Evaluation of a Rural Telepsychiatry Service

Abstract

Objective: To evaluate a telepsychiatry clinical service to Wagga Wagga in rural New South Wales, comprising a face-to-face interview with a psychiatrist followed by a telepsychiatry interview with a Sydney-based psychiatrist.

Methods: Thirty-one patients were referred to a specialist mood disorder clinic in a rural setting for consultation and assessment. A retrospective evaluation was made to determine the acceptance of the teleconferenced psychiatry and face-to-face psychiatry, as well as the overall patient response.

Results: Twenty participants completed all evaluation components. Their results indicated a satisfaction level of 95% with the consultation process as a whole, with 80% happy to use telepsychiatry again and 60% preferring telepsychiatry over travelling to a larger centre for face-to-face consultation. The face-to-face component was satisfactory for 85% of patients while the telepsychiatry component was satisfactory for 72%.

Conclusions: Although face-to-face psychiatry was preferred by this sample, the telepsychiatry component was highly rated and preferred over travel to larger centres for face-to-face consultation, by residents of rural and remote locations. Certain issues are of more concern in telepsychiatry than face-to-face psychiatry, including confidentiality, rapport, explanation and education.

Keywords

evaluation mood disorders telemedicine telepsychiatry rural health

Mood disorders are of high prevalence and are significantly underserviced in Australia.[1] Regional rural and remote Australia is more underserviced than metropolitan Australia with, for example, 90% of psychiatrists in New South Wales (NSW) living within 20 km of the Sydney CBD.2–4 Thirty per cent of the population live in towns of less than 50 000 people.2–4 There are approximately 115 psychiatrists providing some kind of service to rural patients in NSW, less than 38 resident in rural NSW.[5] Health Insurance Commission data indicate that Medicare benefits paid to rural patients amount to $61.40 per person per year, whereas capital cities average $149.10 per person per year (Greenwood J: pers. comm., 2001). Five per cent of specialist consultations occur in the local area in rural NSW, as compared to 65% in metropolitan areas.[6]

Suicide figures are significant. The overall rate in Australia was 14 per 100 000 in 1998; this is the average of the male and female rates.[7] The female rate was lower at 5 per 100 000 while the male rate was higher at 19 per 100 000. However, in the rural areas male suicide rates rise to 25 per 100 000 and in remote areas (defined as a population <10 000 people) the rate of male suicide is 30 per 100 000.[7] Recent evidence suggests that exposure to antidepressant medication may reduce rates of suicide in susceptible groups.[8]

In a systematic review of the literature, Williams et al. found 93 studies of telehealth.[9] One-quarter were of telepsychiatry, and one-third involved samples of less than 20 patients. Only one-third of studies considered preference between telemedicine and face-to-face consultation, while less than half measured more than two dimensions of satisfaction. Another review indicated that ‘before adoption into routine use, any new technology has to be proved to be superior to the approach that it is intended to replace, that is, it has to be more effective or more cost-effective than the alternative(s)’.[10]

Such issues argued for an evaluative study to be undertaken on a larger group in a rural region. The present study considers 36 consecutive patients, measures preference between telepsychiatry and face-to-face consultation and examines multiple dimensions of patient satisfaction.

THE STUDY

Wagga Wagga is a town of approximately 60 000 people in southern NSW. It has a general base hospital with a gazetted regional psychiatric unit. It is also relatively underserviced in that, at the time of establishment, there were no resident psychiatrists in the area. All hospital and community psychiatric services were provided by ‘fly in’ psychiatrists on a daily basis. There were approximately 30 general practitioners (GPs) in the immediate environs. A child and adolescent service was provided by three local mental health staff and a ‘fly in’ child and adolescent psychiatrist 1 day per week. The nearest resident psychiatrists were 125 km away in Albury or 150 km away in Canberra.

In March 2002, the Black Dog Institute commenced a satellite clinic in a rural site to bring specialized mood disorder consultants into the country and to advance research and education in mood disorders. Patients were selected by referral from GPs, psychiatrists and community mental health centres. Specific objectives were set, including: (i) establishment of a mood disorder consultation and assessment service with video-conference linkage to the Institute in Sydney; (ii) provision of specialist mood disorder assessment equivalent to the long-established Mood Disorders Unit at the Prince of Wales Hospital in Sydney, the site of the Black Dog Institute;[9] (iii) provision of a service to supplement existing facilities; (iv) laying of a base for future educational services for rural GPs; and (v) evaluation of telepsychiatry as a means of consultation and assessment in psychiatric practice.

It was decided that follow up would extend for over 12 months to assess the impact of such a telepsychiatry service. A second study is under way to evaluate outcomes from the clinical assessment process, using prospective predictive variables. It was intended that this initial study would identify whether the establishment of such a clinic would meet a local need, whether telepsychiatry would be accepted by patients, and whether it would have positive benefits for the patient and referring agency.

METHOD

Referral agencies were informed about the availability of the Black Dog Clinic in Wagga Wagga. Referrals were made to the clinic by telephone call from either the patient, on the advice of the referrer, or the referrer themselves. A self-completion questionnaire, similar to that used by the Prince of Wales Mood Disorder Unit,[11] was posted to the prospective patient and a referral questionnaire to the referring agent, both being returned prior to consultation. Non-responders were sent a second set of questionnaires from which some further responses were obtained. Finally, research assistants conducted individual interviews by telephone to achieve a maximal response rate.

