The need for increased access to mental health care for the aging population is evident. In attempting to meet this need, potential solutions must be cost effective in order to be sustainable. There are several factors that affect the cost of providing care by telepsychiatry. While economic considerations will be examined in greater detail in later chapters, a brief overview is provided here.

In order to be sustainable, the cost of providing telepsychiatric care must be offset by savings. Direct costs include cost of audiovisual conferencing hardware and software technologies, installation/setup fess, and other supply costs. (Technological requirements will be reviewed in a later chapter.) Fixed costs factor in staff salaries and wages as well as other administrative expenses. There are also variable expenses to include data transmission fees and costs associated with equipment maintenance [8]. Due to these expenses, earlier studies found telepsychiatry to be cost ineffective. In 1998, Werner et al. compared the cost of a face-to-face community mental health medication management visit to remote care. Two remote care options were examined—(1) university based telepsychiatry consultation to a rural community mental health clinic and (2) other rural site based telepsychiatry consultation to rural community mental health clinic. Results revealed two to three fold higher costs per visit for telepsychiatric care ($244/visit for other rural site based telepsychiatry visit, $179 for university based telepsychiatry visit, and $78.50 for in-person community mental health center visit) [9].

In contrast to these earlier findings, more recent studies have found that care by telepsychiatry leads to overall decrease in total costs due mainly to savings in travel costs. Compared to telepsychiatry, face-to-face psychiatric evaluations to remote sites require not only travel and accommodation expenses for the physician, but often times, higher compensation due to travel requirements. In 2007, O’Reilly et al. found that the average cost of telepsychiatric care was 10% less per patient and 16% less per visit compared to in-person care [10]. In 2010, Rabinowitz et al. examined the cost associated with 278 nursing home telepsychiatry consultations and found personnel cost savings of over $30,000 and physician savings of over $80,000 when compared to face-to-face care [11]. One potential explanation for the differences between earlier and recent findings with regard to cost is an overall decrease in cost of technology and remote communication. In fact, in 2011 Doolittle et al. found that since 1995, there has been a 70% decrease in cost per patient in providing telemedicine care. This decrease was attributed to both decreased technology costs and increased number of patient visits [12]. These figures support the notion of telepsychiatry as cost effective method of meeting the increasing mental health care demands of the growing geriatric population.

Telepsychiatry has the potential to increase access to specialized mental health care while decreasing costs. Equally important are its accuracy and effectiveness in providing a means by which patients can be evaluated and treated. Telepsychiatry has been applied to patients in multiple different settings to include outpatient general medical clinics, hospital emergency departments, nursing and group homes, hospice facilities, rural facilities, and forensics/correctional settings. Several models of consultative services can be employed and may vary based on the clinical setting .

Furthermore, the telepsychiatry interaction can be either synchronous or asynchronous. Synchronous evaluations involve communication between the patient and the psychiatrist that occurs at the same time, typically via two-way videoconferencing , chat, or telephone. Asynchronous encounters, also known as store-and-forward, consist of the psychiatrist reviewing pre-recorded interactions between the patient and primary care provider. The psychiatrist then formulates a diagnosis, treatment plan, and provides the primary care provider with treatment recommendations. Irrespective of the clinical setting or the consultation model employed, telepsychiatry has been demonstrated to be feasible, reliable, and equivalent to face-to-face care [8].

In 2013, Conn et al. described a 7-year experience of utilizing a university based telepsychiatry program to provide consultations to six rural communities in Canada. Almost 300 patients were evaluated and treated with the most common conditions encountered being dementia, depression, and mild cognitive impairment [14]. In 2001, Johnston and Jones reported on successful utilization of telepsychiatry to provide 71 consultations to 40 rural nursing home patients age 60–95. Again, the most frequently encountered diagnoses were dementia related behavioral disturbances and depressive disorders. The authors cited increased contact with patients and staff at the rural nursing facility, improved follow through of recommendations, and elimination of psychiatrist’s travel as the major advantages of the program [15].

Geriatric telepsychiatry is not only feasible, but also diagnostically reliable . Telepsychiatry can be used to reliably diagnose various mental health disorders including mood disorders, panic disorder, and alcohol dependence [16]. Grob et al. conducted a study with residents of a Veterans Affairs nursing home examining in-person versus remote administration of three screening tools—the Mini Mental State Examination (MMSE) , Geriatric Depression Scale (GDS) , and the Brief Psychiatric Rating Scale (BPRS) . Results showed no significant differences between groups [17]. In 2004, Shores et al. found 100% agreement in initial diagnosis of dementia in residential care veterans who were assessed in-person versus by telepsychiatry [18]. Cullum et al. demonstrated that a battery of neuropsychological tests can be successfully administered to patients with cognitive impairment via videoconferencing [19]. These findings demonstrate telepsychiatry as an effective modality by which patients can be accurately assessed and diagnosed.

Furthermore, telepsychiatric care produces outcomes equivalent to in-person care. O’Reilly et al. examined reduction in Brief Symptom Inventory scores in a general adult population assessed in-person versus remotely. Outcomes were equivalent for both groups [10]. Similar results were found when comparing treatment of depressed veterans in-person versus remotely, with comparable reductions in scores on the Hamilton Depression Rating Scale and Beck Depression Inventory. In addition, there is equivalent compliance in keeping appointments and adhering to medications [20].

Another outcome of interest when telepsychiatry is employed is its potential impact on overall resource utilization. The application of telemedicine to the care of geriatric nursing home patients can allow for more patients to be served with shorter follow-up intervals [21]. This can lead to downstream effects on the healthcare system as a whole including up to 10% decrease in emergency department visits and acute hospitalizations [21]. This benefit to the healthcare system holds true for telepsychiatry as well. Lyketsos et al. found approximately 50% decrease in acute hospitalizations with overall fewer days in the hospital when geriatric nursing home patients with dementia had access to telepsychiatric assessment and treatment [22]. As the aging population continues to grow, efficient use of limited resources must remain a priority.