Abstract
The efficacy of cognitive–behavioural therapy (CBT) is well documented. Recent research suggests that in depressive and panic disorders it is as effective as medication and provides longer term protection from relapse [1–3]. It can be especially useful in patients for whom medication is unwanted or undesirable. A major problem for patients who would benefit from this form of therapy is access to services. This is especially true of regional South Australia where few psychiatrists or psychologists practice outside of Adelaide, and weekly sessions for brief therapy are difficult to obtain.
Since 1994 a telepsychiatry service has been operating in Adelaide. It has been situated at Glenside hospital for the last 5 years after the appointment of Dr Fiona Hawker as Director. There is a strong clinical focus aimed at providing specialist mental health services to rural South Australia. Apart from education to regional health workers and administration functions there have been three major types of clinical consultation: acute assessments for emergency/semi-emergency psychiatric problems, inpatient liaison and postdischarge follow-up support [4].
Research on the use of videoconferencing [5] has demonstrated that the reliability of psychiatric assessment in this setting is equivalent to that in a face-to-face consultation. Utilizing this technology for therapy has not been a focus for practice or research as yet.
Clinical picture
A 38-year-old married woman receiving a disability pension for agoraphobia was referred with worsening panic attacks, agoraphobia and depression. Ms M described a childhood of intermittent physical and sexual abuse in a home where her mother suffered chronic alcoholism. Her history of panic disorder dated back to age 16. From age 18–30 she received multiple trials of psychiatric treatment both inpatient and outpatient which she had not found helpful. Agoraphobic symptoms developed from the age of 18 and she was intermittently depressed and suicidal. She had attempted suicide on one occasion in her early 20s.
At the age of 30 she met her future husband and formed her first intimate relationship. Together they moved to a remote country area and Ms M avoided further contact with mental health services. Her panic attacks subsided and her mood symptoms improved but she remained hampered by agoraphobia and was unable to work, drive a car or leave the house alone for any period of time.
At the beginning of 1999 her mother died and her symptoms rapidly escalated with panic attacks three to four times per day, neurovegetative and mood symptoms of depression and worsening agoraphobia. She had presented to the local hospital in acute distress on several occasions believing she was dying. All physical investigations were normal. Her local doctor suggested antidepressant medication but the patient refused, believing it may worsen her panic symptoms. She took diazepam up to 15 mg per day and trifluoperazine up to 15 mg per day.
After referral, arrangements were made for the patient to receive weekly CBT sessions utilizing the videoconferencing equipment located in her local hospital. Due to scarce resources she was seen alone after the facilities were set up by reception staff.
At the commencement of CBT, the patient's Beck Depression Inventory (BDI) score was 14 and her Beck Anxiety Inventory (BAI) score was 46. After an assessment and conceptualization phase of two sessions, initial goals for treatment were collaboratively set. These included decreasing the number and severity of panic attacks, decreasing the sense of hopelessness experienced and understanding the risks and benefits of various medications so that informed choices could be made.
Standard cognitive approaches of education, exposure, experiments and thought records were used. Within four sessions the frequency of panic attacks had decreased to about one per week and the patient had not presented to local medical services. Trifluoperazine had only been used on one occasion and diazepam usage had decreased to 7.5 mg per day After medication education in session four, together with cognitive techniques examining pros and cons, the patient agreed to trial medication. Paroxetine at 20 mg was successfully commenced. Both depression and anxiety improved with the use of the antidepressant and further CBT interventions. No further panic attacks occurred. Further goals were set regarding the agoraphobic symptoms. Response to behavioural and cognitive exercises was excellent and the patient managed to drive and shop alone. From this point on her improvement escalated and by session eight she was able to commence voluntary work in the community and refer herself for rehabilitation in order to prepare for paid employment.
Sessions 10 and 11 were concerned with relapse prevention issues. Final BDI and BAI scores were 0 and 3 respectively. Follow up 1 month later revealed that improvement had been maintained.
Discussion
The improvement in this individual patient occurred despite certain technological and practical issues that impacted on therapy.
Technical issues
Videoconferencing equipment at the rural site was basic and did not permit the transmission of printed material that could be shared by both patient and psychiatrist simultaneously. Thus early plans to collaboratively write educational material, thought records and homework with the use of a document camera had to be abandoned.
Transmission speed was 128 kbits/s which is utilized at all South Australian sites as it is adequate for mental health applications and spares the expense of the 384 kbit/s speed. Unfortunately, technical problems with sound echo at this site interfered at times with the flow of sessions. The sessions were further interrupted by people entering both rooms despite ‘occupied’ signs on the doors. Unlike consulting rooms, the conferencing equipment is often located away from reception staff in rooms utilized for several purposes. These difficulties were noted by the patient during sessional feedback when she complained about the lack of privacy.
Therapy issues
As part of the CBT management of panic disorder, the patient is often asked to hyperventilate with the therapist to stimulate the autonomic sensations of a panic attack. This is usually a fearful task for the patient. When discussing this activity it became clear that there was a risk of the patient collapsing or having a full panic attack while alone in a room 300 km away, an anxiety-provoking situation for both client and therapist. After full discussion of the risks and benefits the exercise went ahead without harm to the patient although she became tearful afterwards. Further activities of this nature occurred uneventfully.
Rapport
The importance of the therapeutic relationship in CBT is well documented [4]. This raised concerns over the ability to establish and maintain rapport in such a technological environment. At times of Ms M's distress there appeared to be some restriction on the empathic ‘presence’ of the therapist. The lack of physical presence seemed to require the use of more active verbal support to maintain rapport and allow understanding to be conveyed. Despite this, Ms M remained committed to attending sessions and provided positive feedback regarding the degree to which she felt understood. Other patients may have less tolerance for these difficulties and rapport may suffer as a consequence.
Conclusion
Brief therapy of this type can be done via videoconferencing facilities even though there are some limitations. Further study in the area is required. The current case is an example of the benefits to a rural patient who could not have accessed city services without large financial costs to the health system and personal costs to the individual. The brief therapy is likely to have prevented a hospital admission as well as the ongoing morbidity associated with disorders of this nature.