|Year : 2020 | Volume
| Issue : 2 | Page : 95-97
Telepsychiatry – A step into the future
Abhijit R Rozatkar1, Vipul Singh2
1 Department of Psychiatry, AIIMS, Bhopal, Madhya Pradesh, India
2 Department of Psychiatry, Government Medical College, Kannauj, Uttar Pradesh, India
|Date of Submission||21-May-2020|
|Date of Acceptance||21-May-2020|
|Date of Web Publication||27-Jun-2020|
Dr. Abhijit R Rozatkar
AIIMS, Habibganj, Bhopal - 462 020, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rozatkar AR, Singh V. Telepsychiatry – A step into the future. Indian J Soc Psychiatry 2020;36:95-7
| Treatment Gap in Mental Health Services|| |
Treatment gap, defined as the number of people with active disease who are not on treatment or on inadequate treatment, is a useful indicator of morbidity due to mental illness in a given geographic area. A global study on the treatment gap has reported a global average treatment gap in schizophrenia and nonaffective psychosis to be 31.1%, 53.9% for major depression, 48.9% for bipolar disorders, and 76.2% for alcohol dependence and abuse. In India, the National Mental Health Survey 2015–2016 found that common mental disorders had a treatment gap of 85%, severe mental disorders 73.6%, substance use disorders 90%, suicidal risk behavior 80%, and the overall treatment gap being 83%. For a 1.3 billion country, that would mean an astronomical 11.44 crore people in India are not on treatment.
| Mental Health Services as Contributor to Treatment Gap|| |
Barriers for the treatment in mental illness include patient/family-related factors such as perceived stigma, poor awareness of illness and others, and services related factors such as availability of mental health professionals and treatment facilities. Latest statistics from India show that we have 0.29 psychiatrist, 0.07 psychologist, 0.80 mental health nurse, and 0.06 social workers per 100,000 population. Number of beds per 100,000 population in mental hospitals, general hospital psychiatry units and in Child and adolescent units is 1.43, 0.56, and 0.03, respectively. The number of mental health professionals in India is not only low but also inequitably distributed. This means much of our population must travel to seek services. We certainly have made progress in the past two decades with the implementation of District Mental Health Program, central grants for establishing and upgrading mental health services, revamping of MBBS curriculum to improve undergraduate training in psychiatry, but the treatment gap is huge and would need many more decades to reduce.
| Revolution in Communication Technology|| |
The last two decades has also witnessed a revolution in the communication technology. We have moved from fixed line phone to mobile phones, to mobile phone with internet access, to smartphones with high-speed internet access. As per the recent report of Telecom Regulatory Authority of India, by the end of 2018, India had 1176 million mobile telephone users, 578.2 million wireless data subscribers and expected increase in data subscribers over the next 5 years. With increased availability of good quality camera on mobile phones, high-speed data transmission, numerous applications facilitating enhanced textual or audio-visual communication and the reducing cost of internet data packs, people to people interaction is now easy and common. Thus, technology now removes the barrier of distance between people which can be leveraged to reduce the mental health treatment gap.
| Telemedicine and Telepsychiatry|| |
Telemedicine has been defined as, “the delivery of healthcare services, where distance is a critical factor, by all health-care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities”. Although it is an umbrella term to encompass health-care delivery, health education, health research, health surveillance and public health promotion, in the context of this article, the term is used for its use in health-care delivery only. Broadly, the modes of communication in telemedicine have been grouped as asynchronous wherein information is stored, transmitted and retrieved at different points of time (like E-mail) and synchronous wherein the process is simultaneous (videoconference). Video conferencing allows a live, two-way interaction which mimics a face-to-face interview. Until recently, this technology was restrained by the speed of data transmission which resulted in poor quality of videos, loss of audio, frequent break in transmission, etc. Telemedicine services are increasingly used all across the world and many institutes in India such as Postgraduate Institute of Medical Education and Research, Chandigarh, Schizophrenia Research Foundation, Chennai and National Institute of Mental Health and Neuro Sciences, Bengaluru, spearheaded its use in mental health.
Telepsychiatry has been used for various disorders (affective, psychotic, anxiety, substance use, and others) and in various populations (young and old). Interventions have been offered in different settings (prisons and emergency visits), by different health workers (psychologist, nonpsychiatrist physician, and psychiatrists), for different purposes (assessment, follow-up, therapies, neuropsychological assessment, therapies including cognitive behavior therapy). When compared to in-person interviews, patients have reported equivalent satisfaction to telepsychiatry interviews, although mental health professionals have reported less satisfaction. Studies have shown that telepsychiatry is not inferior to in-person assessment and intervention.,
With the increased ease of access to mobile-based internet and emerging evidence of effectiveness of telemedicine, this method of service provision would flourish in times to come. It is a potential game changer in reducing the treatment gap due to mental illness. Unfortunately, in 2018, honourable High Court of Mumbai, in a plea of anticipatory bail filed by a doctor over death of a patient after giving telephonic advice for treatment, observed that such consultation is not covered under existing laws and regulations of the country.
