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 Table of Contents  
INVITED PERSPECTIVE
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 162-167

Telepsychiatry and COVID-19: A new dawn for digital psychiatry?


1 Derbyshire Healthcare Foundation Trust, Radbourne Unit, Royal Derby Hospital, Chandigarh, India
2 Dr. Parmod Clinic, Chandigarh, India
3 Horton Park Centre, Bradford District Care Foundation Trust, Bradford, United Kingdom
4 Derbyshire Healthcare NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom

Date of Submission24-Aug-2020
Date of Acceptance24-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Subodh Dave
Derbyshire Healthcare Foundation Trust, Radbourne Unit, Royal Derby Hospital, Derby, DE22 3WQ
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_289_20

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  Abstract 


Psychiatrists all over the world are being presented with the unique challenge of continuing to deliver mental health care during, and after the first wave of the COVID-19 pandemic. Telepsychiatry has emerged as a potential solution to this challenge, especially when physical distancing has become the norm in social discourse. India, with its vast rural population and technological prowess, has been one of the early adopters of telepsychiatry. However, given the reach of mobile telephony in India, its usage is not as widespread as anticipated. In the post COVID-19 world, the rapid and broad adoption of telepsychiatry could offer a potential solution to bridge the gap between the availability and need for mental health professionals and interventions. Evidence suggests that telepsychiatry is at least as effective as face-to-face consultations in improving mental health outcomes. There is emerging literature on the remote assessment of patients in various settings globally and from India. This article aims to help clinicians translate this evidence into action in their clinical practice by providing practice guidance on conducting comprehensive telepsychiatry assessments. It also sheds light on the challenges and opportunities encountered with telepsychiatry in the Indian setting.

Keywords: Consultations, COVID-19, mental health, pandemic, telepsychiatry


How to cite this article:
Dave S, Abraham S, Kumar P, Pillai AS, Mahalingappa SS. Telepsychiatry and COVID-19: A new dawn for digital psychiatry?. Indian J Soc Psychiatry 2020;36, Suppl S1:162-7

How to cite this URL:
Dave S, Abraham S, Kumar P, Pillai AS, Mahalingappa SS. Telepsychiatry and COVID-19: A new dawn for digital psychiatry?. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:162-7. Available from: https://www.indjsp.org/text.asp?2020/36/5/162/297162




  Introduction Top


The COVID-19 pandemic has led to a lot of dramatic changes to health-care systems around the world. Globally, mental health services are being presented with unique challenges of providing effective and safe patient care while undertaking the provisions of managing the pandemic using social distancing, quarantining, shielding, and isolating. Telepsychiatry, hitherto a niche mode of care delivery, has emerged as a possible solution to this challenge.

Telepsychiatry refers to the delivery of mental health services via video-based conferencing, allowing the provider and client to use telemonitor with auditory and visual capabilities to communicate with each other.[1]

India is no stranger to telepsychiatry as a number of telepsychiatry projects have shown to improve access to mental health care across the country.[2],[3],[4] Indian practitioners are generally comfortable with providing easy and informal access to patients/carers through social media such as WhatsApp or through mobile phones. While this is usually restricted to audio conversations or text messaging, video interactions are becoming increasingly common in medical consultations.[5]


  Capacity Gap Top


The National Mental Health Survey of India undertaken in 2015–2016 estimated the prevalence of mental disorders to be around 10.6% and lifetime prevalence of around 13.7%.[6] The survey also showed that approximately 1.9% of the population was affected in their lifetime with severe mental illness such as schizophrenia and mood disorders, with productive age groups being affected the most. The treatment gap was noted to be high and appeared to be driven by multiple factors such as variations between rural and urban areas and limited access to mental health services, to name a few. The State Mental Health Systems Assessment analyzed various components of the health-care system as part of the survey, highlighting a number of factors to mitigate the need. These included paucity of trained medical officers to deliver mental health services, need for mental health finances to be streamlined, need for collaboration within and outside the health sector, and lack of rehabilitation programs among others. Garg et al.[7] noted that India has 0.75 psychiatrists per 100,000 and the desirable number to be above three psychiatrists for the same population. Telepsychiatry can bridge this gap, as clinicians can assess and manage patients regardless of geographic or rural–urban barriers for a majority of low- and middle-income countries (LAMI) like India.


