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The Use of Videoconferencing with Patients with Psychosis: a Review of the Literature Ian R Sharp1*, Kenneth a Kobak1,2 and Douglas a Osman1

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The Use of Videoconferencing with Patients with Psychosis: a Review of the Literature Ian R Sharp1*, Kenneth a Kobak1,2 and Douglas a Osman1 Sharp et al. Annals of General Psychiatry 2011, 10:14 http://www.annals-general-psychiatry.com/content/10/1/14 REVIEW Open Access The use of videoconferencing with patients with psychosis: a review of the literature Ian R Sharp1*, Kenneth A Kobak1,2 and Douglas A Osman1 Abstract Videoconferencing has become an increasingly viable tool in psychiatry, with a growing body of literature on its use with a range of patient populations. A number of factors make it particularly well suited for patients with psychosis. For example, patients living in remote or underserved areas can be seen by a specialist without need for travel. However, the hallmark symptoms of psychotic disorders might lead one to question the feasibility of videoconferencing with these patients. For example, does videoconferencing exacerbate delusions, such as paranoia or delusions of reference? Are acutely psychotic patients willing to be interviewed remotely by videoconferencing? To address these and other issues, we conducted an extensive review of Medline, PsychINFO, and the Telemedicine Information Exchange databases for literature on videoconferencing and psychosis. Findings generally indicated that assessment and treatment via videoconferencing is equivalent to in person and is tolerated and well accepted. There is little evidence that patients with psychosis have difficulty with videoconferencing or experience any exacerbation of symptoms; in fact, there is some evidence to suggest that the distance afforded can be a positive factor. The results of two large clinical trials support the reliability and effectiveness of centralized remote assessment of patients with schizophrenia. Introduction Several factors make the assessment and treatment of Technological advances in recent years have made psychosis particularly well suited for VC. For one, as psy- remote psychiatric assessment and treatment signifi- chotic patients are often hospitalized, VC allows patients cantly more feasible. In particular, the increased avail- to be connected with specialists without need for travel. ability and affordability of high-speed connections have Assessment and treatment using VC is also a potential made the use of videoconferencing (VC) a viable tool solution for patients with psychosis living in remote or for interacting with patients remotely. There is a grow- underserved areas where there is a shortage of specialists. ing body of literature on telemedicine and the subfield As a tool in clinical research, VC makes it possible to use of telepsychiatry. The initial thrust to develop these centralized remote expert raters who are able to remain fields was prompted by attempts to meet demands for blind to study design and conditions, therefore decreas- mental health services with underserved and difficult-to- ing rater bias and improving inter-rater reliability and serve populations (for example, rural areas, prisons). For interview quality [1]. instance, extensive telepsychiatry networks in rural Aus- The hallmark symptoms of psychotic disorders might tralia and Canada were created to improve access to lead one to question the feasibility of using VC with this mental health services. More recently, other VC applica- patient population. For example, are acutely psychotic tions such as the training of mental health professionals patients generally willing to be interviewed remotely by and centralized ratings in clinical trials have grown out videoconference? Does videoconferencing exacerbate of this rapidly expanding field. As telepsychiatry evolves, delusions, such as delusions of reference? Are scores on a broader range of patient populations can be served symptom severity rating scales and diagnoses obtained through this medium. remotely by videoconference equivalent to ratings and diagnosis performed face to face, given the complex nat- ure of the disorder and the importance of non-verbal * Correspondence: [email protected] signs, such as negative symptoms? Is treatment con- 1MedAvante Research Institute, Hamilton, NJ, USA Full list of author information is available at the end of the article ducted remotely by videoconference as effective as © 2011 Sharp et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sharp et al. Annals of General Psychiatry 2011, 10:14 Page 2 of 11 http://www.annals-general-psychiatry.com/content/10/1/14 treatment conducted in person? Are evaluations con- Results ducted over VC sensitive enough to distinguish active Clinical interventions drug from placebo in clinical trials? The majority of articles written about the clinical utility In the present work we attempted to provide answers of VC with psychotic patients have been retrospective to these questions by conducting a thorough review of reports of programs that provided services to remote the literature. For the purposes of this review, video- areas. Dwyer [5] described a series of programs and gen- conferencing refers to an interactive video connection eral clinical uses of a closed circuit interactive television between two sites. This primarily includes two-way (IATV) system set up, a precursor to VC, between videoconferencing using monitors or computers con- Massachusetts General Hospital and a medical station in nected over telephone lines (for example, integrated Boston. Approximately 5% of all those seen on IATV had services digital network (ISDN)), public internet con- severe psychiatric disorders. The author admitted that he nections, or private networks, but may also include the ‘approached the use of television to interview psychiatric use of closed-circuit televisions, especially in older stu- patients with considerable negative prejudice, believing dies, for example, Dongier et al.[2].Animportant that the degree of personal contact with the patient variable in evaluating VC studies is bandwidth. In would be limited and that many of the skills that are use- videoconferencing, bandwidth refers to the speed of ful in a psychiatric interview would be diminished or lost. transmission of data between two points, typically I was delightfully surprised to discover that this was not expressed in kilobits per second (kbps). The studies true’. The author reported that approximately 30 psychia- reviewed had a range of bandwidths from narrow (for trists and an equal number of psychiatric residents and example, 33 kbps) to broad (for example, 384 kbps). medical students used the television system, and all As a rule of thumb, the higher the bandwidth, the bet- responded positively to their experiences. The author ter the quality of audio and video. The current VC suggested that, for some patients, communication with a industry standard bandwidth is 384 kbps. A second psychiatrist by means of IATV was ‘easier’ than contact important variable in understanding the quality of VC in the same room. It was suggested that this is especially is frame rate. Frame rate refers to the number of true of patients with schizophrenia. The author also frames presented on a monitor, typically expressed in reported that a number of patients with delusions were frames per second (fps). The higher the frame rate the interviewed and none incorporated the television into his better motion is presented in video. A speed of 30 fps or her distorted thinking. provides a continuous picture similar to television Graham [6] discussed a program designed exclusively quality and generally requires 384 kbps transmission for chronically mentally ill individuals. The project was [3]. As found in other reviews [4], this variable was called APPAL-LINK, the Southwestern Virginia Telepsy- frequently not reported. chiatry Project, and provided services by connecting hos- pital psychiatrists to patients at two rural community Methods mental health centers. The author reported that 39 We reviewed the Medline, PsychINFO, and the Teleme- patients with a wide variety of diagnoses were followed dicine Information Exchange databases for literature on through the initial 6 months of operation. The majority videoconferencing and psychosis. We used the following of these patients had a major psychotic illness such as key words: telemedicine, telepsychiatry, televideo, video- schizophrenia, bipolar disorder, or schizoaffective disor- conferencing, video conferencing, video and schizoph- ders. The author reported that the availability of telepsy- ren*, schizoaffective, psychotic, and psychosis. No date chiatry consultation for crisis intervention led to a restrictions were used. Articles relevant to the use of decrease in hospitalizations and no significant adverse videoconferencing with persons with psychosis were effects were reported. It was also noted that patients and included in this review. We also reviewed reference sec- psychiatrists adjusted well to the VC interaction and that tions for additional relevant articles. The literature the program provided evidence that VC is ‘a safe, effec- search was completed in September 2010. tive, and useful method for the outpatient treatment of We present our findings in the following categories: chronically mentally ill patients’. clinical interventions (7 articles); assessment (12 articles); In a report of a larger program involving the use of satisfaction and acceptance (12 articles); and clinical trials telemedicine, Zaylor [7] reviewed the
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