patients via the link to eventual Diagnostic stability has been maintained at later resolution of the episode of illness and discharge face-to-face clinic interview. The link was used at out-patients clinic. on one occasion to obtain collateral history from One woman was referred as a first assessment an in-patient's relatives, where an elderly woman three weeks after the birth of her third child by and her son were interviewed by a psychiatrist cesarean section. She was a 34-year-old woman and a social worker. An arrangement is in place Table 1. Patients referred for assessment Gender Age Diagnosis No. of sessions Reason for referral FFFFFFFFM342640286730435446Postnatal dépressionDepressive death-wishFirstreferral, episodeDepressive depressedFirstreferral, illnessDepressive depressedRelapsereferral, illnessPanic illnessAnxietyof disorderDepressive symptomsDepressedRoutine illnessBipolar disorderSchizophreniaSchizophrenia343131111Firstaffective reviewRoutine reviewRoutine review 48 Mannion et al BRIEFINGS whereby the CPN, following domiciliary visits, one island alone means that the link is not cost can contact the psychiatric unit to set up a link, effective if reserved for the use of psychiatry if he deems this necessary. Though the number alone. This has been a pilot project, with the of patients involved has been small, the link has psychiatric services being the first speciality worked well and proved both acceptable and locally to investigate the possible uses of a accessible to the patients concerned. All patients video-conferencing link. Specialists in plastic and staff who have used the link were questioned surgery and dermatology have expressed interest directly as to their response to the link. One in using the link and arrangements are being woman was seen initially by a doctor and made to include these departments and hope subsequently on two occasions by a psychol fully others in the clinical service. ogist. She expressed reservations about discuss Our experience has been that video-confer ing personal issues on the videolink. In general, encing systems are acceptable and satisfactory patients involved have been comfortable with the for patients and staff alike. While our video technology, and it has not proved a barrier to conferencing link has had its limitations, we establishment of rapport. All health profes believe that further research into this area of sionals who have used the link have found it 'telecare' would prove useful in psychiatry. satisfactory. We are investigating the possibility of the addition of software that would allow us to transmit documents, including prescriptions References and clinical notes. KAVANAGH.S.L. & YELLOWLEES,P.M. (1995) Telemediclne - clinical applications in mental health.
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