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Background: Cognitive impairment is associated with long-term disability that results in the deterioration of both the social and professional status of individuals with schizophrenia. The impact of antipsychotic therapy on cognitive function is insufficient. Cognitive training is therefore proposed as a tool for cognitive rehabilitation in schizophrenia. In this study we investigated the effect of self-administered cognitive training using a smartphone-based application on the cognitive function of paranoid schizophrenia patients focusing on response time, correct answer rate, incorrect answer rate, and fatigability to check, if these functions can be functional markers of successful cognitive-smartphone rehabilitation. Methods: 1-year multicenter, open-label randomized study was conducted on 290 patients in a state of symptomatic remission. 191 patients were equipped with the full version of the application and conducted cognitive training twice a week. Reference group (n = 99) was provided with a version of the application having only limited functionality, testing the cognitive performance of patients every 6 months. Results: Statistically significant improvement was observed in both the rate of correct answers (by 4.8%, p = 0.0001), and cognitive fatigability (by 2.9%, p = 0.0001) in the study group, along with a slight improvement in the rate of incorrect answers (by 0.9%, p = 0.15). In contrast, the reference group, who performed cognitive training every 6 months, demonstrated no significant changes in any cognitive activities. Conclusions: Cognitive trainings facilitated by a smartphone-based application, performed regularly for a longer period of time are feasible and may have the potential to improve the cognitive functioning of individuals with schizophrenia. Correct answers and cognitive fatigability have potential to be functional markers of successful smartphone-based psychiatric rehabilitations in schizophrenia patients.

The Internet is providing a bridge across some of the barriers that keeps people from accessing the psychological help they need. As psychotherapists have ventured into cyberspace, more and more people who would not otherwise have been helped are finding a path to healing. As of recently, “e-mental health” is the term that covers the use of telecommunication technologies in the provision of mental health services to individuals in communities that are underserved due to geographic, linguistic, or cultural isolation. Consequently, immigrants, asylum seekers, and refugees belong to potential users of remote (psycho)therapy. It is primarily due to linguistical and cultural barriers which they are facing in respective host countries. When/if cultural competent bilingual therapist is available on distance, refugees tend to prefer remote contact via mother tongue rather than in-person consultation via an interpreter. The historical background, types of remote interventions, advantages and disadvantages as well as ethical issues related to remote psychotherapeutic interventions are described in the chapter.

For asylum seekers, refugees, and migrants in Denmark access to mental healthcare is a problem due to lack of clinicians who understand their language, culture, and special needs. It is well known that patients who do not speak the language of respective care providers report feeling discriminated against in clinical settings, whereas communicating with health professionals in a common language is associated with increased trust and confidence. That is probably why “ethnic matching” appears to be the most desirable model used in addressing language barriers and cultural disparities in mental healthcare provision. Since early 2000, a telepsychiatry-based ethnic-matching model has been developed and established in outskirt areas of Denmark through various pilot projects. The aim of this approach was to improve access to scarce, culturally appropriate care providers (i.e., culturally competent, bilingual clinicians) by the use of videoconferencing.

This article reports on a project running over 24 months from July 2010 until July 2012, conducted by The Little Prince Psychiatric Centre in Copenhagen in cooperation with three general practitioner’s clinics on the outskirts of Denmark. The article outlines the conceptual shared care model, in which psychiatrists and psychologists collaborate with general physicians in the assessment, diagnosis and treatment of mental health patients in the context of the general physician’s office by use of telepsychiatry service. A formal evaluation of the project was conducted and outcomes are discussed along with issues related to the requirements for sustaining the service over time and broadening its applicability. The results has shown that collaboration via use of videoconferencing across levels of health care sectors can be a useful alternative that offers learning, leads to continuity, reduces costs and improves the quality of care. Telepsychiatry, in the form of video conferencing, has been well received by patients (n=27) and general practitioners (n=3) as a method reducing waiting time and bridging the distance between patients and specialized psychiatric care.

