Curr Psychiatry Rep (2015) 17:89

DOI 10.1007/s11920-015-0630-9

PSYCHIATRY IN THE DIGITAL AGE (JS LUO, SECTION EDITOR)

Telepsychiatry Today
Steven Chan 1 & Michelle Parish 1,2 & Peter Yellowlees 1

# Springer Science+Business Media New York 2015

Abstract The use of video-based telepsychiatry is increasing

in response to consumer demand for convenient, inexpensive,
and readily accessible services; improved financial reimbursement; and a robust body of evidence-based literature.
Telepsychiatry leads to high patient and provider satisfaction
ratings, and outcomes equivalent to in-person care, while
younger generations often prefer telepsychiatry over face-toface encounters. The evidence base for telepsychiatry is especially strong with respect to the treatment of post-traumatic
stress disorder (PTSD), depression, and ADHD, while its use
in underserved ethnic groups is well described in the American Indian, Hispanic, and Asian populations. Despite this,
telepsychiatry barriers still persist. These include personal biasespecially in leadershipand insufficient training; the
challenging business environment and legislative processes;
and inconsistent reimbursement, licensing, and prescription
policies. Technology is now less of a barrier, and it is clear
that telepsychiatry overall is flourishing and changing the way
that providers are working and patients are being treated.
Keywords Telepsychiatry . Telemedicine . Video
consultation . Technology . Innovation

This article is part of the Topical Collection on Psychiatry in the Digital

Age
* Steven Chan
steven@berkeley.edu
1

Department of Psychiatry & Behavioral Sciences, University of

California, Davis School of Medicine & Health System, 2230
Stockton Boulevard, Sacramento, CA 95817, USA

Betty Irene Moore School of Nursing, University of California,

Davis, 2230 Stockton Boulevard, Sacramento, CA 95817, USA

Introduction
Telemedicines definitions vary in scope. Some broadly define
it as the transfer of medical information from one site to another by electronic communications, encompassing not just
two-way video, but also e-mail, smartphones, and other telecommunications technology, with the ultimate goal of diagnosing and treating illnesses [1, 2]. This broad definition implies the potential to shift medical care towards new models of
Bencounterless^ digital communication [3]. In a more focused
definition, the Centers for Medicare and Medicaid Services
define telemedicine as two-way, real-time interactive communication. This occurs between a patient and a practitioner at
distant sites [4]. This often is referred to as synchronous
telemedicine.
Telepsychiatryinterchangeably known as telemental
healthis the application of telemedicine to mental health.
Though telepsychiatry can encapsulate the aforementioned
broader definition of not just video but also smartphone apps,
mobile devices, and sensors [511], this paper will specifically
cover synchronous telepsychiatry as video-based health services involving the transmission of video over distance, and
briefly discuss non-real-timeor asynchronousmethods of
video consults. Research from 2012 through 2015 will primarily be discussed and reviewed.

Advantages of Telepsychiatry
A significant amount of research has demonstrated the advantages of telepsychiatry beyond increasing access to care. Use
of telepsychiatry leads to high patient and provider satisfaction ratings and achieves health outcomes equivalent to inperson care [12]. Younger generationschildren and adolescentsparticularly prefer telepsychiatry over in-person

89

Page 2 of 9

face-to-face encounters, due to their familiarity with video

apps. In our experience, telepsychiatry encourages intimate
conversations and unique clinical observation opportunities
such as the patients home environment; is often preferable
where patients have paranoia, anxiety, or PTSD; and works
in settings such as nursing home populations, where patients
have multiple disabilities.
Telepsychiatry is versatile and is already used in a variety of settings. In outpatient clinics, the technology is used
for diagnosis and treatment, which can include medication
management, individual psychotherapy, and group psychotherapy. It can also be used for consultations in primary
care, to the home, and to specialist clinics, including pain,
obesity, and surgery clinics. Within hospitals and mental
health facilities, telepsychiatry is used for consultation and
emergencies, as well as widely in correctional, and substance use rehabilitation settings. The technology has been
implemented and used for all ages: children, adults, and the
elderly.

Historical and Current Trends in Adopting

Telepsychiatry
Historically, video-based telepsychiatry first developed as
a way for mental health professionals to reach patients in
remote areas. The University of Nebraskas Nebraska Psychiatric Institute hosted the first video-based psychiatric
consults in 1959 [13]. Renewed interest in telepsychiatry
occurred in the 1990salong with interest in teleradiology
and teledermatologywith large networks built throughout the USA [14], Canada, and Australia, though its
adoption was still hampered by limited bandwidth. Since
the 2000s, telepsychiatry experienced another boost in
popularity due to increased network speeds and new reimbursement models.
More recently, telemedicine has shifted towards web
and mobile technologies, with a boom in commercial companies and medical services. A variety of factors have
fueled this trend: increased Internet access even in isolated
communities; consumer preferences for convenient, inexpensive on-demand services; and expectations and acceptance of telemedicine by Millennials. Federal reimbursement is slowly gaining traction as the Centers for Medicare
and Medicaid have made recent moves towards telehealth
parity coverage and expanded reimbursement [15]. Businesses have also taken note, as the number of employers
offering telemedicine is predicted to expand from 22 % in
2014 to 37 % in 2015 [16]. The US government plans to
expand VA telemedicine services in FY 2016 by 11.5 %
[17]. Telepsychiatry, however, is still largely supported by
internal or grant fundingsuch as within the US Department of Veterans Affairs (VA)and then in decreasing

