Journal of Telemedicine

and Telecare
http://jtt.sagepub.com/

International telepsychiatry: a review of what has been published

Hussam Jefee Bahloul and Nithya Mani
J Telemed Telecare 2013 19: 293
DOI: 10.1177/1357633X13495480
The online version of this article can be found at:
http://jtt.sagepub.com/content/19/5/293

Published by:
http://www.sagepublications.com

Additional services and information for Journal of Telemedicine and Telecare can be found at:
Email Alerts: http://jtt.sagepub.com/cgi/alerts
Subscriptions: http://jtt.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Sep 5, 2013

What is This?

Downloaded from jtt.sagepub.com at UNIV AUTONOMA DE NUEVO LEON on November 22, 2013

TAILPIECE

Correspondence

.................................................................................................................................

International telepsychiatry: a review of

what has been published

..............................................................
Telepsychiatry is a cost-effective way of increasing access
to mental health care.1 Recent systematic reviews and
meta-analyses of randomised controlled trials suggest that
telepsychiatry is as effective as in-person psychiatry
encounters.2,3 The use of telepsychiatry to treat underserved
minority groups and patients in rural areas has been
suggested by many authors.4 7 However little is known
about the effectiveness and problems that may be faced if
telepsychiatry is used to provide care internationally. To our
knowledge this has not been studied thoroughly. We
therefore conducted a comprehensive review of the
literature in April 2013.
The studies identified in the search were cross-border
international studies of the clinical use of telepsychiatry,
conducted in real-time (i.e. by videoconferencing) and
written in English. We excluded the domestic use of
telepsychiatry in rural areas, use of real-time modalities
other than videoconferencing (e.g. telephone, email,
audio-chat), and non-real-time telepsychiatry (e.g.
store-and-forward). Three search engines were used:
Pubmed, PsycINFO (Ovid) and Google Scholar. PubMed and
Ovid were searched using the following terms: (telepsych
OR e-health OR videoconfer ) AND (international OR
cross-border OR borders OR global). Google Scholar was
searched using combinations of the following terms:
international, cross-border, telepsychiatry, telepsychology.
References in the articles found were searched as well for
potential studies not identified by the initial search.
The search findings of the two reviewers were compared
with each other and disagreements were resolved by
consensus. The highest level of evidence would be large
randomized controlled trials (RCTs) that compared
international telepsychiatry to control interventions, such
as no treatment, waiting lists, domestic face-to-face
encounters or domestic telepsychiatry. Based on previous
studies that graded the evidence for domestic
telepsychiatry,2 we used the Cochrane8 and UpToDate9
grading recommendations to propose a grading scale for
studies concerning international telepsychiatry (Table 1).
Table 1 Strength of evidence for international telepsychiatry studies
Level Evidence Description
I

Strong

II

Fair

III

Poor

Large well designed RCT comparing international

telepsychiatry to no-treatment control interventions,
face-to-face encounters or domestic telepsychiatry
Small well designed RCT (or large RCT with limitations)
comparing international telepsychiatry to no-treatment
control interventions, face-to-face encounters or
domestic telepsychiatry
RCTs with serious flaws, feasibility studies, observational
studies, acceptability studies, case studies or
descriptive studies with no clinical outcome measures

Our initial search resulted in 882 papers (PubMed 237,

Ovid 172, Google Scholar 473). After removing duplicates,
186 studies were screened, resulting in 20 studies that were
read in full-text. Of those studies only four met the full
criteria. The studies found were all feasibility studies.
No RCTs were found. All studies were graded Level III,
indicating poor evidence for the effectiveness of
international telepsychiatry.

