Efficacy, patient-doctor relationship, costs and benefits of utilizing telepsychiatry for the management of post-traumatic stress disorder (PTSD): a systematic review.

INTRODUCTION
Post-traumatic stress disorder (PTSD) is one of the most common psychiatric disorders found among victims of disaster, kidnapping, accidents, sexual assaults and war in Indonesia. However, lacking and unequal distribution of psychiatric medical personnel remains a barrier to its management. This review aims to introduce and evaluate the potential contribution of telepsychiatry to the management of PTSD based on published literature.


METHODS
Original studies were obtained from PubMed, Science Direct, ProQuest, High Wire, and Elsevier Clinical Key databases.


RESULTS
A total of 125 articles were found, of which 15 articles (12 randomized controlled trials, 2 open trials and 1 pilot study) fulfilled the inclusion criteria. A total of 991 subjects were found with a follow-up period ranging between 5 weeks and 18 months. Telepsychiatry is an innovative use of technology to aid the delivery of PTSD treatments in areas difficult to reach. The quality of care given by telepsychiatry both through video conferencing as well as web- and application-based is comparable to that of face-to-face therapy. Patient satisfaction, quality of doctor-patient relationship also remains high, with lower costs and shorter therapeutic time when compared to face-to-face therapy.


CONCLUSION
Various studies have shown that telepsychiatry is an effective solution for the management of PTSD. Studies have also reported that the quality of treatment through telepsychiatry is as effective as face-to-face therapy, with greater efficiency. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD.


Introduction
Globally, around 61% of males and 50% of females reported that the prevalence of psychiatric disorders was 9.8%, rising from 6% in 2013, although there were no specific data on the prevalence of PTSD. 3 This may be a result of an increase in the number of sex-related cases, 4 violent criminal offenses, 5 road accidents, 6 all of which are main triggers of PTSD. Furthermore, terrorism, forced evictions and increasing competition in life have also contributed to the rise in PTSD cases in Indonesia, especially in disaster-prone areas. [7][8][9] PTSD is a psychiatric disorder caused by traumatic events or a series of traumatic events involving oneself, others or their loved ones and having resulted in death, serious injuries or both. 10 Patients with PTSD show signs of anxiousness, fear, repeated flashbacks of the traumatic event, avoidance of objects, locations etc. associated with the event; they withdraw themselves emotionally (emotional numbing) and respond overwhelmingly to similar events. 11-13 PTSD does not always appear immediately after the triggering event, but may appear within weeks or even 30 years after the event has occurred. 10 Symptoms also fluctuate over time and especially worsen during periods of stress. Without proper management, only 30% of patients recover on their own, 40% will always present minor symptoms and 10% worsen over time. A poorer prognosis is observed among children and the elderly, due to their greater emotional vulnerability and poor coping mechanisms. 10 Untreated PTSD has been proven to affect both cognitive and learning function. Patients with PTSD have difficulties in concentration, cognition and emotion management, which can negatively impact their interpersonal relations and impair their decision-making skills in life. PTSD also lowers work and academic achievements. In the end, PTSD can lower one's quality of life, productivity and inadvertently lead to huge social costs to society. 14,15 Although PTSD leads to numerous negative consequences, patients with PTSD are often not managed adequately. This is potentially caused by lack of awareness among PTSD sufferers as well as difficulty receiving therapy, due to the scarcity of psychiatric medical resources. 10 [18][19][20] In 2016, the WHO reported that 77% of 125 countries throughout the world had implemented telemedicine. One of the main reasons behind telemedicine use is its ability to provide health care to remote areas, which are difficult to reach by health professionals. 21 Telemedicine is also able to facilitate training of volunteers as well as health professionals both in remote areas and during natural disasters. 17,22 Hence, telemedicine has great potential in bridging the current need for better PTSD management throughout in Indonesia and similar developing countries with a low mental health professional to population ratio. The use of telemedicine for the care of psychiatric patients is referred to as telepsychiatry. 2,23,24 This review therefore aims to evaluate the potential of telepsychiatry as an alternative solution to overcome the barriers to better PTSD care in Indonesia and other countries.

Data source
The databases searched to obtain the articles The following keywords were used: "post-traumatic stress disorder or delayed stress disorder" and "telepsychiatry or telemedicine or telehealth or e-health or teleconsultation or video conference or telecare AND psychiatry." When multiple articles deriving from the same study were found, only the most recent publication was included. An approach based on title, abstract, and full text was used to evaluate the relevance of articles.

