TELEMEDICINE AND e-HEALTH

Volume 12, Number 5, 2006

© Mary Ann Liebert, Inc.

Original Research
Cost Effectiveness, Safety, and Satisfaction with Video
Telepsychiatry versus Face-to-Face Care in
Ambulatory Settings

ILAN MODAI, M.D., M.H.A,1,2 MAHMOUD JABARIN, M.D.,1 RENA KURS, B.A.,3
PERETZ BARAK, M.D.,1 ILAN HANAN, M.D.,1 and LUDMILA KITAIN, M.D.1

ABSTRACT

Videoconference telepsychiatry provides an alternative for the psychiatric treatment of mental

health patients who reside in remote communities. The objective of this study was to compare
institutional ambulatory and hospitalization costs, treatment adherence, patient and physician
satisfaction, and treatment safety between mental healthcare via videoconferencing and care pro-
vided in person. Data collected for 1 year of telepsychiatry treatment was compared to that of
the preceding year and a matched comparison group. Twenty-nine patients from Or Akiva and
20 patients from Reut Hostel in Hadera who met the inclusion criteria agreed to participate; 24
and 15 patients, respectively, completed the study. Forty-two matched patients, who continued
face-to-face interviews, comprised the comparison group. Drop-out patients and those who did
not consent to telepsychiatry treatment were not involved. During the year of telepsychiatry treat-
ment, patients and physicians were satisfied and treatment was safe. However, 1 hour of telepsy-
chiatry treatment was more expensive than face-to-face care, and a tendency of increased hospi-
talizations was noted. Adherence ratios before and during telepsychiatry treatment were similar,
but were twice as high versus the comparison group. The limited sample size precludes the draw-
ing of definite conclusions, and further studies involving a larger study population and longer
duration of investigation is warranted.

INTRODUCTION included questionnaires for the evaluation of

telepsychiatry3 and more recent studies dem-

N EW TELECOMMUNICATION TECHNOLOGIES
have already influenced the spatial and
temporal relationships between health profes-
sionals and patients.1 Studies have shown that
telepsychiatry offers a viable alternative for ser-
vice delivery to patients who live in distant
rural areas.2 The 1980s introduced studies that
onstrated patient and physician satisfaction.4–6
In their systematic review of patient satisfac-
tion with telehealth care Williams et al.7 re-
ported levels of satisfaction greater than 80%
and frequent reports of 100% satisfaction. Stud-
ies from the late 1990s found that diagnosis and
treatment via telepsychiatry was as reliable and

1Shaar-Menashe Mental Health Center, Mobile Post Hefer, Israel.

2Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
3Lev-Hasharon Mental Health Center, Netanya, Israel.