Studies reviewed

..............................................................
Samuels made a brief report, in a letter to the editor, about
an international telepsychiatry experience.10 The
consulting psychiatrist was licensed in Australia but living
in New Zealand while providing care for two patients in a
facility in Australia. One of the cases was a new consultation
and the other was a follow up. The letter only described the
experience and no clinical or non-clinical outcome
measures were reported.10
Harley et al. reported a six-month trial of telepsychiatry
tertiary care provided from South London to the island of
Jersey. The study reported five teleconsultations consisting
of one second-opinion consultation and four case reviews.
All of the cases in the study involved treatment-resistance. A
post-encounter survey reported a high level of satisfaction
from all parties involved, although no clinical outcome
measures were tested.11,12
Mucic reported a pilot trans-cultural telepsychiatry
project, in which 61 asylum seekers, refugees and
immigrant patients living in Denmark were seen via
videoconferencing by psychiatrists located either in
Denmark (n 31) or Sweden (n 30). Both diagnostic
assessments and treatment planning were provided by
telepsychiatry. Psychiatrists were matched by language and
cultural backgrounds with the patients. The majority of
patients reported satisfaction with the telepsychiatry
experience and a preference to use it in future, rather than
travelling to see a psychiatrist face-to-face who spoke their
native language.13,14 Again no clinical outcome measures
were tested.
Fishkin et al. reported using videoconferencing to provide
psychoanalytical treatments and training, to psychoanalysis
candidates in China by psychoanalysts living in the US.
Forty psychoanalytic and 30 psychodynamic
psychotherapies were reported. The authors did not report
any data about acceptance or clinical outcomes.15
Finally, one study met three of our four inclusion criteria.
The study was designed to test the feasibility of educational,
not clinical, international telepsychiatry in teaching
Swedish medical students about trans-cultural issues in
refugees with mental health problems. Telepsychiatry was
performed from Sweden to the US or Australia, with one real
patient at the American site and one simulated patient at

Journal of Telemedicine and Telecare 2013; 19: 293 294

Downloaded from jtt.sagepub.com at UNIV AUTONOMA DE NUEVO LEON on November 22, 2013

H Jefee Bahloul and N Mani

International telepsychiatry

the Australian site. The patients were interviewed by experts

while medical students observed the interview by
videoconference and participated in the discussion. The
only reported outcome was of acceptability, for which all
parties gave good ratings.16

Discussion

..............................................................

To conclude, our work highlights the need for more

and better-designed studies that evaluate the utility and
effectiveness of international telepsychiatry. There is
primarily a need for clinical trials that compare the
effectiveness of international telepsychiatry with
conventional domestic face-to-face psychiatry. There is
also a need to study the logistical problems that will arise
when attempting to practise psychiatry among different
countries. The literature lacks studies designed for
developing countries that lack mental health services.
This is particularly important as international
telepsychiatry can be proposed as a mean of lightening
the global mental health burden.

The studies identified in the review reported the use of

telepsychiatry between two or more countries. None of the
studies involved an underserved or developing country.
However, one study targeted a patient population that was
considered underserved, the refugee population.13,14 Given
the paucity of findings in our review, we expanded our
definition of international to include a study conducted
between England and the island of Jersey.11,12 Jersey is a
British Crown Dependency, with its own financial, legal and
judicial systems.17 Therefore, it has an international
identity separate from that of England.
None of the studies identified in the review provided
any clinical outcome data. Only two studies provided data
about patient and/or provider satisfaction with the
telepsychiatry services, and both showed a high level of
satisfaction.11 14 The scarcity of RCTs concerning
international telepsychiatry could be due to limited
interest, insufficient guidelines or the cost of conducting
comparison studies. We believe that there are multiple
challenges facing international telepsychiatry such as
legislational, jurisdictional and medico-legal matters, and
the infrastructure of the receiving developing countries.
This may explain why the domestic effectiveness of
telepsychiatry has not yet been confirmed internationally.
Most of the studies identified in the review were culturally
sensitive, since treatment was provided by psychiatrists who
shared the language and the cultural backgrounds of their
patients. We found only one study of cross-cultural
characteristics where Chinese psychoanalytic candidates
received psychoanalytic psychotherapies by providers
trained in the US.15 Although differing cultural
backgrounds are inherent in all types of psychiatry,
they may play a larger role in the context of international
telepsychiatry. In these situations the doctor has less
common ground from which to understand the patients
circumstances, which may compromise the quality of care.
The Global Healthcare Applications Projects (GHAP) and
the International Society for Mental Health Online
(ISMHO) have published guidelines for domestic
telemedicine and telepsychiatry, respectively, but neither
mention international telepsychiatry.18,19 There is a need
for international guidelines. These should ensure that,
when international telepsychiatry is provided, there are no
difficulties with matters such as licensing, liability,
medico-legal and malpractice. At the same time these
guidelines should ensure that any services provided will
meet accepted international standards of care.

