A British psychiatrist has developed a system he says allows the treatment of patients anywhere in the world through online chat or videoconferencing -- an approach he believes might be even more effective than face-to-face counselling for some patients. But Dr. Russell Razzaque, founder of the CyberAnalysis site, which went live Tuesday, said it's not certain that American insurance companies approve of his brand of virtual therapy. And a human resources manager at a major Internet company, who declined to be identified, said there's "no way in hell" that any of her company's insurance plans would pay for employees' online therapy, because the concept is too new and untested. Razzaque said virtual therapy may be able to achieve better results by giving patients direct access to the tools they can use to analyse themselves. Some patients, who are anxious about admitting certain things to a therapist in a face-to-face session, find it easier to communicate online, Razzaque said. "I think this form of disclosure facilitates more open discussion for many patients," he said. "In this setting, often they come straight to the point, and we can get down to work on their core problems very quickly." Another bonus of the system is that care can be provided more cheaply online than in face-to-face meetings, he said. Patients taking advantage of Razzaque's online services can expect to pay 10 to 20 percent less per session than he charges for office visits, he said. Under Britain's national health system, while most medical care is free or cheap, mental health services are not covered and patients must pick up the tab, Razzaque noted. The average cost of a therapy session in Britain is equivalent to about $65, he said -- a bargain by American standards. (Many American therapists charge around $100 per hour.) Although his system may be cheaper than seeing a local therapist, Razzaque said he's not sure whether American insurance companies will pay for their members to use his system. "This is really a new approach, so the insurance questions will have to be worked out," he said. An administrator at a major New England-based health management organisation, who declined to be named, said she does not know of any HMOs that would pay for health services delivered online. "We don't authorise any online services, including psychotherapy, for a variety of reasons," but mainly because the HMO fears patients' confidentiality would not be assured, the administrator said. The system isn't for all patients, however. Razzaque said he will not treat patients online who are suicidal or delusional, saying those patients belong in a hospital setting. But the main advantage of the system stems from the Web itself, Razzaque maintains. "The type of therapy I practice is particularly appropriate for the Web because it requires two things: a certain amount of emotional space between the patient and the therapist, and a relaxing environment for the patient," he said. Taking each patient individually, Razzaque will design a course of therapy using elements of major psychoanalytic schools, including Freudian psychotherapy and cognitive analytical therapy, he said. "I'm going to personally see to every patient on this site," he added. Razzaque, who says he was educated at the University of London and is now a senior official at the Royal College of Psychiatry, is among a growing number of mental health professionals who consider the Internet an effective tool for communicating with patients. But the idea has also generated considerable controversy. The number of Web sites and bulletin boards offering discussions on mental health issues are legion, but so far few actually offer the services of therapists online, said Marlene Maheu, a Californian psychologist who operates nine e-mail discussion groups and a Web site devoted to mental health issues. Maheu believes the trend toward "e-mail therapy" is a dangerous one. "Some problems are not very easily admitted, and we are trained to use visual and auditory cues to help patients to come to terms with certain issues," she said. "I've talked to people for six months before they've admitted they throw up every day." Mental health experts are grappling with the issue of the Web's utility because it does seem, on the surface, to be an excellent tool for doctors to connect with patients, Maheu said. But most depressed or anxious people ultimately derive benefits from face-to-face therapeutic encounters that can never be duplicated in cyberspace, and some might actually feel more isolated after online therapy, she said. "If you look at the professional discussion forums, there are flame wars going on daily on this issue," Maheu said. Asked about the controversy, Razzaque said he believes his approach will benefit many patients who would benefit from more traditional forms of therapy, and said that screening out more acutely sick patients should eliminate most risks. As with other services delivered online, consumers must take a "let the buyer beware" approach to Internet medical services, said Frank Connolly, an IS professor at American University who writes frequently on Internet culture issues. "It's a question of quality control, like anything else," Connolly said. "You have to think about who has oversight over this person if you have a problem with their services. If they're in the United States and they're licensed, then the AMA (American Medical Association) has oversight. But if not, then you might not have any recourse in the event of a problem." Since anyone could theoretically set up shop online and claim to be licensed to practice medicine, caution is probably the best approach for anyone considering such services, he said. "How do you vet this person to be sure he's not a quack?" Connolly said. But having said that, he noted that online communications are often more detailed than verbal communications, meaning some patients might provide better information to therapists online than face-to-face. "When I taught classes online, the answers I'd get from students were much better thought out in e-mails than they were when they'd just raise their hands and say what came into their heads," he said.