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The importance of understanding psychological differences when using telepsychiatry across cultures Rune Weise Kofoed (115431), Denmark Nicklas Skov Pape (768621), Denmark Department of Social and Behavioral Sciences, Tilburg University, P. O. Box 90153, 5000 LE Tilburg, The Netherlands, R.WeiseKofoed@uvt.nl, N.SkovPape@uvt.nl Keywords: Telemedicine, telepsychiatry, ICT, cross-cultural psychology, health, mental health, unipolar depression
Introduction The general topic of this research review is to investigate the cross-cultural understanding of mental health and the use of telepsychiatric services across cultures. Recent studies show that citizens of many low- and middle-income countries around the world still suffer significantly from viral infections, diarrhoea, cardiac disorders and HIV/AIDS. However, the most recent estimations from the World Health Organisation (WHO) show that the Global Burden of Disease (GBD) has been reduced greatly over the last decades and that the world is experiencing an epidemiological shift, especially in third world countries, where non-communicable diseases are gradually assuming a larger burden of ill-health (WHO, 2004). In 1997, Murray and Lopez presented predictions indicating that depression will become the second largest burden, measured in Disability Adjusted Life Years (DALYs), by 2020 (Murray & Lopez, 1997). Furthermore, more recent assessments conducted by the WHO, predicts unipolar depression to become the number one largest burden in the third world countries by 2030 (WHO, 2004). However, despite these worrying prospects, the annual expenditure on treatments of mental disorders in these countries is no more than 25 USD-cents per person, according to recent studies made by the WHO. Additionally, there is an extreme lack of qualified psychiatrists, as the numbers of these in low-income countries constitute a mere 0.05 psychiatrists per 100,000 citizens (Morris et al., 2011, pp. 10-11).
2 In the light of these findings, it is assumed that there is an urgent need for alternative solutions, dealing with the treatment of patients with mental disorders in third world countries struggling with scarcity of professional psychiatrists and therapists. Recent studies and research indicate that the use of telemedicine in third world countries have shown great potential, stating that information and communication technologies (ICTs) can potentially help address some of the challenges faced by both developed and developing countries (Wootton & Bonnardot, 2010; Kay et al., 2010). In regards to the psychopathological field, studies of the effectiveness and feasibility of videoconference-based telepsychiatric services for resource-constrained environments, indicate that the use of videoconferencing, as a means of diagnosing and treating patients with mental disorders, also show seemingly great potential for future developments (Chipps et al., 2012). Apart from for instance the economical and cost-effectiveness aspects and lack of experience with implementing telepsychiatric solutions in third world countries, the cultural barriers within a potential cross-cultural psychotherapeutic process also constitute a field that needs to be investigated further (Kay et al., 2010). The goal of this research review is therefore to discuss previous experiences with telepsychiatry and research regarding the importance of cross-cultural understanding. We ultimately wish to address the potential psychological barriers within a crosscultural telepsychiatric treatment. History of telemedicine The concept of telemedicine, as a means of treating patients via telecommunicative measures, has existed for well over a hundred years. The telephone was invented by Alexander Graham Bell in 1876. Only three years later, it was suggested that this new invention could be used as an aid for doctors to ease their daily practice. This is seen as the beginning of modern telemedicine, and at that time the economic advantages of this treatment service was apparent although the apprehension of too many and unnecessary calls and the possibility that patients would choose the phone over a physical consultation was a concern (Aronson, 1977). The development of other telecommunication modalities and the use of these have evolved significantly since the 1870ies, and today, the modern broader objective of
3 telemedicine is to enhance the access of medical care as well as providing information about diseases in areas where distance is an obstacle for patients and/or doctors (Kay et al., 2010; Mars, 2012; Wootton & Bonnardot, 2010). However, in spite of more than a hundred years of technological development and an increasing need for medical expertise and assistance in low- and middle-income countries, the usage of telemedicine seems to be still at its infancy (Kay et al., 2010; Mars, 2012). Yet, it is still believed to encompass potential to address some of the general challenges surrounding the use of telemedicine (Kay et al., 2010; Mars, 2012; Monnier et al., 2003; Wootton & Bonnardot, 2010; Chipps et al., 2012) Prevalence of telepsychiatry today To obtain an impression of the current state in the domain, a recent report by WHO (2010), is focusing on and measuring the prevalence of four of the most popular and established services of telemedicine: Teleradiology, Telepathology, Teledermatology and Telepsychiatry. The latter is defined as the“(‌) use of ICT for psychiatric evaluations and/or consultation via video and telephonyâ€? (Kay et al., 2010, p. 37). 