A patient in long-term dynamic psychotherapy who is also taking antidepressants for depression sends me numerous e-mails, sometimes with medication questions and other times about her relationships or the therapy session. Should I respond and, if so, how?

What you describe is increasingly common in psychiatric practice. We are all getting e-mails and text messages from patients on a regular basis. We must first understand that there are no consensual guidelines regarding the use of e-mail in communication with psychiatric patients. There are three major ethical concerns to keep in mind: 1) problems inherent in the mechanics of e-mail, 2) privacy and confidentiality issues, and 3) the loss of essential elements of the clinical encounter when electronic communication is used.

E-mails can be inadvertently deleted or placed on the "back burner" in a busy practice. Access to computers is not a given in the course of a psychiatrist's typical week. Patients who may be highly distressed and want to reach the psychiatrist quickly may find that the psychiatrist doesn't get to the e-mail until days later. One must always keep in mind that privacy can be compromised with e-mail. Every time an e-mail is sent there is a possibility that an unintended recipient may end up reading it. There is an illusion of privacy and confidentiality that lulls both sender and reader into a false sense of security. Computers are frequently left on both in the home and in the office, and a slip of the finger can result in a breach of confidentiality. Finally, the capacity to make clinical judgments is severely compromised when one's information is limited to words on a screen. One cannot see the patient, assess nonverbal aspects of the communication, and reach sound clinical conclusions from an e-mail. Moreover, e-mail communication, by its very nature promotes transference distortion. A busy physician may not have the time to respond to an e-mail message in a long and reflective fashion, and a terse response may be misread by a distressed patient.

In light of the complexities of using e-mail:, Kassaw and Gabbard (1) have recommended several guidelines:

In my opinion, the exchanges between psychiatrist and patient should be limited to brief administrative communications about things such as appointment changes. Medication questions are complicated: they often involve psychological issues that are attributed to medication side effects or true physical problems that require assessment. These concerns need to be evaluated in person. Similarly, relationship issues that are suitable for therapy should be discussed in person so that the psychiatrist can make a thorough assessment of the themes inherent in the question.