515
516
efficient as face-to-face interviews, with high
interrater reliability in the diagnosis of people
suffering from obsessive-compulsive disor-
der,8 anxiety and depressive disorders,1 schizo-
phrenia,9 and paranoid schizophrenia with
no exacerbation of delusional symptoms.3
Telepsychiatry has also been successfully used
for treatment of posttraumatic stress disorder10
and for the treatment of depression.11
More recent studies placed the emphasis on
actual geographic distance between the exam-
iners and the patients and found that patients
expressed equal satisfaction and ability to de-
velop a relationship in both in-person and
telepsychiatric interviews.1,12
Since 1960, the use of telepsychiatry has
proven beneficial in solving the problem of lack
of adequate psychiatric services in remote com-
munities. Many projects of telepsychiatric ser-
vices have been described in the literature. The
most expansive project was undertaken in
southern Australia, and began in 1994.13
Telepsychiatry was implemented to provide a
solution for a broad spectrum of psychiatric
services for community-based clients scattered
across 1 million square kilometers. More than
2,000 consultations–emergency services and li-
aison services for inpatients, and follow-up vis-
its were administered during the first 4 years
of the project.
Freuh et al.14 conducted a survey of telepsy-
chiatry that dealt mainly with administration
of psychiatric services in geographically distant
communities and reported a lack of empirical
studies of telepsychiatry (i.e., clinical outcome
studies and cost analysis). In a comprehensive
systematic review of the literature of the as-
sessment of telemedicine, Roine et al.15 con-
cluded that while relatively convincing evi-
dence of effectiveness was found for
telepsychiatry, evidence regarding the effec-
tiveness and cost-effectiveness of telemedicine
is still limited.
We opened the first two satellite videocon-
ference telepsychiatry (VCTP) clinics in Israel,
in Or Akiva (OA) and Hadera (Hd), located 20
and 15 km, respectively, from the Shaar-
Menashe Mental Health Center (SMMHC) am-
bulatory clinic. Prior to the study, the treating
psychiatrist traveled to Hd to see patients. OA
patients came to the ambulatory clinic at
MODAI ET AL.
SMMHC. Transportation costs and travel-asso-
ciated hardships of OA patients account in part
for the occasional difficulties in adherence to
follow-up care.
We sought to evaluate the cost of ambula-
tory care and hospitalization, treatment adher-
ence, clinical safety, and patients’ and thera-
pists’ satisfaction in two VCTP settings in
comparison to face-to-face care.
MATERIALS AND METHODS
Subjects
Patients were over 18 years of age, spoke He-
brew, and had at least 1-year of face-to-face
treatment before the initiation of the study. One
hundred four patients from the towns of OA
and Reut Hostel in Hd sought help from
SMMHC ambulatory clinic during the trial pe-
riod. Twenty-nine patients from OA and 20 pa-
tients from Reut Hostel in Hd who met the in-
clusion criteria agreed to replace face-to-face
interviews with VCTP and participated in the
study; 24 and 15 patients, respectively, com-
pleted the study. Forty-two matched patients
who did not participate in VCTP treatment
comprised the comparison group. Five patients
from OA and 5 from Hd dropped out. In OA,
2 withdrew consent, 2 relocated, and 1 discon-
tinued after hospitalization. In Hd, 1 patient
committed suicide while hospitalized in a gen-
eral hospital and 4 relocated. Patients who did
not meet inclusion criteria for participation in
the study and patients who dropped out from
VCTP treatment were not included in the
analyses. All participants met International Sta-
tistical Classification of Diseases and Related Health
Problems (ICD-10) diagnostic criteria for major
psychiatric disorders. The Institutional Review
Board (IRB) of SMMHC approved the study.
The participants retained the option to return
to face-to-face care.
Demographics of the VCTP and comparison
groups are presented in Table 1. The groups
matched for age, gender, education, family sta-
tus, and diagnoses. The social counselor from
OA and the social worker from Reut Hostel
who served as case managers accompanied the
patients during their sessions.
VIDEO TELEPSYCHIATRY VS. FACE-TO-FACE CARE 517

TABLE 1. DEMOGRAPHICS OF VIDEOCONFERENCE TELEPSYCHIATRY (n  39) AND COMPARISON (n  42) GROUPS

VCTP group Comparison group Statistics

Gender M  26 M  22
2  1.709
F  13 F  20 df  1
p  0.191
Age (y) 44.64  9.48 46.21  13.60 df  79
t  0.607
p  0.546
Family status Bachelors  17 Bachelors  15
2  0.607
Married  13 Married  17 df  3
Divorced  8 Divorced  9 p  0.895
Widowed  1 Widowed  1
Education (y) 10.15  3.34 10.54  7.07 df  79
t  0.324
p  0.747
Diagnosis Schizophrenia  33 Schizophrenia  27
2  6.030
AD  2 AD  3 df  4
Anxiety  2 Anxiety  2 p  0.197
Dementia  1 Dementia  5
Organic PD  5

VCTP, videoconference telepsychiatry; AD, affective disorders; PD, personality disorders.

