These include environmental and patient-specific factors. Environmental factors include ambient lighting, noise, session privacy, and room set up. Patient-specific factors such as vision or hearing impairment may affect suitability for telepsychiatry based evaluation and management. In emergencies, glasses and/or hearing aids may not accompany the patient. To compensate, increased volume on the equipment’s speakers can exceed the typical sound attenuation (materials like walls/doors and the distance between other patients) of the evaluation area. These factors can compromise privacy. Emergency departments also often have very high levels of background noise, which can further obscure communication. When the vision-impaired patient cannot see the provider well, they may also lose non-verbal communication such as gestures (e.g., nods) facilitating continued discussion or rapport building. This may also make verbal communication more difficult as the provider’s lips cannot be read. In such circumstances, enhanced efforts on the part of the telepsychiatrist to clarify and encourage verbal response to questions may be necessary to compensate for these barriers.

Sabin and Skimming identified the following challenges to telepsychiatry services, particularly from an ethical perspective [23].

No matter how robust the technology, patient encounters and resulting outcomes require well-trained and diligent providers.

As there are varieties of mental illnesses faced by the elderly, as well as different settings and levels of care, so there are numerous opportunities for implementation and intervention via conventional, telemedicine, or combinations thereof. Yellowlees mentions the only contraindications from the patient’s perspective are “a refusal to take part, or current actual physical violence towards the self or others” [18]. There are some varieties of psychotic symptoms including referential thinking, which may limit or perhaps even make videoconferencing counter-therapeutic. Patients reluctant to engage in face-to-face encounters may refuse telepsychiatric assessment. An example is a patient on a psychiatric unit who was chronically concerned that she was being filmed. This inpatient refused to appear before a camera and feared there were hidden cameras continuously surveilling her actions. She required in-person assessment for these reasons.

Occasionally individuals express chagrin at not having face-to-face encounters; however, some may later become cooperative and allow evaluation when it is explained that they may not be able to leave the emergency department without an interview. Other patients view telepsychiatry from a more positive perspective . Apart from timesavings, increased access, and many benefits addressed elsewhere in this book, there are additional advantages. As noted by Yellowlees, during telepsychiatry connections, patients “feel more in control during video consultations, and can, if they wish, literally switch off the doctor at their end and leave the consultation without any physical embarrassment or loss of face.” Further, “the online relationship, in most situations, tends to be more egalitarian than that which occurs in-person” [18].

Traditional healthcare with its commute, waiting room, and de rigueur interaction can be viewed as “outmoded and inconvenient” [18]. Telehealth solutions mirror the ease and immediacy of other goods and services of the present day, particularly in the developed world.

The hybrid model often has one component at the primary care provider’s (PCP) office. Initially the patient (and sometimes family) are interviewed followed by a joint feedback session with the PCP. At the time with PCP present, the telepsychiatrist instructs the patient to tell the PCP “what their diagnosis is, and what the proposed treatment plans are.” “This is a powerful approach that shifts the locus of care away from the telepsychiatrist, as the distant expert, and back fully to patient and the PCP. It also ensures the patient understood the consultation findings” [18].