|Year : 2022 | Volume
| Issue : 2 | Page : 75-81
Can telepsychiatry bridge the treatment gap?
Sandeep Kumar Goyal
Department of Psychiatry, SPS Hospitals, Ludhiana, Punjab, India
|Date of Submission||01-Jul-2022|
|Date of Decision||20-Aug-2022|
|Date of Acceptance||22-Aug-2022|
|Date of Web Publication||13-Jan-2023|
Dr. Sandeep Kumar Goyal
Department of Psychiatry, SPS Hospitals, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Goyal SK. Can telepsychiatry bridge the treatment gap?. J Mental Health Hum Behav 2022;27:75-81
At first, I bow my head before the Almighty for the blessing showered upon me, without which I could not have reached this position. I am obliged to my respected teachers, Dr. Paramjit Singh and Dr. P. D. Gargi, for teaching me the ABC of Psychiatry. I am forever indebted to my parents for inculcating the best ethical values in me. I am thankful to my wife and sons for their constant support and encouragement at every moment in my life. I am sincerely thankful to all the members of the Indian Psychiatric Society North Zone to entrust me to serve as the president of the society. It is indeed a great honor for me. Last but not least, I want to acknowledge the contribution of Dr. Sandeep Grover for his help in choosing a suitable topic for Presidential address.
| Magnitude of Problem|| |
The National Mental Health Survey (NMHS) of India, 2015–2016, estimated that the current mental morbidity and the lifetime prevalence in the surveyed population (excluding tobacco use disorders) were 10.6% and 13.7%, respectively. Common mental disorders (CMDs), including depression, anxiety disorders, and substance use disorders (SUDs), affect nearly 10.0% of the population. The lifetime and current prevalence of severe mental disorders was found to be 1.9% and 0.8%, respectively. Translated to real numbers, nearly 150 million Indians need active interventions. SUDs were prevalent in 22.4% of the population above 18 years.
NMHS reported that a huge treatment gap still exists for all types of mental health problems, ranging from 28% to 83% for mental disorders and 86% for alcohol use disorders.
The treatment gap is defined as the number of people with active disease who are not on treatment or are on inadequate treatment and is expressed as a percentage of the total number of people with active disease. The difference between true prevalence and treated prevalence can be called the treatment gap. The treatment gap is a useful indicator for accessibility, utilization, and quality of health care.
In India, there are very few reliable studies that report a treatment gap of 50%–60% for schizophrenia, 88% for depression, and 97.2% for alcohol use disorders.,,
The treatment gap is prevalent in all countries. A large multicountry survey showed that 35%–50% and 76%–85% of the serious cases in developed countries and less-developed countries, respectively, did not receive treatment in the previous 12 months.
In a study in Nepal, a high treatment gap was found for depressive disorder (91.5%) and alcohol use disorder (94.9%).
| Reasons for Treatment Gap|| |
A wide treatment gap can be due to demand-side barriers or due to supply-side barriers. Key demand-side barriers are stigma and low perceived need due to limited awareness and sociocultural beliefs. Insufficient, inequitably distributed, and inefficiently used resources are supply-side barriers. Cost and distance-related factors are other important barriers to seeking mental health treatment.,
According to a study by Luitel et al., the major reported barriers to treatment were lacking financial means to afford care, fear of being perceived as weak or crazy, having no one to help in seeking mental health care and being too unwell to ask for help. However, there was not much difference between stigma- and nonstigma-related barriers, and the perceived barriers also did not differ by sociodemographic characteristics and type of mental health problem.
| Limited Awareness about Psychiatric Illness|| |
Many communities perceive that mental health problems are caused by bad deeds or black magic, and thus visit faith healers before mental health professionals. This leads to a delay in help-seeking.,
Lack of knowledge about the symptoms of mental illnesses and ignorance about how to access mental health assessment and treatment are the factors that lead to delays in treatment-seeking.
| Stigma|| |
Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice due to which people with mental illness turn against themselves.
Due to disabilities associated with the disease and prejudice resulting from misconceptions about mental illness, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, and satisfactory health care.
Stigma presents as prejudice and discrimination against people who have a mental illness. Discrimination may be obvious and direct (e.g., someone making a negative remark about a person with mental illness), or it may be unintentional or subtle (e.g., someone avoiding a person with mental illness assuming that he/she can be violent or dangerous due to mental illness).