114 Member States participated in the survey and revealed that the usage of telemedicine is seen mostly in high-income countries and is far less progressed in uppermiddle, lower-middle and low-income countries. The survey also reveals that telepsychiatry was progressed in less than 15% of the countries and almost absent in lowincome states (less than 5%) (Kay et al., 2010). Although the economic advantages of the telephonic consultation service were obvious by the first encounter in 1879, researchers today contradict this assumption and find that the lack of information about the cost-effectiveness in particular, acts as one of the greatest challenges in the research paradigm of telemedicine (Kay et al., 2010; Monnier et al., 2003; Wootton & Bonnardot, 2010). Furthermore, the absence of technical expertise and underdeveloped infrastructure is considered to be probable barriers for the developing countries (Kay et al., 2010). Experience with telepsychiatry As described in the introduction of this paper, the future need for psychiatric aid in low- and middle-income countries is projected to be excessive. Therefore we find it important to investigate the use of telepsychiatry in these countries and also look at
4 earlier experiences using ICTs. We will obtain information in the recent literature reviews by Monnier et al. (2003), Chipps et al. (2012) and Wootton & Bonnardot (2010) to help us find preliminary raison d'ĂŞtre of the use of telepsychiatric services in these limiting environments, as well as to help us address this question of concern. The latter research review focuses on telemedicine in general, while the first two mentioned focus on telepsychiatry. In our review of these reviews, we found initial evidence that some patients with disorders such as depression, PTSD and psychosis, have shown positive outcomes after treatment by the use of telepsychiatric services (Monnier et al., 2003; Chipps et al., 2012). However, in some cases it is stressed that the base of evidence is not strong enough to be able to conclude the general effectiveness (Chipps et al., 2012). One example of a successful treatment is mentioned by Monnier et al. (2003), as a patient with panic disorder, agoraphobia and major depression, showed a significant decrease in symptoms and improved functioning following 12 sessions of therapy delivered via telepsychiatry. A significant amount of further therapies were found equally successful and both patients and therapists were generally reported having a high level of satisfaction and acceptance of the telepsychiatric services (Monnier et al., 2003). Moreover, several studies found that telepsychiatry compared with in-person services indicated no difference in results and that telepsychiatric treatment is recommended as equivalent to face-to-face treatments (Monnier et al., 2003; Chipps et al., 2012; Shore et al., 2006). Some patients expressed concerns about confidentiality while other studies show that the use of telepsychiatry made patients more satisfied because of less travel, time off from work and so on (Monnier et al., 2003; Shore et al., 2006). It is worth mentioning that a review by Wootton & Bonnardot (2010) found that almost all studies reported positively in favour of telemedicine, and that this might be a case of publication bias. The need for further research in the area of telemedicine and telepsychiatry is needed and is also argued to increase credibility by several researches (Kay et al., 2010; Wootton & Bonnardot, 2010; Monnier et al., 2003).
5 The majority of these studies were conducted in western countries and the crosscultural aspect between patients and therapists are almost absent in the literature reviews of telepsychiatry. The latter are also emphasized by Chipps et al. (2003). Psychopathologic concepts and the importance of a cross-cultural understanding of mental health Since we have learned that telepsychiatry to some extend can be seen as an in-person service, we will address this with concern by reviewing some crucial subjects on health in relation to cross-cultural context. Firstly, we will present an outline of the general understandings and concepts of mental health across cultures. Secondly, cross-cultural variations and differences in expression and conceptualizations will be addressed, as these give an understanding of cultural differences in the concept of mental disorders. Lastly, we will focus on the cross-cultural understanding of depressive disorders, as we have found depression to be a good example of a mental disorder that can be sufficiently remedied by the use of telepsychiatric measures. Universally, disease is perceived as a health problem that consists of a physiological malfunction, resulting in an actual or potential reduction in physical capacities and/or a reduced life expectancy. Similarly, the term illness is perceived as the human experience and perception of a physical malfunction. Hence, illness acts as the subjectively interpreted undesirable state of health, based on the general explanations of the given sickness (Berry et al., 2011, p. 407). Lastly, the term sickness acts as “the society’s way of making sense of and dealing with the individual perception of malfunctioning (illness); and the underlying pathology (disease)� (Berry et al., 2011, p. 408). However, none of these states demands the presence of one another, as it is possible for an individual to subjectively experience illness, without the presence of an actual disease. Correspondingly, it is possible that an individual is the victim of a given disease, without experiencing illness (Berry et al., 2011, p. 408). In a cross-cultural perspective, it is safe to say that an understanding of these distinctions and cultural differences in perceived illness and social acceptance of mental disorders are crucial aspects when researching differences in health and health help-seeking behaviours in developing countries. Firstly, because what is regarded as a disease by Western biomedicine may carry rather different meanings in non-western communities (Little-
