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Psychiatry and Health Behavior
Joseph P. McEvoy, MD, has disclosed that he has received funds for research support from Alkermes, Auspex, Biogen, Boehringer Ingelheim, Neurocrine Biosciences, and Takeda and consulting fees from Intracellular and Sunovion.
What Is Telepsychiatry?
Telepsychiatry is the delivery of psychiatric healthcare through virtual means. Telepsychiatry began as a strategy to more efficiently and inexpensively provide psychiatric healthcare, especially in rural, sparsely populated areas where travel to clinical sites may take hours. The COVID-19 pandemic accelerated the uptake of telepsychiatry methods, including videoconferencing, teleconferencing (voice only), and text messaging, to reduce exposure to infection. In 2018, the American Psychiatric Association released position statements supporting the use of telepsychiatry (in particular, through videoconferencing) as a “validated and effective practice of medicine that increases access to care . . . a legitimate component of a mental health delivery system.”1
Multiple lines of evidence suggest that the diagnostic accuracy, treatment outcomes, and patient satisfaction achieved through telepsychiatry are similar to those achieved through traditional in-person care, with reduced costs and healthcare resource use.1 Telemedicine can help extend the physician workforce and improve access to healthcare for patients. Patients and/or family/important others do not need to take time off work or to expend the time and costs for traveling to the clinic. Clinic space is less crowded and less space is needed.
Telepsychiatry studies have focused on outcomes in mental health services. Less is known about the detection and monitoring of medication-related movement disorders, such as tardive dyskinesia (TD). Here, I describe the latest evidence and expert opinion on the use of telepsychiatry in the diagnosis and management of TD.
Patients, family/important others, or healthcare professionals can initiate text-messaging interactions at any time and recipients can respond when it is convenient. Text-messaging leaves an enduring record of the contact; for example, clear instructions about a new medication remain available to patients and family/important others who support their care. However, the only information available to healthcare professionals is the content of the typed message—inadequate for the assessment of antipsychotic medication–induced movement disorders.
Teleconferencing permits faster and fuller exchange of information (via speech rather than typing). Healthcare professionals can hear urgency or confusion in patients’ speech and address these. Healthcare professionals can emphasize points through cadence and tone. Family/important others can participate through a speaker phone contact or merged calling to report what they observe and assist patients in following simple instructions.
Videoconferencing has all the benefits of teleconferencing plus visual information and is the preferred strategy for assessment of antipsychotic medication–induced movement disorders. Healthcare professionals must plan and prepare for videoconferencing to gather complete information. Healthcare professionals must be located far enough from the camera for patients to see them demonstrate desired activation maneuvers (eg, tapping each finger to the thumb in sequence). Ancillary staff can teleconference with patients prior to healthcare professional contact to assure adequate lighting at each patient’s location and to address noise issues. Ancillary staff can train patients on strategies (camera placement, angle, and distance) to obtain close assessment of the face, middistant assessment of the upper or lower body, and more distant assessment of gait.
Whatever strategy is used, healthcare professionals begin by asking patients about movements: Where are the movements on the body? When did they begin and are they progressing? How are they experienced, and do they cause distress and changes in social behaviors (eg, withdrawal from usual activities)? Whatever strategy used, involvement of family/important others or other clinical or ancillary staff is helpful.
The Use of Telepsychiatry in Patients With, or at Risk for, TD
Practice guidelines from the American Psychiatric Association suggest inquiring about abnormal movements and examining for TD movements regularly in patients treated with antipsychotic medications. Using antipsychotic medications only in patients likely to accrue substantial benefit, and at the lowest effective doses for the shortest periods of time, encourages prevention of TD. Early recognition through routine screening may optimize the likelihood of complete suppression of abnormal movements with currently available treatments.
The Abnormal Involuntary Movement Scale (AIMS) is the gold-standard instrument for monitoring and includes clear and simple instructions for administration and scoring. However, the busy healthcare professional can also rapidly (2 minutes) screen using 2 activation maneuvers:
The AIMS was originally intended for in-person administration but has proved to be reliable in videoconferencing. In a study involving 4 raters, 2 in-person with the patient and 2 via videoconference, simultaneously examining 50 patients with significant exposure to antipsychotic medications, ratings were highly concordant.2
No current systematic data demonstrate that healthcare professionals can correctly diagnose TD via telepsychiatry without the use of the AIMS. A full AIMS rating should occur at the telepsychiatry baseline if possible and every 6 months thereafter. Brief activation maneuvers can be done at every visit. If the healthcare professional suspects new-onset TD, a full AIMS should be done in-person prior to starting treatment.
Strategies To Diagnose Tardive Dyskinesia Virtually
No current systematic data exists to demonstrate whether healthcare professionals can diagnose TD in a reliable manner via telemedicine, without the use of the AIMS. Therefore, we recommend that healthcare professionals incorporate the AIMS into practice when assessing patients for the presence of TD. It is also important to obtain a baseline assessment of the patient using the AIMS prior to antipsychotic treatment or at first clinic visit to compare with findings so that he/she can be appropriately monitored with this instrument during follow-up.3 Cases where the presence of TD is suspected but uncertain should be evaluated in-person.
If possible, both the healthcare professional and patient should use computer screens, rather than smart phones, to maximize visual quality and leave all participants hands-free.3 Ideally, the patient should be sitting in a hard-backed chair without arms. If possible, have family/important others on the videoconference if this is the initial examination. Start by asking them what they have noticed in terms of movements and the patient’s functioning. Demonstrate for them what you would like the patient to do, such as holding her/his mouth open. Ask the family/important other or staff to move the camera to the ideal distance and angle and to walk with patients who are frail or at risk for falls.3-5
With patients’ permission, trained ancillary staff can implement the AIMS examination via recorded videoconference and the healthcare professional can rate it later, or a colleague can be asked to opine on complicated cases. Recorded videos can demonstrate change with treatment to the healthcare professional, patient, and family/important others.
Developing Your “Webside” Manner in Telepsychiatry
Ensure that patients feel that the telepsychiatry contact is a private and secure event.1 Explain that you will strive to overcome the limitations of a virtual—as opposed to in-person—examination. Let the patient know that you will take notes (and even when you look away, you are concentrating on the patient’s care). Periodically focus on your computer’s camera to approximate looking directly at the patient.5 Allow for a pause after the patient speaks to avoid speaking over the patient if there is audio lag. Emphasize gestures and tone to get points across. At the end of the session, let the patient leave the meeting first.5
Tell us about your experiences using telepsychiatry for the detection and assessment of movement disorders. What have your experiences been like managing TD virtually? What tips do you have for the rest of us to benefit from? Please share your experiences and thoughts in the comments box.