Background: Access to mental health specialists in Denmark is limited due to long waiting time, especially in the remote areas. Telepsychiatry service, which provides quick and direct access across distances, has been tested as a means of clarifying the vocational potential of unemployed individuals with suspected mental conditions. Aim: To examine, whether telepsychiatric assessments are feasible for clarification of vocational potential of suspected mentally ill persons, including immigrants. Methods: A three-phase pilot project was carried out. Ten job centers, located in different parts of Denmark, participated by referring their clients to ‘The Little Prince Psychiatric Center‘ in Copenhagen. Mental health specialists with the relevant language skills conducted the assessment interviews via videoconference and generated an assessment report. A satisfaction questionnaire was completed by the caseworkers and the clients. Results: Forty nine unemployed individuals were referred by twenty caseworkers during a period of 19 months. A variety of psychiatric diagnoses was disclosed. The overall satisfaction with the telepsychiatry service was reported by the clients and the caseworkers. Conclusion: Telepsychiatric assessments are feasible with unemployed individuals suspected to be mentally ill, including immigrants. Technical means used in telemedicine are also feasible in related contexts like vocational assessments.

The main aim was to develop recommendations on eMental health interventions for the treatment of psychotic disorders. A systematic literature search on eMental health interventions was performed, and 24 articles about interventions in psychotic disorders were retrieved and systematically assessed for their quality. Studies were characterized by a large heterogeneity with regard to study type, sample sizes, interventions and outcome measures. Five graded recommendations were developed dealing with the feasibility of eMental health interventions, beneficial effects of psychoeducation, preliminary results of clinical efficacy, the need of moderation in peer support eMental health groups and the need to develop quality standards.

Current refugee crisis within European Union (EU) challenges mental health care systems in each EU country. For ethnic minorities in EU access to mental health care is a problem due lack of clinicians who understand their language, culture and special needs. Linguistic, cultural and even racial differences between patient and provider can have an impact on the therapeutic alliance. Therefore communication between providers (mental health professionals) and cross-cultural patients is even more complicated with a third person i.e. interpreter, involved. However, refugees and asylum seekers still receive the most of treatment provided via interpreters. Innovative solution for this problem might be “cross-cultural telepsychiatry model” within various settings. Since 2004, “cross-cultural telepsychiatry” has been tested, developed and established in outskirts areas of of Denmark through various pilot projects. Overall high patient satisfaction was reported by patients as well as by involved professionals.

Cross-cultural patient mental health-care demands a high standard of communication between the patient and the provider, since linguistic and other differences may influence it and consequently affect quality of care and satisfaction. Geographical distances, culture, religious, and linguistic, make it difficult for some patient populations to access mental health professionals in their desired way. Clinicians with a positive attitude to differences and who advocate for patients may seek out e-Mental Health (eMH) innovations to overcome barriers, increase the quality of mental health care for ethnic minorities, and enhance their own education. Indeed, eMH applications offer new possibilities for reducing disparities in access to relevant mental health care to most vulnerable patient groups, such as refugees, migrants, and asylum seekers worldwide. National and international cross-cultural eMH services may contribute to reduce stigma and improve quality of health care of these groups in their host countries. Equal access to mental health services is a human right, for both domestic and immigrant population in modern communities worldwide.

Web- and Internet-based resources are remarkably popular with the public, patients, and providers’ interventions over the last decade. Opportunities exist for health information, support groups, formal education programs, tools for self-directed lifestyle and illness management, obtaining advice/consultation, and self- or provider-directed treatments (e.g., cognitive behavioral therapy or e-mental healthcare). Traditional treatments are more easily disseminated to the point-of-service. Modification of regular treatments is being developed, based on smartphone applications and applying virtual reality/avatars from games into medicine. Innovative new treatments for special populations are made possible, and hybrid models of care may be our future. Access to information, providers, that can be adjusted to patient needs and comfort, with or without clinician supervision, which creates a completely new world of opportunities. These steps empower patients to initiate, participate, and steer their care. Clinicians have to become aware of, adapt, and serve new advisory roles to patients, as we are all challenged to make the best healthcare more accessible.

Telemedicine and Internet-enabled clinical systems are already widely available and are starting to have an impact on the doctor-patient relationship and will increasingly do this more in future. Research shows that online MH interventions are as effective as traditional face-to-face therapy for disorders such as depression and anxiety. We explore the impact of technology on the doctor-patient relationship as new technologies and clinical processes are applied to patient care (e.g., virtual patient advocates). In the future, we will likely change clinical processes, add models of care (e.g., hybrids), better apply new technologies to the underserved (e.g., cross-cultural populations), and have even newer technologies to size up.