Curr Psychiatry Rep (2015) 17:89

order, federal funding, private grants from foundations or

endowments, andmore infrequentlystate or local
funding [18, 19], with relatively few mental health programs showing long-term commercial sustainability.
A shortage of psychiatrists, psychiatric services, and
funding nationwide has contributed to the enthusiasm for
telepsychiatry, with 55 % of US counties unable to recruit
mental health practitioners. Funding constraints have led to
the closure of hospital beds; now, only 27 % of community
hospitals have inpatient psychiatric units [20].
Health systems are adopting telepsychiatry as they perceive telemedicine as a competitive advantage in attracting
patients [21]. The largest health system in the USA, the
Veterans Health Administration (VHA), has embraced
telepsychiatry. Within VHA, telemental health experienced
rapid growth from 2006 through 2010 for individual psychotherapy with medication management (218 %), followed by group psychotherapy (178 %), diagnostic assessment
(175 %), individual psychotherapy without medication
management (174 %), and medication management alone
(140 %) [22] as shown in an analysis of 342,288 telemental
health encounters from national-level VHA data. A separate study of 98,609 mental health patients before and after
enrollment in telemental health services demonstrated a
25 % average reduction of patient hospitalizations in this
same time period [23]. The VA has also piloted homebased telepsychiatry using home webcams on veteranowned computers and secure encrypted software [24]. Interestingly, the second largest health system in the USA,
Kaiser Permanente, uses telemedicine and virtual visits
[25], but has no published reporting of telepsychiatry services. Telepsychiatry is also used internationally; within
Canadas Ontario Telemedicine Network, over one-half of
the 204,058 telemedicine consults in FY 20112012 were
for telepsychiatry [26].
Telepsychiatry is expanding beyond its historical roots as a
tool for rural underserved communities. Within the correctional
setting, more than 10,000 psychiatric consultations have taken
place annually in Texas since 2006, while at least eight other
states have implemented telepsychiatry programs within correctional facilities. This has resulted in increased access for
inmates to mental healthcare and decreased costs in provider
travel, inmate travel, and use of other medical services [27].
Telepsychiatry also has been used to augment limited mental
health clinic hours in urban settings as well, such as within the
Maryland VA health system [28] and Los Angeles county [29].
Finally, telepsychiatry is expanding beyond synchronous
communication and into asynchronous communication. Most
published research in telepsychiatry is in the area of synchronous telepsychiatry, with real-time, two-way video communication of a provider and a patient. However, a newer modality,
asynchronous telepsychiatry, involves recording a patientclinician interview to a video file and forwarding the file to a

Curr Psychiatry Rep (2015) 17:89

psychiatrist for assessment and treatment recommendations.

The psychiatrist then writes a consult note for the patients
primary care provider. This method is similar to store-andforward teledermatology and teleradiology [30, 31],
representing a disruptive innovation in mental healthcare that
has demonstrated feasible outcomes plus clinical and economic efficiency [32]. Cost analyses show that, with sufficient
patient volume, asynchronous telepsychiatry is more costeffective compared to both synchronous telepsychiatry and
in-person psychiatric consultations [33]. Current work includes demonstrating widescale efficacy in a randomized clinical trial [34], adopting new techniques using cross-language
methods and machine translation technologies in Hispanic
communities [35, 36], and demonstrating feasibility for elderly patients in skilled nursing facilities [37].

How to Get Started in Telepsychiatry

Numerous commercial companies and entrepreneurial startup organizations are providing telepsychiatry services and
other augmented models of care, particularly in cameraequipped smartphone apps. Consumers can download apps
to their mobile devices to speak with a psychiatrist or psychotherapist over secure video chat channels.
How can one measure and classify all of these services and
projects? A 2012 expert consensus found four key factors to
be important: process and acceptability, clinical outcomes,
access, and cost [38]. Considerations for process and
acceptability include patient satisfaction, provider satisfaction, coordination of care, integration of care, usability, rapport, stigma, and motivational readiness. Clinical outcomes
include measurement of percent of no shows (e.g., for failed
technology or other logistical causes), accuracy of assessment,
symptom outcomes, completion of treatment, quality of care
(e.g., through HEDIS system performance measures and concordance with treatment guidelines), and treatment utilization.
Access includes the number of additional services that can be
accessed, numbers served (e.g., through relative value units),
wait times, length of session, distance to service, the likelihood of using telemental health versus traditional care, and
cultural access. Finally, cost outcome considerations include
value proposition; direct and indirect costs for travel and technology; whether the project uses private or public funding;
societal burden on social network; personnel costs; supply
costs; and costs for training, facilities, and maintenance [39].
Professional guidelines do exist. Telemental health guidelines written by the American Telemedicine Association cover
evidence-based practice for video-based online mental health
services [40, 41]. Practice parameters have also been published for child and adolescent populations [42], with a 2015
revision in progress. The American Psychiatric Associations
website curates resources on telepsychiatry [43]. The

Page 3 of 9 89

American Psychological Association publishes telemental

health guidelines; though geared towards psychologists, these
include important topics such as data security and informed
consent [44].
With this information available, how does an individual
provider start their own solo direct-to-consumer telepsychiatry
practice? As of 2015, the process is complicated: providers
must follow multiple steps, including determining the type of
telepsychiatry they want to practice, ensuring legal and technical requirements are met, getting the proper licenses, addressing in-person examination (i.e., face-to-face visit) requirements, determining prescribing requirements, addressing
fraud and abuse issues, addressing reimbursement issues, and
considering all care issues such as handling of emergent situations like suicidal threats [14]. Taking a locum tenens
telepsychiatry positionin which a psychiatrist takes a temporary position to address a psychiatrist workforce shortage
can be another pathway to starting a telepsychiatry career, as
these positions are increasingly being filled using
telepsychiatry [45]. Alternatively, increasing numbers of psychiatrists are signing on with commercial telepsychiatry companies either to work for them, usually as independent contractors, or to use the commercial technology platform to see
their own patients just as if they were renting physical space.
Unfortunately, telepsychiatry education and assistance with
developing the resources and knowledge to build a practice
are still in their infancy, with little teaching or experience
available on telepsychiatry in most medical schools and residency training programs. Residency training in telepsychiatry
thus far has mainly consisted of supervised clinical care, with
some didactics around transcultural, medicolegal, and health
system issues on telepsychiatry [46]. The American Psychiatric Association has recognized this gap: a workgroup is developing a telepsychiatry Btoolkit^ for practicing psychiatrists. A
series of courses have been run by the American Telemedicine
Association on BTelemental Health 101,^ both at annual conferences [47] and online [48].