Instruments tocol (IP) version 3 for IP and Integrated Ser-

Safety was monitored using the Brief Psy-
chiatric Rating Scale (BPRS)16 and the Clinical
Global Impression Scale (CGI)17 at baseline and
every 3 months thereafter.
Satisfaction was measured at the 3-, 6-, 9-,
and 12-month visits using the Patient Satisfac-
tion Questionnaire (PSQ)-completed by pa-
tients and Therapist Satisfaction Questionnaire
(TSQ)-completed by therapists, modifications
of the Missouri Telehealth Network18 satisfac-
tion questionnaire. Answers for both question-
naires ranged from 1, (not satisfied) to 5 (ex-
tremely satisfied). The PSQ included the
following items: general impression, the ability
to contact the therapist, the ability of the ther-
apist to diagnose, feeling of comfort, the level
of discomfort and nervousness, accessibility,
the quality of treatment, similarity to face-to-
face interview, the quality of equipment, will-
ingness to use again and the sense of therapist’s
presence. TSQ included similar items aside
from “the sense of comfort” and “nervous-
ness.”
Videoconference telepsychiatry materials
VCTP facilities were set up near the town
center of OA and in Reut Hostel located in Hd.
The equipment used was Falcon Internet Pro-
vices Digital Network (ISDN) (VCON Ltd.,
Ra’anana, Israel). ISDN communication lines
connected the main clinic to the two satellites
and 29-inch television monitors were used for
viewing.
Statistical analyses
Analysis of variance ANOVA with re-
peated measures was used for the compari-
son of BPRS, CGI, and satisfaction question-
naires, two-tailed t test was used to compare
duration of hospitalizations. The adherence
ratio was the mean number of visits/mean
number of missed visits. t Test or
2 was
used for the comparison of demographic
data.
RESULTS
Results are presented in Tables 2, 3, and 4.
Adherence ratios were twice as high in the
VCTP group as in the comparison group but
similar within the groups. Mean hospitaliza-
tion days were not significantly increased (2.49;
8.28; p
0.05) during VCTP as well as in the
parallel periods of the matched comparison
group (12.45; 28.59; p
0.05).
518 MODAI ET AL.

TABLE 2. PATIENTS’ ADHERENCE RATIO AND NUMBER OF HOSPITALIZATION DAYS FOR ONE YEAR PRIOR TO AND FOR THE
YEAR-LONG DURATION OF VIDEOCONFERENCE TELEPSYCHIATRY TREATMENT COMPARED TO FACE-TO-FACE TREATMENT

VCTP group (n  39) Comparison group (n  42)

Before During Before During

Adherence ratioa 11.05/2.15  5.13 12.33/2.66  4.63 16.74/8.38  1.99 15.33/6.52  2.35
No of hospitalization days 2.49  10.33b,c 8.28  24.29b,d 12.45  32.20d,e 28.59  101.15c,e
(Mean  SD)
aMean number of visits/mean number of missed visits.
bp  0.19.
cp  0.38
dp  0.062.
ep  0.270.

SD, standard deviation.

Average institutional costs for hospitaliza-
tion were 223.7% higher during VCTP treat-
ment and 132.5% during the parallel periods of
the matched comparison groups. The costs of
an hour-long session were 32% higher during
VCTP treatment. When travel expenses of OA
patients for the year preceding VCTP were in-
cluded in calculations, VCTP hour costs were
higher by only 10.6%.
As expected, patients and therapists were
generally satisfied (df  3,172; F  9.38, p 
0.0001; df  3,172; F  12.69, p  0.0001, re-
spectively). All PSQ final scores significantly
improved (p  0.05) and were above 4 except
treatment quality (df  3,172; F  2.69, p

0.05), satisfaction with equipment (df  3,172;
F  0.74, p
0.05) and nervousness (df  3,172;
F  1.47, p
0.05), which remained stable. In
addition, all TSQ final scores were above 4 and
significantly improved during the study (df 
3,172; p  0.0001). The sense of presence dur-
ing interview, an item not generally included
in satisfaction scales also showed significant
improvement in patients’ and therapists’ eval-
uations during the study (df  3,172; F  5.81,
p  0.001; df  3,172; F  15.93, p  0.0001, re-
spectively).
As presented in Table 4, VCTP treatment was
clinically safe; BPRS scores significantly de-
creased during the study and CGI scores re-
mained stable.
DISCUSSION
Institutional costs (hospitalizations and ses-
sions) are higher during VCTP. Ruskin et al.11
found that the cost of remote treatment was
equal to that of in-person treatment if the psy-
chiatrist had to travel 35.2 km. In a more dis-
tant facility, VCTP treatment was even less ex-
pensive than in-person treatment. In the

TABLE 3. COMPARISON OF COSTS FOR ONE YEAR PRIOR TO AND FOR THE YEAR-LONG
DURATION OF VIDEOCONFERENCE TELEPSYCHIATRY TREATMENT

