- Email: [email protected]
Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the ED
YAJEM-57056; No of Pages 2 American Journal of Emergency Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department
Keywords: Telehealth Mental health
To the Editor: Mental health illnesses are becoming increasingly common across the United States. In 2014 approximately 18% of all U.S. adults, nearly 44 million individuals, were diagnosed with some form of psychiatric or behavioral disorder during the past year [1]. The associated morbidity and mortality of mental health illness is significant and represents a growing challenge affecting multiple practice care environments [2-4]. In particular, emergency departments (EDs) have seen an increasing proportion of visits related to mental health complaints. Approximately 1 in 8 ED visits involve a mental health chief complaints [5], with the rate of mental health related ED visits increasing over 15% during the period of 2007 and 2011 [6]. The care of patients with mental health complaints in the ED presents numerous challenges for the acute care provider. Psychiatric specialist consultation or nearby referral may not be readily available for continuous ED coverage or limited due to geographic restrictions [7]. Additionally, some patients presenting to the ED with behavioral chief complaints may require extensive coordination of outpatient psychiatric services and social services which would otherwise result in prolonged ED observations and potentially unnecessary inpatient admissions. In the setting of these challenges, the development of novel patient platforms such as telemedicine may offer an innovative approach to mental health care in the ED that may optimize and improve patient outcomes while also helping to reduce challenges such as ED overcrowding and limited specialist availability. Telemedicine is defined broadly as the practice of medical care using interactive audio, visual, and data communications [8]. Over the last decade the use of telemedicine has seen a robust growth with regards to addressing a wide range of medical complaints across the outpatient setting. Its implementation in the urgent care setting has been found to reduce overall patient wait times [9] and overall treatment times [10]. Telemedicine has not been limited to minor medical complaints. The development of telemedicine neurology programs across EDs has resulted in “telestroke” initiatives, whereby on-call stroke neurologists and emergency providers are able to assess and at times treat acute ischemic events remotely [11]. To date such programs have shown potential improvements in time to administration of critical interventions such as time to thrombolysis while maintaining similar safety profiles as traditional stroke care programs [12]. Telepsychiatry can be defined as the use of information and communication technology to deliver or support psychiatric services across
distances [13]. Synchronous or interactive forms of communication such as live video-conferencing offer the potential for multiple forms of psychiatric intervention in the ED. The evidence for the use of telepsychiatry in the inpatient and outpatient setting has been growing. Past work has found that telepsychiatry platforms have been equivalent with regards to psychiatric diagnostic accuracy and assessment for mental illnesses such as depression, schizophrenia, and posttraumatic stress disorder [14]. Additionally, numerous programs have published their success in administering various forms of psychotherapy using a telemedicine platform, including cognitive behavior therapy [14,15], group therapy for depression and anxiety [16] and supportive therapy for PTSD patients such as war veterans and women survivors of domestic violence [17]. Initial evidence on the success of these telepsychiatry programs has been encouraging. Numerous studies have found that among adults and adolescents, overall patient satisfaction and subjective effectiveness of telepsychiatry has been equivalent to traditional forms of psychiatric care [18]. Additionally, particular patients have been found to actually prefer telepsychiatry to in-person care; individuals with severe anxiety disorders, or individuals with severe physical limitations may find the remote treatment particularly useful [19]. While telemedicine programs have witnessed an explosion of growth across EDs the use of ED telepsychiatry remains relatively rare [20]. In a survey of several ED telepsychiatry programs, researchers found that key challenges included financial sustainability of such programs ranging from initial upfront startup costs to ongoing carrying costs associated with maintaining such a program. In this setting, a critical need for rigorous study of ED telepsychiatry is needed. Future work may explore the potential impact of telepsychiatry on a broad range of outcomes. For example, ED overcrowding has been associated with multiple negative outcomes from patient satisfaction, medical errors, and patient perceptions of clinician communication [21-24]. ED telepsychiatry may help offset patient burden in the ED and improve overall length of stay and patient satisfaction in the management of certain acute psychiatric complaints. Such improvements in ED outcomes may help lend support to institutional support for the use of programs and interventions. ED telepsychiatry represents a promising avenue for the timely evaluation and management of certain mental health complaints. Future research devoted to increasing our understanding of the potential role for such technological platforms in the ED will help place emergency medicine providers at the forefront of the development of novel strategies aimed at optimizing patient care delivery and improving the overall well-being of patients with mental illness.
