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To the Editor: In response to a review of research on telepsychiatry (1), Werner (2) focused on a number of important issues in the development and implementation of telepsychiatry for delivery of care. He emphasized the cost of an organizational structure and the need for high utilization to justify a telepsychiatry system. Given his impression that high-bandwidth interactive telepsychiatry is not economically feasible, he suggested alternative approaches to interactive telepsychiatry. These alternatives included the provision of services by nurses, psychiatric physician assistants, and trained primary care physicians, followed by a telephone call to a psychiatrist and the review of videotaped structured interviews by a psychiatrist, followed by a telephone call to the treating clinician. However, Werner rightly concluded that maybe the most difficult questions are related to "the quality of human interaction and the importance of personal contact with a caregiver."
I have been involved with a telepsychiatry project between the department of psychiatry at the University of Michigan and Hiawatha Community Mental Health in the Upper Peninsula of Michigan. The purpose of the project was to determine the feasibility of adolescent telepsychiatry. After some clinical experience with high-bandwidth (384 kB) interactive telepsychiatry for evaluation and treatment I think it worthy of further development, but I question whether the use of other professionals or videotapes augmented by telephone contact with a psychiatrist would suffice in providing adequate care to children and adolescents with serious psychiatric disorders. These patients have constituted some of the most difficult and unstable cases in the local mental health system because of two factors—numerous comorbid conditions, some of which had not been previously identified, and the use of multiple medications. The management of such complex cases is difficult even in face-to-face encounters. The care of these patients involved case management, reviews of cases with parents, provision of services by support system personnel, and, ultimately, seeing a patient face-to-face.
Without question, other health professionals could not have delivered the same quality of care, because they are not trained to identify important clinical phenomena and to ask specific questions when these phenomena need clarification. The use of videotaped structured interviews also would not have resulted in the same high-quality care, because it does not allow a clinician to pursue clinical areas that need clarification within the time frame of the direct contact. The detection of some clinical phenomena requires more than simply hearing a voice over the telephone. Only during eye-to-eye, face-to-face contact can a clinician discern certain diagnoses and explore the subtleties of various diagnoses and the response of these conditions to multiple medications. High-bandwidth interactive telepsychiatry allows clinicians to have such an experience with patients.
Telepsychiatry is an area that needs further investigation and clarification. It is easy to rush into the use of a new technology without a thorough investigation of important factors. It is just as easy to dismiss the value of a new technology. Nevertheless, unless systems of high-bandwidth interactive telepsychiatry are developed, some patients will never receive adequate care under any circumstances. Their conditions will go unrecognized or, worse, the patients will receive poor-quality psychiatric care under the name of adequate care. From my perspective, the development of high-bandwidth interactive telepsychiatry is a viable alternative.
Dr. Alessi is affiliated with the psychiatric informatics program in the department of psychiatry at the University of Michigan in Ann Arbor.
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