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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 3  |  Page : 273-280

Telepsychiatry in the developing world: Whither promised joy?


Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Web Publication3-Nov-2016

Correspondence Address:
Subho Chakrabarti
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.193200

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  Abstract 

Telepsychiatry, the use of information and communication technologies to provide psychiatric services from a distance, has matured as a mode of service delivery and has expanded its reach since its inception. Telepsychiatry promotes equality of access to high-quality specialized care for underserved users. It enables, empowers and brings about high levels of satisfaction among users. Telepsychiatry can deliver a broad array of clinical services and support several other nonclinical activities. Accumulated evidence demonstrates that clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among patients of all ages, ethnicities, cultures, and diagnostic groups across diverse clinical settings. However, negative attitudes, concerns about the quality of the evidence, doubts about cost-effectiveness, technological vagaries, uncertainty regarding the doctor–patient alliance, and a number of legal, ethical and regulatory hurdles continue to hinder the widespread implementation of telepsychiatric services. A particularly disappointing aspect has been the lack of development of telepsychiatric services in developing countries, where they are required the most because of the large mental-health gap in care with the more traditional forms of services. Problems of costs, lack of infrastructure and connectivity, shortage of trained personnel, sociocultural differences, limited data on effectiveness, and lack of institutional support are the principal challenges to the wider adoption of telepsychiatry in these resource-constrained countries. It is evident that much more effort by all stakeholders, innovative solutions, and hybrid models of care are required before telepsychiatry is able to fulfil its true potential and bring about the promised change in mental health outcomes in the developing world.

Keywords: developing countries, India, telepsychiatry, telemental health


How to cite this article:
Chakrabarti S, Shah R. Telepsychiatry in the developing world: Whither promised joy?. Indian J Soc Psychiatry 2016;32:273-80

How to cite this URL:
Chakrabarti S, Shah R. Telepsychiatry in the developing world: Whither promised joy?. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 Aug 24];32:273-80. Available from: http://www.indjsp.org/text.asp?2016/32/3/273/193200


  Introduction Top


The best laid schemes of mice and men Go often awry, And leave us nothing but grief and pain, For promised joy!

"To a mouse, on turning her up in her nest with the plough"- Robert Burns, 1785

Telepsychiatry derives its name from telemedicine, designating as it does psychiatric applications of telemedicine.[1] Telemedicine has been eloquently described as “healing at a distance.”[2],[3] At the root of all definitions of telepsychiatry lies the use of information and communication technologies (ICTs) to provide psychiatric care from a central or nodal site to a peripheral, distant, or remote site.[4],[5] Broader definitions incorporate the types of health care professionals and the varieties of ICTs used.[3],[6] The World Health Organization (WHO) definition of telemedicine also adds the potential uses of such services including: “diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”[3] All these uses are relevant to telepsychiatry. The prefix “tele,” which means at or over a distance (as in telephone or television) is also used in two related terms: telecare (or telemental health care) and telehealth (or telemental health).[1],[3] Subtle distinctions are often made between these terms and their latest avatars, eHealth and mHealth.[1],[3],[7] Nowadays, telepsychiatry almost exclusively refers to two-way interactive and “real-time” communication using videoconferencing, which is the oldest form of this service-modality. Telemental health care is generally used to refer to the delivery of personalized social care services through ICT devices to residential or community settings.[8],[9] Telemental health is used as an umbrella term for all mental health applications used in providing care from a distance including telepsychiatry and telemental health care. It encompasses a broader range of services delivered by all manner of mental health professionals and not just psychiatrists; includes all forms of technology utilized in the practice of mental health care from a distance; and, is meant for promotion of mental health care and prevention of mental health conditions in addition to their treatment.[1],[3],[10],[11] The term e-mental health overlaps with telemental health, but appears to signify a more user-centred, responsive, and personalized approach to providing networked ways of care.[12],[13] Finally the WHO defines mHealth as “the use of mobile and wireless technologies to support the achievement of health objectives.”[7] These overlapping terms may create confusion and difficulties in evaluation unless the precise descriptions of the ICTs used and interventions implemented are available.[2],[11],[14] In this article, the term telepsychiatry has been used uniformly and is intended to encompass all these different terms. However, precise definitions or using one or the other term may not be more important than focusing on what the service-modality intends to achieve. The unequivocal answer to that is providing information, support, and care, providing access to a wider range of high-quality specialized services by removing geographical barriers and other resource limitations, promoting equity and enabling and empowering users; all this with the ultimate purpose of improving mental health outcomes.[1],[3]