Grant BC is supported by a mentored career development grant by the National Institute of Health/NCAT (KL2 TRANSFORM: KL2TR0001874) and the NY Empire Clinical Research Investigator Program.
0735-6757/© 2017 Published by Elsevier Inc.
Please cite this article as: Heravian A, Chang BP, Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.053
2
Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department
Meetings None. Anisa Heravian M.D.1 Bernard P. Chang M.D., Ph.D.* Department of Emergency Medicine, Columbia University Medical Center (BC), Department of Emergency Medicine, Permanente Medical Group Oakland Medical Center (AH), United States *Corresponding author at: 622 West 168th Street, Department of Emergency Medicine, VC 2nd Floor Suite 260, New York, NY 10032, United States. E-mail address: [email protected] (B. P. Chang). 20 October 2017 Available online xxxx https://doi.org/10.1016/j.ajem.2017.10.053
References [1] Olfson M, Blanco C, Wang S, Laje G, Correll CU. National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA Psychiat 2014;71:81–90. [2] Parks J, Svendsen D, Singer P, Foti ME, Mauer B. Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council; 2006; 25. [3] Lenzenweger MF, Nakayama K, Chang BP. Methodological excursions in pursuit of a somatosensory dysfunction in schizotypy and schizophrenia; 2003. [4] Chang B, Franklin J, Ribeiro J, et al. Biological risk factors for suicidal behaviors: a meta-analysis. Transl Psychiatry 2016;e887:6. [5] Owens P, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007 (Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief# 92); 2016. [6] Weiss A, Barrett M, Heslin K, Stocks C. Trends in emergency department visit involving mental and substance use disorders, 2006–2013. , 216Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project Statistical Brief; 2016. [7] Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med 2004;11:193–5.
[8] Wootton R, Craig DJ, Patterson V. Introduction to telemedicine. Royal Society of Medicine Press London; 2006. [9] Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff 2010;29:1630–6. [10] Farmer A, Gibson O, Hayton P, et al. A real-time, mobile phone-based telemedicine system to support young adults with type 1 diabetes. J Innov Health Inf 2005;13: 171–7. [11] Switzer JA, Hall C, Gross H, et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. J Emerg Med 2009;36:12–8. [12] Pervez MA, Silva G, Masrur S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010;41:e18–24. [13] Malhotra S, Chakrabarti S, Shah R. Telepsychiatry: promise, potential, and challenges. Indian J Psychiatry 2013;55:3. [14] García-Lizana F, Muñoz-Mayorga I. What about telepsychiatry? A systematic review. Prim Care Companion J Clin Psychiatry 2010;12. [15] Monnier J, Knapp RG, Frueh BC. Recent advances in telepsychiatry: an updated review. Psychiatr Serv 2003;54:1604–9. [16] Fortney JC, Pyne JM, Edlund MJ, et al. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med 2007;22:1086–93. [17] Hassija C, Gray MJ. The effectiveness and feasibility of videoconferencing technology to provide evidence-based treatment to rural domestic violence and sexual assault populations. Telemedicine and e-health, 17. ; 2011. p. 309–15. [18] Bishop JE, O'Reilly RL, Maddox K, Hutchinson LJ. Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. J Telemed Telecare 2002;8:217–21. [19] Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv 2007;58:1493–6. [20] Williams M, Pfeffer MM, Hilty DM. Telepsychiatry in the emergency department. California HealthCare Foundation; 2009. [21] Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med Off J Soc Acad Emerg Med 2006;13:873–8. [22] Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med 2008;15:825–31. [23] Chang BP, Sumner JA, Haerizadeh M, Carter E, Edmondson D. Perceived clinician-patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome. Emerg Med J 2016;33:626–31. [24] Chang BP, Carter E, Suh EH, Kronish IM, Edmondson D. Patient treatment in ED hallways and patient perception of clinician-patient communication. Am J Emerg Med 2016;34:1163–4.
