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"Shrinking" in the Kitchen: Telepsychiatry makes housecalls at last


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Screams filled the home as the perspiring and frantic woman yelled, “I can’t breathe, I can’t breathe and I need to go to the ER NOW!” In most American homes, this would have been a warning that 911 needed to put its gears into action, but not here. The woman had screamed, ranted to distraction, and it was the “new normal” for her. Her husband knew the drill and it wasn’t to call 911, either. The click of a few strokes on the keyboard and “rescue” was at hand.

Calmly, the woman on the computer monitor began to reassure the screamer that she was not in danger of dying, she wasn’t having a heart attack and she would survive this day. They began a slow progression of exercises that brought calm once again to the woman in the throes of a panic attack


All of this is in a day’s work for mental health professionals hooked up to the latest technology tool for their practice; telepsychiatry. Today, there would be no trip to the ER as there had been in months and years past. Technology had arrived in rural America.


The strides being made in the area of delivering mental health services worldwide deserve new consideration and implementation into practices. The future is here in China thanks to a new AI “friend” who listens to over 1M people daily who relate their problems to “her.”


Mental Health Need and Services


 A mental health professional shortage exists in the United States. Six and one-half million people in the United States living in rural areas have a mental illness. Many vulnerable patients are in nursing homes where psychiatric care may not be available. The task of treating them has become a burden worldwide for the general practitioner without specialized training. 


Worldwide, it is estimated that several billion people cannot access mental health services and innovation is the only viable alternative. India, one of the countries with a high rate of depression and with a population of over one billion has only 9K psychiatrists according to the World Health Organization. For this reason, whether in rural America or around the world, new modes of medicine, such as Ellie, have evolved. What is Ellie?


Ellie is an AI product of the University of Southern California’s Institute for Creative Technologies. She has motions and speech that can mimic a real therapist. While psychiatrists who responded to an international survey indicated that they believed technology could never substitute for the empathy shown by professionals, this appears to be in conflict with Ellie’s apparent abilities and success. And the programming is continuing to make her even more responsive to people’s interactions.


People who tune in to this virtual-reality program are free from the stigma of going to therapy, as they indicate. Originally created to assist the military in helping veterans with PTSD (post-traumatic stress disorder), it has now been found to have a wider range of uses, including for depression and anxiety. 


The setup is basic; a computer with a webcam and microphone allows patient observation and feedback to AI questions. Programming makes it possible for virtual therapists to know when to nod, as a therapist would in a session. 


Emotional cues for 66 points on the patient’s face can be evaluated to read facial expression and variation during the session. Patient responses can then be further analyzed for appropriate interactions with the AI therapist. Alan Turning’s dream of computing’s future is now becoming a reality.

An additional variant of telepsychiatry is also being offered; hybrid telepsychiatry. In this form of treatment, patients have face-to-face appointments with psychiatrists as well as online interactions. 


However, for those without the resources to obtain internet equipment in their homes, the benefits of telepsychiatry may still not be within their reach. Mental health centers may fill the void in some instances. But exceptions still exist and patients may fall between lines in terms of reimbursement and, therefore, be ineligible for these services.


AI and Psychiatric Care


A study of psychiatrists’ attitudes toward AI identified 10 key tasks as being part of the routine they perform. The areas currently tasked to these professionals are:


1. Documentation about patients

2. Mental status examination

3. Interview to obtain a medical history

4. Assess for homicidal thoughts

5. Assess and or detect suicidal thoughts

6. Synthesize the information into a diagnosis

7. Set a treatment plan for medication and/or therapy treatment

8. Decide whether outpatient or inpatient is the best treatment option

9. Predict the course (prognosis) of the condition

10. Provide empathic care to patients


The global physician survey of AI and psychiatry in the future looked at all of the emerging technologies as well as the tasks assigned to psychiatrists. Calculations were made on the responses of the sample of 791 psychiatrists in 22 countries in North and South America, Europe and Asia-Pacific. 


 Forty percent of the psychiatrists were under the age of 44 and 34% were over the age of 55. The sample had 30% women, two-thirds of the sample was white with the remainder identifying as Asian, Black, Hispanic or mixed. No mental health professionals other than psychiatrists were included in the sample.


An evaluation of the working environment of the participants found it included public clinics (52%), private practice (35%) and academia (13%). The majority of the participants were seeing more than 10 patients per day on average.


Study results indicated that 48.7% of the participants believed that AI/ML (machine learning) “would have no influence or only minimal influence on the future work of psychiatrists over the next 25 years. Only 3.8% of respondents felt it was likely that future technology would make their jobs obsolete. Another 47% predicted that their jobs would be moderately changed by AI/ML over the next 25 years.”

There was agreement, however, in many areas where support such as AI programs would be invaluable, but the one area foreseen as problematic was empathy. AI advances, however, are proving even this prediction to be questionable.


Aligning Telehealth/Telepsychiatry With the Laws


Guidelines for the practice of telehealth programs and the work of practitioners have been developed in collaboration by the American Psychiatric Association and the American Telemedicine Association. They state, in part:


Licensure and Malpractice Health care services have been defined as delivered in the state where the patient is located. Providers of telemental health services shall comply with state licensure laws, which typically entail holding an active professional license issued by the state in which the patient is physically located during a telemental health session, and shall have appropriate malpractice coverage. 

“Providers shall conduct their own due diligence to determine the type of licensure required, and ensure they are in compliance with state licensing board regulations. If providing care within a federal healthcare system (e.g., Department of Veterans Affairs, Department of Defense, Indian Health Service), providers shall follow the specific organization guidelines around licensure, which may allow for a single state licensure across multiple jurisdictions. 


“Providers may utilize 3 © Copyright 2018, American Psychiatric Association, all rights reserved. Best Practices in Videoconferencing-Based Telemental Health the interstate licensure compact or special telemedicine licensures offered by certain states provided they comply with all individual state licensure and program requirements.”


Psychologists, similarly, have developed guidelines through their professional association, the American Psychological Association, and are forewarned regarding practicing across state lines

“…Psychological service delivery systems within such institutions as the U.S. Department of Defense and the Department of Veterans Affairs have already established internal policies and procedures for providing services within their systems that cross-jurisdictional and international borders. 


“However, the laws and regulations that govern service delivery by psychologists outside of those systems vary by state, province, territory, and country (APAPO, 2010). Psychologists should make reasonable effort to be familiar with and, as appropriate, to address the laws and regulations that govern telepsychology service delivery within the jurisdictions in which they are situated and the jurisdictions where their clients/patients are located.


A New Day for Mental Health?


Advances in healthcare and new technologies bring with them concerns and requirements for limitations to protect those who would use the services. They also provide opportunities for further advances and The Center for Medical Interoperability has been created to facilitate these innovations. In part, they state they are :


“…a 501(c)(3) cooperative research and development lab founded by health systems to simplify and advance data sharing among medical technologies and systems. We provide a centralized, vendor-neutral approach to performing technical work that enables person-centered care, testing and certifying devices and systems, and promoting the adoption of scalable solutions.”


Healthcare’s demand is growing with an aging world population, often in need but without adequate access to services. One fruitful response to this need may be via technological innovations that are affordable, available and easy-to-use devices. 

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DR. PATRICIA A. FARRELL