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Telemental health: Are we there yet?

An unacceptably large proportion of mentally ill individuals do not receive any care. Reasons vary but include the dearth of providers, the cost of treatment, and stigma. Telemental health, which uses digital technology for the remote delivery of mental health services, may help toward finding a solution. By bringing treatment to users’ fingertips, telemental health can address the access obstacle. By reducing reliance on expensive clinic infrastructure and the need to commute, it can save time and trim costs. By freeing patients of the need to go to psychiatric facilities, it can anonymize the process and diminish stigma. Several components comprise telemental health, including computerized cognitive behavioral therapy, online therapy, pharmacotherapy via videoconferencing, virtual reality exposure therapy, and mobile therapy.

Computerized cognitive behavioral therapy (cCBT) uses software programs to deliver automated psychotherapy via CD-ROMs and desktop programs. It is the oldest form of telemental health to be systematically developed and was utilized well before the advent of the Internet. Since CBT is often a standardized treatment, it was seen as lending itself well to the use of technology without active therapist participation. Thus, programs were developed that walked users through modules inspired by traditional CBT but meant to treat conditions like panic disorder and obsessive compulsive disorder with no therapist in sight.

Promising early results subsequently encouraged scholars to take advantage of the powers of the Internet in order to move cCBT from the aging compact disc to cyberspace. Thus, online therapy, including online CBT, was born. Three main forms of online therapy have been tested and are in use: “standalone” online therapy, i.e., self-paced web-based modules that bypass the therapist; “assisted” online therapy that allows for limited therapist involvement, such as via exchanged emails of text messages; or, “real time” online therapy, which consists of live online conversations with full therapist involvement, sometimes with a face-to-face component made possible through a video link.

Compared to the study of remote psychotherapy, the study of remote medication treatment for psychiatric illness has lagged relatively behind. Reasons include the need for more “hands on” care by the prescriber, such as to obtain vital signs or laboratory tests to track medication side effects or blood levels. However, limited data, such as from the field of treating attention deficit and hyperactivity disorder, point to the feasibility of remote medication delivery, provided certain conditions are met, such as the availability of local medical providers who can handle aspects of care that cannot be conducted remotely.

NEC-Medical-51 by NEC Corporation of America, CC BY 2.0 via Flickr
NEC-Medical-51 by NEC Corporation of America, CC BY 2.0 via Flickr.

Virtual Reality Exposure Therapy (VRET) can be seen as a therapeutic offshoot of the not-so-therapeutic video game addiction that now consumes many people’s lives. It refers to the use of virtual environments similar to those used in many video games to conduct exposure therapy by mimicking anxiety-triggering real-life situations. Through head-mounted displays, screens that wrap around patients, and other sophisticated equipment, VRET can produce realistic, 3-D representations of phobias and fears, such as driving on a bridge or seeing a snake, then gradually “desensitizes” patients to the resulting anxiety.

The most recent chapter of the telemental health revolution involves mobile therapy (mTherapy) and mirrors the broader shift to “mobile” that has overtaken the culture at large. mTherapy uses smartphone applications — over 3,000 mental health apps exist in the Apple and Google stores — and text messaging to deliver a wide range of therapy-enhancing services, such as text messages that serve as reminders of traditional appointments and applications that allow accurate in-the-moment symptom reporting. While research into their efficacy remains scarce, preliminary data suggest an expanding role for mTherapy, at least as tools that enhance traditional therapy.

It is estimated that up to half of healthcare delivery will be conducted electronically by 2020. However, despite promising data from several platforms, more research is needed to further test the efficacy, safety, confidentiality, and treatment adherence of the various telemental health options. Only with more research can their wider adoption be wholeheartedly recommended, especially when the traditional “gold standard” is available to the patient.

Featured image credit: “Runkeeper and health on iPhone” by Jason Howle. CC by 2.0 via Flickr

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