6 wood, 1990, p. 310), but also because local health concepts and phrases used to describe syndromes appear different in some societies (Bass et al., 2007). Hence, as the diagnostic process is highly dependent on the individual’s ability to express his or her thoughts and feelings, it is crucial that the psychiatrist in question has a highly sufficient understanding of the given patient’s culture and social setting. Summing up, these points, the aforementioned findings and recent research all tells us that it is crucial, for a cross-cultural psychiatric treatment, consultation or diagnostics to be successful, that the psychiatrist in question has a deep understanding of the culture and norms as well as an understanding of the given society’s view on mental illness, as well as whether these behavioural aspects are accepted in the given society, also play an important role (Berry et al., 2011, p. 411). In regards to the potential use of telepsychiatric measures in developing countries, the understanding of local concepts of mental illness and specific syndromes is needed, firstly, as pointed out by Bass, Bolton and Murray (2007) to develop a locally appropriate study instrument that can be used for measurement of prevalence and incidence of illness and evaluation of the effectiveness of innovative intervention strategies (e.g. telepsychiatry)(Bass et al., 2007), but also later in the actual telepsychiatric process, for instance. As pointed out by Berry et al. (2011), the terms extreme universals, moderate universals and culturally relative are important theoretical aspects of cross-cultural psychopathology and the understanding of mental health phenomena and their expression across cultures (Berry et al., 2011). However, despite this distinction in health phenomena across cultures, ‘culture-bound syndromes’ as a term for local patterns of behaviour that did not fit into the Western psychiatric classification, has been claimed to act as a redundant term, as all reactions are to some extent culturally determined (Littlewood, 1990). Nevertheless, this classification helps us understand health phenomena that are restricted to a limited number of cultures on the basis of psychosocial features. Whether different psychopathologic phenomena are universal or culturally relative, is measured by calculating differences in prevalence rates. These differences provide useful knowledge as to whether psychopathology is either relative, or moderately universal (Berry et al., 2011, p. 413). In regards to our focus on cross-cultural telepsychi-
7 atric treatment, this is important as the Western psychiatrist otherwise would risk falling under, what American psychiatrist and researcher Arthur Kleinman named, the “category fallacy” (Kleinman, 1977). By imputing the illness categories of his or her own culture to the patient’s culture, the psychiatrist, in this case sitting in another part of the world, could risk making erroneous assumptions and thereby misdiagnosing the patient – which could then precariously lead to, for instance, prescribing the wrong medication. As mentioned earlier, unipolar depression is predicted to become the number one burden in low- and middle-income countries by the year 2030 (WHO, 2004). However, we assert that depression is one of the disorders that the introduction of telepsychiatric measures in developing countries could effectively alleviate, though depression is still stated to be difficult to reduce to its fundamental and presumably invariant features. Depression, diagnostic differences and cultural variations To this day, there is still no evidence to support actual differences in major psychiatric disorders across cultures and societies (Cheng, 2000) and recent research claim that descriptions of a mental illness developed in one set of cultures are in fact equally applicable to other foreign cultures (Simon et al., 2002). Nevertheless, alongside the establishment of the sub-disciplinary study of cultural differences in psychopathology commonly known as Comparative Psychiatry, the field of cross-cultural psychotherapy has become aware of the potential consequences of an uncritical application of standard diagnostic criteria across cultures (Simon et al., 2002; Berry et al., 2011, pp. 422-423). Implying that if the nature of emotions, thoughts, and behaviours are culturally variable, diagnostics made on standard, western psychotherapeutic criteria could potentially lead to misleading or erroneous results (Kleinman, 1988), even though the depressive syndrome for instance, has later been claimed to be remarkably similar throughout a wide range of languages, cultures and economic development (Simon et al., 2002). Relatively early studies in the field of the cross-cultural understanding of depression claimed that differential depression diagnosis across cultures is likely not to exist (Draguns & Tanaka-Matsumi, 2003), suggesting that depression is a seemingly consistent phenomenon throughout the world. Similarly, later studies showed that cross cultural diagnostic differences disappeared when patients were diagnosed on the basis
