Question 1

Has research been done to prove child & adolescent telepsychiatry works? What’s the evidence base?

Accepted Answer

Yes, children, adolescents, and families can benefit from telepsychiatry. In a variety of mental health conditions such as ADHD, autism, and OCD, studies have indicated that video visits are useful in accessing psychiatric specialists and improving symptoms.

In attention deficit hyperactivity disorder (ADHD) studies with telepsychiatry, for instance, improvement in hyperactivity and combined ADHD has been shown in hundreds of children in randomized clinical trials, combining video visits with child psychiatrists along with caregiver behavior, versus treatment with their primary care providers augmented with telepsychiatry consults. In autism, clinicians can use telepsychiatry videoconferencing for diagnosis & assessment. And, in obsessive-compulsive disorder (OCD), video visits reduced symptoms versus a waitlist control in a randomized clinical trial.

We additionally see video visits used to give behavioral parent training, with live therapists, showing treatment response and improvements in children ’s symptoms as well as easing of parental burden. Video visits can also help with parental coaching for children with autism, to help conduct home assessments, and for communication coaching.

The American Academy of Child and Adolescent Psychiatry provides expert guidance on how to deliver psychiatric services to this population, including optimizing clinical visits. This guidance is assembled by experts on the Committee on Telepsychiatry and the Committee on Quality Issues.

### Sources:

* Myers K, vander Stoep A, Zhou C, et al. Effectiveness of a telehealth service delivery model for treating attention-deficit hyperactivity disorder: results of a community-based randomized controlled trial. J Amer Asso Child Adolesc Psychiatry 2015;54(4):263-74.
* American Academy of Child and Adolescent Psychiatry Committee on Telepsychiatry and the Committee on Quality Issues. Clinical Update for Telepsychiatry with Children and Adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2017;56(10):875–893.
* Comer JS, Furr JM, Miguel E, Cooper-Vince CE, Carpenter AL, …Myers KM & Chase R. Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered Parent-Child Interaction Therapy (I-PCIT). Journal of Consulting and Clinical Psychology. 2017; 85 (9): 909–917.
* Lee JF, Schieltz KM, Suess AN, Wacker DP, Romani PW, Lindgren SD, Kopelman TG, Padilla Dalmau YC. Guidelines for developing telehealth services and troubleshooting problems with telehealth technology when coaching parents to conduct functional analyses and functional communication training in their homes. Behavior Analysis Practice DOI 10.1007/s40617-014-0031-2; Published online 27 November 2014.
* Myers K and Roth DE. Telepsychiatry with children and adolescents. In: Martin A, Volkmar FR, and Bloch MH (Eds), Lewis's Child and Adolescent Psychiatry: A Comprehensive Textbook, 5th Edition. Wolters Kluwer, Philadelphia, 2018; Chapter 6.3.5.
* Reese RM, Jamison R, Wendland M, Fleming K, Braun MJ, Schuttler JO et al. Evaluating interactive videoconferencing for assessing symptoms of autism. Telemedicine and J E Health. 2013;19(9):671-677.
* Storch EA, Caporino NE, Morgan JR, Lewin AB, Rojas A, Brauer L et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Research. 2011;189(3):407-412.
* Vander Stoep A, McCarty C, Zhou C, Rockhill CM, Schoenfelder E, Myers K. The Children’s Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study: caregivers’ outcomes. Journal of Abnormal Child Psychology. 2016; 45(1):27-43.

Question 2

Can you get reimbursements for video devices for patients who don't have a computer or smartphone?

Accepted Answer

Getting reimbursements for video devices vary depending on your work setting. Look to your workplace's patient support services, local and state government funding programs, and federally-supported services.

Federal government agencies — such as the Veterans Health Administration (Veterans Affairs, or VA) — have instituted a ["Digital Divide" consult](https://mobile.va.gov/sites/default/files/vamobile-discussion-series-202009-slides.pdf) that will contact patients, discuss their needs, and send them telehealth equipment such as Apple iPads with wireless services.

Comcast offers [Internet Essentials](https://internetessentials.com), with affordable high-speed Internet wifi, a discounted laptop or desktop computer, for those who qualify for their low-income program.

The federal government has [Lifeline](https://www.fcc.gov/lifeline-consumers), a "discount on monthly telephone service, broadband Internet service, or bundled voice-broadband packages purchased from participating wireline or wireless providers." Service providers like [SafeLink Wireless](https://www.safelinkwireless.com), [Assurance Wireless](https://www.assurancewireless.com), [TruConnect](https://www.truconnect.com) provide wireless devices, hotspots, and accounts.  States such as California implement Lifeline as [Your Call Wireless](https://yourcallwireless.com/lifeline/), providing phone services and cell phones.

Finally, large commercial organizations such as [T-mobile](https://www.t-mobile.com/offers/lifeline-program), [Verizon](https://www.verizon.com/solutions-and-services/lifeline/), and [AT&T](https://www.att.com/home-phone/lifeline/) offer Lifeline services.

