BRIEF REPORTS

Pilot Studies of Telemedicine for Patients

With Obsessive-Compulsive Disorder

Lee Baer, Ph.D., Peter Cukor, Ph.D., Michael A. Jenike, M.D.,

Linda Leahy, B.S., John O’Laughlen, M.B.A., and Joseph T. Coyle, M.D.

Objective: Remote video psychiatric assessment holds promise for providing expert consul-
tation to underserved areas. The authors assessed the reliability of rating scales administered
in person and over video to patients with obsessive-compulsive disorder. Method: Rating scales
I or obsessive-compulsive, depressive, and anxiety symptoms were administered in person
(N=1 6) and by means ofnarrow-bandwidth video transmission over one digital telephone line
(N= 1 0). Interrater reliability was determined for each condition; for the video interviews one
rater sat at the local site in front of the videoconsulting apparatus and asked the questions,
and the patient and the second rater sat at the remote site. Results: Reliability was excellent
in both conditions, and there was no degradation in reliability when the assessment was con-
ducted over video. Conclusions: Telemedicine resulted in near-perfect interrater agreement on
rating scale scores. Its use for other disorders and for more in-depth assessments should be
explored.
(Am J Psychiatry 1995; 152:1383-1385)

T elemedicine
tions
is the application
and audio-video technology
of telecommunica-
to provide ex-
of acceptable
of a videoconference
quality essentially in real time. At the start
at this bandwidth, an initially
pert medical services from sites remote from the patient. blurry picture stabilizes within 2 to S seconds, and
Although telemedicine had its roots in psychiatry in the thereafter the image is continually refreshed at 12 to 15
1950s, this method has received little attention in the frames/sec. Rapid movement produces some jerkiness
past four decades (1-5). However, given the search for and blurring in the part of the image that has moved,
methods to provide high-quality psychiatric care at low which then stabilizes within 2-S seconds after the rapid
cost, especially in underserved areas, interest in video- movement ends.) The image processing and transmis-
consulting has been revived in the last few years (6). sion are accomplished by using computerized compres-
Psychiatry appears to be an ideal specialty for videocon- sion/decompression devices to compress salient parts of
suiting, because of the primacy of face-to-face question- the video image and audio and then transmit them over
and-answer interaction. 1-24 digital telephone lines.
One reason for this revival of interest is greatly im- We decided to begin with a narrow-bandwidth ap-
proved technology that no longer requires expensive, proach (e.g., one ISDN telephone line, 128 kbit/sec), to
specialized conference rooms and dedicated transmis- determine the reliability of assessments made with such
sion lines between sites but, instead, allows tnansmis- images. This is a low-cost approach that would be the
sion of video images over a few digital telephone lines most widely available.
in existing telephone networks. One component of such Since few basic studies have been conducted with
a system is the integrated services digital network videoconsulting in any medical specialty, we developed
(ISDN), a standard digital connection between the user a reliability testing paradigm that can be used to quan-
and the network. (Transmission at 128 kbit/sec over a tify the reliability of assessments made by using this
single ISDN line is capable of transmitting video images medium.

Received Aug. 22, 1994; revision received Nov. 28, 1994; accepted METhOD
Jan. 1995. From the Consolidated
27, Department ofPsychiatny, Han-
yard Medical School, Boston. Address reprint requests to Dr. Baen, The simultaneous live reliability interview is an accepted method
CNY-9, Massachusetts General Hospital, Chanlestown, MA 02129. for estimating the reliability of an investigator-administered scale
Video equipment used in this study was obtained with the assistance (7). We developed an analogous approach that we termed the “si-
of PictureTel Corp., Danvens, Mass. multaneous video reliability interview. “ In this system one rater sat
The authors thank Daniel Miley for assistance in carrying out this at the local site in front of the videoconsulting apparatus and asked
project. the questions, while the patient and a second rater sat together at the

Am J Psychiatry I 52:9, September 1995 1383

BRIEF REPORTS

TABLE 1. Interrater Reliability of Rating Scale Scores Obtained by obsessive-compulsive disorder and 2) assess a wide variety of symp-
Live Versus Video Interviews of Patients With Obsessive-Compulsive toms: obsessive-compulsive, depressive, and anxiety. Thus, we ad-
Disord& ministered the Yale-Brown Obsessive Compulsive Scale (7), Hamil-
ton Depression Rating Scale (8), and Hamilton Anxiety Rating Scale
lntraclass (9) during all rating interviews.
Correlation
Coefficient