| Telemedicine Guidelines|| |
The government of India (GoI) has brought a legislature to establish the National Medical Commission, an over-arching body governing aspects of health-care services which would replace the existing Medical Council of India (MCI). Until the notification of National Medical Commission, the rules and regulations of MCI continue to be applicable, and the functioning of MCI is entrusted to a Board of Governors appointed by the central government. In wake of the recent global pandemic of coronavirus disease-19, GoI issued orders to lock down various activities including the movement of general public and closing of nonemergency services in hospitals. Hundreds and thousands of patients were no longer able to access the routine healthcare services and could have deteriorated in the clinical status due to expiry to prescription. At this opportune moment, the Board of Governors issued the Telemedicine Guidelines under Appendix 5 of the Indian Medical Council (Professional Conduct, Etiquette, and Ethics Regulation, 2002) which provides a legal cover for doctors and patients for teleconsultation. The guideline provides comprehensive norms for doctor–patient and doctor-–health professional interaction outside their hospital/clinic and deals with the issues of patient evaluation, treatment and continuity of care, informed consent, emergency referrals, maintenance of records, consultation charges, etc., Clinicians can practice telemedicine through telephone, E-mail, video conferencing, social media, and chat platforms such as WhatsApp, Facebook Messenger, etc., Clients are required to submit the proof of identity, whereas clinicians are required to display their credentials and contact details. Consent to the treatment is deemed to be given if the patient initiates the consultation while explicit patient consent is needed if a health worker, caregiver or another clinician initiates the telemedicine consultation.
The clinician is expected to gather sufficient medical information about the patient's condition before making any professional judgment. They are required to exercise their professional judgment to decide if a telemedicine consultation is appropriate for the given circumstance and can request an in-person consultation or refuse teleconsultation if he/she deems fit. Clinician cannot insist on teleconsultation if the patient is willing to meet in-person. The physician can prescribe medicines through telemedicine only when he/she is satisfied that they have gathered adequate and relevant information about the patient's medical condition and that prescribing medicines is in the best interest of the patient. The guidelines explicitly state that prescribing medicines without an appropriate diagnosis/provisional diagnosis will amount to a professional misconduct. The clinician is required to provide an image or scan copy of a signed prescription to the patient by E-mail or any other method.
The practice guidelines also enlists medications that can be prescribed for first consultation by any mode (list O), first video consultation (list A), first video teleconsultation after in person consultation in the past 6 months or follow-up video consultation (list B). Medicines in “List O” are medicines used for common conditions and are available “over the counter”, such as paracetamol, multivitamins, etc., List A includes relatively safe medicines with low potential for abuse, such as anti-psychotics, mood stabilizers, anti-depressants and “List B” includes list A plus drugs such as benzodiazepines. Medicines listed in the Narcotic Drugs and Psychotropic Substances, Act, 1985 and Schedule X of Drug and Cosmetic Act, 1940 fall under the “Prohibited List” and cannot be prescribed through telemedicine. An amendment to the telemedicine practice guideline (MCI-211 (2)/2019(Ethics)/201874 dated April 11, 2020), now allows drugs used in psychiatry such as phenobarbitone, clobazam, and clonazepam to be prescribed on first video consultation.
Clinicians using the telemedicine are required to maintain the same professional and ethical norms as applicable to traditional in-person care. They are required to maintain log records/documents of telemedicine interactions and patient records, including reports, images, prescriptions, etc., Clinicians cannot share patient's images or any other data, especially which are private and sensitive in nature, without their consent. Clinicians are also not permitted to solicit the patients for telemedicine through any advertisements or inducements. The clinician must protect all patient-related data. However, in the event of data leak, the physician cannot be held responsible for the breach of confidentiality if there is reasonable evidence to show that a patient's privacy and confidentiality has been compromised by a technology breach or by a person other than the clinicians. The clinician is required to fully abide by the relevant provisions of the Information Technology Act, 2000 and applicable data privacy laws. The guidelines bar technology platforms based on artificial intelligence or machine learning are not allowed to counsel patients or prescribe any medicines to a patient.
The practice guidelines are comprehensive and offer to protect both the patients and clinicians. It allows all available communications platform to use giving reasonable degree of freedom to patients. As per the guideline, MCI will develop a short-term training course for telemedicine. Issues that have not been covered in the guideline include data management and insurance coverage of telemedicine consultations. The guidelines may also cause jurisdictional issues. For example, if patient is held-up outside India, prescription to continue medication cannot be issued. Similarly, if a patient has to initiate any complaint against a doctor, where should they approach, in their state or in the state of doctors practice?
| Future of Psychiatry Services|| |
Telepsychiatry should make a huge difference to those who find it difficult to travel for reasons such as physical disability, old age, and daily wage earner. Patients with perceived stigma might feel comfortable in taking advice by using telepsychiatry. However, culturally neutral, neuropsychological test will have to be developed in digital format so that clinical assessments are accompanied by objective measures, just like in the clinical settings. An integration of digital psychiatry tools in teleconsultation practice can also happen in near future. It needs to be seen how the provision of Mental Health Care Act, 2017, like advance directives and record keeping, are integrated with telepsychiatry consultations. Availability of psychotropic medications in nonurban location is a matter of concern but since availability is governed by market forces (demand and supply), this issue will most likely change over the next few years.
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