Patient- or person-centered healthcare confronts us with questions on how to deliver quality, affordable, and timely care in a variety of settings. The international history of medicine, patient-centered care models, healthcare financing, and use of technology frame how e-mental health (eMH) develops, is employed, and positively influences outcomes. Models of care and patient-centered approaches are steering eMH services forward from in-person to videoconferencing to online formats—technology complements existing traditional medical approaches. Telemedicine empowers patients, personalizes care, increases administrative efficiency, and ensures expertise gets to the place it is most needed—wherever the patient is. Telepsychiatry, as the oldest eMH application, is effective, well accepted, and comparable to in-person care. As we employ technology, we must maintain high-quality clinical care and professional standards and be sensitive to differences in participants. Good care requires evaluation and attends to clinical, legal, reimbursement about the technological issues. eMH may soon reshape healthcare service delivery particularly as telepsychiatry appears better for some disorders and in some models of care than traditional in-person approaches; online services will boost this shift even more. Mental health providers may soon practice in-person, virtually, or both.

Background: Web and Internet-based resources are remarkably popular with the public, patients and others as a way to access mental health information, tools for self-care, advice/consultation from a professional, and providerdirected treatments. Objective: This paper provides a framework of a spectrum that includes person-centered health education options (conceptual endpoint), patient and caregiver-centered mental health care interventions (evidence-based literature review), and more formal provider-directed treatments (conceptual endpoint). Methods: The evidence-based literature review was focused on treatment studies, using a minimum of three key words and the 1996-2015 period, resulting in 13,612 articles. This was reduced to 388 (title words used), to 125 (abstracts for methods, design, and outcomes) and 40 (evidence-based criteria of guidelines). Results: Technology is frequently used, is readily accessible and satisfies persons, patients, and caregivers. Its impact on openness to engage with others and begin self-care appears very positive; its ability to help people change behaviors and engage additional clinical services appears modest, though this is inadequately evaluated. Formal treatments over the Internet, asynchronous care models, or traditional video-based synchronous services are as good as or better than in-person services, though an incomplete range of services has been evaluated. Relatively few treatment studies assess outcomes, compare in-person and e-Mental Health care, and or compare technology-based care options to one another; hybrid models of care have emerged, but have rarely been studied. Conclusions: For persons or patients not in care, use of the internet for common, non-acute problems appears to work, though a one-time clinical evaluation may help them place options in context. Clinicians and patients should specifically plan how to use technology and exercise sound judgment, based on guidelines when available. More research is needed on the application of new technologies to clinical care, with randomized trials and health services studies for effectiveness suggested.

An international telepsychiatry service was established between Denmark and Sweden for cross-cultural patient groups, such as asylum seekers, refugees and migrants. Over an 18-month period starting in mid 2006, 30 patients were treated by telepsychiatry (21 men and 9 women). The patients received mental health care by videoconferencing from providers who spoke the patients' own language, i.e. without the assistance of interpreters. The total number of telepsychiatry sessions was 203 (range 1–22; average 6.8 sessions per patient). Patients completed a satisfaction questionnaire at the end of treatment. Seven patients (23%) were not able to complete a questionnaire, due to illiteracy and/or a psychotic condition. The rest of the patients ( n=23) reported a high level of acceptance and satisfaction with telepsychiatry, as well as a willingness to use it again or recommend it to others. Any disadvantages of telemedicine were compensated by the fact that the doctor and patient spoke the same language and had similar cultural and/or national references. Mentally ill asylum seekers, refugees and migrants are under-served in their mother tongue and telepsychiatry can improve access to scarce health-care resources.

In this chapter the author gives the short review over wide range of telepsychiatry applications. Furthermore, describes completely new and innovative approach regarding assessment and/or treatment of asylum seekers, refugees and migrants in Europe. Experiences from both Danish telepsychiatry survey and the first international telepsychiatry collaboration in Europe ever, will be reviewed in this chapter. Numbers of benefits within mental health care systems all over the European Union can be achieved by establishing of an International European Telepsychiatry Network. The chapter ends by suggestions for future development within mental health services in EU.

This study explored Danish men’s attitudes and behavior towards extramarital sexual relations (ESR), seen from two sides: men who had engaged in such relations (involved) and men who had not (non-involved). The participants, 439 men aged 51, completed a questionnaire concerning sexuality (behavior, attitudes and experience) as a part of a Danish cohort-investigation of health risk-factors. Thereafter 100 of the 439 men were interviewed. A high degree of permissiveness toward ESR emerged in both involved and non-involved individuals but approval of ESR was higher among the participants who were involved in ESR. The frequency of ESR increased with higher social rank. Both involved and non-involved participants mostly did not consider the ESR as a serious threat to the marital happiness. Attitudes-behavior discrepancies are discussed seen in the light of the social norms and known attitudes-behavior models.