Current Telepsychiatry Research by Diagnosis

Though telepsychiatry has been used clinically for most diagnoses, research studies have emphasized certain diagnoses
more than others. A recent study of mental health encounters
in FY 2012comparing 176,246 telemental health to 11.8M
in-person visitsshowed that post-traumatic stress disorder
(PTSD), depression, and anxiety were more likely to be addressed using telepsychiatry than alcohol use disorders, substance use disorders, and psychotic disorders. The research
base is now well established for PTSD and depression, whereas less research is available for other diagnoses [49]. This
section covers the most recent telepsychiatry studies from
2011 through 2015.

89

Curr Psychiatry Rep (2015) 17:89

Page 4 of 9

Post-traumatic Stress Disorder

There is robust literature for telepsychiatry applications in
PTSD, given the high prevalence of this diagnosis in veteran
populations where much of the research on telepsychiatry has
occurred. Recent published telepsychiatry research has demonstrated its effectiveness in PTSD in American Indian veterans and Pacific Islander populations, as well as it being a
medium for exposure therapy, group psychotherapy, and cognitive processing therapy. The Telemedicine Outreach for
PTSD randomized clinical trial involved 11 VA community
outpatient clinics and showed significantly larger decreases in
Posttraumatic Diagnostic Scale scores in PTSD patients who
received telemental health servicesincluding
telepsychologists providing cognitive processing therapy and
telepsychiatrists providing medication managementcompared to usual care at 12 months [50]. The authors suggested
that this was likely due to the increased engagement of remote
rural patients.
Researchers at the University of Colorado in Denver have
launched projects to serve the American Indian population,
creating new models of care. The PTSD treatment model for
American Indian Veteran Telemental Health Clinics involves
a spectrum of PTSD services, from community engagement
with tribal/telehealth outreach workers, Tribal Veterans Representatives, education, and outreach; patient education and
system navigation; family education and support; skills building, including cognitive behavioral therapy (CBT) for PTSD
and coping skills; insight-oriented psychotherapies; and dynamic and process-oriented therapies with cognitive processing therapy and group sessions [51].
A particular type of trauma-focused psychotherapy, cognitive processing therapy-cognitive only (CPT-C, which excludes the written trauma narrative), has also been delivered
in a rural Hawaiian area sample of 61 ethnically diverse veterans with PTSD through video-based telepsychiatry. The
study found that video encounters provided a reduction in
PTSD symptomssimilar to the 64-person control group that
received face-to-face therapywith high levels of therapeutic
alliance, treatment compliance, and satisfaction. The modality
did not negatively impact therapeutic process measures
[5254]. In this parent study, different cohorts in two different
treatment conditions took anger management group CBT either with video or with in-person care; the group
telepsychotherapy condition was shown to have significantly
lower total costs for providing this care to veterans who could
not normally be able to access such treatments, due to costly
air transport between the Hawaiian islands [55].
Exposure therapy has also been delivered in a nonrandomized controlled trial to veterans and found to reduce
PTSD, anxiety, depression, stress, and general impairment
symptoms, though the lack of randomization precludes
between-group effect conclusions [56]. Overall,

telepsychiatry has increased the engagement of veterans with

PTSD in care, has especially benefited rural PTSD patients,
and generally has led to reduced symptoms and increased
access, compared with usual care.
Depression
Telepsychiatry has long been shown to benefit patients with
depression [12], with a number of studies showing greater
symptom improvement in the telemental health group compared with the in-person groups. A recent 2015 study showed
that patients taking antidepressants reported fewer
antidepressant-related side effects in a high-intensity telemedicine-based collaborative care model, compared with lowintensity practice-based collaborative care [57]. A 2012 study
of 167 patients in a community clinic demonstrated that patients had improved access to depression-specific care using
telepsychiatry [58].
Telepsychiatry can also augment collaborative care models
when these are used for depression treatment. A 2013 nonblinded randomized comparative effectiveness trial in a Federally Qualified Health Center compared two groups of patients who, on average, had moderately severe depression.
The control group received the standard model of care at
the time: in-person nurse care manager depression treatment.
The intervention group used telepsychiatry, with access to an
off-site nurse care manager, pharmacist, psychologist, and
psychiatrist available by videoconferencing. Both groups
had access to an on-site primary care provider. The intervention group showed greater reductions in depression symptom
severity over time [59] despite patient attendance, engagement, and utilization of telepsychotherapy being relatively
low. The authors surmised that the main difference between
the groups was that the fidelity of nurse care managerdelivered depression treatment was better by telemedicine
than in-person, and it was thought that the low use of psychotherapy was due to the traditional referral process used in
the intervention group [60].
One caveat about the use of telepsychiatry for depression
relates to cost. The VA collaborative care project showed increased costs in the short term due to an intended increase in
depression-related encounters [61]. However, most other research studies have shown that telepsychiatry can realize longterm cost savings [12, 27, 33, 55].
Child and Adolescent Populations
Not surprisingly, children, brought up in the era of the Internet
and mobile videoconferencing, find telepsychiatry to be a
fairly natural way to meet with a physician. A 2014 review
of e-health solutions for youth, including telepsychiatry, described numerous case studies with successful outcomes that
used telepsychiatry. The authors also noted the high

Curr Psychiatry Rep (2015) 17:89

concordance of child psychiatrist diagnoses and treatment recommendations between videoconferencing and face-to-face
modes [62].
A recent randomized controlled trial used a hybrid approach to care for children with ADHD living in underserved
communities. The trial combined synchronous, asynchronous,
and in-person modes of interaction, as well as web-based educational approaches and the involvement of teachers, parents, and primary care physicians, all supported by an electronically enabled treatment team from the University of
Washington. The results in 224 children were significant with
improvement in both inattention and hyperactivity symptoms
[6366]. This novel telepsychiatry service model of hybrid
collaborative mental health services using multiple technologies has already been described as not only being a new way
to practice but also demonstrating a new standard of practice
that is potentially significantly better than the traditional inperson gold standard level of care [62].

