Telepsychiatry in Denmark

"Telepsychiatry" refers to the use of telecommunication technologies with the aim of providing psychiatric services from a distance [1]. Telepsychiatry connects patients and mental health professionals, permitting effective diagnosis, treatment, education, transfer of medical data and other activities related to mental health care. Several studies demonstrated high reliability- and patients acceptance of telepsychiatry [2,3,4,5,6,7].

It is no secret that mental health system in Denmark did face (and still does) significant barriers in providing appropriate psychiatric care towards refugees/migrants on their own language. Psychiatric treatment of refugees/migrants in Denmark is concentrated to several centres around the country where the treatment provides mostly via translators.

There are only few "ethnic psychiatrists" in a country where 8,2% of population consists of refugees/migrants [8]. Mental health care provided via translators is per definition time-consuming and affected by high risk of lack of confidence. One solution to these problems is to increase access to psychiatric expertise by using telepsychiatry (videoconference in real time). Psychiatric Centre Little Prince in Copenhagen employ clinicians that aside from Danish speak their patients' respective languages (www.denlilleprins.org). Telepsychiatry have been developed and used in the centre since 2001. This paper describes recent telepsychiatry project started in the summer 2004.

The key aim of the project is to provide psychiatric service on patients’ own language there where the access to ethnic clinicians is limited. Furthermore, the project is designed to serve outlying areas with resource shortage.

MATERIAL AND METHODS
The main part of the work in this project was providing diagnostic assessment with subsequent treatment suggestions.

Participants involved in the project are mentally ill refugees/migrants. Total number of participants involved in the survey until January 2007. was 45 (14 women and 31 men). Mean age for males were 41,6 years and 46,4 years for females. Countries of participants` origin are: Ex –Yugoslavia, Syria, Iraq, Somalia, Poland, Iran, Lebanon and Morocco. Duration of participants' education was as followed: 0-4 years (18%); 5-8 years (27 %); 9-12 years (39 %) and over 12 years (16 %).

Most of participants (82%) did not have any contact to mental health system before arrival to Denmark. 61% of participants were in contact either with psychiatrist and/or psychologist in Denmark before being involved in the project.

The mean number of sessions (by 45-60 min) completed for all 45 subjects was six (6). Five (5) participants had at least one face–to face contact. The rest of the sample received only remote service. All participants were asked to complete the 10-items questionnaire after end of the telepsychiatry-contact in order to determine satisfactory level, advantages and disadvantages by using telepsychiatry (Table I). There were 5 possible ways to answer: "Yes, in high degree", "Yes, in some degree", "No, only in less degree", "Not at all" and "Don't know". The last two questions needed descriptive answers.

QUESTIONNAIRE
1.Did you get enough information about telepsychiatry?
2.Do you perceive "contact via TV" as uncomfortable?
3.Did you feel safe under telepsychiatry contact?
4.Have you been satisfied with sound quality?
5.Have you been satisfied with picture quality?
6.Did you achieve your goal via telepsychiatry / could you express everything you wanted to?
7.Would you recommend telepsychiatry to others?
8.Would you prefer contact via translator in future?
9.What were you most satisfied with during the telepsychiatry contact?
10.What were you most unsatisfied with during the telepsychiatry contact?

Technical set-up
The videoconferencing system links Psychiatric Centre Little Prince in Copenhagen with 4 sites around the country (two Psychiatric departments; one activity centre and one asylum-seeker centre). These 4 sites are aprox. 150-200 km away from Copenhagen. Videoconferencing is via broadband sHDSL by 2Mb/s, using Polycom VX7000 equipment.

The project period is 3 years (July 2004- July 2007).

RESULTS
All patients referred to telepsychiatry assessment and/or treatment agreed to participate in the survey. Diagnostic assessments disclosed wide range of psychiatric disturbances.

Participants' responses to telepsychiatry so far have been very positive regardless degree of mental illness. They reported a high level of acceptance and overall satisfaction with telepsychiatry regardless their ethnicity, educational level or previous experiences within mental health system There were no difference in satisfaction rates between patients that received subsequent face-to-face consultations and the rest of the sample.

Participants find telepsychiatry acceptable and useful cause of possibility to express their intimately emotional and existential problems on their motherhood language. Furthermore, they mentioned reduced need for travel. Participants responded positive when asked if they would recommend telepsychiatry to others. The most of participants reported willingness to use telepsychiatry again as well as they would prefer help by telepsychiatry on own language rather than face- to-face contact with the doctor via translator.