The relationship between stigma and discrimination and access to care is multifaceted. Stigma and discrimination can impede access at an institutional level (legislation, funding, and availability of services), community level (public attitudes and behaviors), and individual level.,,,,
People with psychosis are more likely to be perceived as violent and unpredictable, relative to people with other mental health problems.,
Persons suffering from schizophrenia, alcohol dependence, and drug addictions are perceived as dangerous and unpredictable. The public blames people with alcohol and drug addictions for their addiction. People with mental illness are perceived as unreliable, especially in terms of looking after children. Many believe that mental illness reduces intelligence and the ability to make decisions.,,
Discrimination and stigma have been linked to ignorance, and studies show that the majority of the public has limited knowledge of mental illness, and the knowledge they do have is often factually incorrect.
The media have often been accused of sensationalism by portraying mental illness inaccurately in their quest to gain higher ratings.
Even the movies increase the stigma associated with psychiatric illnesses as psychiatric patients are labeled as dangerous, villains are often psychotic and electroconvulsive therapy is shown as inhumane treatment.
| Explanatory Models of Mental Illness and Care-seeking Behavior|| |
The beliefs and perspectives of illness held by patients, their families, and the local culture, called explanatory models, profoundly affect care-seeking behavior and adherence to the recommended interventions.,,
In a study of belief models in first-episode schizophrenia in Southern India, 73% of the patients held black magic as an explanation for the psychosis. Sixty-two percent of the patients identified one clear cause and 22% reported more than one cause. Female sex, low education, and visits to traditional healers were the factors associated with holding spiritual/mystical models (black magic and evil spirits). Thirty-five percent of patients held more than one treatment model for their psychosis.
In another study of families of schizophrenic patients attending a teaching hospital in India, regarding help-seeking behavior and belief system of illness causation, 33 patients (40%) believed in the supernatural model, 35 (42%) had a medical model, and 15 (18%) had a dichotomous belief. The belief system appears to have an important relationship with the nature of the health facility chosen as the first contact healer. About 79% of the patients having the supernatural belief of illness causation visited indigenous healers, whereas 60% of the patients with dichotomous belief and none of the patients with the medical model of causation visited indigenous healers.
| Mental Health Workforce|| |
The limited and unequal (more in urban areas) availability of specialist mental health human resources (psychiatrists, clinical psychologists, and psychiatric social workers) has been one of the barriers to providing essential mental health care to all. In NMHS, the availability of psychiatrists (per lakh population) varied from 0.05 in Madhya Pradesh to 1.2 in Kerala. Kerala also had the highest number of clinical psychologists (0.6 per lakh population). The availability of psychiatric social workers was relatively low across all the NMHS states.
Despite three decades of implementing the NMHP, the proportion of districts covered by the District Mental Health Programme (DMHP) ranged from 13.64% in Punjab to 100% in Kerala.
Currently, India has 9000 psychiatrists (0.75 psychiatrists per 100,000 people). The number of psychiatrists required to reach the goal of three psychiatrists per 100,000 populations is 36,000. Hence, India has a shortage of 27,000 doctors, and we need to train 2700 new psychiatrists every year to bridge the gap in the next 10 years (if we keep the population growth rates and attrition rates of psychiatrists at 0%). However, every year only 700 psychiatrists are trained in PG seats.,
As per the National Medical Commission (NMC) website, 554 medical colleges are teaching MBBS and only 243 have MD psychiatry courses. In some states such as Nagaland, there is no medical college.,
The paucity of specialist mental health professionals in India warrants the engagement of nonspecialist professionals for mental health care.
Studies from India have reported that primary health-care professionals are often inadequately trained, and reluctant or unable to detect, diagnose, or manage CMDs.,
In a study, nonpsychiatric physicians were not confident in treating depressed patients, and they reported that incomplete knowledge and training were major barriers that limited their involvement.
| How to Bridge the Treatment Gap?|| |
To narrow the treatment gap, there is a need to address both the supply-side barriers and demand-side barriers. Interventions to address supply-side barriers include focusing on the integration of mental health into primary care. Availability and distribution of the mental health workforce can be increased through capacity building and task-sharing. Other interventions include increasing the funds allocated for mental health care, scaling up existing services like DMHP, integrating mental health into the ongoing National Programme For Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, and developing innovative mental health services to reach remote areas.