8 of WHO’s standardized diagnostic system (ICD-8)(Draguns & Tanaka-Matsumi, 2003, p. 758). However, studies by Marselle (1980) concluded that no universal conception of depression exists, though variants of depressive disorders similar to those in Western cultures sometimes have been found among cultures without a conceptual equivalent (Draguns & Tanaka-Matsumi, 2003). As an example of a variation however, several studies, conducted over a course of more than twenty years, have shown that the sense of guilt has emerged as a source of cultural variation among the symptoms of depression (Draguns & Tanaka-Matsumi, 2003, p. 762). Furthermore, studies have shown that patients in less-developed societies with limited knowledge of mental disorders experience somatizations in relation to depressive disorders (Simon et al., 2002), suggesting that patients, unaware of the probability of a mental disorder occurring, are likely to report bodily malfunctions in connection with a depressive state. Lastly, Cox (1977) and Cheng (1989) have both pointed out the importance of ensuring the semantic or psycholinguistic equivalents of the psychiatric symptoms across cultures, before psychopathological diagnostic instruments can be operationalized, and we believe that this is equally important to take into account when implementing telepsychiatric measures across cultures. Some important cultural aspects in telepsychiatry As discussed above, there are indeed important cultural aspects and implication to take into consideration when implementing telepsychiatry in a cross-cultural setting. Culturally appropriate care has been pointed out as an essential, if not crucial, component of telepsychiatry in regards to process and outcome (Shore et al., 2006). Furthermore, studies show that cultural understanding is becoming an increasingly larger part of the patient-doctor relationship within the use of telepsychiatry. However, to this day there still does not exist a systematic framework clearly addressing cultural aspects of telepsychiatry (Shore et al., 2006; Bass et al., 2007). Using telepsychiatry across borders and cultures constitute obvious barriers, such as language barriers, trust, technological knowledge and experience, and potential unfamiliarity with the patient’s cultural setting. These examples are all aspects that have been accentuated as important subjects for further research in the field of telepsychiatry (Shore et al., 2006). As previously stated, differences in local health concepts is a subject that demand the involved psychiatrists’ attention, as the given setting creates
9 the psychosocial context through which the patient will express feelings and thoughts (Bass et al., 2007; Berry et al., 2011; Kleinman, 1988). Again, it is clear that cultural insight and understanding constitute an essential characteristic to a successful treatment via telepsychiatry. Recently, a group of researchers involved in telepsychiatric studies and tests with both North American Indian communities and Alaskan native elders, published a study dealing with the cultural aspects of telepsychiatry within these relatively secluded, rural communities. Conclusively, the research group presents a list of issues that future providers of telepsychiatry are suggested to take into account. These issues include enquiring about the patient’s level of comfort with technology, becoming familiar with and adapting to the local communication styles, and assessing the patient’s understanding and feelings towards confidentiality and the implications of telepsychiatry for their confidentiality (Shore et al., 2006). These examples are a just few of the issues we believe are equally relevant to take into account when potentially implementing a telepsychiatric solution across cultures and borders, and by including these points, we would like to encourage researchers to conduct further studies within this particular field and context, since we have found that the field of telepsychiatry and the importance of a cross-cultural aspects, as an interrelated entity, generally lack research. This is supported by Shore et al. as they claim similar difficulty in finding existing articles on the subject of cultural appropriateness or cultural competency in telepsychiatry specifically (Shore et al., 2006).
Conclusion The objective of this research review was to discuss previous experiences with telepsychiatry as well as research regarding the importance of cross-cultural understanding of mental health. Furthermore, potential psychological barriers within a cross-cultural telepsychiatric treatment in less developed countries were investigated. By examining previews research reviews in the field of telemedicine it was discovered that the prevalence of the technology seems to be still at its beginnings and that great potential possibly lie ahead. In spite of an overall positive evaluation of telepsychiatry, relatively low quotas of countries worldwide are establishing these solutions
10 and even less in middle- and low-income countries. Preliminary studies show that patients suffering from different mental disorders can be relieved by the use of telepsychiatric services and that in-person and telepsychiatric consultations are seen equivalent in several cases. With concern, we find that the cross-cultural aspect between patients and therapists are almost absent in the recent literature reviews investigated. This is an obvious worry since our review in the area of cross-cultural understanding of mental health finds that patients' health believes, attitudes and behaviours are rooted in each cultural setting, and that not having this in mind can have consequences for the patients. It is exceedingly important that the involved clinicians and psychiatrists have a highly appropriate understanding of both the cultural background and psychosocial environment. Conclusively we argue, that what seems to be a dichotomy between telepsychiatry and cross-cultural psychology within researchers is important to disrupt in order to insure better and safer consultations across cultures when using telepsychiatric solutions.
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