Growth of telepsychiatry

Telepsychiatry has completed almost 60 years of existence and is now well into its seventh decade, but like fine wine has it got better with age? There is no doubting that telepsychiatric services have grown both in their scope and reach. From being a predominantly north-American and European phenomenon till the 1990s, telepsychiatric programmes have now been established in many countries across the world. Telepsychiatric services were originally conceived of to meet mental health needs of users in remote, rural, and inaccessible locations.[15],[16],[17] Compared with traditional modes of service delivery, telepsychiatry was ideally suited for combating this “tyranny of distance.” It improved access to high-quality specialized services for people in these communities and appeared to diminish costs of care. With the evolution of telepsychiatric services, they are also being increasingly used in urban areas for the same benefits.[17] The development of a broader array of ICTs has also meant that telepsychiatric services are being used in a larger group of people, some of whom are not ill and others who are only mildly or moderately ill.[8] An expansion of the evidence-base has accompanied the growth in services. Beginning from somewhere around the year 2000 there has been burgeoning of publications about telepsychiatry. A cursory search of the Internet yielded close to 20 reviews in the last year alone. While 2015 might have been a good year for writing reviews on telepsychiatry, it was by no means an exceptional one. The earliest review appeared about 20 years ago,[18] and since then there have been more than a few reviews on telepsychiatry every year. Not with standing the scores of reviews on the subject, telepsychiatry is clearly not one of those areas where more is written about than done. On the contrary, there has been a veritable explosion of studies, from around 20 in the review by Baer et al.[18] in 1997 to well over 1000 in the latest ones spanning the last 15 years or so.[19],[20] The evidence-base has also expanded to include a wider variety of psychiatric disorders, patient groups, settings, and applications. Although the rapid advances in technology, reduced costs of ICTs, and increased access to the Internet-based platforms have been the prime drivers of this expansion, advances in research methodology have also contributed to the growth of telepsychiatry.[1],[3],[7],[18] Along with improved methodology, research on telepsychiatry has also undergone a subtle change in focus. The growth in research can be roughly divided into three phases.[21],[22],[23] The first phase consisted of descriptions of novel programmes, reliability of telepsychiatric assessments, preliminary research on clinical outcomes and cost-effectiveness, and satisfaction and acceptance among users. Randomized controlled trials of outcome with larger samples and improved designs emerged during the second phase. As the number of such trials grew a realistic evaluation of the effectiveness of telepsychiatry became possible. The third phase is witnessing a more critical appraisal of the evidence, development of models and guidelines for optimum care, as well as more nuanced research on aspects such as costs and funding, ethical and regulatory issues, and dissemination and sustainability of telepsychiatric services. Thus, both the growth of services and of the research-evidence clearly suggests that telepsychiatric services have matured to the point where they are a viable form of mental health care delivery.