Question 3

Has research been done to prove telepsychiatry works? What’s the evidence base?

Accepted Answer

Yes, telepsychiatry is comparable to in-person visits. In fact, studies have shown that telepsychiatry is effective for diagnosing mental disorders across ages — children, adults, and the elderly — and across ethnicities. Across studies, telepsychiatry has shown to provide clinical outcomes equivalent to face-to-face visits. Plus, across studies, diagnoses, and demographics, patients generally achieve improved symptoms and improved quality of life.

In fact, telepsychiatry has advantages over in-person care. Video visits increase access to a psychiatric practitioner, and can assist with collaborative care. Even those in rural communities and remote areas of the world — in other words, geographies with sparse populations — can access specialty care with the help of telepsychiatry.

Telepsychiatry is cost-effective. A study limited to the cost of providing clinical service has shown 10% reduction in cost per patient, when telepsychiatry was used versus in-person care. In the majority of studies, telepsychiatry is more cost-effective.

And both patients and providers are satisfied with telepsychiatry video visits. Patients feel they get along with their provider

### Sources:

* Hubley, S., Lynch, S. B., Schneck, C., Thomas, M., & Shore, J. (2016). Review of key telemental health outcomes. World journal of psychiatry, 6(2), 269.
* Hilty DM, Ferrer DC, Parish MB, et al. The Effectiveness of telemental health: A 2013 review. Telemed J E Health 2013;(19):444-454.
* Janca, 2000. Telepsychiatry: an update on technology & implications. Curr Op Psych 13: 591-7.
* O'Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58(6):836-43.
* Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The empirical evidence for telemedicine interventions in mental disorders. Telemedicine and e-Health, 22(2), 87-113.

Question 4

Is telepsychiatry appropriate for inpatient settings?

Accepted Answer

Telepsychiatry has been utilized in a variety of inpatient units with success and is an acceptable mode of delivering care in these settings.  Both government and corporate health care organizations have embraced telepsychiatry for this purpose.  In the early days of telepsychiatry, some administrators and providers were hesitant or skeptical about using telepsychiatry for inpatient units.  Reasons given were mostly a subjective and vague concern about the ability of providers to appropriately care for severely ill patients without being on site, in person.

However, in recent years, as telepsychiatry has become more widely adopted, those concerns have diminished.  Those who have experience with inpatient telepsychiatry have come to understand that providing care in this way is not substantially different that how it would be provided in-person.  In fact, there are several advantages of telepsychiatry over onsite psychiatry in the inpatient unit:

* Telepsychiatry allows inpatient units in underserved and rural areas to be adequately staff
* Telepsychiatry allows the provider to work from the comfort of his home, rather than being forced to sit for long hours under fluorescent lights within a noisy, musty and uncomfortable inpatient unit.  
* Telepsychiatry gives providers opportunities to create any variety of schedule that works best for their lifestyle, including working during odd hours, weekdays, nights, part time, or full time.  With telepsychiatry, shifts can more easily be modified and swapped to fit the needs of the providers. 
* Telepsychiatry allows the inpatient unit to supplement staff easily and efficiently.  This is especially useful when facilities are running short on staff due to illness, surges in patient volume, or any other factors. 
* Telepsychiatry allows for 24/7 coverage of inpatient units, which is often hard to do when relying solely on in-person onsite coverage.

**The Importance of Effective Communication:** 
Effective communication is important in virtually any healthcare setting, and inpatient telepsychiatry is no different. Communication between the telepsychiatrist and members of the inpatient treatment team allows optimal coordination of patient care.  This includes:

* Reviewing the treatment plan
* Reviewing progress of the patient toward discharge goals
* Addressing urgent and emergent patient issues
* Relaying factors on the unit which may affect patient experience.  For example, excess noise from other patients, physical plant issues (like plumbing or electrical issues in the unit), overcrowding on the unit, or hostile patients that are disrupting the environment for other patients.
* Oftentimes, the way a patient presents to the psychiatrist may be different than how they behave on the unit.  It is helpful for the psychiatrist to know how the patient is doing both on and off camera.

Efforts should also be made to establish adequate communication between the telepsychiatrist and the patient.  Although communication with a severely mentally ill person can often be challenging, the telepsychiatrist should try to involve the patient in the treatment goals and plans as well as answer any patient questions and concerns.

**What about paranoid and psychotic inpatients?  Are they appropriate for telepsychiatry? **

There is no absolute contraindication for telepsychiatry and virtually any mental health condition can be treated via telepsychiatry.  However, there are certain clinical situations where a patient's mental status or condition may require that arrangements are made for onsite psychiatric care.  For more information, please see the article ["Are psychotic patients appropriate for telepsychiatry?"](https://ask.orbithealth.com/faqs/are-psychotic-patients-appropriate-for-telepsychiatry)

In summary, telepsychiatry is an appropriate and effective way to provide care to inpatient facilities, especially when there is good communication.

