A study on collaborative telepsychiatric consultations to outpatients of district hospitals of Karnataka, India

Schizophrenia spectrum disorders in India: A population-based study

Introduction

Schizophrenia spectrum disorders represent a significant global health concern, contributing significantly to the global burden of disease. The National Mental Health Survey (NMHS) of India, conducted between 2015 and 2016, investigated the prevalence and epidemiological correlates of schizophrenia spectrum disorders in India.

Materials and Methods

The NMHS conducted a population-based cross-sectional study in 12 Indian states from 2015 to 2016, encompassing 34,802 adults. The overall study design of the NMHS was a multistage, stratified, random cluster sampling technique, incorporating random selection based on probability proportion to size at each stage. The Mini-International Neuropsychiatric Interview 6.0 was used for psychiatric diagnoses, disability was assessed using Sheehan's disability scale, and the illness-related socioeconomic impact was assessed using a questionnaire based on the World Health Organization Disability Assessment Schedule 2.0. Firth penalized logistic regression was employed to understand the correlates of current schizophrenia spectrum disorder.

Results

The study found a lifetime prevalence of schizophrenia spectrum disorders at 1.41%, with a current prevalence of 0.42%. A substantial treatment gap of 72% existed for current cases, rising to 83.3% in urban non-metro areas. The penalized logistic regression revealed that the age group category of 30-49 years, unemployed status, and lower education level had higher odds of association with schizophrenia spectrum disorders.

Conclusion

The primary finding of this study is a lifetime prevalence of 1.41%, a current prevalence of 0.42%, and a substantial treatment gap of 72%. Addressing this treatment gap and holistic intervention is crucial for reducing the socioeconomic impact of this disorder. Strengthening the National Mental Health Program and implementing community-based rehabilitation are essential first steps in this direction.

Manipal model of telepsychiatry

Telepsychiatry can be understood as an interactive mental health service providing mode using information and communication technology. In recent decades, services provided under the umbrella term of telepsychiatry expanded to cater clinical services, diagnostic services, interventions, therapies, education, and research. Since telepsychiatry has been practiced in India for two decades, various models have emerged to meet the country's demands and the logistics that are available. Both synchronous and asynchronous modes of telepsychiatry had been in practice in India depending on the availability of logistics. Most of the telepsychiatry services in India had focused on providing clinical care to reach the unreached population. Furthermore, telepsychiatry had been used to train mental health professionals and healthcare workers from other disciplines. However, not many models had incorporated the idea of hands-on training of the postgraduates/trainees of psychiatric social work (PSW) in telepsychiatry under supervision. This was addressed in the Manipal model of telepsychiatry. Manipal model of telepsychiatry has begun in 2016 with a novel idea to train mental health profession trainees in addition to cover other clinical services, research, and education. In the last eight years, four centers of Karnataka state have been covered under this model with progressive growth in a number of patients and this acted as a hands-on training model for the postgraduate trainees in starting telepsychiatry services independently. Furthermore, it provided an opportunity to develop the organization skills of trainees, improved their oratory skills, and improved their expertise in using information technology for mental healthcare delivery.

Mobile Mental Health in Women's Community-Based Organizations: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Of every 10 women in rural India, 1 suffers from a common mental disorder such as depression, and untreated depression is associated with significant morbidity and mortality. Several factors lead to a large treatment gap, specifically for women in rural India, including stigma, lack of provider mental health workforce, and travel times. There is an urgent need to improve the rates of detection and treatment of depression among women in rural India without overburdening the scarce mental health resources.

OBJECTIVE

We propose to develop, test, and deploy a mental health app, MITHRA (Multiuser Interactive Health Response Application), for depression screening and brief intervention, designed for use in women's self-help groups (SHGs) in rural India.

METHODS

We will use focus groups with SHG members and community health workers to guide the initial development of the app, followed by iterative modification based on input from a participatory design group consisting of proposed end users of the app (SHG members). The final version of the app will then be deployed for testing in a pilot cluster randomized trial, with 3 SHGs randomized to receive the app and 3 to receive enhanced care as usual.

RESULTS

This study was funded in June 2021. As of September 2022, we have completed both focus groups, 1 participatory design group, and app development.