Current Cultural Telepsychiatry Research

Telepsychiatry has the potential to bridge ethnic disparities in
mental health, providing care for underserved ethnic or demographic groups and bridging language gaps. Research from
2011 through 2015 has addressed primarily American Indian,
Hispanic, and Asian populations. No known studies within
this time frame have been performed with a focus on African
American populations, or specifically on women, where there
are in particularly substantial needs in veteran groups as a
consequence of sexual trauma.
American Indian Populations
Telepsychiatry has been extensively studied in American Indian populations. The overall process of adapting
telepsychiatry for American Indian cultures has been described as part of the cultural adaptation model for remote
monitoring. This process includes gathering information;
adapting processes; testing; and gathering feedback and data,
such as satisfaction interviews, adherence data, patient response patterns, adverse events, and outcome data [67].
In a descriptive, retrospective chart review of 85 patients
with 1631 telemental health clinic visits, Shore et al. found a
high rate of comorbid general medical conditions and mental
disorders, as well as significant increases in prescriptions of
psychotropic medications across drug classes [68]. Supporting
this population with culturally appropriate care is critical, with
on-site tribal outreach workers, collaboration with community
services, and providers knowledgeable of tribe customs. A
pilot clinic, initially established by the University of Colorado
Denvers Centers for American Indian and Alaska, has since
expanded to serve tribes in Idaho, Montana, South Dakota,

Page 5 of 9 89

and Wyoming [51] as described in a decade-long series of

more than 15 publications. What makes these programs particularly unique is the emphasis on a local facilitatorthe
tribal/telehealth outreach workerbased with tribal organizations, which values tribal culture, including traditional healers,
and building trust and rapport with Tribal Veteran
Representatives.
An analysis of all 2008 VA outpatient encounters for American Indian or Alaska Native patients found that they were
more likely to be from rural or Bhighly rural^ regions (with a
population density fewer than seven persons per square mile)
compared to non-Native veterans (49 versus 37 %). This population had higher-than-average levels of service-connected
disability (27 versus 17 %) [69].
Hispanic Populations
Telepsychiatry has also been researched in Hispanic populations, demonstrating acceptability but with varying results for
feasibility. One study of low-income un-acculturated Hispanic patients with depression incorporated culturally compatible
telepsychiatry components. The patients rated the program
high in satisfaction, but the program faced uncertain feasibility due to difficulties in scheduling around the patients job
demands and their inability to pay for services [70]. Another
study using consumer webcams and computers with 167
Hispanic patients showed improvement in depression symptoms and good satisfaction rates with monthly depressionspecific telepsychiatry encounters, held in a community
health center [58].
As a result of the difficulty some Hispanic field workers
had attending consultations, asynchronous telepsychiatry consultations have been tested in this population, with both
Spanish- and English-speaking psychiatrists providing the
asynchronous consultations [71]. This innovative approach
has been shown to be feasible with broad diagnostic reliability
demonstrated across languages following translation [32].
These asynchronous, or store-and-forward, encounters that
are amenable to translation could potentially be used across
many ethnic groups and languages and may well be a model
for future telepsychiatry directions and innovations. [72].
Asian and Pacific Islander Populations
Studies in Asian populations have been limited despite the fact
that the Chinese American population tends to underutilize
psychiatric services due to high cultural stigma, even though
they have a high burden of depression [73]. In a pilot study,
Korean mental health patients in Georgia connected with a
culturally and linguistically competent psychiatrist based in
California, demonstrating high level of acceptance [74]. As
part of this study, a protocol for a collaborative care study
was published involving an initial assessment by

89

Curr Psychiatry Rep (2015) 17:89

Page 6 of 9

telepsychiatry; scheduled phone visits; and collaboration with

a primary care provider, psychiatrist, and case manager, all
geared towards depressed Chinese Americans in primary care.
PTSD treatment has been given to Pacific Islanders on the
Hawaiian islands, as previously described above [55].

Challenges and Barriers in Adopting Telepsychiatry

It is certainly the case that the Btipping point^ for telepsychiatry
in the USA has passed and that telepsychiatry is, almost 60 years
after the first video consultations at the University of Nebraska,
finally becoming accepted as a part of routine mental healthcare.
Significant barriers still persist however. These concern the business environment, personal and leadership reasons, and technology and clinical workflow issues [75].

Younger generations of leaders are mid-way through their

careers and are not yet able to influence traditionally conservative health environments to change and to adopt innovations
like telepsychiatry more extensively.
At a provider level, personal reasons can prevent psychiatrists from confidently handling a telepsychiatry encounter.
These include concern about establishing rapport, detecting
nonverbal cues like poor hygiene or alcohol use, and not having formal instruction in telepsychiatry [75]. This is changing
and employers, such as the VA, provide more formal instruction and organizations, such as the American Telemedicine
Association, offer accreditation [81] and webinars. Many authors have written training handbooks and book chapters on
the subject [14], while a number of online courses [48, 82,
83] exist to train clinicians.
Clinical and Technology Issues

Business Environment
The business environment, though improving, has not been
historically conducive towards telemedicine. Reimbursement
remains an issue with payers, such as the Centers for Medicare
and Medicaid Services, placing constraints on how telemedicine services can be used. Inconsistent laws across states also
play a role, though as of May 2015, 27 states and the District of
Columbia had legislated Bparity^ in the reimbursement of telemedicine services. Other states still do not reimburse telemedicine visits at the level of an in-person visit [76]. Licensure
requirements, prescription rules, and documentation requirements also vary by state [14, 77]. The VA has legislation
supporting national licensing to their own facilities for all their
providers, and it is likely that this will be extended to the US
Department of Defense and possibly all federal programs soon,
but a national licensing process for all physicians practicing
telemedicine is still likely some years away. Summary analysis
reports of these constantly changing policies and legislative
activities are freely available online [78, 79]. Finally, there are
logistical and financial challenges for anyone setting up
telepsychiatry programs, such as telemedicine infrastructure
costs and high turnover rates for rural healthcare workers [80].
Personal Biases and Lack of Training
Attitudinal change is still a problem at both health system
leadership and provider levels. Most health system leaders in
the USA are still from a generation that has not fully adopted
technology and are wary of the sorts of changes that technology can bring. Their gold standard is still the in-person consultation, despite the massive changes in some medical disciplinesnamely pathology, radiology, cardiology, and dermatologyenabled by information technologies. Many are unable to envision the sorts of changes that might occur in mental health if technologies were adopted more aggressively.

