Use of Standard Webcam and Internet Equipment for Telepsychiatry Treatment of Depression Among Underserved Hispanics

A total of 182 self-identified Hispanic patients with a major depressive episode were invited to participate; four refused and 11 were ineligible (screened out or did not follow up with baseline assessments), leaving 167 enrolled study participants, most of whom were foreign born. The demographic characteristics of the sample, including general health, marital, financial, and employment status and other characteristics have been reported elsewhere (6).

Registration staff members at a community health center were instructed to invite every registering patient to complete depression screening with the nine-item Patient Health Questionnaire (PHQ-9). Participants with a PHQ-9 score of 10 or higher during routine clinic screening (7,8) were invited to participate in formal diagnostic confirmation of a DSM-IV-TR major depressive episode with the Mini-International Neuropsychiatric Interview (MINI) (9).

Patients were excluded if they had a diagnosis of bipolar affective disorder, schizophrenia, schizoaffective disorder, dementia, current substance dependence based on the MINI, or any concurrent DSM-IV axis I disorder that required inpatient or crisis residential treatment at the time of screening. Patients were also excluded if they manifested signs or symptoms of serious general medical or neurological illness (for example, severe liver or renal failure) that in the opinion of the primary care provider was likely to increase the risk of complications during treatment or if they manifested signs or symptoms of serious general medical illness that may have explained the observed depressive symptoms (for example, traumatic brain injury or uncontrolled seizures). Patients were also excluded if they had active suicidal or homicidal ideation or were felt by one of the investigators on the basis of clinical presentation and history to pose a significant risk of harm to themselves or others, if they were pregnant or lactating, or if they lacked mental capacity to provide informed consent.

After complete description of the study to participants in the participant’s preferred language, written informed consent was obtained before the MINI was administered. Patients who met all entry criteria were randomly assigned to the Webcam condition (N=80) or the control condition of treatment as usual (N=87). Participants were offered treatment and data collection visits for a period of six months between July 2008 and June 2010. Clinician ratings were conducted by a rater who was blind to the participant’s treatment condition. [A flowchart depicting study recruitment and completion is available online as a data supplement to this article.]

Patients assigned to the Webcam intervention were given appointments with one of two bilingual psychiatrists, who provided services in the patient’s preferred language (all the patients preferred Spanish). For patients, the remote session took place in a consulting room at the community health center where they received medical care. All equipment in the consulting room complied with provisions in the Health Insurance Portability and Accountability Act. It included a fax (used for signature requirements for prescriptions, consent forms, and treatment plans and for medical records exchange) and a standard computer set up with commercially available higher-resolution Webcam equipment (Logitech QuickCam Orbit AF).

This intervention consisted of six monthly Webcam sessions with the psychiatrist. The first session, which lasted 45 to 60 minutes, included initial psychiatric evaluation and treatment. The six subsequent sessions lasted 20 to 30 minutes and included evaluation and management. Psychiatrists offered medication management using measurement-based treatment consistent with the Texas Medication Algorithm Project (TMAP) (10). In addition, patients received psychoeducation and other brief eclectic interventions as appropriate, mostly supportive in nature. Before each session, the project recruiter initiated the Webcam connection and ensured that the psychiatrist and patient were in place and the equipment was functional. At the end of the six months, patients were transitioned back to the primary care provider or specialist for appropriate management. This process included sharing study records, including a written psychiatric assessment, follow-up progress notes, and the medication log. The study recruiter provided notification and clinical updates as she handed Webcam participants back to the primary care provider. Study psychiatrists were also available for case discussions when required and routinely wrote follow-up treatment recommendations, most importantly in cases where participants remained depressed.

Emergency contact information was provided to participants in each treatment condition. Webcam patients were covered by the psychiatry department crisis system, and patients receiving treatment as usual were covered through their home clinic crisis line. The study psychiatrists could adjust the treatment schedule or content as necessary to secure the safety of the patient and others and to ensure adequate clinical progress. All participants received general medical care from their primary care providers.

Depression treatments for patients randomly assigned to treatment as usual were determined by their assigned primary care provider and based on guidelines by the Agency for Healthcare Research and Quality (11). Treatments often included generic antidepressants; some patients received counseling through the behavioral health clinicians on site. Patients in the treatment-as-usual group who required additional mental health care were referred to community mental health agencies. Primary care providers included three family physicians and three independent family nurse practitioners. They were sufficiently fluent in Spanish to conduct general medical assessments and monitor specific depression symptoms; however, they were generally less able to converse in depth about important social and psychological issues contributing to patients’ clinical presentation and management.