Telepsychiatry (n  39) Comparison group (n  42)

A year before A year during A year before A year during

Institutional operating costs $71.50 $94.40 $70.90 $70.90

per houra
Total operating costs per hourb $85.30 $94.40 $84.70 $84.70
Mean cost of hospitalization $372.50 $1,205.80 $1,842.20 $4,282.80
per patient
aSalaries, psychiatrist travel expenses, running costs, phone expenses, equipment depreciation (10-year basis).
bPlus patients travel expenses.
VIDEO TELEPSYCHIATRY VS. FACE-TO-FACE CARE
TABLE 4. MEAN ( SD) SCORES OF BPRS AND CGI AT EACH TIME POINT
THIRTY-NINE PATIENTS DURING TELEPSYCHIATRY TREATMENT
Baseline 3 months 6 months
BPRS 32.04  5.68 30.67  5.74 28.93  5.99
CGIs 4.31  0.81 4.3  0.81 4.33  0.87
CGIc — 3.83  0.59 3.71  0.62
SD, standard deviation; BPRS, Brief Psychiatric Rating Scale; CGI, Clinical Global Impression Scale.
present study, the distance between the main
clinic and satellites was less than 35.2 km (15
to 20 km), nevertheless, costs during VCTP
treatment were increased most probably as a
result of the fact that travel expenses affected
the therapist in Hd and the patients in OA.
Hospitalization rates and costs increased
(not significantly) during VCTP treatment and
in the parallel periods within the comparison
group. Because only a few patients were hos-
pitalized and the study groups were relatively
small, results were statistically not significant
and should be considered with caution.
Adherence ratios were twice as high in the
VCTP group as a whole than those of the com-
parison group but did not change within groups.
The differences in adherence ratios between
VCTP and comparison groups might arise from
methodology; it might be that the compliance of
those patients who agreed to participate in VCTP
was better than those who refused.
VCTP in the treatment of major psychiatric
disorders is known to be safe and both thera-
pists and patients have expressed satisfac-
tion.1,4–6,9,11,12
Ruskin et al.11 reported that telepsychiatry
was effective in the ambulatory treatment of
119 depressed outpatients as measured by de-
pression, anxiety, global, clinical and health
scales. Medication adherence and patient satis-
faction were also positive.
In the present study, both therapists and pa-
tients experienced “presence,” a fact that may
account for the ability to establish positive re-
lationships between them,1,12 and overcome
detachment that might be created while speak-
ing to a faceless electronic device.
Two unique phenomena associated with
VCTP sessions were observed. First, patients
519
OF
9 months Year Statistics
27.69  6.12 26.18  6.37 df  4,222; F 
5.90, p  0.0005
4.27  0.87 4.08  0.87 df  4,220; F  0.60,
p  0.66
3.71  0.62 3.36  0.62 df  3,172; f 
3.98, p  0.83
were more meticulous about their appearance,
and second, the interviews were more orga-
nized, with patient and doctor more courteous
in that they did not interrupt one another.
This study had several limitations. The fact
that the comparison group included patients
that did not consent to VCTP treatment might
account for inherent differences between the
comparison and the VCTP groups. The small
number of hospitalized patients and study
groups might account for the statistically in-
significant differences in hospitalization days
between the investigated groups. The cost anal-
ysis is limited to the presented procedures; out-
reach and in-person clinics, items included in
calculations, and the setting of a governmental
institution, and might differ when other pro-
cedures or psychiatric settings such as private
institutions are evaluated.
CONCLUSION
Patients and physicians are satisfied with
VCTP, treatment is safe and effective, and ad-
herence to treatment remains stable. However,
operational costs of VCTP may be higher than
face-to-face care, and a tendency of increased
hospitalization costs was noted. The limited sam-
ple size precludes the drawing of definite con-
clusions, and further studies involving a larger
study population and longer duration of inves-
tigation is warranted.
ACKNOWLEDGMENTS
The research was made possible with a grant
from the Galil Center for Telemedicine and
520 MODAI ET AL.

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11. Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Brad-
ham DD, Hebel JR, Barrett D, Knowles F 3rd, Hauser
P. Treatment outcomes in depression: Comparison of
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