Primary Psychiatry. 2002;9(9): 24-28
Dr. Hyler is senior attending psychiatrist at St. Luke’s-Roosevelt Hospital Center, clinical professor of psychiatry in the Department of Psychiatry at Columbia University, and staff member of the New York State Psychiatric Institute, all in New York City.
Dr. Gangure is resident in psychiatry at St. Luke’s-Roosevelt Hospital Center and Chair of the Residents’ Committee of the American Psychiatric Association, New York County District Branch.
Acknowledgments: The authors report no financial, academic, or other support of this work.
What are the current technological advances in telepsychiatry and how can clinicians begin to use this new technology in their practice? This article begin with a historical overview and reviews the language of technology and communications used in telepsychiatry. The four state-of-the-art telepsychiatry systems are presented: budget personal computer low, medium, and high bandwith systems, and the satellite broad bandwidth system with signal encryption. The needs of special populations discussed include?mobile cameras for children, higher image resolution for geriatric populations, increased safety of technological devices in prisons, special camera positioning in psychoanalysis, and adjunctive add-ons for testing.
Transport of the mails, transport of the human voice, transport of flickering pictures—in this century, as in others, our highest accomplishments still have the single aim of bringing men together.
—Antoine de Saint-Exupery1
Did Sigmund Freud ever use the telephone in his clinical work with patients? Since the telephone was invented in 1876, it certainly would have been available for use by the upper middle class in Vienna by the early 20th century. This question was recently posed to Drs. Robert Glick and Otto Kernberg of the Columbia Psychoanalytic Institute in New York City, and their response was that they were not aware of any consistent writing on the issue. An Internet search conducted by the authors revealed a single excerpt2 in which Freud mentions the telephone:
I forbade a patient to speak on the telephone to his lady-love, with whom he himself was willing to break off all relations, as each conversation only renewed the struggling against it. He was to write her his final decision, although there were some difficulties in the way of delivering the letter to her. He visited me at one o’clock to tell me that he had found a way of avoiding these difficulties, and among other things he asked me whether he might refer to me in my professional capacity.
At two o’clock, while he was engaged in composing the letter of refusal, he interrupted himself suddenly and said to his mother, “Well, I have forgotten to ask the Professor whether I may use his name in the letter.” He hurried to the telephone, got the connection, and asked the question, “May I speak to the Professor after his dinner?” In answer he got an astonished, “Adolf, have you gone crazy?” The answering voice was the very voice which at my command he had listened to for the last time. He had simply “made a mistake,” and in place of the physician’ number had called up that of his beloved.
Fast forward to the early 21st century. New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professional and patient. At the beginning of the 21st century, there are no surprises in videoconferencing and the transmission of sound and vision through analogue or digital relays.3 This technology seems to have become an unremarkable component of the normal social experience, and its ubiquity has become almost unquestionable even though it is the harbinger of a “revolution” in communications on an epoch-making scale.4
The United Kingdom National Health Service has commented thus: “Opportunities in the field of telemedicine will be seized to remove distance from health care, to improve quality of that care, and to help deliver new and integrated services.”5 Conceivably, any channel of telecommunication can be used as an adjunctive support for psychiatric service. These include telephone, fax, mail, E-mail, recorded videotapes, the Internet, closed-circuit television systems, and interactive videoconferencing.
The purpose of this article is to review recent technological advances in telecommunications as applied to psychiatry. We begin with a historical overview, review the language of technology and communications used in telepsychiatry, present state-of-the-art telepsychiatry hardware and systems, discuss the special needs of certain populations, and finish with some prognostication about the future.
The year 1844 marks the invention of the electrical telegraph and coincidental founding of the American Psychiatric Association. (See Table 1 for a psychiatry and telecommunications timeline). The invention of the electrical telegraph made it possible to reliably separate doctor and patient in time and space for the purposes of particular kinds of communicative acts.6,7
The word telephone comes from the Greek roots tele (far) and phone (sound).8 On March 10, 1876, Alexander Graham Bell spoke the first words ever transmitted by telephone: “Mr. Watson, come here, I want you.” These words were actually a call for medical help; Bell had just overturned the wet battery powering his transmitter and spilled sulfuric acid on his clothes.8 Around the same time, Charcot began teaching at the Salpetriere in Paris.
By the mid-1950s television was becoming the focus of attention in living rooms across the world, and Dr. Cecil Wittson of the Nebraska Psychiatric Institute initiated the use of telecommunications in psychiatry.9,10 Via a 2-way closed-circuit television setup, he introduced both staff education and treatment sessions at a distance. Some 20 years later, the first experimental telepsychiatry session via satellite transmission took place from Salt Lake City.11
The term “telepsychiatry” first appeared in the professional literature in 1973 in an article by Dwyer,12 referring to “psychiatric consultation via interactive television.” A recent MEDLINE search (March 2002) by the authors revealed some 380 published studies from 1956–2002 related to telepsychiatry.