The clinical workflow and business case for telepsychiatry must

be in synchrony to ensure the right tools are being used for the
right purposes. A follow-up survey of researchers who published on telepsychiatry and telemental health projects from
2008 to 2014 found that telepsychiatry projects often
discontinued because of one of three reasons: lack of funding,
changing telepsychiatry needs, and a lack of long-term planning
[19]. Technical barriers included a lack of data interoperability,
inconsistent electronic medical record systems, and changes in
bandwidth demand [75]. Some rural communities may also
lack videoconferencing equipment and network capacity [84].

Conclusion
The field of telepsychiatry is an exciting area within which to
work. Compared with the past, there is now a rapidly changing and much more hospitable legislative and business climate, a solid evidence base, and enthusiasm for the approach
from both psychiatrists and patients. Telemedicine, with
telepsychiatry at the forefront, will continue to be actively
promoted by patients and increasingly by younger generations
of providers and health leaders. At a policy level,
telepsychiatry is increasingly being promoted by health insurers, given increasing efforts for telemedicine reimbursement parity, a new telemedicine accreditation program for
telemedicine medical service companies from the American
Telemedicine Association [81], and telemedicines move beyond national borders [14].
Eventually, there will be hybrid models of care that combine both in-person and technology-driven care, the latter of
which can include e-mail, instant messaging, asynchronous
telemedicine, and more. We envision seeing telepsychiatry
taught routinely in medical schools, residency training, and
continuing medical education programs [66].

Curr Psychiatry Rep (2015) 17:89

Demand for mental health services will continue to be

higher than the supply of providers in the near future. There
is still a vast amount of untreated mental illness nationally and
internationally; thus, there is an urgent need for the expedient
integration of technology into innovative models of mental
healthcare [85]. More research into the most effective models
and ways of providing technology-enabled mental healthcare,
while making the best use of our expert mental health workforce to treat the largest number of patients, is sorely needed.
Compliance with Ethics Guidelines
Conflict of Interest Michelle Parish declares that she has no conflict of
interest.
Steven Chans work on translation technologies is supported by the
APA/SAMHSA Minority Fellowship Program and a UC Davis Behavioral Center of Excellence grant. Steven Chan serves as an Associate
Editor for iMedicalApps.
Peter Yellowlees is a co-founder and Chair of the Board of the commercial telepsychiatry company, HealthLinkNow.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.

References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
1.

What is Telemedicine? In: American Telemedicine Association.

American Telemedicine Association. 2015. http://www.
americantelemed.org/about-telemedicine/what-is-telemedicine - .
VYj9xuvL-CA. Accessed 06/22/2015 2015.
2. Trade, foreign policy, diplomacy and health: E-Health. World
Health Organization. 2015. http://www.who.int/trade/glossary/
story021/en/. Accessed 6/22/2015 2015.
3. Fortney JC, Burgess Jr JF, Bosworth HB, Booth BM, Kaboli PJ. A
re-conceptualization of access for 21st century healthcare. J Gen
Intern Med. 2011;26 Suppl 2:63947. doi:10.1007/s11606-0111806-6.
4. Telemedicine. Centers for Medicare & Medicaid Services,
Baltimore, MD. 2015. http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Delivery-Systems/Telemedicine.
html. Accessed 6/22/2015 2015.
5. Chan S, Torous J, Hinton L, Yellowlees P. Mobile tele-mental
health: increasing applications and a move to hybrid models of care.
Health Care. 2014;2(2):220.
6. Chan S, Torous J, Hinton L, Yellowlees P. Psychiatric apps: patient
self-assessment, communication, and potential treatment interventions. In: Mucic D, Hilty D, editors. e-Mental Health. Basel: Karger
Medical and Scientific Publishers; 2015.
7. Hilty D, Chan SR, Parish MB, Yellowlees P. Telepsychiatry: effective, evidence-based and at a tipping point in healthcare delivery?
In: Baron D, Gross L, editors. Clinical Psychiatry: Recent

Page 7 of 9 89
Advances and Future Directions, An Issue of Psychiatric Clinics
of North America. Clinics Review Articles: Elsevier; 2015
8. Torous J, Staples P, Onnela JP. Realizing the potential of mobile
mental health: new methods for new data in psychiatry. Curr
Psychiatry Rep. 2015;17(8):602. doi:10.1007/s11920-015-0602-0.
9. Torous J, Chan RS, Yee-Marie Tan S, Behrens J, Mathew I, Conrad
JE, et al. Patient smartphone ownership and interest in mobile apps
to monitor symptoms of mental health conditions: a survey in four
geographically distinct psychiatric clinics. J Med Internet Res Ment
Health. 2014;1:e5. doi:10.2196/mental.4004.
10. Torous J, Friedman R, Keshvan M. Smartphone ownership and
interest in mobile applications to monitor symptoms of mental
health conditions. J Med Internet Res Mhealth Uhealth. 2014;2:
e2. doi:10.2196/mhealth.2994.
11. Glenn T, Monteith S. New measures of mental state and behavior
based on data collected from sensors, smartphones, and the Internet.
Curr Psychiatry Rep. 2014;16(12):523. doi:10.1007/s11920-0140523-3.
12. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ,
Yellowlees PM. The effectiveness of telemental health: a 2013
review. Telemedicine and e-Health. 2013;19(6):44454. doi:10.
1089/tmj.2013.0075. This review of telemental health 2003
through 2013 literature summarized studies in a tabular
format. It showed telemental health was effective for many
populations (adult, child, geriatric, ethnic) in many settings
(emergency, home health). It also identified new models of
care such as collaborative, asynchronous, mobile shown
to be effective.
13. Wittson CL, Benschoter R. Two-way television: helping the
Medical Center reach out. Am J Psychiatry. 1972;129(5):6247.
14. Vanderpool D. An overview of practicing high quality
telepsychiatry. Mental Health Practice in a Digital World.
Springer; 2015. p. 15981. Written from the perspective of a
JD MBA, this summarizes regulatory constraints, clinical requirements, reimbursement issues, and quality & effectiveness
evaluation methods for telepsychiatry practice.
15. Daschle T, Dorsey ER. The return of the house call. Ann Intern
Med. 2015;162(8):5878. doi:10.7326/M14-2769.
16. Towers Watson expects a 68% increase in the number of employers
offering telemedicine in 2015. Towers Watson, Arlington, VA.
2014. http://www.towerswatson.com/en-US/Press/2014/08/
current-telemedicine-technology-could-mean-big-savings.
Accessed 6/22/2015 2015.
17. Clancy C. Statement Of Dr. Carolyn Clancy Interim Under
Secretary For Health Veterans Health Administration Department
Of Veterans Affairs For Presentation Before The Senate Committee
On Appropriations Subcommittee On Military Construction,
Veterans Affairs, And Related Agencies. 2015. http://www.
appropriations.senate.gov/sites/default/files/hearings/MilCon-VA
Interim Under Secretary Clancy Testimony 031015.pdf. Accessed
7/4/2015 2015.
18. Bashshur RL, Shannon G, Krupinski EA, Grigsby J. Sustaining and
realizing the promise of telemedicine. Telemed J E Health.
2013;19(5):33945. doi:10.1089/tmj.2012.0282.
19. Lauckner C, Whitten P. The state and sustainability of
telepsychiatry programs. J Behav Health Serv Res. 2015. doi:10.
1007/s11414-015-9461-z.
20. Trendwatch: Bringing Behavioral Health into the Care Continuum:
Opportunities to Improve Quality, Costs and Outcomes. American
Hospital Association, Washington, DC. 2012. http://www.aha.org/
research/reports/tw/12jan-tw-behavhealth.pdf. Accessed 06/22/
2015 2015.
21. Adler-Milstein J, Kvedar J, Bates DW. Telehealth among US hospitals: several factors, including state reimbursement and licensure
policies, influence adoption. Health Aff (Millwood). 2014;33(2):
20715. doi:10.1377/hlthaff.2013.1054. This summarizes the

