Pilot Study of Televideo Psychiatric Assessments in an Underserviced Community
Publication: American Journal of Psychiatry
Abstract
OBJECTIVE: The goal of this study was to evaluate patient and physician acceptance of televideo interviews for general psychiatric assessments. METHOD: DSM-III-R diagnoses for axes I and II were made for 40 patients by using the Structured Clinical Interview for DSM-III-R. The patients were then randomly assigned to face-to-face or televideo interviews for general psychiatric assessments conducted by psychiatrists. After each interview the patient and psychiatrist completed measures evaluating perceived rapport and level of satisfaction with the interview. RESULTS: The patients gave high ratings to both satisfaction and ability to develop rapport for both the televideo and face-to-face interviews. The psychiatrists expressed significantly less satisfaction with the televideo interviews, but their actual ratings were positive. CONCLUSIONS: Despite geographic distance, televideo interviews allow a sense of connection between patient and psychiatrist. Lower-cost technology may increase the use of televideo to extend psychiatric service to geographically isolated communities.
Since the 1960s, televideo (a two-way televideo connection) has promised to ameliorate the problem of insufficient psychiatric service to geographically isolated communities. Although past use of televideo was restricted by cost and technologic limitations, currently televideo is more widely available and less expensive. Studies of earlier use of televideo technology in the field of psychiatry provided descriptive reports of its success (1). More recent studies have included control groups and outcome measures but have focused on the delivery of structured interviews by means of televideo. To our knowledge, there has been only one study (2) that used an outcome questionnaire to evaluate the use of televideo to provide general psychiatric assessments; the results suggested a generally high level of acceptance of televideo interviews among patients and doctors. The limitations of the study were use of a vague definition of “interview satisfaction” as an outcome measure and simulation of geographic distance by connecting two rooms in the same building. The purpose of the present study was to conduct a “real-life” pilot test of televideo while measuring more specifically patient and physician response to a general psychiatric interview conducted over an actual geographic distance.
METHOD
Patients were recruited from family practices in Campbellford, Ont., Canada (2 hours north of Toronto), and from an outpatient community mental health service associated with Campbellford Hospital. A recruitment letter was sent requesting patients who were in need of general psychiatric assessment. We excluded patients who could not speak English or were under 18 years of age, who were actively suicidal or homicidal or were in need of immediate hospitalization (the study protocol could not accommodate a need for immediate assessment), or who were seeking assessment for court or insurance purposes. After complete description of the study to the subjects, written informed consent was obtained.
All subjects underwent a face-to-face Structured Clinical Interview for DSM-III-R—Patient Version 1.0 (SCID-P) (3). Recruitment continued until there were 19 psychotic and 21 nonpsychotic patients. The patients in these two subgroups were then randomly assigned to the two types of interviews, televideo and face to face, which were unstructured and conducted by psychiatrists (A.S., N.D., D.G., P.V., and J.F.). The face-to-face interviews took place in Campbellford. In the televideo format, a psychiatrist in Toronto and a patient in Campbellford each sat in front of a televideo system that displayed a visual image of the other person on a 27-inch screen. Six switched-56 telephone lines (384 kbyte/sec) were used to transmit information digitally.
The five assessing psychiatrists were staff psychiatrists who were blind to the SCID-P diagnoses. They carried out 90-minute assessments meant to provide DSM-III-R diagnoses and treatment recommendations. Treatment recommendations included medical interventions, medications, individual therapy, family counseling, and psychoeducation. After each interview, the subject and psychiatrist filled out a modified version of the California Psychotherapy Alliance Scale (4, 5) and the Interview Satisfaction Scale. The California Psychotherapy Alliance Scale is a self-report measure using Likert scales to assess the patient’s and physician’s ability to work together and to develop rapport. The Interview Satisfaction Scale (available on request from the authors) was developed for the purposes of this study to ascertain the acceptability of the interview modality used. There is both a patient and a therapist version. This self-report questionnaire consists of 12 questions using Likert scales that address issues such as perception of eye contact, distance from the other person, and ability to read facial expression.
The SCID-P provided demographic data. Two-tailed t tests were used to assess whether the psychotic and nonpsychotic groups differed significantly in age. Chi-square tests were used to assess whether the two subject groups differed significantly according to sex, marital status, education, or employment status. The internal consistency of the Interview Satisfaction Scale and the California Psychotherapy Alliance Scale was tested by using an item-total correlation. The impact of the type of interview (televideo or face to face) on ratings on the outcome measures was assessed by using two-tailed t tests.