The Language of Telepsychiatry
For the purposes of this article we will use the term telepsychiatry rather than “videoconferencing,” “video teleconferencing,” or “teleconferencing” to refer to telepsychiatric equipment as well as the process. A typical telepsychiatry setup involves a “host” site that can connect to one or more “remote” locations. Each site generally has a capturing device that consists of a video camera and a microphone.
More expensive video cameras yield better quality pictures. Factors to consider include lens quality, whether the camera is fixed or can pan around a room, and whether the camera can zoom in and out. The clarity of the image and motion handling are primarily a function of the bandwidth and algorithm used to compress the image prior to transmission to the other site. At the receiving end, the viewing device consists of the monitor, speakers, and a computer powerful enough to process and, optionally, memorize the information received. The monitoring device might consist of the personal computer display in less expensive configurations, while a high-end television monitor is used in more expensive systems.
The channel of communication between sites is the coder-decoder (CODEC), which is the heart of the system. It transforms the analog signal (ie, the picture that is picked up by the video camera and the audio signals picked up by the microphone) to digital signals and compresses them for transmission to the remote site. At the receiving end (remote site) another CODEC transforms the digital signal back to analog, allowing it to be viewed on the video monitor with the audio coming through the speakers. At each end, the CODECs are generally managed by a computerized device similar to those found in most personal computers.
There are a variety of avenues for data transmission between sites. These include geosynchronous satellite transmission (capable of the largest presently available bandwidth), fiber optic lines (the largest bandwidth of terrestrial technologies), Integrated Services Digital Network (ISDN), and the Plain-Old Telephone System (POTS).
There are several compression algorithms responsible for the quality of the signal that is ultimately received. There are industry standards for video and sound compression and for internetwork compatibility with other teleconferencing systems. Bandwidth refers to the amount of data that can be transmitted electronically in a unit of time. POTS/analog lines operate at 56–64 kilobits per second (KBS), which is enough bandwidth to handle smooth voice communication only (motion and image distortions appear when video signals are transmitted in this low bandwidth). ISDN lines operating at 128 KBS are currently the most commonly used. Several years ago, the use of high bandwidth (T1-384 KBS, half of T1-768 KBS, as well as 1.54 megabits per second [MBS]) started to gain prominence, the thought behind it being that such high bandwidths were essential for adequate resolution to assure clinical accuracy. However, lately it has been observed that the quality of information transmission can be preserved in low bandwidth with an improvement in the compression algorithm. The emerging technologies of tomorrow include low-earth orbit satellites, digital wireless technology, cable television, and digital subscriber line.13
The equipment and transmission systems described above form the “hard” technology. Bloomfield and Vurdubakis14 have observed that “hard” technology is not the only kind in play in telepsychiatry. Equally important is the “soft” technology that is constituted by the body of knowledge and practice surrounding, structuring, framing, and enacting physician teleinteractions with their patients. This “soft” technology is formed around the intricately constructed set of interaction techniques and communication skills employed by clinicians as they try to assess or manage the patient in the medical interview.15 Although the “hard” technology is unquestionably important, it is not the most complex aspect of telemental health program management. Because the “hard” technologies involved in telehealth are now robust, the connection between patients and technology, not the technology itself, is usually the major management challenge.16
The framing and presenting of the patient and the practitioner in telemental health is of particular importance and is now referred to by many in the field as “telemedicine etiquette.” For instance, the lighting and sound properties of the teleconsulting room can make all the difference between an experience that the patient enjoys and wants to repeat, and one that is an instant aversion to therapy.16
Technical specifications of several commercially available videoconference systems in various price ranges are listed in Table 2. Price range is current as of mid-2002, and cost continues to decrease as quality increases. For those with serious interest in setting up a telepsychiatry system, it is recommended that they obtain price quotes from several vendors before deciding on a system.
One of the most frequent problems that occur when setting up a system concerns the coordination of the hardware with the line connections of the telecommunications companies, such as the local telephone and long-distance service providers. As there are no worldwide standards that insure “plug and play” compatibility, it is imperative that buyers obtain from vendors a guarantee of compatibility between the connected sites and other outside systems. Establishing connections to systems that are not directly compatible may be difficult and expensive, requiring the establishment of a temporary “bridge” connection between the two sites.
As with the hardware, the prices of communications lines are also tumbling. A rough estimate of a typical monthly fee is $120 for a 384 KBS connection, with additional fees of ~18 cents/minute.