  India and Telepsychiatry Top


Telepsychiatry has an extensive evidence base globally and has been noted to be as effective as face-to-face psychiatric consultations in a vast majority of studies.[8]

It has also shown high patient satisfaction rates along with benefits of being cost-effective.[9] Telepsychiatry models have shown overwhelmingly positive results in various studies carried out in India. This include Schizophrenia Research Foundation (SCARF) telepsychiatry in Pudukkotai (STEP) model,[2] SCARF mobile telepsychiatry model,[3] Ganiyari model,[4] the hub-and-spoke model of National Institute of Mental Health and Neurosciences (NIMHANS),[10] and the Clinical Decision Support System from PGIMER, Chandigarh.[11] These studies have shown that telepsychiatry can help provide continuity of care in the face of disasters such as the tsunami in 2006 with STEP model and bridge the rural–urban gap with Ganiyari model in Bilaspur. The telepsychiatry after-care study conducted at NIMHANS has shown that it is possible to provide highly acceptable and good aftercare for existing patients through telepsychiatry.[12] Telepsychiatry can therefore be considered a potential solution for the improvement of delivery of mental health services in India, especially in the hour of need.

The explosive increase in demand for video consultations has led to a matched effort from statutory and regulatory bodies to provide central guidance on the use of telemedicine in clinical practice. Telemedicine guidelines were published by the Ministry of Health and Family Welfare (MoHFW) in March 2020.[13] This was right at the onset of the COVID-19 pandemic and the resulting lockdowns. Leading on from this, NIMHANS published a set of Telepsychiatry Guidelines in May 2020, which are to be used in conjunction with the Telemedicine Guidelines and Mental Health Care Act, 2017.[14]

Historically, there has been a dearth of guidelines in this area despite insistent demands from the Telemedicine Society of India (TSI) and other medical professionals. It is worth noting that the TSI has been around for more than two decades and yet has remained practically unnoticed until now. The pandemic has clearly accelerated the rate of development of information and guidance available in the area. The following practical tips for the busy clinician may help him/her conduct tele-consultations safely and effectively.


  Practical Considerations for Clinicians Undertaking Telepsychiatry Assessments Top


Replacing or supplementing face-to-face consultations with telepsychiatry is new to many of us. Clinicians should approach the telepsychiatry consultations as they would with a face-to-face consultation, while accepting the limitations of telepsychiatry.

Telepsychiatry requires high level of professionalism, knowledge of technology, and even high liability. It is not mandatory for all practitioners. However it is the need of the hour and will carry on, into the future as well. It should be practiced by only those who are comfortable with it, along the guidelines provided by the MoHFW [13] and NIMHANS.[14]

The mnemonic “TELEPSYCHS” helps make the following tips memorable.

Technology

The videoconferencing platforms which were available even before COVID-19 have evolved further since the pandemic. Some of the common platforms in India include Practo, DocPulse, and Motherhood along with widely available informal platforms such as WhatsApp, Facebook, and Skype. Choice of a particular platform is based on various factors such as cost; secure storage of data; and ease of use for patients, carers, and professionals. Hospitals and registered medical practitioners using these platforms should consider training to skill themselves prior to undertaking telepsychiatry assessments. Some of the practitioners have their own platforms, which provide all services related to telepsychiatry. All platforms need to be Health Information Technology for Clinical and Economic Health Act (HIPPA) compliant and should fulfill the criterion laid down under the Information Technology Act, 2000. It is pertinent to mention here that professionals should not practice telepsychiatry “while on the go;” rather, one should have an office-based practice only.

It is important that the hardware is user friendly and in working order. These include cameras, microphones, computers, laptops, smartphones, or any other information technology (IT) equipment. Handheld devices are best placed on firm surfaces to ensure that your hands are free as this can enhance your professional appearance. It is imperative that you ensure correct details for the consultations are at hand for example – dial-in details and correct phone number of the patients.

As technologies are not infallible, there should always be a backup plan. This should be communicated at the outset of the consultation. This can alleviate some of the anxieties that could arise in such situations, both for patients and professionals. These glitches can be in the form of failure of internet connections, hardware failure, etc., It would be useful to ensure adequate technical support, backup generators, etc., to cover such issues if possible. Patients and carers are generally not well versed with technology; hence, it would be useful to provide practical information at the initial part of the consultation.

Environment

Patient and clinician environments should be considered as clinical environments. An appropriate environment is key to a mutually productive consultation. Informing the patient of this might be required at the start of the consultation. It is possible that the consultation may involve multiple professionals, for example – interpreters, nurses, psychologists, occupational therapists, and dieticians as well as carers and family members.

