Within the first year of establishing the Toronto Paediatric Telepsychiatry Program (TPTP), our research team developed and implemented a comprehensive multiphase program of qualitative research. A critical review of existing literature was conducted and an annotated bibliography was produced. The review revealed little research on the educative and knowledge-transfer potential of telepsychiatry programs. Most studies consisted of post encounter client satisfaction surveys that considered issues primarily of user comfort and satisfaction with the technology.
Input was obtained from all stakeholder groups (funder, hub site and far site) through surveys, focus groups and individual interviews. These groups identified the critical importance of considering all stakeholders in the evaluation and of taking into account the unique context (geographical, cultural and social) of each telepsychiatry site and its community (Boydell, Greenberg, & Volpe, 2004).
Perspectives of service providers and family members
Service providers reported that having access to specialty mental health expertise through the TPTP enhanced their capacity to support clients (young people and their families) with specific and often complex problems. Increased confidence was also mentioned as a benefit. Often, the telepsychiatry consultation confirmed the diagnosis that the rural practitioner had already suspected and the appropriateness of the intervention. The program reduced the burden on family members, eliminating the need to drive long distances for specialty care, thus alleviating financial strain and decreasing time lost from work. Overall, family members and clinicians felt strongly supported through their consultation experience. Though face-to-face connection would be preferable, when that is not possible, consultation employing ITV was frequently cited as “the next best thing to being there” (Greenberg, Boydell, & Volpe, 2006).
Perspectives of consulting psychiatrists, community general practitioners, and pediatricians
In face-to-face interviews, consulting psychiatrists reported that they valued their role as consultants as it meant that they were able to provide services without being burdened with an ongoing caseload. This helped with program buy-in and provided a robust directive to maintain a consultative model of service delivery. Research results also identified some difficulties encountered in the identification of non-verbal cues and subtle facial expressions during telepsychiatry consultations. Physicians selected from a random sample of TPTP sites were interviewed via telephone. Many physicians were either unaware of the pediatric telepsychiatry program or lacked information about the ways that they could be involved. This is not necessarily surprising since TPTP services are currently directed at clinicians of children’s mental health agencies. Physicians identified factors that would facilitate their involvement in the program, including remuneration issues and education regarding the prescribing of newer psychotropic medications (Boydell, Volpe, Watson-Gaze, Kertes & Greenberg, 2008). In response, the TPTP created medication information sheets and developed a process for effective distribution.
Outcomes of consultation recommendations
One hundred telepsychiatry consultations were randomly selected from the TPTP program files, and data were reviewed for presenting issues, reasons for referral and recommendations made during the consultation. It was found that multiple recommendations were made for youth with needs that were described as extremely complex. Successful implementation of recommendations was frequently the result of the value placed on the authority and expertise of consulting psychiatrists by case managers, family members, school personnel and physicians. Additional factors that facilitated implementation were very specific treatment directives, meaningful engagement of the young person and his or her family and the availability of follow-up sessions for complicated situations. Barriers to implementation included an absence of cooperation or willingness on the part of family members and youth, the brief nature of the consultation and the scarcity of available community resources. The video technology and consultations by consultants unknown to the local community were not identified as barriers. Challenges were attributed to lack of local resources, treatment biases of families and young people, and high local staff turnover (Boydell, Volpe, Kertes, & Greenberg, 2007).
Views of young people who have received a telepsychiatry consultation
A study funded by an external grant from the Provincial Centre of Excellence for Child and Youth Mental Health at the Children's Hospital of Eastern Ontario (CHEO) is currently in progress.
Objective: It is critical to consult young people about their experiences. This study addresses the lack of research on the perspective of young people in general, and in paediatric telepsychiatry specifically. The goal is to understand the experience of young people receiving telepsychiatry.
Method: Interpretive interactionism (Denzin, 1989) was used to interview 30 young people, immediately following the consultation and four to six weeks later. Analysis occurred via a series of steps in keeping with the interpretive interactionist framework.
Results: Four themes arose repeatedly:
- the encounter with the psychiatrist and experience of having others in the room;
- the helpfulness of the session;
- a sense of personal choice during the consultation; and
- the technology.