Utility of telepsychiatry

The evidence-base for the usefulness of telepsychiatric applications is large as well as diverse. For an overall perspective, several different facets of this research-evidence need to be considered. Over the years telepsychiatric applications have come to utilize a wide variety of ICTs from the traditional synchronous or real-time telepsychiatry as in videoconferencing or telephone-based systems, to the novel asynchronous (store-and-forward) forms of telepsychiatry utilizing text, images, audio or video datasets, and emerging applications based on mobile and wireless technologies (mHealth).[3],[7],[23],[24] As the technology has progressed, research reports using all these modes of telepsychiatric applications have appeared. Although synchronous videoconferencing is still in vogue and asynchronous telepsychiatry has been used uncommonly in telepsychiatric research, studies utilizing newer ICTs such as Internet, Web, computer, or smartphone-based applications are already beginning to exceed studies on videoconferencing.[7],[12],[25],[26],[28] Telepsychiatry has both clinical and nonclinical uses. Not surprisingly, the bulk of studies are on patient-care services including diagnostic assessments, delivery of pharmacological, and psychosocial interventions, treatment monitoring, and home-based care.[8],[10] Additionally, there are studies on the use of telepsychiatry for case management and care planning, crisis intervention, neuropsychological testing, legal aid, forensic evaluations, liaison services, and nursing care.[1] Research has also been conducted on administrative aspects such as record-keeping and educational uses of telepsychiatry such as teaching, training, and supervision of trainees.[8],[29],[30],[31],[32] All these studies have been conducted among almost all commonly occurring psychiatric disorders, among patients of all ages and ethnic and cultural groups, and across a number of settings including clinical, community, residential, correctional, and military ones. Finally, a range of outcomes have been considered including diagnostic reliability, efficacy and effectiveness, access, acceptance and satisfaction among users, therapeutic alliance, cost-effectiveness, safety, and feasibility and sustainability. Thus, when one considers the entire range of studies, it appears that compared with other forms of service-delivery telepsychiatry has undergone the most comprehensive scrutiny of its utility.[16] The results of this impressive body of research have been encouraging to say the least.[1],[14],[19],[20],[22],[23],[29] Telepsychiatry-based diagnostic assessments including structured interviews, scales, neuropsychiatric, neuropsychological, and forensic assessments have proved to be as reliable and accurate as face-to-face evaluations. Initial comparisons indicated that interventions using telepsychiatry were comparable in effectiveness to conventional treatment, but these studies were not adequately designed or powered. Randomized controlled trials began to appear by early 2000s and in the last 10 years several large and well-designed trials and naturalistic studies have demonstrated either equivalent, or even superior outcomes in the groups receiving telepsychiatry-based interventions compared to in-person treatment. Trials have been conducted in anxiety and depressive disorders, posttraumatic stress disorders, eating disorders, schizophrenia, substance abuse and suicide prevention among adults, children and the elderly, and among other patient populations. The research among clinical populations has been supplemented by a large number of studies on videoconferencing, Internet, computer or Web-based psychotherapy mainly cognitive behavioral therapy (CBT), which has shown that psychotherapy delivered by telepsychiatric means is as effective as in-person therapy.[39],[40],[41],[42] Patient satisfaction with telepsychiatric assessments and treatment including psychotherapy has been found to be consistently high in almost all studies, and there is unequivocal evidence that telepsychiatry increases access to high-quality mental health care and reduces inequities in provision of care. However, the evidence regarding cost-effectiveness is somewhat mixed and other outcomes such as treatment-engagement, social functioning, and quality of life have not been examined as often as clinical or treatment outcomes. Thus, despite its many flaws the sheer weight of the evidence suggests that telepsychiatric services perform, as well as traditional services in terms of feasibility, effectiveness, quality of care, and user satisfaction.[10],[20],[21],[22],[23],[43] Accordingly, they meet the WHO yardstick for an ideal mental health service including accessibility, comprehensiveness, coordination and continuity of care, effectiveness, equity, autonomy, and empowerment.[44]