All study participants were allowed to continue using—or were referred for—other services available at the clinic, such as individual, couples, and family counseling provided by master’s-level bilingual behavioral health counselors. The Webcam participants had a mean±SD of 4.0±2.3 visits, and those receiving treatment as usual had 4.3±3.6 counseling visits.

Effectiveness was measured with widely used scales that address aspects of depression symptom severity and that measure continuous and categorical response and remission changes. These scales included the clinician-rated Montgomery-Åsberg Depression Rating Scale (MADRS) (12) and the self-rated PHQ-9 (7). Categorical outcomes were prospectively defined: response was a 50% or greater decrease in severity ratings, and remission occurred when the decrease was 75% or greater. Similarly, impact of depressive symptoms on quality of life was measured with the self-rated Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (13), and health-related functional ability was measured with the self-rated Sheehan Disability Scale (SDS) (14).

The main hypothesis was that patients who were randomly assigned to the Webcam intervention would show a greater decrease in depression rating scores and greater improvements in quality of life and functional ability than patients randomly assigned to treatment as usual.

Data analysis software (Predictive Analytics Software [15]) was used to conduct analysis of variance (ANOVA) with repeated measures (baseline and three and six months) and to analyze clinician-rated (MADRS) and patient-rated (PHQ-9) depression severity measures and measures of quality of life (Q-LES-Q) and functional ability (SDS). Between-subjects variables included treatment condition (Webcam intervention versus treatment as usual). Categorical changes were assessed with t tests, using intent-to-treat analysis with last observation carried forward and comparing the proportion of patients showing response and remission in the two treatment groups.

To monitor protocol adherence to the Webcam intervention, study notes were reviewed for 50% of the patients (N=40) and video-recordings were reviewed for 10% (N=8). Bilingual psychiatric clinicians who were not involved in providing care conducted these reviews.

To enhance reliability, a single clinician who was blind to the treatment condition conducted the MADRS ratings during separately scheduled clinic visits. All self-ratings were obtained by the study recruiter–clinician on the date of the treatment visit.

A total of 87 participants were assigned to treatment as usual—75 women (86%) and 12 men (14%)—with a mean±SD age of 43.2±11.9 years. A total of 80 participants were assigned to the Webcam intervention—73 women (91%) and seven men (9%)—with a mean age of 42.8±12.0. No statistically significant differences were found between groups in demographic characteristics, such as age, sex, education level, employment or marital status, and perceived general medical health (6). The study was conducted with minimal variation from the study protocol. Independent raters assessed fidelity of treatment for the Webcam providers and found them to be in compliance with the format proposed for evaluation and treatment. Any variations from the TMAP algorithm were reconciled and were either explained by patient choice or corrected upon supervisory review. Results for the target outcomes are presented below. [The online appendix includes figures summarizing the time trajectory of mean scores on the MADRS, PHQ-9, Q-LES-Q, and SDS for both treatment groups.]

For patients in both treatment conditions, significant reductions in symptom severity were seen over time (Table 1). ANOVA with repeated measures showed a significant main effect of time for the MADRS (F=120.55, df=2 and 122, p<.001) and a significant interaction of time by intervention (F=5.93, df=2 and 244, p<.01) favoring the Webcam intervention. For the PHQ-9 there was also a significant main effect of time (F=212.14, df=2 and 130, p<.001) and a significant interaction of time by intervention (F=3.6, df=2 and 260, p<.05) favoring the Webcam intervention. Analyses using last observation carried forward yielded the following results. Of 159 evaluable cases for whom at least baseline ratings were collected (85 treatment as usual and 74 Webcam intervention), 88 patients (55%) showed a treatment response—40 (47 %) in the treatment-as-usual group and 48 (65%) in the Webcam group (t=2.75, df=157, p=.024). In addition, 65 patients (41%) achieved remission—29 (34%) in the treatment-as-usual group and 36 (49%) in the Webcam intervention group (t=1.87, df=157, p=.06) (Figure 1).

Q-LES-Q scores indicated significant increases in quality of life over time for both treatment groups. ANOVA with repeated measures showed a significant main effect of time for Q-LES-Q (F=112.16, df=2 and 130, p<.01) and a significant interaction of time by intervention (F=3.1, df=2 and 260, p<.05) favoring the Webcam intervention.

Disability ratings decreased significantly over time for both treatment groups. ANOVA with repeated measures showed a significant main effect of time for the SDS scores (F=129.43, df=2 and 131, p<.01) and a significant interaction of time by intervention (F=3.23, df=2 and 262, p<.05) favoring the Webcam intervention.