Demand-side barriers can be addressed by creating public awareness about mental health and strengthening the protection of the human rights of people with mental disorders as well as those of their families.,
The awareness campaigns to reduce stigma should include sensitizing media to STOP reporting inaccurate representations of mental illness and educating the public to STOP believing negative views about mental illness.
| Increasing Workforce|| |
Increasing the number of PG seats in psychiatry is one way forward. All medical colleges should have MD Psychiatry Program. However, bridging the gap by increasing the number of PG seats in psychiatry is not only impossible but improbable too.
Recently, the National Institute of Mental Health and Neurosciences (NIMHANS) reserved a certain number of MD seats for North-Eastern states, Uttarakhand, and Chhattisgarh as these states are grossly deficient in human resources in psychiatry. This initiative can help in building mental health workforce in these areas.
Making psychiatry an examination subject, as has been done in AIIMS, Rishikesh, can train undergraduate medical students in mental health.
| How to Reach the Unreached?|| |
Technology is bringing about a revolution in every field, and mental health care is no exception. The ongoing COVID-19 pandemic has provided us with both a need and an opportunity to use technology as means to improve access to mental health care.
According to the WHO, telemedicine refers to “The delivery of health-care 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 diseases 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.”
Telemedicine can be synchronous or asynchronous. Synchronous telemedicine “provides live, two-way interactive transmission between patient and provider at distant locations via telephony, online communication (e.g. chat forums), and video-conferencing.” Asynchronous telemedicine “involves acquiring medical data and then transmitting this clinical information in the form of data, audio, video clips, or recordings via e-mail or web applications for later review by a specialist.”,
Some of these modes of communication may include video, audio, or text based. Teleconsultation can occur between patient to registered medical practitioner (RMP), caregiver to RMP, RMP to RMP (primary care doctor and specialist at the tertiary care), and health worker to RMP (between a specialist and para-medical staff such as a nurse and pharmacist).
Telepsychiatry is a branch of telemedicine and it can act as a bridge between mental health seekers and providers, and a patient in a remote and inaccessible area can take treatment from a psychiatrist who lives far away.
Previously setting up of telepsychiatry unit in remote areas was an uphill task, but now most people have smartphones and telepsychiatry can be practiced easily or paramedical staff (ASHA and ANM) can be trained and can be provided smart phones in areas where people cannot afford smartphones.
In particular, the increased availability and affordability of high-speed connections have made the use of videoconferencing (VC) a viable tool for interacting with patients remotely.
| Uses of Telepsychiatry|| |
Telepsychiatry can meet demands for mental health services in under-served areas, where there is a shortage of specialists and there are difficult-to-serve populations (for example, rural areas and custodial settings such as prisons, juvenile homes, and rehabilitation centers). Telepsychiatry can be used for follow-up of a patient staying far away since the patient is not required to travel unnecessarily and hence saving money and time. Telepsychiatry can be useful in the emergency department, disaster situations, and community settings like rehabilitation centers, e.g. halfway homes, long-stay homes, elderly care homes, orphanages, etc., where psychiatric morbidities are high.,
Due to the limited number of psychiatrists available in military services, telepsychiatry can be used effectively for military patients also. The U. S. Military at the National Naval Medical Centre has developed telepsychiatry services for the remote military medical clinic. It was also found to be cost-effective in terms of costs of health-care services, equipment, patient travel, and lost work time.
| Benefits|| |
Bringing down costs
Telepsychiatry can reduce the treatment cost for the patient directly by reduction of transportation costs and indirectly by not losing his productivity as he needs not to take leave from his work. Professional also saves money as telepsychiatry minimizes the need to set up a full-fledged medical infrastructure.
Privacy and anonymity
It is important to note that due to the social stigma attached to mental illness, people are reluctant to seek professional help, especially in small towns and villages. The easy availability of telepsychiatry can motivate more people to seek psychiatric treatment.
A meta-analysis of studies comparing psychiatric assessment via video-conferencing (VC) to in person concluded that objective assessments delivered via VC were equivalent to in person in both accuracy and satisfaction.