89

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

Page 8 of 9
adoption of telehealth for each state from a macroeconomic
perspective. Adler-Milstein et al. find that hospitals that tend
to have telehealth include teaching hospitals, hospitals with
more advanced medical technology, those that are part of a
larger system, and those that are nonprofit institutions.
Deen TL, Godleski L, Fortney JC. A description of telemental
health services provided by the Veterans Health Administration in
20062010. Psychiatr Serv. 2012;63(11):11313. doi:10.1176/
appi.ps.201100458.
Godleski L, Darkins A, Peters J. Outcomes of 98,609 U.S.
Department of Veterans Affairs patients enrolled in telemental
health services, 20062010. Psychiatr Serv. 2012;63(4):3835.
doi:10.1176/appi.ps.201100206.
Shore P, Goranson A, Ward MF, Lu MW. Meeting veterans where
theyre @: a VA Home-Based Telemental Health (HBTMH) pilot
program. Int J Psychiatry Med. 2014;48(1):517. doi:10.2190/
PM.48.1.b.
Pearl R. Kaiser Permanente Northern California: current experiences with internet, mobile, and video technologies. Health Aff
(Millwood). 2014;33(2):2517. doi:10.1377/hlthaff.2013.1005.
Brown EM. The Ontario Telemedicine Network: a case report.
Telemed J E Health. 2013;19(5):3736. doi:10.1089/tmj.2012.
0299.
Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in correctional facilities: using technology to improve access and decrease costs of mental health care in underserved populations.
Perm J. 2013;17(3):806. doi:10.7812/TPP/12-123.
Koch EF. The VA Maryland Health Care Systems telemental
health program. Psychological Services. 2012;9(2):2035. doi:
dx.doi.org+10.1037/a0026144.
Mendoza R, Yellowlees P, Kaftarian E, Hilty D, editors. Cultural
Bfit^ and selection of the Bbest^ model for telemental health. The
American Telemedicine Association Twentieth Annual
Telemedicine Meeting and Trade Show; 2015 5/5/2015; Los
Angeles, CA: American Telemedicine Association; 2015
Odor A, Yellowlees P, Hilty D, Burke Parish M, Nafiz N, Iosif AM.
PsychVACS: a system for asynchronous telepsychiatry. Telemed J
E Health. 2011;17(4):299303.
Maghazil A, Yellowlees P. Novel approaches to clinical care in
mental health: from asynchronous telepsychiatry to virtual reality.
In: Lech M, Song I, Yellowlees P, Diederich J, editors. Mental
Health Informatics. Berlin: Springer; 2014. p. 5778.
Yellowlees P, Odor A, Patrice K, Parish MB, Nafiz N, Iosif AM,
et al. Disruptive innovation: the future of healthcare? Telemed J E
Health. 2011;17(3):2314. doi:10.1089/tmj.2010.0130.
Butler TN, Yellowlees P. Cost analysis of store-and-forward
telepsychiatry as a consultation model for primary care. Telemed
e-Health. 2012;18(1):747. doi:10.1089/tmj.2011.0086.
University of California, Davis. A controlled trial of patient centered telepsychiatry interventions. U.S. National Institutes of
Health. 2014. https://clinicaltrials.gov/ct2/show/NCT02084979.
Accessed 6/28/2015 2015.
Yellowlees PM, Odor A, Parish MB. Cross-lingual asynchronous
telepsychiatry: disruptive innovation? Psychiatr Serv. 2012;63(9):
945. doi:10.1176/appi.ps.2012op945.
Yellowlees P. Telepsychiatry services across languages: development and testing of an automated translation and transcription tool
using speech recognition technologies. UC Davis. 2015. http://
www.ucdmc.ucdavis.edu/behavioralhealth/pages/yellowlees.html.
Accessed 06/22/2015 2015.
Xiong G. A pilot study examining use of asynchronic and synchronous telepsychiatry consultation for skilled nursing facility residents. UC Davis. 2015. http://www.ucdmc.ucdavis.edu/
behavioralhealth/pages/xiong.html. Accessed 06/22/2015 2015.
Mishkind MC, Doarn CR, Bernard J, Shore JH. The use of collaboration science to define consensus outcome measures: a telemental

