A recently published study within the journal Healthcare (Basel) examines the use of telepsychiatry services to provide mental healthcare for prisoners within the correctional system of Greece. The research was conducted by Evangelia Karachaliou, Phoebe Douzenis, Fotios Chatzinikolaou, Nikos Pantazis, Sophia Martinaki, Panagiota Bali, Konstantinos Tasios, and Athanasios Douzenis, and found several positive effects to adopting telepsychiatry for this specific patient population in comparison to more traditional methods of treatment.
Background and Research Purposes
Numerous studies in multiple settings have documented the prevalence of mental health and substance use disorders among incarcerated individuals, which often manifest at higher rates than within the general public. Effective care by qualified professionals is required to help develop more positive outcomes. The typical treatment model, however, involves in-person interaction between the patient and their healthcare provider. In prisons without mental health services available on site, the procedure may involve transporting the patient beyond the grounds of the correctional facility, which requires expenditures of time and budgetary resources. Security concerns also mandate restrictive measures – such as handcuffs or other forms of restraint – must be implemented upon prisoners receiving this care. This may, in turn, have the effect of hindering the quality of the treatment, and in worst-case scenarios may even be considered a human rights violation.
“Current protocols for inmates experiencing psychiatric problems (in the acute phase or not) provide for them to be transferred to a local hospital or an appropriate medical facility. This implies transportation over long distances, thus entailing significant costs, cumbersome procedures, increased human resources, and coordination between different administrative bodies, elements which often lead to delays.”
The study’s purpose was to determine how prisoners described their healthcare when it was provided within an in-person setting as opposed to how they described their healthcare using telepsychiatry methods. By comparing these two scenarios, the researchers could gain insight directly from those receiving treatment, and both draw conclusions and offer recommendations based on the data.
Methodology
The six-month study took place between 2020 and 2021 within the Greek correctional system, specifically at the Malandrino correctional facility (capacity 431 inmates) and the Trikala correctional facility (capacity 600 inmates). Both facilities housed only male prisoners, and had both implemented telepsychiatry service options through the Forensic Psychiatry Unit of the Second Psychiatric Clinic, National and Kapodistrian University of Athens (EKPA), Attikon Hospital. Potential participants were identified through the following criteria:
- They had received psychiatric services within six months prior to the start of the study
- They had experience in receiving mental health treatment in both face-to-face and telepsychiatry settings
- They had received at least four telepsychiatry sessions
- They could communicate in either Greek or English
Of the 142 inmates at both facilities who met this criteria, the researchers gained consent from 100 prisoners to participate – 66 from Malandrino, 34 from Trikala.
Three distinct surveys were conducted to gather data for the study:
- Demographic Data Questionnaire: This gathered information on age, nationality, and other identifying characteristics, including details of their incarceration
- Participant Satisfaction Questionnaire (Face-to-Face): This 30-question survey assessed the subject’s satisfaction with in-person mental health care prior to receiving telepsychiatry services
- Participant Satisfaction Questionnaire (Telepsychiatry): This 38-question survey assessed the subject’s satisfaction with telepsychiatry care
The “satisfaction” questionnaires were modeled on the Greek Ministry of Health questionnaires that measured patient satisfaction with NHS hospital services, and has been used in prior research involving mental health services in Greece. They adopted a 5-point Likert scale ranging from “very bad” to “very good” and measured these satisfaction levels against such characteristics of treatment as:
- Physical aspects (eg, cleanliness, accessibility, spaciousness) of the treatment space
- Service aspects (eg, waiting times, staff behavior)
- Psychiatric assessment (eg, ease of communication, relapse prevention management)
- Psychiatric care delivered (eg, diagnosis and/or medication)
- Knowledge and ability to provide a full briefing on the patient’s condition
- Behavior and methods of healthcare professionals within the facility.
- Confidentiality and privacy
The telepsychiatry satisfaction questionnaire also asked for responses related to technology elements such as video and audio quality, and two open-ended questions on the participant’s attitudes toward engaging telepsychiatry in the future.