1 Hyler SE, Gangure DP. A review of the costs of telepsychiatry. Psychiatr Serv
2003;54:976 80
oz-Mayorga I. What about telepsychiatry? A
2 Garca-Lizana F, Mun
systematic review. Prim Care Companion J Clin Psychiatry 2010;12(2)
3 Hyler SE, Gangure DP, Batchelder ST. Can telepsychiatry replace in-person
psychiatric assessments? A review and meta-analysis of comparison
studies. CNS Spectr 2005;10:403 13
4 Rabinowitz T, Murphy KM, Amour JL, Ricci MA, Caputo MP, Newhouse
PA. Benefits of a telepsychiatry consultation service for rural nursing
home residents. Telemed J E Health 2010;16:34 40
5 Rohland BM. Telepsychiatry in the heartland: if we build it, will they
come? Community Ment Health J 2001;37:449 59
6 Shore JH, Manson SM. A developmental model for rural telepsychiatry.
Psychiatr Serv 2005;56:976 80
7 Thara R. Using mobile telepsychiatry to close the mental health gap. Curr
Psychiatry Rep 2012;14:167 8
8 Cochrane Collaboration. The GRADE approach. See http://handbook.
cochrane.org/chapter_12/12_2_1_the_grade_approach.htm (last checked
18 May 2013)
9 Wolters Kluwer Health. Grading guide. See http://www.uptodate.com/
home/grading-guide (last checked 18 May 2013)
10 Samuels A. International telepsychiatry: a link between New Zealand and
Australia. Aust N Z J Psychiatry 1999;33:284 6
11 Harley J. Economic evaluation of a tertiary telepsychiatry service to an
island. J Telemed Telecare 2006;12:354 7
12 Harley J, McLaren P, Blackwood G, Tierney K, Everett M. The use of
videoconferencing to enhance tertiary mental health service provision to
the island of Jersey. J Telemed Telecare 2002;8(Suppl. 2):36 8
13 Mucic D. International telepsychiatry: a study of patient acceptability.
J Telemed Telecare 2008;14:241 3
14 Mucic D. Transcultural telepsychiatry and its impact on patient
satisfaction. J Telemed Telecare 2010;16:237 42
15 Fishkin R, Fishkin L, Leli U, Katz B, Snyder E. Psychodynamic treatment,
training, and supervision using internet-based technologies. J Am Acad
Psychoanal Dyn Psychiatry 2011;39:155 68
16 Ekblad S, Manicavasagar V, Silove D, et al. The use of international
videoconferencing as a strategy for teaching medical students about
transcultural psychiatry. Transcult Psychiatry 2004;41:120 9
17 States of Jersey. Jersey facts and figures. See http://www.gov.je/Jersey/
Pages/Profile.aspx (last checked 18 May 2013)
18 Hsiung RC. Suggested principles of professional ethics for the online
provision of mental health services. Telemed J E Health 2001;7:39 45
19 Nerlich M, Balas EA, Schall T, et al. Teleconsultation practice guidelines:
report from G8 Global Health Applications Subproject 4. Telemed J E
Health 2002;8:411 8

294

Journal of Telemedicine and Telecare Volume 19 Number 5

Hussam Jefee Bahloul and Nithya Mani

Department of Psychiatry, University of Texas Southwestern, Dallas, Texas, USA
Correspondence: Dr Hussam Jefee Bahloul, Department of Psychiatry,
University of Texas Southwestern, Dallas, Texas 75235, USA
(Email: hussam.jefeebahloul@gmail.com)
DOI: 10.1177/1357633X13495480

References

Downloaded from jtt.sagepub.com at UNIV AUTONOMA DE NUEVO LEON on November 22, 2013

2013