Use of clinical scales
Many studies showed that clinical scales can be effectively administered using VC. Ball et al. administered the Folstein Mini-Mental State Examination (MMSE) to patients from an acute psychiatric ward. Each patient was interviewed both in person and over VC, and the authors concluded that the MMSE may be reliably performed with patients using VC.
In a study, six psychotic patients were simultaneously rated on brief psychiatric rating scale (BPRS) by a psychiatrist via VC and a psychiatrist who was on site. They noted that the only frequent rating disagreement was on a self-neglect item and concluded that some patients' self-neglect was difficult to observe via VC.
Boon for group therapy
Telepsychiatry through a group chat or video conference can be a potent tool for several groups who suffered some social abuse and who need counseling. Thus, telepsychiatry could serve as an effective way for group therapy.
Cognitive behavior therapy
Telepsychiatry can also be used for providing therapies such as cognitive behavioral therapy, family therapy, and supportive therapy. A randomized controlled trial (RCT) that compared cognitive behavior therapy (CBT) for bulimia and other eating disorders found that CBT delivered via VC shows a similar reduction of eating disorder and depression symptoms as compared to in-person treatment.,
A few RCTs compared the effectiveness of CBT delivered via face to face or by VC in posttraumatic stress disorder (PTSD), panic disorder with agoraphobia, mood, or anxiety disorder and concluded that CBT delivered by VC was as effective as CBT delivered face-to-face.,,
Telepsychiatry for psychotic patients
Whether telepsychiatry can be used for the assessment and treatment of psychotic patients has been a topic of debate for a long time. The hallmark symptoms of psychotic disorders might lead one to question the feasibility of VC with these patients. In 2011, Sharp et al. published a systematic analysis of 33 different types of articles and concluded that patients with psychosis can be reliably interviewed and evaluated via VC, including using symptom severity scales (e.g. BPRS) and diagnostic, clinical, and psychiatric interviews. In another study, Dongier et al. concluded that “even patients with schizophrenia with ideas of reference including T. V. accepted the CCTV interaction very well and no exacerbation of their delusions was observed.”,
Reaching the people, who do not reach the clinics
Research shows disparities in accessing health-care services by ethnic minority populations across the globe.
The location of health services and poor levels of interpreting provision in the emergency department are barriers to accessing routine services for certain mobile populations (for example, traveler gypsies) and isolated minorities.,,
It has been observed that in health and medical research, people from lower socioeconomic status groups are under-represented, and researchers make efforts to engage participants from socially disadvantaged groups.,,
Telepsychiatry can offer a solution to these problems. These people can access health-care facilities and participate in research without traveling to faraway places. Telepsychiatry services can be provided by culturally and linguistically, competent staff. Telepsychiatry can help to resolve regional obstacles to the delivery of health-care facilities.
We need to comply with the Mental Healthcare Act, 2017, and telemedicine practice guidelines 2020 for documentation of telepsychiatry consultation. Telepsychiatry can improve documentation as most telemedicine platforms are integrated with an electronic health record (EHR). EHR helps in encoding, storing, and retrieval of the medical records that are maintained online.,
Health education/capacity building
Under the DMHP, mental health education activities are isolated, sporadic, and invisible in nature and lack focus and direction. There is a need to involve grassroots-level health functionaries such as ASHA/USHA and ANM in mental health programs through skill-enhancing programs. Telepsychiatry can be used to impart training to health personnel at district and subdistrict levels.
NIMHANS started Diploma in Community Mental Health and Diploma in Primary Care Psychiatry in Chhattisgarh, Bihar, and Uttarakhand to empower primary care doctors in psychiatry. These kinds of activities can be started by all premier institutes in all the states.,,
Telepsychiatry in India
The Ministry of Health and Family Welfare issued the Telemedicine Practice Guidelines-2020 on March 25, 2020. These guidelines enabled doctors to provide health care using telemedicine. It does not mean that telemedicine was not practiced earlier in India.
On March 30, 2000, Mr. Bill Clinton the then president of the United States of America, during his India tour, formally launched telemedicine in India and commissioned the first telemedicine unit in the village of Aragonda, a remote village in Andhra Pradesh.
The Schizophrenia Research Foundation (SCARF) pioneered telepsychiatry services in India. They reached out to the victims of the tsunami of December 2004 in two coastal districts, Cuddalore and Nagapattinam, of Tamil Nadu via telepsychiatry services.