Question 5

Are psychotic patients appropriate for telepsychiatry?

Accepted Answer

There is no absolute contraindication for telepsychiatry and virtually any mental health condition can be treated via telepsychiatry.  Generally, the concerns about psychotic patients becoming more paranoid or distrustful with telepsychiatry are overblown.

However, in rare cases, a patient may not be appropriate for telepsychiatry if they are truly fearful about a delusion that involves the camera or videoconferencing equipment.  Does this mean that telepsychiatry is inappropriate or impossible to effectively treat such as patient?  Not necessarily...

It is important to remember that psychotic patients can incorporate anything from their environment into their delusional beliefs.  For example, a patient may be delusional that they are being held captive in a secret Nazi prison camp. This does not mean that they should be discharged from the unit out to the street.  Likewise, a patient who has delusions about telepsychiatry does not necessarily fail to benefit from telepsychiatry.

Nevertheless, it is theoretically possible for a patient to be so paranoid about telepsychiatry that they become mute or refuse to participate in the telepsychiatry session.  If that same patient is willing to converse with a psychiatrist in the facility, then perhaps onsite psychiatry may be a more effective option.   This would be a clinical decision based on the case factors.  Ultimately, if the treatment team feels that the patient fundamentally cannot benefit from telepsychiatry due to their delusional beliefs about that modality of care, then other arrangements should be made to provide care onsite.

In summary, there are certain clinical situations where a patient's mental status or condition may require that arrangements are made for onsite psychiatric care.  However, this happens very rarely.  Overall, telepsychiatry is an effective option in the vast majority of mental health cases.

Question 6

Is telepsychiatry subject to specific guidelines and laws?

Accepted Answer

Orbit Health psychiatric professionals strictly adhere to the federal and state guidelines that apply to their practices.  Additionally, different states may implement and apply different guidelines specific to telepsychiatry.

For example, telepsychiatry practitioners must carefully follow laws that regulate prescriptions for controlled substances. This is done by a rule called the “Ryan Haight Online Pharmacy Consumer Protection Act of 2008,” enforced by the DEA (Drug Enforcement Agency).

The Ryan Haight Act requires a practitioner to conduct in-person medical evaluation before they can prescribe a controlled substance. Some exceptions apply for systems like federal healthcare providers at Indian Health System.

With the COVID-19 public health emergency, an in-person medical evaluation is not feasible. This is where telepsychiatry has a protective advantage for clinical staff and for patients. For instance, the DEA will allow prescriptions to be issued for audiovisual telemedicine communication.

Question 7

I need a psychiatrist

Accepted Answer

If you are an administrator seeking services for your healthcare organization or facility, please contact us through our website,https://www.orbithealth.com/contact-us/  However, if you are a patient seeking services for yourself or your family/friend, we cannot provide care directly to you.  If this is a medical or mental health emergency, please call 911 or go to an emergency room immediately.

Question 8

How can telepsychiatry help during COVID-19?

Accepted Answer

Right now, most Americans are stuck inside their homes, while the COVID-19 coronavirus pandemic continues across the U.S. and worldwide. Normal business functions have, for the most part, shut down indefinitely. Many people, however, need services beyond food and water. Staying mentally healthy during these difficult times is one of the most challenging parts of the entire ordeal, and also one of the most important. The field of telepsychiatry allows individuals who are subject to shelter-in-place orders to get the mental health services they need without having to risk physical proximity near other individuals.

Question 9

I need help

Accepted Answer

If you are an administrator seeking services for your healthcare organization or facility, please contact us through our website,https://www.orbithealth.com/contact-us/  However, if you are a patient seeking services for yourself or your family/friend, we cannot provide care directly to you.  If this is a medical or mental health emergency, please call 911 or go to an emergency room immediately.

Question 10

What is telepsychiatry?

Accepted Answer

Telepsychiatry is the delivery of psychiatric care remotely using technology, usually through videoconferencing platforms.  It can involve mental health evaluations, therapy, medication management, and patient education.    Telepsychiatry is the fastest growing sector of the telemedicine and is the future of mental health care.

Telepsychiatry is a form of telemedicine that generally refers to the delivery of psychiatric assessment and care via telecommunication, typically using videoconferencing software. The practice of telepsychiatry has been in development since well before the pandemic quarantines, as an effort to account for the millions of Americans who suffer from mental illnesses but are unable to get proper psychiatric care.

Telepsychiatry brings mental health care to individuals who are unable to see a medical professional in person for any of a variety of reasons, including the cost and availability of travel, incarceration, or contagion. Now, with shelter orders and quarantines keeping medical offices closed and people restricted to their homes, telepsychiatry provides a promising alternative to in-person psychiatric care.

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