Despite the technological triumph of this description, there are currently only a few telepsychiatry systems in play, most of which operate on a small scale. Telepsychiatry, the conduct of psychiatric practices mediated by telecommunications systems, offers the possibility of the routine separation of clinician and client in space, and possibly in time. In doing so, it undercuts a central convention of medical work: the involvement of both parties in a physical co-presence.3
Conventionally, clinician and patient encounter each other in a specified place that has a well-understood symbolic identity. Physical colocation and the sense that the clinician is “with” the patient have enormous cultural significance.17 Over the course of 2 millennia, the actual presence of the doctor has been regarded as necessary for the proper conduct of clinical work.18 Today, many debate on the greater importance of nonverbal interactions such as handshakes, olfaction, real visualization, and the ability to extend courtesies such as the use of a handkerchief rather than personal presence.19
A standard telepsychiatry setup as described in this article may be adequate for general practice. Special populations, however, require technological particularities. For example, mobile cameras in specially designed rooms for children,20 higher image resolution for application to geriatric populations,21 increased safety measures (eg, increased protection of technological devices) in prisons,22 and special positioning of the camera and monitor for use in psychoanalysis.23 Adjunctive add-ons might include writing tablets or white boards to facilitate testing of children or performing complete Mini-Mental State Examinations.
Rapid technological “advances” in the medical field seem to be consistently met with contradictory impulses. On one hand, there are demands and expectations for even more effective medical treatments and interventions, while on the other there is growing mistrust of the complex of professional and commercial interests that underpins treatment, and of the potential iatrogenic form that clinical practices might take.24,25 As with any technology, telepsychiatry users should anticipate having to deal with equipment failure. It is essential that there be adequate personnel at the remote site in case of an equipment failure and/or clinical emergency.
A concern in the use of telepsychiatry is the level of signal delay, as even the most expensive systems do not always function perfectly. Manning and colleagues26 conducted a study of signal delay effect (0 ms, 300 ms, and 1,000 ms) on the rapport between patient and clinician compared with in-person sessions (N=48). The level of client-perceived rapport was measured using a self-report instrument that was administered following the session. The results did not provide evidence of an effect on rapport from the delay.
It is difficult to predict whether a limited number of dominant formats will be available for telepsychiatry or whether multiple technologies will be used in combination. Due to continuous technological advances in the telecommunications field, which in turn generate a dynamic of costs both domestically and globally, it is uncertain what the prevailing mode of telepsychiatry technology will be.27 A clinic of the future might have a wing with several telepsychiatry offices used to connect with providers at distance. Once the technology reaches the average patient’s home, one could receive routine telepsychiatry follow-ups, with the recommendation to make periodic in-person psychiatric check-ups—an equivalent to the periodic physical examination.
Commercially run teleconference sites currently charge ~$200/hour per site to provide video teleconference services, mainly to large corporations. These sites could see an increased demand for their services by providing patient access to the psychiatrist. Instead of traveling great distances to a psychiatrist’s office, the patient would go to a centrally located videoconference service center and connect with a psychiatrist who could be located in a city several hundreds miles away. Rigorous assessment of telepsychiatry technology has only recently begun. Key questions that remain to be answered include: Given current technology, in which situations is telepsychiatry cost-effective? What is an appropriate control condition against which to assess clinical and cost outcome data when in-person psychiatry is not available in a geographic area? Which patients will benefit from telepsychiatry in properly controlled, randomized trials?28 What is missing and what is added by using telepsychiatry? Or, as Malagodi and colleagues13 ask, “Will telepsychiatry be a passing fad or the wave of the future?”
New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professionals and their patients. Conceivably, any channel of telecommunication can be used as an adjunctive support for psychiatric service. These include telephone, fax, mail, E-mail, recorded videotapes, the Internet, closed-circuit television systems, and interactive videoconferencing.
A typical telepsychiatry setup involves a “host” site that can connect to one or more “remote” locations. Each site generally has a capturing device that consists of a videocamera and a microphone. At the receiving end, the viewing device consists of the monitor, speakers, and a computer powerful enough to process and, optionally, memorize the information received. Because the “hard” technologies involved in telehealth are now robust, the major management challenge is not the technology itself but how we can connect people with that technology. Furthermore, rapid technological “advances” in the medical field seem to be consistently met with contradictory impulses. On one hand, there are demands and expectations for even more effective medical treatments and interventions, while on the other there is growing mistrust of the complex of professional and commercial interests that underpins treatment, and of the potential iatrogenic form that clinical practices might take.