Participants highlighted the importance of their relationship with the psychiatrist. Participants’ narratives were replete with examples of ways that they actively took responsibility and exerted control within the session itself.
Conclusion: Young people have a significant role to play in their own care. It is critical that telepsychiatry recommendations be explained and opportunities for young people to express their concerns and discuss alternatives are provided. Further efforts to include young people may include ensuring offering alternate treatments and/or negotiated when recommended treatments are unacceptable and/or resisted (Boydell, Volpe & Pignatiello, 2010).
Choosing child and adolescent psychiatry: Factors influencing medical students
Objective: To examine the factors influencing medical students to choose child and adolescent psychiatry as a career specialty.
Method: Quantitative and qualitative methods were used. A web-based survey was distributed to child and adolescent psychiatrists at the University of Toronto. In-depth interviews were held with select child and adolescent psychiatrists as well as a focus group with psychiatry residents. Retrospective accounts of the factors that influenced their decision to choose psychiatry and/or child and adolescent psychiatry as a specialty were collected.
Results: Ninety-two per cent of participants indicated that recruitment of child psychiatrists in Canada is a problem. The recent decision by the Royal College of Physicians and Surgeons to recognize child and adolescent psychiatry as a subspecialty and introduce an extra year of training was identified as a further challenge to recruitment efforts. Other deterrents included lower salary than other subspecialties, lack of exposure during training, stigma, and lack of interest in treating children. Recruitment into psychiatry was enhanced by good role modeling, early exposure in medical school, an interest in brain research and career and lifestyle issues.
Conclusions: A rebranding of the role and perception of psychiatry is needed to attract future psychiatrists. Early exposure to innovations in child and adolescent psychiatry and positive role models are critical in attracting medical students. Recruitment should begin in the first year of medical school and include an enriched paediatric curriculum (Volpe, Boydell & Pignatiello, 2013).
Attracting child psychiatrists to a televideo consultation service
Objective: Identify aspects of psychiatry work that are rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services.
Method: A web-based survey was distributed to psychiatrists within the Division of Child Psychiatry at the University of Toronto. As well, semi-structured interviews were conducted with six child psychiatrists providing services to a telepsychiatry program. Finally, a focus group interview was held with four psychiatry residents.
Results: Child psychiatrists are very comfortable conducting assessments via televideo. Factors identified as being important in the decision to participate in telepsychiatry include: assisting under-serviced communities, supportive administrative staff, enhanced rural provider capacity, financial incentives and convenience. The study’s qualitative phase identified four themes in the decision to participate in telepsychiatry:
- shared values,
- innovation, and
- the consultation model.
Conclusion: The success of televideo consultation programs in attracting child psychiatrists to provide consultation services to under resourced communities makes an important contribution to psychiatric workforce shortages. Understanding what aspects of telepsychiatry are most appreciated by consulting psychiatrists and residents offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train and retain psychiatry practitioners (Volpe, Boydell & Pignatiello, 2013).
Mental health services for Nunavut children and youth: Evaluating a telepsychiatry pilot project
Introduction: This study examines the delivery of psychiatric consultation services using videoconferencing technology to Nunavut health and mental health workers. The research provides insights into the TeleLink Nunavut Mental Health Program and the delivery of professional-to-professional program consultations and continuing education seminars.
Methods: Participant observation of 12 program consultations and four continuing education sessions was conducted. Individual interviews were conducted with the consulting psychiatrist and the lead program coordinator in Nunavut. As well a focus group was held with Nunavut workers who participated in the televideo sessions.
Results: The study found a number of factors that facilitated or hindered the process and content of a consultation-based telepsychiatry program and its effect on building capacity among frontline staff. Four main themes emerged related to the delivery of psychiatric services via televideo. They include:
- gaining access,
- ensuring culturally appropriate services,
- providing relevant continuing education, and
- offering stable and confidential technology.
Conclusions: The use of live interactive videoconferencing technology is an innovative and effective way of delivering specialized mental health services to professionals working in remote areas of Nunavut. Study results provide important strategies for expanding this approach to other jurisdictions in Nunavut and other Inuit regions (Volpe, Boydell & Pignatiello, 2014).