1 Department of Emergency Medicine, Permanente Medical Group Oakland, 3600 Broadway, Oakland, CA 94611.
Please cite this article as: Heravian A, Chang BP, Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.053
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department
Keywords: Telehealth Mental health
To the Editor: Mental health illnesses are becoming increasingly common across the United States. In 2014 approximately 18% of all U.S. adults, nearly 44 million individuals, were diagnosed with some form of psychiatric or behavioral disorder during the past year [1]. The associated morbidity and mortality of mental health illness is significant and represents a growing challenge affecting multiple practice care environments [2-4]. In particular, emergency departments (EDs) have seen an increasing proportion of visits related to mental health complaints. Approximately 1 in 8 ED visits involve a mental health chief complaints [5], with the rate of mental health related ED visits increasing over 15% during the period of 2007 and 2011 [6]. The care of patients with mental health complaints in the ED presents numerous challenges for the acute care provider. Psychiatric specialist consultation or nearby referral may not be readily available for continuous ED coverage or limited due to geographic restrictions [7]. Additionally, some patients presenting to the ED with behavioral chief complaints may require extensive coordination of outpatient psychiatric services and social services which would otherwise result in prolonged ED observations and potentially unnecessary inpatient admissions. In the setting of these challenges, the development of novel patient platforms such as telemedicine may offer an innovative approach to mental health care in the ED that may optimize and improve patient outcomes while also helping to reduce challenges such as ED overcrowding and limited specialist availability. Telemedicine is defined broadly as the practice of medical care using interactive audio, visual, and data communications [8]. Over the last decade the use of telemedicine has seen a robust growth with regards to addressing a wide range of medical complaints across the outpatient setting. Its implementation in the urgent care setting has been found to reduce overall patient wait times [9] and overall treatment times [10]. Telemedicine has not been limited to minor medical complaints. The development of telemedicine neurology programs across EDs has resulted in “telestroke” initiatives, whereby on-call stroke neurologists and emergency providers are able to assess and at times treat acute ischemic events remotely [11]. To date such programs have shown potential improvements in time to administration of critical interventions such as time to thrombolysis while maintaining similar safety profiles as traditional stroke care programs [12]. Telepsychiatry can be defined as the use of information and communication technology to deliver or support psychiatric services across
distances [13]. Synchronous or interactive forms of communication such as live video-conferencing offer the potential for multiple forms of psychiatric intervention in the ED. The evidence for the use of telepsychiatry in the inpatient and outpatient setting has been growing. Past work has found that telepsychiatry platforms have been equivalent with regards to psychiatric diagnostic accuracy and assessment for mental illnesses such as depression, schizophrenia, and posttraumatic stress disorder [14]. Additionally, numerous programs have published their success in administering various forms of psychotherapy using a telemedicine platform, including cognitive behavior therapy [14,15], group therapy for depression and anxiety [16] and supportive therapy for PTSD patients such as war veterans and women survivors of domestic violence [17]. Initial evidence on the success of these telepsychiatry programs has been encouraging. Numerous studies have found that among adults and adolescents, overall patient satisfaction and subjective effectiveness of telepsychiatry has been equivalent to traditional forms of psychiatric care [18]. Additionally, particular patients have been found to actually prefer telepsychiatry to in-person care; individuals with severe anxiety disorders, or individuals with severe physical limitations may find the remote treatment particularly useful [19]. While telemedicine programs have witnessed an explosion of growth across EDs the use of ED telepsychiatry remains relatively rare [20]. In a survey of several ED telepsychiatry programs, researchers found that key challenges included financial sustainability of such programs ranging from initial upfront startup costs to ongoing carrying costs associated with maintaining such a program. In this setting, a critical need for rigorous study of ED telepsychiatry is needed. Future work may explore the potential impact of telepsychiatry on a broad range of outcomes. For example, ED overcrowding has been associated with multiple negative outcomes from patient satisfaction, medical errors, and patient perceptions of clinician communication [21-24]. ED telepsychiatry may help offset patient burden in the ED and improve overall length of stay and patient satisfaction in the management of certain acute psychiatric complaints. Such improvements in ED outcomes may help lend support to institutional support for the use of programs and interventions. ED telepsychiatry represents a promising avenue for the timely evaluation and management of certain mental health complaints. Future research devoted to increasing our understanding of the potential role for such technological platforms in the ED will help place emergency medicine providers at the forefront of the development of novel strategies aimed at optimizing patient care delivery and improving the overall well-being of patients with mental illness.