RESULTS
We recruited 18 men and 22 women into the study. The mean age of the subjects was 43.8 years (range=18–73). There were no significant differences between the psychotic and nonpsychotic groups with respect to sex, age, marital status, employment, and educational status. Results of the SCID-P indicated a broad range of diagnoses. Nine of the 19 patients with psychoses were randomly assigned to televideo interviews, and 10 were assigned to face-to-face interviews. Of the 21 nonpsychotic subjects, 11 were randomly assigned to televideo and 10 to face-to-face interviews.
Item-total correlations for the patient and therapist versions of the Interview Satisfaction Scale were reasonably good (alpha, 0.83 and 0.80, respectively). The item-total correlations (alpha, 0.84 and 0.93, respectively) for the modified patient and therapist versions of the California Psychotherapy Alliance Scale were equivalent to those previously reported, 5). Mean scores on each outcome measure for the total study group and for the televideo and face-to-face interviews can be seen in table 1.
There was no significant difference between the ratings for the televideo and face-to-face interviews on the patient version of the Interview Satisfaction Scale or on either the patient or therapist version of the California Psychotherapy Alliance Scale. However, there was a significant difference on the therapist version of the Interview Satisfaction Scale (table 1); the physicians rated the televideo interviews significantly less positively than those performed face to face.
DISCUSSION
Using psychometric evaluation, this study validated past anecdotal findings that patients accept televideo interviews as readily as those done face to face. Both patients and psychiatrists found that they were able to develop a sense of rapport equally well over televideo. These findings suggest that despite a real geographic distance, the televideo modality allows a sense of connection and understanding between users. The finding that physicians rated televideo interviews less positively on the Interview Satisfaction Scale than face-to-face interviews is similar to a result reported by Dongier et al., 2). While the difference was statistically significant, the actual physician ratings of satisfaction with the televideo interviews were positive. The less positive physician ratings of the televideo interviews may be explained by the fact that the physicians were exposed to both types of interviews and could more directly compare the two.
Although a wide range of psychiatric pathology was assessed in this study, the study group was small and did not include emergency or involuntary patients. This study also did not include a follow-up on the impact of treatment recommendations. However, the consulting psychiatrists were available to discuss their recommendations with the referring clinicians over the telephone. This mode of communication seemed acceptable but was not formally assessed.
Since the inception of this study, equipment that allows a televideo connection to be made through personal computers at a much lower cost (approximately $4,500 in Canadian dollars) has become available. This less costly technology is currently being used to establish an ongoing link between the Clarke Institute of Psychiatry and the Campbellford Wellness Clinic.
Footnote
Received Oct. 16, 1997; revisions received April 3 and Aug. 31, 1998; accepted Sept. 24, 1998. From the Department of Psychiatry, The Centre for Addiction and Mental Health—Clarke Division. Address reprint requests to Dr. Stevens, Psychotherapy Centre, The Centre for Addiction and Mental Health—Clarke Division, Rm. G7, 250 College St., Toronto, Ont., Canada M5T 1R8; [email protected] (e-mail). Funded by Health Canada through grant 6606-5514-55 from the National Health Research and Development Program. Video equipment used in this study was rented with the assistance of Tanberg Canada, and telephone connections were provided by Bell Canada. The authors thank the Campbellford Community Wellness Centre and Jacqueline Brunshaw for their contributions to this project, Dr. Elsa Marziali for feedback on the initial protocol, and Mrs. Olga Bunker for help in preparing the manuscript.
References
1.
Baer L, Elford R, Cukor P: Telepsychiatry at forty: what have we learned? Harvard Rev Psychiatry 1997; 5(1):7–17
2.
Dongier M, Tempier R, Lalinec-Michaud M, Meunier D: Telepsychiatry: psychiatric consultation through two-way television: a controlled study. Can J Psychiatry 1986; 31:32–34
3.
Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R—Patient Version 1.0 (SCID-P). Washington, DC, American Psychiatric Press, 1990
4.
Marmar CR, Horowitz MJ, Weiss DS, Marziali E: The development of the Therapeutic Alliance Rating System, in The Psychotherapeutic Process: A Research Handbook. Edited by Greenberg LS, Pinsof WM. New York, Guilford Press, 1986, pp 367–390
5.
Gaston L: Reliability and criterion-related validity of the California Psychotherapy Alliance Scales—patient version. J Consult Clin Psychol 1991; 3:68–74
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Published online: 1 May 1999
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