CONCLUSIONS

Delivering app-based depression screening and treatment in community settings such as SHGs can address stigma and transportation-related barriers to access to depression care and overcome cultural and contextual barriers to mobile health use. It can also address the mental health workforce shortage. If we find that the MITHRA approach is feasible, we will test the implementation and effectiveness of MITHRA in multiple SHGs across India in a larger randomized controlled trial. This approach of leveraging community-based organizations to improve the reach of depression screening and treatment is applicable in rural and underserved areas across the globe.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42919.

Impact of Technology Driven Mental Health Task-shifting for Accredited Social Health Activists (ASHAs): Results from a Randomised Controlled Trial of Two Methods of Training

Mental health task shifting is a potential way to address the burgeoning treatment gap for mental illness. Easily available and accessible digital technology can be utilised to continuously engage grassroot level health workers (for example, Accredited Social Health Activists (ASHAs). However, the impact of such a strategy is not yet systematically evaluated. In this randomised controlled trial, longitudinal hybrid training of ASHAs [1 day in-person classroom training and seven online sessions (ECHO model), aimed to screen and refer to commonly prevalent mental health issues in communities] was compared with traditional one-day in-person classroom training. ASHAs (n = 75) from six Primary Health Centres in Ramanagara district, Karnataka, India were randomized into study (SG-ASHAs) and control (CG-ASHAs) groups. After excluding drop-outs, 26 ASHAs in each group were included in the final analysis of the scores on their Knowledge, attitude, and practices (KAP) in mental health. Two house-to-house surveys were conducted by both groups to identify and refer possible cases. The number of screen positives (potential persons with mental illnesses) and the KAP scores formed the outcome measures. Online sessions for SG-ASHAs were completed over 18 months, the COVID-19 pandemic being the main disruptor. SG-ASHAs identified significantly higher number of persons with potential alcohol use disorders [n = 873 (83%); p ≤ 0.001] and common mental disorders [n = 96(4%); p = 0.018], while CG-ASHAs identified significantly higher number of those with potential severe mental disorders [n = 61(61.61%); p ≤ 0.001]. As regards KAP, after controlling for baseline scores, the time effect in RMANOVA favoured SG-ASHAs. Mean total KAP score increased from 16.76 to18.57 (p < 0·01) in SG-ASHAs and from 18.65 to 18.84 (p = 0.76) in CG-ASHAs. However, the Time-group interaction effect did not favour either (F = 0.105; p = 0.748). Compared to traditional training, mentoring ASHAs for extended periods is more impactful. Easily accessible digital technology makes the latter feasible. Scaling up such initiatives carry the potential to considerably improve treatment access for those in need.

Current telepsychiatry practice in India - An online survey of psychiatrists

CONTEXT

Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines released in 2020 have provided legal backing for telepsychiatry practice.

AIMS

To understand the current telepsychiatry practices in India.

SETTINGS AND DESIGN

An online survey was conducted after ethics approval by the IPS Ethics Review Board. All psychiatrists, who are members of the Indian Psychiatric Society and whose email address was available with the society, were sent the survey link by email.

METHODS AND MATERIAL

Information about existing telepsychiatry consultation practices in India was collected between June and July 2020.

STATISTICAL ANALYSIS USED

Frequency, percentages, mean, and standard deviation were calculated.

RESULTS

340 responses were analyzed. Nearly three-fourths of the responders used smartphones (n = 260, 76.47%) for audio consultations (n = 196, 57.65%). Among those who were using a dedicated software (n = 36), one-third used the Zoom software (n = 12, 33.33%). Nearly three-fourths (n = 218, 73.4%) provided prescriptions with their registration number on a letterhead in the form of an email or text message. Two-thirds of the responders (n = 228, 67.06%) felt that in-person consultation is better. Many preferred a combination of voice, video, and text including emails (n = 134, 42.01%).

CONCLUSIONS

This online survey showed that the use of technology has caught up with the practicing psychiatrists. Many are practicing telepsychiatry either formally or informally in India and are comfortable and satisfied with the telepractice.