The room used for the remote consultation should be well lit and comfortable. The room should be quiet and should be able to provide adequate privacy and confidentiality. The camera should be placed at a level that patients and the professionals are able to see each other properly. It is also prudent to ensure that the background is blurred to ensure that any background objects that could give away personal or confidential data are not visible. It is also equally important to ensure that there are no background noises that may interfere with the consultation. Use of headphones would help make the consultation more private. Use of a side room or a private space would be appropriate in a care home or ward setting.

The newer smartphones generally fulfill all criteria to deliver telepsychiatry services. As mentioned previously, telepsychiatry must be practiced exclusively in a clinic office-based setting for confidentiality. It is generally noticed that few practitioners talk to their patients while at home, in car, or at public places. It can get further complicated when patients call at odd hours, which can force practitioners to talk outside their office environment or out of office hours. This could be managed by setting boundaries at the first consult, for example, explaining about where teleconsultations will be provided, timings for the teleconsultation, and availability aspects.

Legal frameworks and clinical governance

Clinicians need to be well acquainted with the following legal aspects of telepsychiatry – national, local/organization, and clinical governance policies to ensure safety and quality in the care provided. As mentioned previously, telepsychiatry in India is governed by the Telemedicine Practice Guidelines issued by the Medical Council of India.[13]

Telepsychiatry may not be appropriate in the following situations:

  1. Lack of access to medical records
  2. Patient is not willing or unable to give a capacitous consent for the consultation or
  3. When confidentiality is difficult to maintain.


It is recommended that clinicians should have adequate indemnity cover that ensures legal assistance, if required. It is worth bearing in mind that the quality of telepsychiatry consultations should be at par with that provided in face-to-face consultations, although the practical restraints need to be acknowledged and taken into account.

The Board of Governors, in supersession of the Medical Council of India, will be developing a mandatory online program that should be done by clinicians practicing telepsychiatry once in every 3 years. In the interim, clinicians are advised to follow the telemedicine guidelines issued earlier on in this year.[13] These guidelines are generic and do not provide guidance on specific topics in psychiatry, for example – prescribing psychotropic medications. However, the telepsychiatry guidance provides psychiatry-specific guidance. It needs to be borne in mind that issuing prescriptions without adequate assessment or relevant physical examination could amount to professional misconduct.[13] All the guidelines must be followed in their true spirit, and violation of guidelines can increase the chances of litigations, etc.

Expectations of both patients and clinicians

Exploring and meeting the expectations and needs of the patient and carers is vital to the effectiveness of the telepsychiatry consultation.

At the outset, the clinician/s should introduce themselves with full professional identity and professional affiliations. It would be useful for any other professionals, family members, or carers to introduce themselves. Make sure that you check with patients where they are to ensure that they are in a private space, whether there is anyone else present with the patient, and whether they want them to be present or not. It is prudent to ask the patient whether he or she is happy with the family member, carer, or other professionals to be present during the consultation.

Striking the balance with family involvement is crucial, particularly in a family-oriented cultural setting. The whole family might not be able to fully engage in a remote assessment. Possible strategies to mitigate this might include multiple engagements over the time period or asking the family to take turns during assessments. However, this needs to be balanced against the advantages of having a consistent involvement of a dedicated carer/family member.

The patient and carers should be informed about the rationale for the telepsychiatry consultation as opposed to a face-to-face consultation (e.g., patient in a remote village, patient isolating or shielding due to COVID-19 or lockdowns or even very important person [VIP] patients, and patients who prefer privacy with telepsychiatry). One should generally avoid seeing a VIP or very very important persons face to face in the clinic as they would invariably be accompanied by a lot of security personnel. The patient should be informed about the reason for contact, i.e., assessment, health education and promotion, counseling, or prescribing medications. It is also important to inform about the approximate duration and possible outcomes of the consultation.

Inquiring about any current or previous difficulties in communication using telepsychiatry platform and support available would help reduce anxiety and foster rapport.

Open discussion around risk assessment along with risk mitigation strategies might be required at the start of the consultation. Inform the patient that the consultation is confidential. One should have a student or colleague or an interpreter with you to inform the patient about this and request the professionals to introduce themselves. If there are many professionals involved in the consultation, and they are in different localities, make sure the patient is aware of this and there should be time given for all professionals to introduce themselves. Make sure that you check with patients where they are, whether the environment is confidential, whether there is anyone else with them, and whether they want them to be present or not. If you are discussing highly confidential and personal matters pertaining to the patient, you could ask the person with the patient to leave the room.

