Traveling on business, a man realizes he has neglected to pack his medication for anxiety. Using his laptop computer, he e-mails his psychiatrist from a hotel room to obtain a refill.

A patient at home begins to experience new and disturbing side effects from a medication and contacts her physician for a consult via the Internet.

A patient in treatment for depression logs on to the Internet. After completing a short questionnaire, he transmits his answers across town to a psychiatrist, who receives a numerical score and a graph reflecting the patient’s progress since the previous visit.

In a field that has traditionally depended on face-to-face conversations about intimately personal matters, such scenarios might seem out of place. Yet in all of these ways and many others, computer technology has the potential to change the shape of psychiatric practice.

The current uses and future possibilities of computer technology in psychiatry range from the relatively unremarkable—e-mail communications with patients about scheduling of visits and with colleagues about business and clinical matters—to the more ambitious. The latter include an expanding number of computerized rating scales available over the Internet to help with evaluation and diagnosis.

Bertram Warren, M.D., past chair of APA’s Committee on Information Systems, reports that an estimated 80 percent to 90 percent of psychiatrists now use e-mail. Those figures appear to reflect a trend throughout medicine. The proportion of physicians using the Web has nearly doubled from 20 percent in 1997 to 37 percent in 1999, according to an American Medical Association study.

But more expansive use of the new technology in psychiatric practice is still in its infancy. "For the small psychiatric group or solo practitioner who has wanted to computerize, cost has been an inhibiting factor," said psychiatrist John Abess, M.D., of Charleston, S.C. "The systems that provide integrated electronic claims submission, billing, clinical records, and scheduling are all meant for large physician groups where the cost can be shared. Primarily, up to this point, it has only been those psychiatrists with computer savvy who have computerized their offices."

Abess is a participating physician in CyberDocs, an Internet company that calls itself the "only Internet site that provides a ‘LIVE’ physician-based interaction for patients in the comfort of their own home."

Abess believes it is only a matter of time before computerization becomes more widespread. "With time, new solutions are certain to be made available, and I suspect that psychiatrists, along with all the medical specialists, are looking for the right price-benefit ratio to come along," he said. "It is inescapable that computerization will play an increasingly important and useful role in psychiatry and medicine in general."

One area of rapid growth is the use of computer-based tools available over the Internet for evaluating patients. The Mind Health Tracker, for instance, is one of a proliferating number of tools that are completed by patients and used by clinicians to quantify diagnosis and track improvement over time.

The tool, which has been used by patients and psychiatrists at UCLA Medical Center, Golden State Behavioral Medicine Group, and Psychiatric Corporation of America, among others, consists of a series of questions about functioning and well-being that concludes with a personal profile alerting patients to whether they should seek treatment. The tool is located at <www.mediconsult.com/defeat depression/>.

Computerized rating scales for patients are a welcome trend at a time when psychiatrists have less and less time to spend with patients. "It’s good for the psychiatrist to have as much information as possible since we have fewer minutes to see each patient in the current environment," Warren said.

The use of computers in psychiatry, however, is about more than efficiency or saving time; it is also about standardizing evaluation and diagnosis. Computerized evaluation tools merge a growing technology with the demands of payers and managed care companies for measurable indicators of outcome.

"The biggest thing that has been missing in psychiatry in terms of giving it credibility has been a way to quantify diagnosis and response" to treatment, said Joshua Freedman, M.D., a clinical assistant professor of psychiatry at the University of California, Los Angeles, and president of the Psychiatric Society for Informatics. The society, whose members are psychiatrists, promotes the use of information technology to improve the quality and availability of psychiatric care, according to Freedman.

Freedman explained that because the brain has until recently been impervious to direct observation, clinicians have had to depend on language-based diagnostic criteria. Psychiatry is well suited to being improved by informatics "because the majority of [psychiatrists’] information is patient self-reports," he said.

Freedman noted that patients appear to like the instrument because it gives them an objective confirmation of their own subjective distress. At practice sites, the tool has been utilized in an automated telephone format: The patient answers questions using the telephone keypad, and a fax of the patient’s score is transmitted to the clinician. In some sites, patients have filled out the questionnaire by using a computer in the office waiting room. Mind Health Tracker is also being used by at least one primary care provider at UCLA. In the future, the tool will be fully automated, with encrypted information being electronically sent to the clinician’s office, he said.