Live Video RESULTS

Interview Interview
Rating Scale (N=16) (N=10) z p
Severity of obsessive-compulsive disorder, as meas-
Yale-Brown Obsessive ured by the Yale-Brown Obsessive Compulsive Scale,
Compulsive Scale 0.99 0.99 0.00 >0.99 did not differ significantly between the patients in the
Hamilton Depression
live interview group (mean score=18.43, SD=7.98) and
Rating Scale 0.98 0.98 0.00 >0.99
Hamilton Anxiety Rat-
the patients in the video interview group (mean=18.35,
ing Scale 0.97 0.99 1.19 0.25 SD=8.11) (t=0.8, df=24, p=O.93). Table 1 presents the
aFor the video interviews one rater sat at the local site in front of the reliability coefficients for the three rating scales in the
videoconsulting apparatus and asked the questions, and the patient live and video conditions.
and the second rater sat at the remote site. The patients in the video interview group were asked
to rate their comfort level during the interview, their
ability to express themselves, the quality of the inter-
remote site, and both raters scored the patients’ answers to the rat- personal relationship, and the helpfulness of the inter-
ing scale items. Reliability was calculated as the intraclass cornela-
view on a scale including “much below average,” “be-
tion coefficient for the two raters’ total scones for each scale. With
this method, any difference in reliability between the live and video low average,” “average,” “better than average,” and
interviews would be reflected in decreased reliability of the video “much better than average,” compared to other inter-
interview. views. The mean scores for all of these questions fell
The patients in the simultaneous live reliability interviews were 16
between the “average” and “better than average” an-
patients who met the DSM-III-R criteria for obsessive-compulsive dis-
order and were participating in a double-blind medication trial. The
chon points. The raters administering each set of scales
patients in the simultaneous video reliability interviews were 10 pa- also were asked to compare the video experience to a
tients with DSM-III-R obsessive-compulsive disorder who were cur- typical live interview in terms of comfort, ease of ex-
rent patients in the
Massachusetts General Hospital obsessive-com- pressing one’s self, and usefulness of the same scale; in
pulsive disorder clinic
and agreed to participate in the study.
all cases the mean scores were either “average” or
Two PictureTel 4000 model 400 units (PictureTel Corp., Danvens,
Mass.) were located at hospitals separated by approximately 20 “above average.”
miles, and connection was established by dialing the other site
through the local telephone company’s ISDN. The system contained
two video input devices: I ) a digital (change-coupled device) camera DISCUSSION
with both near- and fan-end controls with scanning and zooming ca-
pabilities and 2) a document camera to facilitate the transmission of
graphic material. The primary video output device was a 27-inch Telemedicine using narrow-bandwidth transmission
monitor equipped with window feature. A videocassette recorder al- over one ISDN telephone line resulted in near-perfect
lowed recording of each session. The audio input-output equipment agreement on scores on semistructured rating scales
consisted of a high-quality microphone and speaker built into the
for obsessive-compulsive, depressive, and anxiety
control keyboard.
Image quality in videoconfenencing is a function of the correctness symptoms in patients with obsessive-compulsive dison-
of the algorithm used for image processing and of the availability of den. It is possible that for more difficult diagnoses (e.g.,
bandwidth, which is essentially transmission capacity. In this study mild anxiety disorders or dysthymia) one might pick
the PictureTel 5G3 proprietary algorithm was used for image prod-
up important cues from in-person contact during inter-
essing. With our equipment the best image quality may be obtained
by using the 384-kbit/sec bandwidth. This is, however, an expensive
viewing, and research is now underway to determine
and not always available option. Less expensive and more likely to be whether this method is also useful in other psychiatric
available is the 128-kbit/sec bandwidth. (The list price of the video disorders.
equipment used in this study is currently $50,000 to $60,000 pen site. If this technology is found to also be useful for other
This cost is bandwidth independent. However, if more than one ISDN
disorders and for more in-depth assessments, then it
line is used, inverse multiplexers currently costing approximately
$12,500 are required at each site. Thus, compared to transmission at may prove to be cost-effective and widely applicable
384 kbit/sec, using the narrower bandwidth of 128 kbit/sec eliminates because of its ability to bring expert psychiatric consul-
the need for inverse multiplexens and reduces telephone line changes tation to a number of settings for underserved popula-
by two-thirds, which for each ISDN line are approximately twice
tions, including clinics for the rural and urban poor,
those for an analog telephone line.) The fundamental question is
whether this narrow bandwidth can provide sufficient image quality
homeless shelters, prisons, nursing homes, and health
to allow diagnosis
of certain psychiatric diseases. All interviews ne- care delivery sites without easy access to psychiatric
ported in this paper were conducted by using the 128-kbit/sec band- services.
width. Audio quality, however, is independent ofthe bandwidth used.
The patients in both interview conditions gave signed informed
consent to participate. All 26 patients were rated by the same raters REFERENCES
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 BRIEF REPORTS

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Am J Psychiatry 1 52:9, September 1995 1385