Distance Psychotherapy--New Reality.

High technology progresses fast in the medical area. The most recent advance is the “big data” study, in which multiple technologies are applied to populations in order to incorporate genetic data, biological markers and imaging, to assess risks and predict the occurrence of clinical phenomena. That is a global, multidisciplinary and multinational view, which supports and helps the implementation of preventive actions.

Psychology practice in Brazil, however, still resists to this modernity. Face-to-face psychotherapy is the only modality of treatment accepted by the Brazilian Federal Council of Psychology. However, distance counseling, via Internet or mobile phone, has been increasingly used in the USA, Europe and Oceania. Epstein et al.[1] have reported the increasing use of “e-therapy”, as well as the exponential growth of related publications. In New Zealand, Gibson et al.[2] have reported the experience of adolescents with mobile phone therapy. Eight aspects were identified by adolescents as advantageous: privacy, autonomy, control, anonymity, easy access, personalization, individualization of language, and connection.

The importance of these new methodologies relates to the prevalence and incidence of emotional problems worldwide. For example, depression will be the most common non-fatal disease of the 21st century[3], and an important cause of work disability and loss of quality of life, in addition to being the third cause of suicide among North-American young adults.

An extensive review published in the Journal of the American College of Cardiology by Rozansky[4] in 2014 showed that a number of factors, such as sleep disorders, anxiety, several forms of stress at home and in the workplace, lack of purpose in life, anger and inability to face challenges, are significantly associated with cardiovascular diseases, as well as with cardiac and all-cause mortality. Those associations depend on unhealthy life habits, such as sedentary lifestyle and smoking, and activation of the sympathetic nervous system, which trigger pathophysiological mechanisms that cause cardiovascular diseases[5]. Thus, there is a biologically plausible mechanistic connection of emotional and behavioral problems with organic cardiovascular disease. If, on the one hand, the understanding of the pathophysiological mechanisms belongs to the cellular and molecular biology domains, on the other, when attempting to change behaviors, physicians need the professional help of psychologists. In addition, prevention is precisely one of the pillars in the eradication of chronic non-communicable diseases, such as atherosclerosis, diabetes and hypertension, which are the major causes of mortality causes in the modern world. The fundamental requirements in the preventive strategy are changes in lifestyle, such as smoking cessation, exercise practice and the adoption of healthy diets. This is the point where the two sciences meet.

Moreover, physicians often fail to recognize emotional problems, both the primary ones and those associated with organic diseases. Several psychological treatments are misused, and the number of cases treated is insufficient, barely reaching 50%[3].

On the other hand, the economic burden of depression and dementia is astronomical[6,7]. In the USA, the cost of depression, mainly related to absenteeism and poor work performance, has reached U$53 billion in one year. Regarding dementia, Hurd et al.[7] have estimated individual costs between U$42,000 and 56,000/person/year, and between U$ 157 billion and 250 billion/year in the USA. In Brazil, such costs are unknown, but most likely high as well.

Given that scenario, the following measures are imperative:

to identify psychological factors, as well as primary conditions, in organic diseases;

to adopt global health care, which are patient and not only disease oriented;

to incorporate different methodologies of treatment, such as new drugs and new behavioral treatment forms;

to improve the treatment of mental illness.

Concerning “distance psychotherapy”, we believe that the brazilian law needs to be changed and adapted to the new times. Not disregarding the classic face-to-face therapy, distance counseling should not only be allowed, but encouraged in special situations covered by appropriate legislation. In Brazil, distance psychotherapy is currently allowed in the research only and encourages debate on efficiency and safety, privacy, ethical and legal questions, and other aspects[8]. For example, one therapeutic process could begin with a few initial interviews, followed by distance treatment and face-to-face interviews at intervals. This would benefit patients living far away from large centers, where modern therapeutic techniques, such as cognitive behavioral therapy, are not available. Such alternatives would certainly contribute to the preventive processes so heartedly championed by modern medicine. Both psychologists and their formal representatives should pursue this inevitable update.