The first mobile telepsychiatric services in India were also started by SCARF in 2010 in the District of Pudukkottai, Tamil Nadu. Apart from teleconsultations, the package provides psychosocial interventions including psycho-education for caregivers, delivered by community health workers. Improving awareness about mental illness is another important element of the package. Periodic problems with ISDN lines and the initial reluctance of the population to use the services were the limitations reported.,
Psychiatrist on web
The PGIMER Chandigarh telepsychiatric project has developed a logically linked computerized decision support system for the diagnosis and management of common psychiatric disorders. The application was named “psychiatristonweb.”
The Ganiyari model in Chhattisgarh and Asynchronous Telepsychiatry model in Maharashtra are other models in India.,
Hub and spoke model
The NIMHANS follows a typical hub and spokes model in which NIMHANS acts as the hub and various districts, taluks, prisons, and relief and rehabilitation centers act as spokes. Mental health professional/physician serving at the spokes makes contact with the hub and on a fixed date a consultation takes place between the psychiatrist present at the hub and the mental health worker present at the spokes via VC.
| Future Ahead|| |
Need for standardized tools and methods
There is a need to develop more standardized templates to address psychiatric patients from different backgrounds.
Artificial intelligence can help in reducing the treatment gap and make psychiatric diagnosis and treatment accessible and affordable. It can also help in suicide prediction and prevention, identification of predictors for treatment response, and identifying which particular drug is best suited for a specific patient.
The wearable devices can be used in telemedicine to digitally transmit patient data in real time to psychiatrists and can help in monitoring side effects and drug levels through body fluids, electroencephalography, or electrocardiography changes. Wearable devices can send reminders to the patient and can help in improving drug compliance.
Soft wares for mood charting, and assessment of cognitive functioning
Apps for mood charting
Many smartphone applications (apps) for mental health are available to the public. Moodily, MoodPanda, Daylio, Mood Tracker, MoodMission, and eMoods Bipolar Mood Tracker are some of the popular mood tracking apps, which help patients to chart their moods. Most apps allow users to share their mood data with others. By sharing mood tracking data, these apps can be used for communicating symptoms and collaborating with health-care providers. These apps can be a useful tool in telepsychiatry. However, mood tracking is no substitute for quality mental health care. These apps can be additional tools in telepsychiatry consultation.
More research is needed to investigate and design mood tracking apps with desired reliability, validity, sensitivity, and specificity.
Apps for assessment of cognitive functioning
Tools for app and web-based self-testing for identification of cognitive impairment are widely available but are of uncertain quality. The ACE dementia screening app is comprehensive and efficient, but access is limited to health-care professionals only. This app can be used by health-care professionals in telepsychiatry.
| Challenges|| |
There is a digital divide in India and across the world, and certain rural areas are yet to have proper Internet connectivity. People with a lesser educational background may have a hindrance in using telepsychiatry services. Other challenges include the need to have quality control and regulations to keep these services bug free. The safety of data needs to be taken care, and third-party vendors need to be regulated to prevent exploitation.
| Limitations of telepsychiatry|| |
There can be some legal issues associated with telepsychiatry. There have been issues deciding when a telepsychiatry provider becomes liable for the harm to the patient; whether the treatment delivery is at the patient's site or the telepsychiatry provider's site, as license issues are there. There are no defined standards for telepsychiatry; this may increase the chances of the provider being charged with complaints of malpractice.
Telemedicine guidelines in India prohibit the prescription of medicines listed in Schedule X of the Drug and Cosmetic Act and Rules or any narcotic and psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances Act, 1985. Opioid and alcohol dependence patients cannot be treated as opioids and benzodiazepines (except clonazepam) cannot be prescribed.
| Conclusions|| |
Telepsychiatry can reduce the cost of treatment. The outcome of treatment done by VC is equivalent to face-to-face treatment for various diseases such as depression, anxiety, eating disorders, and PTSD. Telepsychiatry can be used reliably in psychotic patients also. Telepsychiatry can improve the documentation/preservation of treatment details. Telepsychiatry can lead to a reduction in the treatment gap by reaching the unreached, but there is a need to develop more standardized templates to address psychiatric patients from different backgrounds.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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