Surveys were administered within each facility in a separate interview room, with each participant being provided full disclosure by the researcher. All surveys were done in a face-to-face manner to ensure that all questions were answered and understood, and without a prison officer present to invite candid responses. In addition, the researchers conducted an assessment of the amount of time prisoners spent in restraint and/or confinement and transportation while waiting for face-to-face evaluation by conducting independent interviews with the directors of each facility. To refine the measurement instruments prior to beginning the study, researchers conducted a pilot that involved ten randomly selected prisoners who had received telepsychiatry services; their results were not included in the final analysis.
Findings and Interpretations
The study produced a significant and enlightening level of data for the researchers to evaluate.
Demographics
The demographic survey determined the following about the 100 participants in the study:
- The median age of participants was 38 years old
- More than half (59%) of the participants were of Greek origin, while 29% were from North Africa/Asia, and 13% from Eastern European countries
- Only 22 of the 100 participants had completed a high school education or higher; the majority (40%) had failed to complete grades 1 - 6 of primary school
- Approximately one-third (32%) of the participants had been imprisoned for violent offenses
- The median sentence within the participant pool was 15 years
- More than half (55%) were serving their second sentence or more
Satisfaction Survey Comparisons
The researchers found that participant responses to the surveys conducted after receiving telepsychiatry services showed a clear positive trend in comparison to the surveys regarding conventional mental health care services that were conducted prior. Across nearly all metrics, there were statistically significant improvements – in some cases twice or three times more positive than the responses from the initial survey. Results indicated higher satisfaction with:
- Waiting time for appointments
- Appointments occurring at the scheduled time
- Duration of the assessment
- Follow-up contact
- Transfer process within correctional facilities
- Management of psychiatric problems
- Management of medications
- Behavior of mental health providers
- Freedom to express their health concerns
- Confidentiality
Questions related to the technology required for telepsychiatry were also positive, ranging from 72 - 80% answering “good” to “very good.” Most notably, 92% of participants stated that they would “definitely” or “probably” make use of telepsychiatry services in the future and that they would recommend telepsychiatry to others as well.
Other Metrics
The researchers compared data across certain demographic categories as well to learn if other patterns emerged. They observed, for example, that participants from North Africa or Asia generally provided responses indicating less satisfaction with psychiatric services than their Greek counterparts overall, although telepsychiatry was nonetheless given higher scores regardless of ethnicity. In another example, the study showed that offenders sentenced for non-violent crimes showed greater satisfaction with in-person services before receiving telepsychiatry, but that telepsychiatry services were received with especially positive responses from participants who had been sentenced for violent crimes.
The final metric measured by the researchers through interviews with both prisons’ directors was a comparison of how long prisoners were required to be placed in restraints for travel to in-person services against how many hours prisoners were relieved from being restrained during telepsychiatry. Here, the difference was highly significant– prisoners traveling for health services would spend between 5 - 6 hours, on average, in handcuffs. Therefore, telepsychiatry for 100 patients amounted to 500 - 600 hours in which these prisoners did not require handcuffs.
Conclusions
The data collected within this study aligned with findings from previous, related studies – including a 2016 survey of parolees and a 2020 survey of patients with substance use disorders – that indicated a preference for telepsychiatry services. Additionally, the researchers were informed by studies regarding inmates’ access to mental health services, which showed a pattern of deterioration when those services were unavailable and benefits to the introduction of a telepsychiatry option.
The quality of care was perceived to be higher among the study participants, and relapse prevention was considered to be more effective. The ability to forgo coercive restraint also provided a sense of comfort to let the prisoners express their concerns and increased satisfaction with treatment overall, which encouraged them to continue receiving care.
The researchers do note limitations to their study structure, such as the fact that people of color and ethnic minorities are typically overrepresented within correctional systems but that their participant pool skewed opposite to that trend. Regardless, they feel strongly that these findings may be of worth to policymakers, and that the evidence suggests both the reduction of coercive measures required for in-person care and the satisfaction of those receiving telepsychiatry services should prompt consideration for broader reforms and changes to procedure.
Source: Prisoners’ Perceptions and Satisfaction with Telepsychiatry Services in Greece and the Effects of Its Use on the Coercion of Mental Healthcare https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11121354/