Problems afflicting telepsychiatry

The evidence presented above suggests that telepsychiatry has immense potential, has matured as a mode of service delivery over the years, has expanded its reach, and has an impressive evidence-base supporting it claims of usefulness.[45] One would have expected telepsychiatric services to form a major part of the mental health services on ground by now. However, even its proponents are only talking of telepsychiatry having reached a “tipping point” in delivery of mental health care,[23],[45] whereas others are not prepared to concede even that.[11],[32] What then are the barriers that hinder the widespread implementation of telepsychiatry and its integration with routine care? Somewhat surprisingly, the first obstacle appears to be the absence of good quality evidence in favor of the efficacy and effectiveness of telepsychiatry. Although there appear to be several thousand research reports on this aspect, most reviews have found that the number of adequately powered and properly designed studies are well below 100, whereas the number of randomized trials is even less.[1],[14],[15],[19],[20],[21],[22],[23],[24],[25],[46] Although the efficacy of telepsychiatric interventions have been adequately evaluated in depressive and anxiety disorders, research data on other disorders is limited both in size and methodological rigour. Additional evidence of effectiveness is also required for populations such as the children and the elderly, for interventions other than CBT-based treatments, and for newer settings such as acute-care and homes of users.[10],[23] Finally, there is a need to make this evidence available to both providers and clients to positively alter their views about the perceived usefulness of telepsychiatry.[47] Although expanding the evidence-base is certainly warranted, the principal barrier to wider adoption of telepsychiatry appears to be providers’ and (in some instances) users’ unwillingness to use these services.[32],[47],[48],[49],[50],[51],[52] The evidence indicates that although satisfaction among patients is generally high, satisfaction among clinicians is generally lower. Provider scepticism is a significant impediment to dissemination of telepsychiatric services because their attitudes are critical to the implementation and success of these programmes. Dissatisfaction among providers arises from doubts about perceived usefulness and ease of use of telepsychiatry, unawareness, and unfamiliarity about technological aspects, as well as concerns about increased workload. Although there is reasonable evidence that therapeutic alliance is not affected adversely, many clinicians are uncomfortable with lack of nonverbal cues, the absence of sensory information other than sight and sound, and the lack of physical proximity or ‘sense of presence.’ Safety, particularly in unsupervised settings is still an issue, as are apprehensions about regulatory, ethical and legal hurdles associated with use.[1],[2],[3],[21],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53] Cost-effectiveness is another Achilles’ heel of telepsychiatry. The fact that the results of cost-effectiveness studies are mixed does not help, although it appears that programmes can become cost-effective if the “break-even point” of number of consultations, travel, and patient expenses is reached.[14],[17],[22],[23],[29],[43],[54],[55] However, much more needs to be done to make telepsychiatric services cost saving, as costs affect every aspect of such services from reimbursement of routinely provided care to sustained funding for survival of newly established programmes.[48],[53],[56]