On attendance, a psychiatrist conducted a semi-structured interview using a similar format to that of the Prince of Wales Mood Disorder Unit.[11] Linkage was then established with the Black Dog Institute by teleconference using the Area Health ISDN (384 KBps) equipment. A second psychiatrist then conducted an interview with the patient. Consultation then occurred between the two psychiatrists before feedback was given to the patient. A report was prepared by the local psychiatrist and returned to the referrer within 7 days of the consultation. This contained assessment advice regarding diagnosis and management issues.

Patients (n = 36) were in the care of their primary agent throughout. Referrals came from GPs (83%), the community mental health services (10%) and psychiatrists (7%). Over the 12 month period, two patients on the waiting list died by self-induced means while no patients died in the treated group. However, no firm conclusion should be drawn in light of the overall small sample.

Of the 36 participants, four did not experience the telepsychiatry component and one was under the age of 16 years, reducing the number of eligible participants to 31. Twenty eligible participants (65%) fully completed the questionnaire, six (19%) were not contactable and five (16%) refused to participate. The response rate increases to 80% (20/26) with the exclusion of the participants who were not contactable.

RESULTS

The average age was 40 years (range: 21–71 years) with no significant difference between responders and non-responders. Gender distribution was equal. Three-quarters were from Wagga Wagga city and one-quarter from surrounding areas. The diagnoses of patients referred were overwhelmingly mood disorders (80%), followed by anxiety disorders (20%), with a small comorbid spread to other related disorders. There was an average of 35 days from contact to appointment. Employment and marital rates were somewhat lower than that in the local community, while educational level was commensurate with the resident community (excluding transient residents of the local university and TAFE campuses).

In total, 31 patients who experienced telepsychiatry and who were over the age of 16 were evaluated retrospectively, with responses obtained from 20.

Regarding adequate prior provision of material, 85% of participants were satisfied with the information provided concerning the consultation prior to the appointment time. For 60% of participants, this was their first consultation with a psychiatrist and 85% were satisfied with the waiting time (Table 1).

There was a high rate of satisfaction with the face-to-face component of the consultation process (mean positive response 85%). Differences between face-to-face and telepsychiatry were noted for: difficulty discussing problems (35% in telepsychiatry, 20% in face-to-face); not finding the consultation informative (40% in telepsychiatry, 20% in face-to-face); and not feeling comfortable in front of the camera (30%). The change of treatment in the majority of cases seemed to be in line with the high level of satisfaction with respect to the clinic (Table 2).

Overall, 95% of participants were satisfied with the consultation process as a whole, and 80% agreed that they would be happy to use telepsychiatry again. In the space provided for free comments, 90% of participants wrote positive or very positive comments (Table 3).

Table 1:

Examining satisfaction with telepsychiatry consultation (n = 20)

Table 2:

Examining overall satisfaction with Black Dog Clinic consultation (n = 20)

Table 3:

Evaluation of consultation process

DISCUSSION

From the data presented here, it is clear that the clinic was well received by the patients, and that it met a local need. The change of treatment in the majority of cases seemed to be in line with the high level of satisfaction with respect to the clinic.

Reviews have indicated that telepsychiatry has not yet been well evaluated.[7],[8],[10],[12] Further, it is necessary that this mode of health-care delivery is both acceptable and preferable to the alternatives.13–21 Our results support the view that face-to-face consultation is preferable to a telepsychiatry consultation. However, telepsychiatry was rated highly in the present study; the value attached to the diagnosis and treatment component was rated highly and patients were positive about further telepsychiatry consultations and would recommend them to others. On this basis, a satellite clinic with both face-to-face and telepsychiatry consultations is highly acceptable and valued by patients. Responses suggest that the medium of telepsychiatry requires efforts additional to those made for face-to-face interviews, in order to allow the expression of feelings and to explain and inform about the process. However, regardless of these difficulties, 90% found the telepsychiatry interview to be satisfactory overall, most agreeing that the telepsychiatrist was informative, communicated well, treated them with respect, and that the interview was a useful addition to the face-to-face consultation. The prospective study currently under way will evaluate outcomes following consultation and referrer satisfaction with the telepsychiatry process. Future studies will examine telepsychiatry without a local presence compared to telepsychiatry with a local presence, and face-to-face consultation without telepsychiatry.

The undersupply of psychiatric services in rural and regional Australia is likely to persist in the foreseeable future. Alternative innovative means of psychiatric service delivery are needed. This form of consultation liaison psychiatry over long distances can save considerable travel time for patients and medical staff while providing a highly acceptable alternative form of consultation assessment. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines in telepsychiatry recommend the presence of a mental health worker with the patient at the remote end of the telepsychiatry.[22] This was an essential part of this particular study. Further work will need to be done to ascertain the need for this process in the future. Our clinic does not provide ongoing treatment of patients. Whether or not this is effectively delivered by telepsychiatry will need to be examined by other studies. In the meanwhile, it appears that the presence of this clinic and the associated telepsychiatry is highly valued by participating rural resident patients.

Footnotes

Acknowledgements

The authors appreciate the support of The School of Rural Health, a Commonwealth-funded project and an initiative of the University of New South Wales and the Australian Department of Health and Ageing, supported by the communities of the Greater Murray and Mid North Coast regions of New South Wales, particularly Dr Brian Driver, Director of Research and Professor Sandy Reid, Head of the School of Rural Health. We also thank Lea Andric and Sarah Ragg of the Black Dog Institute and Lynette Arthur for her assistance in Wagga Wagga.

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