Curr Psychiatry Rep (2015) 17:89

health case study. Telemed J E Health Off J Am Telemed Assoc.
2013;19(6):4559. doi:10.1089/tmj.2013.0069.
39. Shore JH, Mishkind MC, Bernard J, Doarn CR, Bell Jr I, Bhatla R,
et al. A lexicon of assessment and outcome measures for telemental
health. Telemed J E Health. 2014;20(3):28292. doi:10.1089/tmj.
2013.0357. This expert consensus document provides
definitions, measurement recommendations, and
considerations for telemental health programs. It has the
potential to serve as a framework for evaluating and
standardizing programs.
40. Yellowlees P, Shore J, Roberts L. Practice guidelines for
videoconferencing-based telemental healthOctober 2009.
Telemed E Health. 2010;16(10):107489. This consensus-based
operational best practice reference was written to summarize
experts clinical experiences. It can be useful for those starting
their own telemental health programs.
41. Turvey C, Coleman M, Dennison O, Drude K, Goldenson M,
Hirsch P, et al. ATA practice guidelines for video-based online
mental health services. Telemed E Health. 2013;19(9):72230.
Behavioral health professionals who provide real-time videoconferencing services via the Internet can follow these requirements and recommendations. These guidelines do not cover email, chatting, social network sites, and Bcoaching.^.
42. Myers K, Cain S, Work Group on Quality Issues, American
Academy of Child and Adolescent Psychiatry Staff. Practice parameter for telepsychiatry with children and adolescents. 2008:
146883
43. Telepsychiatry Resources. American Psychiatric Association. 2015.
http://www.psychiatry.org/practice/professional-interests/
underserved-communities/telepsychiatry-internet-resources.
Accessed 06/22/2015 2015.
44. Guidelines For The Practice Of Telepsychology. American
Psychological Association. 2013. http://www.apapracticecentral.
org/ce/guidelines/telepsychology-guidelines.pdf. Accessed 06/22/
2015 2015.
45. Thiele JS, Doarn CR, Shore JH. Locum tenens and telepsychiatry:
trends in psychiatric care. Telemed J E Health. 2015;21(6):5103.
doi:10.1089/tmj.2014.0159.
46. Sunderji N, Crawford A, Jovanovic M. Telepsychiatry in graduate
medical education: a narrative review. Acad Psychiatry. 2015;39(1):
5562. doi:10.1007/s40596-014-0176-x.
47. Kramer G, Caudill R, Hilty D, Brooks E, ONeill P, Rabinowitz T
et al., editors. Best Practices for Telemental Health. American
Telemedicine Association 2014 Annual Meeting; 2014 5/18/2014;
Baltimore, MD: American Telemedicine Association; 2014
48. Hubbard M. American Telemedicine Association launches online
Telemental Health Course. 6/19/2014 ed: American Telemedicine
Association; 2014.
49. Grubbs KM, Fortney JC, Dean T, Williams JS, Godleski L. A
comparison of mental health diagnoses treated via interactive video
and face to face in the Veterans Healthcare Administration. Telemed
J E Health. 2015. doi:10.1089/tmj.2014.0152.
50. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE,
Schneider R, et al. Telemedicine-based collaborative care for
posttraumatic stress disorder: a randomized clinical trial.
J A M A P sy c h i a t r y. 20 1 5; 7 2(1 ) : 58 67 . d oi :1 0 . 10 0 1/
jamapsychiatry.2014.1575.
51. Shore J, Kaufmann LJ, Brooks E, Bair B, Dailey N, Richardson Jr
WJB, et al. Review of American Indian veteran telemental health.
Telemed J E Health Off J Am Telemed Assoc. 2012;18(2):8794.
doi:10.1089/tmj.2011.0057.
52. Morland LA, Mackintosh MA, Greene CJ, Rosen CS, Chard KM,
Resick P, et al. Cognitive processing therapy for posttraumatic
stress disorder delivered to rural veterans via telemental health: a
randomized noninferiority clinical trial. J Clin Psychiatry.
2014;75(5):4706. doi:10.4088/JCP.13m08842.

Curr Psychiatry Rep (2015) 17:89

53.

Morland LA, Hynes AK, Mackintosh MA, Resick PA, Chard KM.
Group cognitive processing therapy delivered to veterans via
telehealth: a pilot cohort. J Trauma Stress. 2011;24(4):4659. doi:
10.1002/jts.20661.
54. Morland LA, Greene CJ, Rosen C, Mauldin PD, Frueh BC. Issues
in the design of a randomized noninferiority clinical trial of
telemental health psychotherapy for rural combat veterans with
PTSD. Contemp Clin Trials. 2009;30(6):51322. doi:10.1016/j.
cct.2009.06.006.
55. Morland LA, Raab M, Mackintosh MA, Rosen CS, Dismuke CE,
Greene CJ, et al. Telemedicine: a cost-reducing means of delivering
psychotherapy to rural combat veterans with PTSD. Telemed J E
Health. 2013;19(10):7549. doi:10.1089/tmj.2012.0298.
56. Gros DF, Yoder M, Tuerk PW, Lozano BE, Acierno R. Exposure
therapy for PTSD delivered to veterans via telehealth: predictors of
treatment completion and outcome and comparison to treatment
delivered in person. Behav Ther. 2011;42(2):27683. doi:10.
1016/j.beth.2010.07.005.
57. Hudson TJ, Fortney JC, Pyne JM, Lu L, Mittal D. Reduction of
patient-reported antidepressant side effects, by type of collaborative
care. Psychiatr Serv. 2015;66(3):2728. doi:10.1176/appi.ps.
201300570.
58. Moreno FA, Chong J, Dumbauld J, Humke M, Byreddy S. Use of
standard webcam and Internet equipment for telepsychiatry treatment of depression among underserved Hispanics. Psychiatr Serv.
2012;63(12):12137.
59. Fortney JC, Pyne JM, Mouden SB, Mittal D, Hudson TJ, Schroeder
GW, et al. Practice-based versus telemedicine-based collaborative
care for depression in rural federally qualified health centers: a
pragmatic randomized comparative effectiveness trial. Am J
Psychiatry. 2013;170(4):41425. doi:10.1176/appi.ajp.2012.
12050696.
60. Deen TL, Fortney JC, Schroeder G. Patient acceptance of and initiation and engagement in telepsychotherapy in primary care.
Psychiatr Serv. 2013;64(4):3804. doi:10.1176/appi.ps.201200198.
61. Fortney JC, Maciejewski ML, Tripathi SP, Deen TL, Pyne JM. A
budget impact analysis of telemedicine-based collaborative care for
depression. Med Care. 2011;49(9):87280. doi:10.1097/MLR.
0b013e31821d2b35.
62. Boydell KM, Hodgins M, Pignatiello A, Teshima J, Edwards H,
Willis D. Using technology to deliver mental health services to
children and youth: a scoping review. J Can Acad Child Adolesc
Psychiatry. 2014;23(2):8799.
63. Myers K, Vander Stoep A, Zhou C, McCarty CA, Katon W.
Effectiveness of a telehealth service delivery model for treating
attention-deficit/hyperactivity disorder: a community-based randomized controlled trial. J Am Acad Child Adolesc Psychiatry.
2015;54(4):26374. doi:10.1016/j.jaac.2015.01.009.
64. Myers K, Vander Stoep A, Lobdell C. Feasibility of conducting a
randomized controlled trial of telemental health with children diagnosed with attention-deficit/hyperactivity disorder in underserved
communities. J Child Adolesc Psychopharmacol. 2013;23(6):372
8. doi:10.1089/cap.2013.0020.
65. Vander Stoep A, Myers K. Methodology for conducting the childrens attention-deficit hyperactivity disorder telemental health
treatment study in multiple underserved communities. Clin Trials.
2013;10(6):94958.
66. Hilty DM, Yellowlees PM. Collaborative mental health services
using multiple technologies: the new way to practice and a new
standard of practice? J Am Acad Child Adolesc Psychiatry.
2015;54(4):2456.
67. Brooks E, Novins DK, Noe T, Bair B, Dailey N, Lowe J, et al.
Reaching rural communities with culturally appropriate care: a
model for adapting remote monitoring to American Indian veterans
with posttraumatic stress disorder. Telemed J E Health. 2013;19(4):
2727. doi:10.1089/tmj.2012.0117.

