When I see someone the first time I usually do:

• the Short Portable Mental State Questionaire (SPMSQ),
• the Hamilton depression scale (HAMD), and
• the Brief Psychiatric Rating Scale (BPRS).

Depending on what else is going on, I sometimes do:

• the Mini-Mental State Exam (MMSE),
• the Hamilton Anxiety scale (HAMA),
• the Young Mania Scale (YMRS),
• the Adult ADHD Self-Report scale (ASRS) , or
• the Yale-Brown Obsessive Compulsive Scale (YBOCS).

For follow up visits, I sometimes do:

• the HAMD
• the HAMA, or
• the YMS,

depending on how the patient is doing.

Really, there aren’t that many things that you can’t do by telepsychiatry, but there are some. For example, it’s impossible to do parts of the AIMS without touching the patient, and the HAMD asks me to look for things like fidgetiness, which might be hard to see on a skype call.

I can see a PhD thesis in here somewhere called “Adapting Psychiatric Rating Scales for Telepsychiatry.”

I think that there is a psychological reaction to telepsychiatry that relates to how both the patient and the psychiatrist experience the encounter when it takes place over the Internet rather than in an office.

The first two psychological issues that come to my mind are:

• The patient and the psychiatrist each come with some attitude toward the technology, and
• The patient and the psychiatrist are in the same environment when they are face-to-face, but not when they are doing  telepsychiatry.

Regarding attitudes toward technology, I’ve certainly come to appreciate just how big the differences are between me and some of my patients. I work part time as a psychiatrist, and part time as an engineer. Not much about technology scares me, and I’m intrinsically friendly toward trying something new. Some of my patients share my attitudes, and some clearly do not. There is a clear age effect: I can’t think of one person under the age of 30 who has had trouble navigating my website or printing an Acrobat document. Among people who are age 50 and above though, I find that a substantial fraction don’t really understand hypertext links, what the scrollbar does, or how to use the back button on a browser.

It takes time for people to adjust to new things, and telepsychiatry isn’t any exception. If someone is phobic of technology, I see that as a problem worthy of treatment. I remember an therapeutic interchange I had with a 80 year old patient a few months ago. The patient lived alone in a rural area, and was just barely able to take care of herself. Her daughter, who lived a few miles away, was very worried for her mother’s safety and begged and begged her mother to carry a cell phone with her so that she could call for help if something happened to  her. The patient stubbornly refused to learn how to use her cell phone. I spent about 20 minutes with the patient one session working on this problem. It took 19 minutes to get the patient to overcome her resistance to trying something new and less than one minute to teach her how to push the speed dial key on her phone that would call 911 if she needed help. At the end of the session, the patient said, “I would have learned this a long time ago if I knew it was this easy.”

This isn’t to say that I can’t think of ways that the patient or the psychiatrist couldn’t get justifiably irritated by technical problems or a slow Internet connection. I also can’t see any reason why normal transference and countertransference issues couldn’t relate to the technology for telepsychiatry.

However, I believe the environment is probably more important for telepsychiatry than technophobia. In a face-to-face session, the patient and psychiatrist are in the same environment, while in telepsychiatry the patient and the psychiatrist are in different environments. When a patient comes to see me, we are both in my office together, and I try to keep the office quiet and to avoid interruptions. Because I have a fair amount of control over my office space, I can make sure that patients have a cup of tea or a glass of water if they want and that their session is not interrupted.  The patient has a few moments while waiting in the waiting room to settle down and think about what they want to say before they come through the door to my office.

The “teletransference” is highly dependent, not only on my environment (which I can control to some extent), but on the patient’s environment (which I can’t control at all.) I realize that I need to think about some straightforward things about my environment (such as what is in the background when I’m on Skype.)

A bigger issue though, is that I obviously need to think about how to help a telepsychiatry patient shape his or her environment to make the interaction better. Some obvious things come to mind:

• Privacy,
• Quiet,
• Comfort with the technology, and
• Freedom from interruptions.

I’ll write more about how to help the patient shape his or her environment in a later post.

So, a video call is probably almost always preferable to a telephone call for psychiatry. I can think of a few exceptions, such as when it isn’t appropriate for one of the parties on the call to show themselves or their environment. For example, I’ve certainly answered a telephone call after just getting out of the shower but that wouldn’t be the right time for a videocall!

So, I think it is hard to argue that whatever standard of care exists for conducting psychiatric care via a telephone is being compromised by a videocall. In fact, I could easily see an argument someday, not so far in the future, when a doctor is being questioned along the lines of “did you think of a videocall to the patient rather than a telephone call?,”  just like the question that comes up now sometimes, “did you think that maybe you should have seen the patient rather than trying to handle this over the phone?”

The interesting comparison here is thus not between a telephone call and a video call, but between a videocall and a face-to-face visit.

All the information that comes through in a face-to-face visit comes through my senses, so going through them one-by-one:

Hearing

Voice quality on most telephone and videocalls is pretty good these days. As long as the microphone is of reasonable quality, close to the speaker’s mouth, and the line isn’t too noisy, I can’t see that there would be much difference in how much auditory information gets through when the visit goes through a videocall versus what I hear when I’m face to face with them.

Smelling

Well, nothing like this comes through the Internet, so face-to face-wins  here. Most of what I do as a psychiatrist doesn’t involve scent, but I can think of three examples:

• Smelling marijuana or alcohol on someone
• Noticing an excessive amount of perfume on someone, and
• Noticing that someone is not being attentive to personal hygiene

Tasting

Can’t taste through the Internet, but I can’t think of any time that I can remember getting any important information that way when I was face to face with someone, except once when a patient brought me one freshly made chocolate chip cookie when she came for an appointment.

Touching

Tactile information doesn’t come easily via the Internet. (I understand though that tactile feedback is extremely important  in situations like robotic surgery.) For psychiatry, there are a few times that touch is essential.

• I can’t get a blood pressure or a pulse on a videocall.
• I can’t push on someone’s ankle to see if he or she has pitting edema.
• I can’t do a point-to-point movement evaluation. (But I can think of a sort of comical equivalent.)

Although touch can sometimes be important, there isn’t much psychiatrically important information that comes that way through in a face-to-face interview.

Seeing

This is where almost all the the potentially clinically important differences between telepsychiatry and face-to-face psychiatry arise. I need to write about this in more detail later, but two things are obvious right away.

First, the visual information I get in a face-to-face interaction is much more detailed. When I first started doing Skype, I was delighted that video quality was good enough to see someone’s eye color or the shape of the earrings someone was wearing. I will bet though that this kind of degradation of visual information isn’t going to be very important in a short time–just look at any decent HDTV these days and you can see the pores on someone’s face. It’s pretty easy to predict that technology will close this gap relatively soon.

Second, if I’m face to face with someone I can glance over towards  her hand as  she reaches for a cup of water and see if she has a tremor without calling this bit of information gathering to her attention. Technology to remotely control a camera already exists and I don’t think it would be that hard for webcams to have a remotely controlled sensor. I’m not sure this will catch on.  I can imagine a scene like a bad science fiction move with the little robot eyeball looking around.

In summary, it looks to me like there’s really not much difference between face-to-face and telepsychiatry in terms of sensory input most of the time.

I’ve not talked about here something really important—the psychological impact of face-to-face versus telepsychiatry—and I need to think about that some more.