The sheer number of tools becoming available demands that the field settle on a common instrument. In the meantime, issues of confidentiality remain paramount to the field; many psychiatrists who practice long-term psychodynamic psychotherapy are liable to resent what they see as the continued depersonalization of the doctor-patient relationship.

Undoubtedly, the most controversial use—or potential use—of computers is in the area of psychotherapy. Even the most avid computer enthusiasts caution against the use of text-based technology for conducting psychotherapy.

"I would strongly recommend against attempting psychotherapy in this format," Abess said. "Simply too much is lost in the communication. Not present are prosody, intonation, expression, and body language. Textual communication can be easily misinterpreted without these more complete language embodiments."

Warren said he has heard reports of mental health professionals using chat rooms for therapy, a practice he denounces. But the need for face-to-face contact is liable to hasten the advent of telepsychiatry, he predicted.

"We need some kind of face-to-face contact, but I don’t think it has to be in the same room," Warren said. "Telepsychiatry, in which the psychiatrist will be able to see the patient and listen to his voice, has so far been reserved for major medical centers, but I think it is the wave of the future."

The technology does appear to be emerging for widespread use. CyberDocs, located at <www.cyberdocs.com>, offers a range of online consulting services, including video teleconferencing.

Here’s how it works: Patients provide information on a secure "CyberCash" credit-card processing system and complete a registration form, including personal information, medical history, and specific questions relating to the patient’s medical concern. The patient then proceeds to the actual consultation or sets up an "appointment" at a CyberDocs "Doctor’s Office." A participating physician reviews the patient information and at the appointed time joins the patient in a secure, encrypted, "one-on-one" virtual conference room for textual chatting or televideo conferencing.

Abess says the videoconferencing offered by CyberDocs is an early form of telemedicine that may bring patients at a remote location into therapy. Conceivably, it could be used for psychotherapy, but Abess believes that most participating psychiatrists are reluctant to do so.

"Most doctors utilizing CyberDocs appreciate that they are practicing medicine in a way that is controversial by traditional standards," he said. "For this reason, I do not prescribe medication or provide psychiatric treatment unless the individual utilizing the system is already a patient known to me from my office."

Abess added that CyberDocs’ teleconferencing awaits refinement. "Some would say the size of the image and the resolution of the image are not as high quality as they need to be in order to not miss nuances of expression, movement disorders, or possible side effects of medication, such as tremulousness," he said. "For this reason, some people would not accept that the CyberDocs system is representative of telemedicine as it needs to exist. However, the system does represent an early implementation of telemedicine, and it will continue to improve in the quality of its service."

Abess said he charges $100 for 30 minutes of televideo or secure chat. "In this situation, I make it clear that I will not prescribe medication or make diagnoses or recommend a treatment," he said. "Instead, I speak in generalities and address the specific areas of interest of the individual seeking the information. CyberDocs interactions are not meant to replace traditional office visits or ongoing relationships between patients and their local caregivers."

Abess added that the CyberDocs televideo system works satisfactorily "only if doctors and patients have broad-bandwidth Internet access, such as is the case with DSL modems and cable modems."

The future appears to belong to the computer. Physicians and policymakers alike look forward to the day when medical records will be universally computerized, and both presidential candidates have hailed information systems as a remedy to rising health care costs.

Expressing the optimistic perspective, Abess predicts a seamless network between all physicians that will eventually include hospitals and other health care providers so that medical records can be immediately reviewed and updated. "Unlike the electronic medical record of today, which is static, technology will enable dynamic data to be visualized such as catheterization or ultrasounds," Abess said.

In the meantime, there can be no doubt that the digital and wireless revolution has transformed the way Americans do their work. Some have observed that the advances, far from making work easier and less consuming, have actually wedded people more completely to their jobs—witness the executives conducting business by cell phone almost everywhere.

Will the introduction of computer technology into practice mean that physicians will never be off duty?

"I found just the opposite was true," Abess said. "By checking e-mail even when vacationing, upon waking and before bedtime, I was able to know that there are no problems, that there are problems but they are being adequately managed, or that there are problems that I should become involved with and help resolve using my agents such as the nursing team or the psychiatrists on call for me."