Telepsychiatry can hinder physical examinations. Physical observations such as blood pressure readings, pulse measurements, body mass index measurements, and blood sugar readings carried out by patient or families might aid the consultation and encourage engagement. Telepsychiatry might be used for triage purposes during the first consult where physical examination or a face-to-face consultation is an absolute requirement to ascertain diagnosis and management. It is important to understand that telepsychiatry is just another tool to deliver mental health services in exceptional situations or for a special population in routine practice as well. Whether telepsychiatry gives the desired and same level of satisfaction (as with face-to-face consultations) to patients, families, and even professionals needs to be assessed in future through research and studies on service and patient satisfaction.

Person-centered care

It is imperative that the care that is provided is person centered regardless of the mode of consultation, face to face or telepsychiatry. All care provisions should be aimed at providing compassionate, confidential, and high-quality care with full involvement of patients in planning their care. Person-centered care is key to mental health practice.[15] A thorough history and information gathering to inform the predisposing, precipitating, and perpetuating factors for the current presentation and providing care and support based on a biopsychosocial approach is at the heart of every psychiatric consultation. It is possible that there might be gaps in information when telepsychiatry assessments are undertaken. It is, therefore, vital that all avenues are explored to address these gaps. This might be in the form of collateral history from family, local health-care workers (with the consent of the patient), or medical records. Acknowledging and exploring any uncertainties that crop up in telepsychiatry assessments could alleviate anxieties of the patients and clinicians.

Following consultations, shared formulation and care plan would help foster active engagement and compliance. Safety net and available support should be discussed with the patients and carers. Any additional support, for example – multidisciplinary team or external agencies should be discussed as appropriate. It is good practice to send a letter to the patient in their language with details about the key discussion points, management plan, and contact details for follow-up.

Suitability and special settings in telepsychiatry

It should not be assumed that telepsychiatry would be appropriate in all clinical settings. The suitability of telepsychiatry should be assessed prior to offering a consultation. Patients may choose face-to-face consultation over a remote consultation. In such situations, an appropriate risk assessment and working knowledge of national and local guidelines regarding contact during COVID-19 is essential prior to initiating a face-to-face consultation. Clinical situations involving patients in acute crisis, potential or existing risks to others, inability to understand the nuances of telepsychiatry, severe learning difficulty, severe sensory impairment, advanced dementia, and dementia with behavioral and psychological symptoms of dementia might be potential barriers to telepsychiatry.

There will be situations where telepsychiatry consultations may need to be aborted, for example – patients becoming agitated or distressed during the consultation. In such situations, face-to-face consultation might be required. The golden rule is that one should deliver only those services, which one is comfortable with as a professional.

Telepsychiatry may be suitable in prison or care home settings to avoid risk associated with transporting patients to hospitals and also reducing risks to the clinicians and other patients.

You are not alone

Psychiatry emphasizes multidisciplinary team work in providing holistic and person-centered care. Using telepsychiatry to drive patient contact does not mean that we are working in silos. Person-centered care is best delivered as part of a multidisciplinary team usually consisting of pharmacists, psychologists, nurses, occupational therapists, and IT support team. Peer and colleague support in both formal (e.g., second opinion) and informal (e.g., WhatsApp groups) are an excellent means of support. Indemnity insurance providers and organizations such as the Indian Medical Association can provide support in relation to employment, medico-legal matters, etc.

Contemporaneous confidential notes

Maintaining contemporaneous and confidential medical records is an important tenet of clinical medicine, which is not to be broken. This is equal, if not more relevant, in telepsychiatry. A detailed documentation of the consultation including the rationale and evidence for the working diagnosis, differential diagnosis, proposed treatment, and risks should be made in clinical notes as per local policy. Recording the consultation with the patient's consent is also an option as per national, organizational, and local policies.

Telepsychiatry consultations should be documented in detail as with other consultation. It is important to document the rationale for remote assessments. The detailed assessment with a summary of the diagnosis, formulation, and key risk factors – both current and historic along with biopsychosocial management plan and medication changes – should be recorded in the notes.[14]

History gathering before the start of the consultation

It is vital that as much available information as possible should be gathered prior to commencing the assessment. Thorough information gathering prior to remote consultation will help the clinician in understanding various comorbidities, current medication, and risks. A good referral letter/information from the referrer will help the clinician with gathering such information in an Indian setting. Clinicians should gain collateral history from family, friends, or carers with the patient's consent. This would be important in diagnostic assessment, assessment of risks, and formulating a care plan. The new consult pro forma stipulated in the Telepsychiatry Operational Guidelines could be used for this purpose.