Grant BC is supported by a mentored career development grant by the National Institute of Health/NCAT (KL2 TRANSFORM: KL2TR0001874) and the NY Empire Clinical Research Investigator Program.
0735-6757/© 2017 Published by Elsevier Inc.
Please cite this article as: Heravian A, Chang BP, Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.053
2
Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department
Meetings None. Anisa Heravian M.D.1 Bernard P. Chang M.D., Ph.D.* Department of Emergency Medicine, Columbia University Medical Center (BC), Department of Emergency Medicine, Permanente Medical Group Oakland Medical Center (AH), United States *Corresponding author at: 622 West 168th Street, Department of Emergency Medicine, VC 2nd Floor Suite 260, New York, NY 10032, United States. E-mail address: [email protected] (B. P. Chang). 20 October 2017 Available online xxxx https://doi.org/10.1016/j.ajem.2017.10.053
References [1] Olfson M, Blanco C, Wang S, Laje G, Correll CU. National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA Psychiat 2014;71:81–90. [2] Parks J, Svendsen D, Singer P, Foti ME, Mauer B. Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council; 2006; 25. [3] Lenzenweger MF, Nakayama K, Chang BP. Methodological excursions in pursuit of a somatosensory dysfunction in schizotypy and schizophrenia; 2003. [4] Chang B, Franklin J, Ribeiro J, et al. Biological risk factors for suicidal behaviors: a meta-analysis. Transl Psychiatry 2016;e887:6. [5] Owens P, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007 (Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief# 92); 2016. [6] Weiss A, Barrett M, Heslin K, Stocks C. Trends in emergency department visit involving mental and substance use disorders, 2006–2013. , 216Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project Statistical Brief; 2016. [7] Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med 2004;11:193–5.
[8] Wootton R, Craig DJ, Patterson V. Introduction to telemedicine. Royal Society of Medicine Press London; 2006. [9] Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff 2010;29:1630–6. [10] Farmer A, Gibson O, Hayton P, et al. A real-time, mobile phone-based telemedicine system to support young adults with type 1 diabetes. J Innov Health Inf 2005;13: 171–7. [11] Switzer JA, Hall C, Gross H, et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. J Emerg Med 2009;36:12–8. [12] Pervez MA, Silva G, Masrur S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010;41:e18–24. [13] Malhotra S, Chakrabarti S, Shah R. Telepsychiatry: promise, potential, and challenges. Indian J Psychiatry 2013;55:3. [14] García-Lizana F, Muñoz-Mayorga I. What about telepsychiatry? A systematic review. Prim Care Companion J Clin Psychiatry 2010;12. [15] Monnier J, Knapp RG, Frueh BC. Recent advances in telepsychiatry: an updated review. Psychiatr Serv 2003;54:1604–9. [16] Fortney JC, Pyne JM, Edlund MJ, et al. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med 2007;22:1086–93. [17] Hassija C, Gray MJ. The effectiveness and feasibility of videoconferencing technology to provide evidence-based treatment to rural domestic violence and sexual assault populations. Telemedicine and e-health, 17. ; 2011. p. 309–15. [18] Bishop JE, O'Reilly RL, Maddox K, Hutchinson LJ. Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. J Telemed Telecare 2002;8:217–21. [19] Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv 2007;58:1493–6. [20] Williams M, Pfeffer MM, Hilty DM. Telepsychiatry in the emergency department. California HealthCare Foundation; 2009. [21] Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med Off J Soc Acad Emerg Med 2006;13:873–8. [22] Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med 2008;15:825–31. [23] Chang BP, Sumner JA, Haerizadeh M, Carter E, Edmondson D. Perceived clinician-patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome. Emerg Med J 2016;33:626–31. [24] Chang BP, Carter E, Suh EH, Kronish IM, Edmondson D. Patient treatment in ED hallways and patient perception of clinician-patient communication. Am J Emerg Med 2016;34:1163–4.
1 Department of Emergency Medicine, Permanente Medical Group Oakland, 3600 Broadway, Oakland, CA 94611.
Please cite this article as: Heravian A, Chang BP, Mental health and telemedicine in the acute care setting: Applications of telepsychiatry in the emergency department, American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2017.10.053