Abstract
Anthony Samuels, Mental Health Services, Hornsby Ku-Ring-Gai Hospital, Sydney, Australia:
The purpose of this letter is to document the first known application in Australia of telepsychiatry across international boundaries. Telemedicine and telepsychiatry have been the subject of much interest in the medical literature in recent times [1], [2], [3]. A number of authors have enthused about the global possibilities in regard to distant medical service provision via the medium of video-conferencing [4], [5]. A Medline search covering the period 1990–1998 and discussion with an expert in the field [Yellowlees P: personal communication] revealed no recorded instance of the use of international telepsychiatry for clinical purposes in Australia.
While working as a consultant psychiatrist in Auckland, New Zealand, the author provided a visiting psychiatrist and telepsychiatry service to Dubbo, New South Wales. Two telepsychiatry consultations utilising the telemedicine facilities of Waitemata Health Service in Auckland and those of the Macquarie Area Health service in Dubbo are described below.
Case A involved a man in his 30s with a rapid cycling bipolar affective disorder. His general practitioner (GP) requested an urgent telepsychiatry consultation as he felt the patient's mental state was deteriorating and the delay until the author's next visit to the region was too great. Present at the assessment was the patient and his de facto, the GPand the case manager. Examination revealed the patient to be disinhibited, distractible and mildly pressured in speech. A recommendation was made to increase the dose of the patient's mood stabiliser and to add in a small dose of a novel antipsychotic medication. Face-to-face follow-up examination a few weeks later revealed the patient to be substantially more settled.
Case B was a man in his 20s who had been seen for the first time by the author a few weeks earlier. He had presented with persecutory ideation, homicidal ideation, auditory hallucinations and unusual olfactory perceptual disturbances suggestive of an epileptic aura. Others present at interview were the patient's girlfriend, the GP and a mental health worker. The purpose of the interview was to review the results of special investigations and to give further management advice. Computerised tomography, electroencephalography and a blood test were all found to be normal. Advice was given to the GP to begin a small dose of a novel antipsychotic and a face-to-face follow-up appointment was made for a few weeks later (with the option of interim telepsychiatry reviews if needed).
At the time of consultation, the author was registered as a medical practitioner in both countries. Important technical issues include the fact that both the telepsychiatry facilities of Waitemata Health and the Macquarie Area Health Service are housed in purpose-designed facilities. The video-conferencing hardware was compatible; four telephone lines were used for the consultation (probably too few) and informed consent was received via facsimile before the interviews were conducted. After the interview, a report was sent by facsimile to the health professionals concerned.
The time difference of 2 h created some practical difficulties in regard to finding a time of day that suited all parties concerned to participate in the process. Feedback from the patients and professionals involved both at the time of the telepsychiatry consultation and subsequently revealed the process to be acceptable and useful. The picture and sound quality from the psychiatrist's perspective was inadequate and this almost certainly could have been improved by better positioning of the microphone and the use of more telephone lines (which obviously adds to the expense of the procedure). Video-conferencing hardware with greater bandwith capacity [1] may increase picture quality and resolution. The picture quality made it difficult to accurately appraise subtleties like facial expression and although adequate for the purposes of reviewing a known patient, this factor would have severely compromised a new assessment.
An important conceptual issue that arises in this context is whether or not the psychiatrist is in effect ‘going to’ the patient, or they are ‘coming to you’. In the author's view, the fact that telepsychiatry in this situation is supplementing the usual visiting role of the psychiatrist and leading to management decisions enacted locally by third parties, the notion of ‘going to the patient’ would seem to make more sense. The extension of this issue is whether or not the psychiatrist needs to be registered in both countries to provide this service. This complex issue will obviously need further debate at the level of medical registration boards, medical indemnity providers and experts in the field of medical law. The maintenance of electronic data security and ensuring that patient confidentiality is not compromised will continue to be a major issue in regard to technologies relying on fibre-optic information transfer [6].
In conclusion, this exciting technology certainly provides potential clinical and teaching opportunities for collaborative mental health ventures straddling Australia, New Zealand and the Pacific Islands. It is the author's contention, however, that for clinical purposes, telepsychiatry should only complement direct clinical contact, as the ‘virtual world’ can never supplement knowledge of mental health systems and relationships with other health professionals acquired in the ‘real world’.
The major limitations to international telepsychiatry would thus seem to be factors which mitigate against the ability of the clinician to provide with some regularity a face-to-face clinical service (e.g. distance and access). Distance is of course no impediment to this technology but it obviously is for visiting clinicians who are likely to be daunted by the prospect of prolonged travelling time and limited transportation options to and from remote regions.