DISCUSSION
The project presented both assessment and treatment via telepsychiatry. In both situations the satisfactory level of participants were high. Key predictor of patient satisfaction with telepsychiatry in this survey was possibility to communicate on motherhood language. Both, participants with or without previous experience by translator provided mental health care prefer remote contact on own language rather then contact via translator.

One may assume that patients need to be seen face-to-face before the telepsychiatry treatment. According to our results, there are no differences in satisfaction level between participants who got subsequent face-to-face consultations and those who didn't. Of course, it is good idea to introduce the patient under face-to-face contact and possibly diminish eventual reluctance against new and unknown technology.

Our results also indicate that participants' ethnicity, educational level and degree of illness had no influence in order to choose telepsychiatry versus psychiatric help provided via translator. This is in discrepancy with an earlier published survey, which indicates that individuals with better physical health and higher adaptive coping scores tended to be more willing to participate in telepsychiatry [9].

CONCLUSION
Telepsychiatry, as suggested by large number of original surveys through last four decades, is a growing field with the potential to deliver high quality; much needed assistance in a variety of settings to persons in need of mental health services [10]. As far as we know, there is no research on use of videoconference in order to provide mental health toward such specific patient population as refugees/migrants. In a field such as assessment and treatment of migrants/refugees, often torture survivors, who are significantly underserved on their own language, telepsychiatry enables access to appropriate speciality service. At the same time, telepsychiatry provide opportunities for participation of other individuals involved in work with the patient (family members, social worker, GP, stuff on psychiatric department etc.). So far, this pilot project has demonstrated high acceptance and usefulness of videoconferencing in order to increase accessibility to mental health services on own language for refugees/migrants.

Used as a supplement to existing mental health system, telepsychiatry brings professional psychiatric expertise to outlying areas with resource shortage. Consequently, it is able to serve not only refugees/migrants but also wide range of Danish patient population. The experiences and attitudes of refugees/migrants can be used in promotion of telepsychiatry towards wide range of Danish patient populations.

Future evaluation need to be done in order to determine potential economical advantages of telepsychiatry in Denmark.

ACKNOWLEDGMENT
Ministry of the Interior and Health, Egmont Foundation and The Health Insurance Foundation founds the project.

REFERENCES
[1] Brown FW.(1998).Rural telepsychiatry. Psychiatr Serv; 49:963-964.
[2] Hawker F, Kavanagh S, Yellowlees P, Kalucy RS. (1998).Telepsychiatry in South Australia. J Telemed Telecare; 4:187-194.
[3] Baigent MF, Lloyd CJ, Kavanagh SJ, et al.(1997) Telepsychiatry: 'tele' yes, but what about the 'psychiatry'? J Telemed Telecare ; 3(Suppl 1):12-14.
[4] Simpson J, Doze S, Urness D, Hailey D, Jacobs P.(2001).Telepsychiatry as a routine service -the perspective of the patient. J Telemed Telecare; 7: 155-60.
[5] Kopel H, Nunn K, Dossetor D.(2001). Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service. Journal of Telemedicine and Telecare 7 (suppl 2):35–40.
[6] Bose U, McLaren P, Riley A, et al.(2001). The use of telepsychiatry in the brief counseling of non-psychotic patients from an inner-London general practice. Journal of Telemedicine and Telecare 7(suppl. 1):8–10.
[7] Bishop JE, O'Reilly RL, Maddox K, et al.(2002). Client satisfaction in a feasibility study comparing face-to-face interviews with telepsychiatry. Journal of Telemedicine and Telecare 8:217–221.
[8] Udlændingestyrelsen (2004). Nøgletal på udlændingeområdet.
[9] Rohland B.M., Saleh S.S., Rohrer J.E. and Romitti,P.A. (2000). Acceptability of Telepsychiatry to a Rural Population. Psychiatr Serv 51:672-674.
[10] Monnier J.,Knapp R.G. and Frueh B.C. (2003).Recent Advances in Telepsychiatry: An Updated Review. Psychiatr Serv 54:1604-1609.

For further information, please contact:
D.Mucic, psychiatrist
Psychiatric Centre Little Prince,
Pyrus Alle 21,2770 Kastrup, Denmark
This email address is being protected from spambots. You need JavaScript enabled to view it.
www.denlilleprins.org

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