Page 9 of 9 89
68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

83.

84.

85.

Shore JH, Brooks E, Anderson H, Bair B, Dailey N, Kaufmann LJ,

et al. Characteristics of telemental health service use by American
Indian veterans. Psychiatr Serv. 2012;63(2):17981.
Kaufman CE, Brooks E, Kaufmann LJ, Noe T, Nagamoto HT, Dailey
N, et al. Rural native veterans in the Veterans Health Administration:
characteristics and service utilization patterns. J Rural Health.
2013;29(3):30410. doi:10.1111/j.1748-0361.2012.00450.x.
Chong J, Moreno F. Feasibility and acceptability of clinic-based
telepsychiatry for low-income Hispanic primary care patients.
Telemed E Health. 2012;18(4):297304.
Yellowlees PM, Odor A, Parish MB, Iosif A-M, Haught K, Hilty D.
A feasibility study of the use of asynchronous telepsychiatry for
psychiatric consultations. Psychiatr Serv. 2010;61(8):83840.
Yellowlees PM, Odor A, Iosif A-M, Parish MB, Nafiz N, Patrice K,
et al. Transcultural psychiatry made simpleasynchronous
telepsychiatry as an approach to providing culturally relevant care.
Telemed J E Health Off J Am Telemed Assoc. 2013;19(4):25964.
doi:10.1089/tmj.2012.0077.
Yeung A, Hails K, Chang T, Trinh NH, Fava M. A study of the
effectiveness of telepsychiatry-based culturally sensitive collaborative treatment of depressed Chinese Americans. BMC Psychiatry.
2011;11:154. doi:10.1186/1471-244X-11-154.
Ye J, Shim R, Lukaszewski T, Yun K, Kim SH, Ruth G.
Telepsychiatry services for Korean immigrants. Telemed E
Health. 2012;18(10):797802. doi:10.1089/tmj.2012.0041.
Brooks E, Turvey C, Augusterfer EF. Provider barriers to telemental
health: obstacles overcome, obstacles remaining. Telemed J E
Health. 2013;19(6):4337. This expert-written article covers 1)
personal barriers, 2) clinical workflow and technology barriers,
and 3) licensure, credentialing, and reimbursement barriers for
telemental health.
Milestone Most States Now Have Telehealth Parity Laws.
American Telemedicine Association, Washington, DC. 2015.
http://www.americantelemed.org/news-landing/2015/05/27/
milestone-most-states-now-have-telehealth-parity-laws - .VYscVvL9UQ. Accessed 6/24/2015 2015.
Ferrer DC, Yellowlees PM. Telepsychiatry: licensing and professional boundary concerns. Virtual Mentor. 2012;14(6):47782. doi:
10.1001/virtualmentor.2012.14.6.pfor1-1206.
State Policy Resource Center. American Telemedicine Association,
Washington, DC. 2015. http://www.americantelemed.org/policy/
state-policy-resource-center. Accessed 6/24/2015 2015.
State Coverage For Telehealth Services. National Conference of
State Legislatures. 2014. http://www.ncsl.org/research/health/statecoverage-for-telehealth-services.aspx. Accessed 6/22/2015 2015.
Weinstein RS, Lopez AM, Joseph BA, Erps KA, Holcomb M,
Barker GP, et al. Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. Am J Med.
2014;127(3):1837. doi:10.1016/j.amjmed.2013.09.032.
Hubbard M. American Telemedicine Association Launches
Program to Accredit Online Healthcare Services. 12/15/2014 ed:
American Telemedicine Association; 2014.
Telemedicine - UC Davis Extension. UC Davis Extension. 2015.
https://extension.ucdavis.edu/course/telemedicine. Accessed 7/4/
2015 2015.
American Telemedicine Association Learning Center. American
Telemedicine Association. 2015. http://learn.americantelemed.org/
diweb/start/. Accessed 7/4/2015 2015.
Clarke G, Yarborough BJ. Evaluating the promise of health IT to
enhance/expand the reach of mental health services. Gen Hosp
Psychiatry. 2013;35(4):33944. doi:10.1016/j.genhosppsych.
2013.03.013.
Jones SP, Patel V, Saxena S, Radcliffe N, Ali Al-Marri S, Darzi A.
How Googles Ten Things We Know To Be True could guide the
development of mental health mobile apps. Health Aff (Millwood).
2014;33(9):160311. doi:10.1377/hlthaff.2014.0380.