Development of a policy-ready paper on the use of technology in the delivery of child and youth mental health services
Funded by the Ontario Centre of Excellence for Child and Youth Mental Health, this project summarizes the link between research and policy implications and provides a comprehensive picture of the potential role that technology (both existing and emerging) can have in improving mental health services in Ontario. There are promising policy implications if technology can be used to provide more accessible mental health services including reduced wait lists; enhanced access to services in under-served communities; reduced barriers related to stigma; and service delivery that is cost-effective and clinically effective (Boydell, Hodgins, Pignatiello, Teshima, Edwards & Willis, 2014).
Objective: To conduct a scoping review on the use of technology to deliver mental health services to children and youth in order to identify the breadth of peer-reviewed literature, summarize findings and identify gaps.
Method: A literature database identified 126 original studies meeting criteria for review. Descriptive numerical summary and thematic analyses were conducted. Two reviewers independently extracted data.
Results: Studies were characterized by diverse technologies including videoconferencing, telephone and mobile phone applications and Internet-based applications such as email, web sites and CD-ROMs.
Conclusion: The use of technologies plays a major role in the delivery of mental health services and supports to children and youth in providing prevention, assessment, diagnosis, counseling and treatment programs. Strategies are growing exponentially on a global basis, thus it is critical to study the impact of these technologies on child and youth mental health service delivery. An in-depth review and synthesis of the quality of findings of studies on effectiveness of the use of technologies in service delivery are also warranted. A full systematic review would provide that opportunity.
Technology-enabled knowledge translation (TEKT) of evidence-based practice (EBP) in paediatric telepsychiatry
This study (funded by the SickKids Foundation/RBC) focuses on exploring the ways in which technology-enabled knowledge translation (TEKT) influences the application and adaptation of knowledge about evidence-based practices at the individual and organizational levels in rural child and youth mental health settings. (Pignatiello, Boydell, Braunberger, Teshima, Willis, Final report available July 2016)
Background: There is a need to share knowledge about evidence-based practice (EBP) in rural and remote communities to address the gap in general and specialist care in child and youth mental health. As EBP gains momentum, practitioners of continuing education are challenged to develop opportunities for application of evidence-based knowledge.
Objective: To explore the ways in which Technology-Enabled Knowledge Translation (TEKT) influences the application and adaptation of knowledge about Evidence-Based Practices (EBPs), at individual and organizational levels, in rural child and youth mental health settings.
Methods: An interpretive interactionist methodology using observational fieldwork, semi-structured interviews and focus groups were used. Such methods allow for examination of the complex interplay between practitioner learning priorities, competing demands on their work, and the extent to which principles of EBP are applied in their particular communities.
Results: Service providers in rural communities indicated that TEKT provided the opportunity to improve their knowledge and skills, increase their confidence, and enhance decision-making with clients. Technological delivery of EBPs is essential to daily practice and is an especially useful format for knowledge sharing and training in the use of evidence-based material. Challenges of TEKT included scheduling constraints, lack of awareness about this resource, and shortage of local resources to support this knowledge translation platform.
Conclusion: TEKT contributes toward a culture of collective learning, knowledge and skill sharing.
Lost in translation: Physician referrals to paediatric telemental health
Objectives: This study explores the physician referral process of a paediatric telemental health program based in a large urban teaching children's hospital, identifying its strengths and challenges from the perspectives of the referrer and the telepsychiatrist consultants.
Methods: An online survey was completed by 43 primary care physicians located in rural communities in Ontario who had referred patients to the telemental health program. Interviews were conducted with 11 child/adolescent telepsychiatrists who provide consultations via teleconferencing.
Results: The majority of physicians (61%) reported somewhat to moderate satisfaction with referral experiences. Challenges identified by physicians were largely related to communication and administration issues such as: the lack of timely follow-up appointments and continuity of care; lengthy referral forms and recommendations for mental health services not accessible in their communities. Similarly, psychiatrist consultants expressed frustration with the information they received from referring physicians and the absence of appropriate service providers/professionals during the consultation to provide collateral information and ensure uptake of recommendations.
Conclusion: Telemental health programs provide a valuable service to family physicians and their child and youth clients that could be significantly enhanced with protocols in place to improve communication and information sharing as well as establish clear expectations between referring physicians and telepsychiatry consultants (Pignatiello, Stasiulis, Solimine, Boydell, under review)