Telepsychiatry in developing countries and the Indian experience

Although telepsychiatry has been somewhat of a success story in developed countries the same cannot be said of developing nations. This is particularly disappointing because traditional services for mental health care are not coping too well with the ever increasing burden of mental health disorders in these countries.[57] The demand problem is intensified by a huge deficit in supply of mental health resources, which together with the grossly inequitable distribution of resources between urban and rural areas and primary and secondary care have led to a significant mental health gap problem.[58],[59] Although telepsychiatry is better equipped to improve access and positively impact health care in several other ways, its potential is not being realized because of several logistic and environmental hindrances. This was brought to light by the second Global Survey on eHealth by the WHO in 114 of its member states. This survey focused on four fields of telemedicine including telepsychiatry.[3] It revealed that only 24% of the countries had some form of telepsychiatric service with established programmes in a mere 13% of them. There was considerable discrepancy between high-income countries and low-income and middle-income countries; whereas 20% of the former had established telepsychiatry services, less than 10% of the latter had such services. This developed-developing divide suggests that the factors impeding the wider implementation of telemedicine (including telepsychiatry) in developing countries arise from limitations in the local health care environments of these countries. Although all the potential barriers listed above are common to both developing and developed countries, high perceived costs, under-developed infrastructure and lack of technical know-how appear to constitute the more salient ones in developing countries.[3] Added to these are poor Internet penetration, poor connectivity, and shortage of trained workers and specialists. The general lack of computer literacy fuels adverse attitudes toward telepsychiatry among both providers and users, as do linguistic and cultural differences between users and providers. Consequently, telepsychiatric services are not deployed on a greater scale and sufficient data on usefulness particularly cost-effectiveness is not being generated. The absence of national governing agencies to provide support, frame policies, and regulate use of services is another major limitation in these countries.[1],[2],[3],[10],[11],[60],[61] The Indian experience provides a typical example of the problems plaguing telepsychiatry in developing countries. Telemedicine projects in India began with successful linkages in the early 2000s by both public and private providers. Several government ministries have set up working groups or task forces to implement national level initiatives and develop resources. A national eHealth policy was adopted in 2006 and has been partially implemented.[62],[63],[64] However, none of these developments seem to have made a difference to the nascent telepsychiatric initiatives in the country. As a result there are only scattered reports of pilot projects, which convey little about the current status of implementation or effectiveness of telepsychiatric programmes.[65],[66],[67],[68],[69],[70] One such initiative was a recently concluded project conducted by the Department of Psychiatry at the Postgraduate Institute of Medical Education and Research-Chandigarh, funded by the Department of Science and Technology-Government of India and developed in joint collaboration with the Tata Consultancy Services.[1],[24],[71],[72],[73],[74],[75],[76] The programme followed a model of service delivery, which was somewhat different from the usual direct-care, consultation-liaison, or collaborative-care models.[22],[77] This “tele-enabling” approach envisaged a model of training and enabling teams of nonspecialist personnel at remote sites to diagnose and treat mental illnesses on their own with minimal supervision from nodal centers. This model was thought to more appropriate for resource-constrained environments of low-income countries like India. To this end a logically derived computerized decision support system was used to develop a software programme for diagnosis and management of common psychiatric disorders in adults and children. The diagnostic module had screening and criteria-based diagnostic sub-modules for automatic generation of diagnoses. These diagnoses were interlinked with standardized modules for treatment and follow-up care. This Internet-based application incorporating videoconferencing enabled nonspecialists accessing it at remote areas to provide care more or less independently after a few hours of online training in its use. Preliminary results regarding accuracy and feasibility of the application in diagnosis and treatment have been promising. However, as in the case of other telepsychiatric programmes in the country, sustaining the service remains a challenge in the absence of support from government agencies or the telecommunications industry.


  Conclusions Top


It is amply clear by now that telepsychiatry has a long way to go in convincingly demonstrating that it can have a significant impact on mental health care in developing countries. In the absence of its proven effectiveness, diversion of the limited resources currently available in these countries to build telepsychiatric services may seem unjustified.[78],[79] Accordingly, telepsychiatric services can remain relevant in the present circumstances only if workable solutions to the problems afflicting these services are found. Fortunately, none of the barriers affecting telepsychiatry either globally or in the developing world lack solutions.[1],[2],[3],[10],[11],[78],[79],[80] Advances in technology and research are expected to overcome many of the current obstacles. Increased awareness and a more realistic appreciation of telepsychiatry’s potential, as well as limitations may contribute to better acceptance among users. Most importantly, although there is an urgent need to build an evidence-base of effective telepsychiatric interventions. The second prerequisite is to develop technologically appropriate, culturally sensitive, and needs adapted interventions, which are value for money. Even then telepsychiatry is unlikely to be the panacea for all mental health care problems of developing countries. It would be more appropriate if telepsychiatric services fit the role of adjuncts to conventional services rather than hope to replace them. If telepsychiatry settles into this niche it has the capability to enhance the overall efficiency of mental health services in developing countries provided that effective, needs-based forms of telepsychiatric services are implemented. Therefore, the way ahead would lie in devising hybrid models of care incorporating both traditional and telepsychiatric forms of mental health-care.[54],[81],[82] Ultimately, the future of telepsychiatry in the developing world is in the hands of its champions. They have to work harder win over the skeptics including the hard-nosed funders both public and private, to overcome the limited progress made up till now. Otherwise, like Burns’ mice and men all of us may be left with grief and pain instead of the promised joy of telepsychiatry.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

 
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