Study selection
Studies were included if they were original studies and if they had one of the following designs:

Results and discussion
Our initial search resulted in 125 articles, of which 39 were excluded due to duplicate citations. Fifty-seven were then excluded on the basis of title and abstract.
Of the remaining 29 studies, 13 were excluded because they did not meet the inclusion criteria, 2 reported on acute stress disorder and not PTSD, 4 were editorials, 5 studied substance abuse with PTSD rather than PTSD alone, and 2 were duplicate publications of the same study. Finally in Canada, 23,24 and the remainder were one each from China, 33 Iraq, 34 the Netherlands, 35 the United States of America, 36 and Sweden. 37

Effectiveness and quality of therapy
Fourteen of the studies evaluated documented that the effectiveness of telepsychiatry was similar to that of face-to-face therapy, although with varying levels of improvements (Table 1)  Effect of telepsychiatry for 8 weeks better than standard face-to-face therapy (effect size 0.47 measured 12 weeks post-therapy). Greatest improvement found 12 months post-therapy, which reduced when therapy was stopped.

Effectiveness in specific patient groups
The use of telepsychiatry for PTSD has also been studied in specific patient groups, with telepsychiatry being found effective on both the elderly and children, for instance. 38 Likewise, the method has been tested in both urban and rural areas 33 and found to be effective.
Its use has also been found to be effective in studies conducted in various regions such as the Middle East, 25,26 Asia, 33 Europe, 28,35 America, 36 and Australia. [30][31][32] Finally, telepsychiatry was able to manage PTSD regardless of the triggering event, and has been tested on patients with PTSD caused by war (veterans), 25,26,34,36,39 natural disasters, 33 post-partum, 29 and other types of traumas.
Similarly to other psychiatric disorders, PTSD still raises stigma in many areas of the world. Hence, patients may fear seeking direct help and attend faceto-face consultations with mental health professionals even when they are accessible. Telepsychiatry can help in managing these patients as it can provide a secure and private environment to patients, from the comfort of their own place. This may help patients be more eager to seek help and increase interaction with mental health professionals. persisting even 1 year post-therapy. 37 The study by Kersting et al. also reported similar improvement in symptoms remaining for one year post-therapy. 29 Knaevelsrud & Maercker reported that improvement of symptoms remained even at 18 months post-therapy. 27 Effect on quality of doctor-patient relationship and patient satisfaction

Length of therapy
The therapeutic length of telepsychiatry for PTSD differed across the different studies evaluated. Some were performed for as short as 1 month 33 while some were 6 months long. 23 However, it was shown that a minimum therapy of 1 month was already able to significantly reduce PTSD symptoms, with improvements remaining even post-therapy. 33,37 On average, therapeutic time with telepsychiatry was also shorter compared to face-to-face therapy: Notwithstanding, two studies reporting on an economic analysis of telepsychiatry underscored that these results should be viewed with caution and may not be generalizable to all settings. 24,30 For instance, synchronized telepsychiatry is hypothetically most beneficial in settings with a large number of PTSD patients, located in remote or disaster-stricken areas with a low patient-to-mental health professional ratio.
In urban areas or developed nations with adequate patient-to-mental health professional ratios, these systems may be more cost-effective compared to faceto-face therapy. 24 However, the use of web-and application-based asynchronized telepsychiatry as explained earlier may be a cost-effective solution in most settings: even though this modality requires a substantial start-up investment, therapy costs are relatively low in the long run, as they require limited patient/mental health professional interaction. The rise of artificial intelligence systems in the future may further reduce these costs.

Practical implications
The use of telepsychiatry in managing PTSD has been found to provide care for patients with comparable effectiveness and similar patient satisfaction as well as quality of doctor patient relationship when compared with face-to-face therapy. 23

Conclusions
Various studies have pointed to telepsychiatry as an effective and efficient way to manage PTSD. The quality of care given by telepsychiatry, both through video conferencing and web-and application-based, is comparable to that of face-to-face therapy, although most studies published so far are from developed nations. Patient satisfaction and quality of doctor-patient relationship also remain high, with therapeutic time comparable to that of face-to-face therapy. Countries, especially those with a low patient-to-mental health professional ratio, should be encouraged to develop telepsychiatry systems to manage PTSD.

Disclosure
No conflicts of interest declared concerning the publication of this article.