Safety and risks

Assessment of risks can be anxiety provoking, especially when undertaken during telepsychiatry consultation. The four main domains of risk include risk to self, others, neglect, and abuse. Additional risks such as the ones due to interventions (psychotropics, drug interactions, and even psychotherapy) should be considered. It is also important to check risks related to driving. A video consultation is better than a telephone consultation in such situations as direct observation of the patient and environment would help in corroborating risk history taken during the assessment. It is always better to have video consultations during all follow-ups. The availability of cost-effective smartphones with almost free-of-cost data makes this possible with almost all patients.


  Challenges With Telepsychiatry Top


The cultural practice of seeking informal advice and lower levels of trust in doctors on health matters often means that “second opinions” are sought casually on the phone. While prescribing practices are coming under closer scrutiny, the level of regulation of prescribing is relatively low and patients are, at times, able to bypass the doctors to obtain medications directly from pharmacists/dispensers.

Telemedicine (i.e., telepsychiatry) offers both the doctors and patients the opportunity to record their consultations. The knowledge that a video recording of the consultation will be available is likely to alter both doctor and patient behavior. The likely advent of a more watchful approach to the practice of telemedicine (i.e., telepsychiatry) may lead to a transition from an informal social contract to a more formal and structured mode of consultation.

It may well be possible that virtual consultations offer a safer practice space for doctors, given the reports of violence against doctors when faced with unpalatable bills or poor patient outcomes.

A survey undertaken by Das et al.[16] to understand the uptake and usage of telepsychiatry and usage by psychiatrists in both public and private sectors, showed that the psychiatrists felt that telepsychiatry was a hindrance to clinical decision-making and treatment. However, the lower requirement for physical examinations and close observations in psychiatry meant that telepsychiatry was the most accepted telemedicine workstream. It is a common concern that psychiatrists are finding it difficult to make patients accept this model of treatment, especially on a consultation fee basis. Patients tended to complain when being advised to register and/or make prior payments prior to the consultation.

It appears that psychiatrists practicing telepsychiatry in line with international and national guidelines had less difficulties adjusting with the changes. Furthermore, psychiatrists who were not tech savvy found telepsychiatry to be more challenging. There appeared to be concern among such doctors that the face-to-face consultations would be replaced by virtual consultation, especially when the large IT firms are making significant investments in this arena. It is also a common worry that such firms would offer low-cost interventions, which could outprice face-to-face interventions.

Majority of the population live in rural areas with patchy Internet and telephone availability. In addition, affordability might be another barrier for accessing technology.

However, it is worth bearing in mind that on the whole, the advent of digital technology has had a more equalizing effect in opening up knowledge and access to information and resources to a very large group of hitherto disenfranchised people. The advent of telepsychiatry in this context offers the opportunity of widening access to expertise at potentially reduced costs.


  Conclusion Top


The occurrence of the COVID-19 pandemic in a globalized and interconnected world has led health-care delivery into an unchartered territory. The pressure on the available resources to provide care is leading to exploration of alternate methods of care provision. In addition, a consumer-led clamor for on-demand care is leading to a rapid growth in telecare. The relatively easy availability of smartphones and growing coverage of Wi-Fi and high-speed mobile phone networks when paired with readily accessible technical expertise create the perfect environment for a boom in tele-health care. Psychiatry is a stigmatized and often underutilized specialty. Through telepsychiatry, the promise of confidential and rapid access to expertise will make potentially lifesaving treatments available to large sections of populations that have historically been underserved by routine health-care services. This is particularly the case in LAMI countries, with India being a prime example.

Telepsychiatry is merely the first step in the journey toward digital psychiatry. Digitization when linked with telecare offers autoscheduled bot-led assessments of mental and physical health-care parameters, algorithm-generated nudges to prescribers to optimize treatments, and analysis of Big Data to help inform preventive psychiatry and other public health approaches to improving mental health outcomes at a population level. Machine learning and artificial intelligence can help improve individual risk assessments and help choose appropriate treatments.[17] However, if the fruits of digital and telepsychiatry are to be realized, the profession and wider society need to invest in collaboratively designing and agreeing structured approaches to telepsychiatry with practically applicable guidelines along with technological solutions which are easy to use, safe, readily available, and tailored to not only the needs of patients and carers but also to those of providers. Such a nuanced approach balancing regulation and protection with costs and ease of use will lay the foundation to usher in a digital age in psychiatry.

The COVID-19 pandemic has put in “fast-forward” motion the winds of change for delivery of mental health care across the world, especially so in India. How the pandemic further unfolds over time will probably help in determining the path that telepsychiatry will carve out for itself in the years to come.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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