Telepsychiatry removes the very presence of another human being, and with it disappears an entire range of levels of interpersonal interactions, including pherohormonal and olfaction senses, symbolic gestures like shaking hands or offering a tissue, unconscious fantasies of physically interacting with the psychiatrist in the very space of the office, and the mystical belief that a human presence can induce feelings and states that no technology could replace.
Telepsychiatry offers assistance to people who would not visit an in-person psychiatrist, a reduction of environmental stimuli that may facilitate an even greater introspection in the inside world of a patient, a chance to have a consultation with the most skilled psychiatrists available in major university centers, potential cost savings, and convenience. Is applying telecommunication technologies to psychiatry a greater benefit or a greater risk? Future research is needed to scientifically answer that question. PP
1. de Saint-Exupery A. Wind, Sand, and Stars. New York, NY: Harcourt Brace Jovanovich; 1968:69.
2. Freud S. Psychopathology of Everyday Life. The Complete Psychological Works of Sigmund Freud. Vol 4. London, England: Hogard Press; 1969:222.
3. May C, Gask L, Atkinson T, Ellis N, Mair F, Esmail A. Resisting and promoting new technologies in clinical practice: the case of telepsychiatry. Soc Sci Med. 2001;52:1889-1901.
4. Robins K, Webster F. Times of the Technoculture: From the Information Society to the Virtual Life. London, England: Routledge; 1999.
5. National Health Service Executive. Information for Health: An Information Strategy for the Modern NHS,1998-2001. London, England: National Health Service Executive; 1998.
6. Reiser SJ. Medicine and the Reign of Technology. Cambridge, England: Cambridge University Press; 1978.
7. Yoxen E. Seeing with sound: a study of the development of medical images. In: Bijker WE, Hughes T, Pinch T, eds. The Social Construction of Technological Systems. Cambridge, Mass: MIT Press; 1987:281-306.
8. Grumet GW. Telephone therapy: a review and case report. Am J Orthopsychiatry. 1979;49:574-584.
9. Wittson CL, Dutton R. A new tool in psychiatric education. Ment Hosp. 1956;7:11-14.
10. Wittson CL, Affleck DC, Johnson V. Two-way television in group therapy. Ment Hosp. 1961;2:22-23.
11. Giannetti RA, Johnson JH, Williams TA. Using satellite transmission for computerized assessments of patients in remote facilities. Hosp Community Psychiatry. 1977;28:427.
12. Dwyer TF. Telepsychiatry: psychiatric consultation by interactive television. Am J Psychiatry. 1973;130:865-869.
13. Malagodi M, Smith S. Prospective role for telemedicine as a communication tool for rural rehabilitation practice. Work. 1999;12:245-259.
14. Bloomfield B, Vurdubakis T. Boundary disputes: negotiating the boundary between the technical and the social in the development of IT systems. Information Technology and People. 1994;7:9-24.
15. Goldberg D, Benjamin S, Creed F. Psychiatry in Medical Practice. 2nd ed. London, England: Routledge; 1994.
16. Darkins A. Program management of telemental health care services. J Geriatr Psychiatry Neurol. 2001;14:80-87.
17. Good BJ. Medicine, Rationality and Experience. Cambridge, England: Cambridge University Press; 1994.
18. Hunter KM. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press; 1991.
19. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Evaluation of a routine telepsychiatry service. J Telemed Telecare. 2001;7:90-98.
20. Ermer D. Experience with a rural telepsychiatry clinic for children and adolescents. Psychiatr Serv. 1999;50:260-261.
21. Jones BN 3rd, Ruskin PE. Telemedicine and geriatric psychiatry: directions for future research and policy. J Geriatr Psychiatry Neurol. 2001;14:59-62.
22 Zaylor C, Whitten P, Kingsley C. Telemedicine services to a county jail. J Telemed Telecare. 2000;6(suppl 1):93-95.
23. Kaplan EH. Telepsychotherapy. Psychotherapy by telephone, videotelephone, and computer videoconferencing. J Psychother Pract Res. 1997;6:227-237.
24. Lupton D. Medicine as Culture. London, England: Sage; 1994.
25. Lupton D. Foucault and the medicalization critique. In: Petersen A, Bunton R, eds. Foucault, Health and Medicine. London, England: Routledge; 1997:94-112.
26. Manning TR, Goetz ET, Street RL. Signal delay effects on rapport in telepsychiatry. Cyberpsychol Behav. 2000;3:119-127.
27. Frueh BC, Deitsch SE, Santos AB, et al. Procedural and methodological issues in telepsychiatry research and program development. Psychiatr Serv. 2000;51:1522-1527.
28. Baer L, Elford DR, Cukor P. Telepsychiatry at forty: what have we learned? Harv Rev Psychiatry. 1997;5:7-17.