The prescriptions of psychotropic medications in telepsychiatry: An online survey of psychiatrists in India

CONTEXT

Over the years, telepsychiatry services have expanded in many institutes. The Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines (TPOG) released in 2020 have been received by the fraternity with a mixture of apprehension, relief, and dissatisfaction on the list of drugs provided in Lists O, A, B, and C. Many psychiatrists have raised the issues of having a consensus in the formulation of List A.

AIMS

To draw consensus on the medications that can be listed in Lists O, A, B, and C in TPOG-2020.

SETTINGS AND DESIGN

This was an online survey with ethics approval by the Indian Psychiatric Society Ethics Review Board. All psychiatrists, who are members of the Indian Psychiatric Society and whose E-mail address was available with the society, were sent the survey link by E-mail.

METHODOLOGY

Opinions and suggestions on Lists O, A, B, and C of TPOG-2020 and reasons for the suggestions were collected.

STATISTICAL ANALYSIS USED

Frequency, percentages, mean, and standard deviation were calculated. T-test and Chi-square tests were used to see the influence of demographics on the concurrence of the lists.

RESULTS

Responses from 340 responders were analyzed. Majority of the responders agreed that List O (277, 85.5%), List B (263, 82.4%), and List C (223, 69%) are apt except for List A (162, 50.3%).

CONCLUSIONS

This online survey showed that majority of the responders agreed to the lists except for List A. The approach taken to include the medications in List A, which was to include the essential drugs, has various benefits. However, the lists are not final, and the results of this survey may become an impetus to modify the list in the next edition of TPOG.

Perceived advantages and disadvantages of telepsychiatry - An online survey of psychiatrists in India

CONTEXT

Telepsychiatry is being practiced in India for many years but was formalized only in 2020. It has many advantages and disadvantages.

AIMS

This study aimed to understand the perceived advantages and disadvantages of telepsychiatry practices in India.

SETTINGS AND DESIGN

An online survey with ethics approval by the Indian Psychiatric Society (IPS) Ethics Review Board. All psychiatrists who are members of the IPS and whose email address was available with the society were sent the survey link by email.

METHODOLOGY

Information about existing telepsychiatry consultation practices in India and perception of advantages and disadvantages by the practitioners were collected between June and July 2020.

STATISTICAL ANALYSIS

Frequency, percentages, mean, and standard deviation were calculated.

RESULTS

Responses by 340 responders were analyzed. Majority of the responders felt that telepsychiatry would provide easy accessibility to mental health services (n = 283, 83.24%) and would lead to less exposure to infections (n = 222, 65.29%). Half of the responders (n = 177, 52.06%) felt that there would be an increased doctor shopping resulting in poor care and nearly three-fourth (n = 245, 72.06%) felt that mental health professionals would fall into a problem while dealing with a suicidal or a homicidal patient. Some expressed that the inability to do physical and central nervous system examinations could lead to missing out comorbidities. About one-third (n = 117, 36.56%) felt that the patient recording the consultation would be a legal issue.

CONCLUSIONS

This online survey showed that psychiatrists perceive many advantages and some disadvantages in practicing telepsychiatry.

Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India

Task-shifting is an important means to address the barrier of inadequate specialist human resources for mental health in countries such as India. This paper aims to report the impact of one such task-shifting initiative. Twenty-two non-specialist Medical Officers of Bihar, an eastern Indian state were engaged in a ten-month long hybrid (a 15-days onsite orientation to psychiatry and periodic online mentoring in primary care psychiatry) training program to enable them to identify commonly presenting psychiatric disorders in their respective clinics. 20 online sessions (hub and spoke ECHO model) occurred over the next 10 months. Apart from didactic topics, 75 cases covering severe mental disorders, common mental disorders and substance use disorders were discussed (case presentations by the primary care doctors (PCDs)) and moderated by a specialist psychiatrist and clinical psychologist). 12 successive self-reported monthly reports (comprising of the number and nature of psychiatric cases seen by the trainee PCDs) were analyzed. The mean (SD) number of sessions attended was 9 (8.0) and median was 13 (Range: 0-20). Mean number of cases (per PCD) discussed was 3.4 (3.4) (Median: 4; Range: 0-10). Total 20,909 patients were cared for in the 12 months after initiation of the training program. Increasingly, a greater number of patients were cared for as the training progressed. This pattern was mainly driven by more identifications of severe mental disorders (SMDs), common mental disorders (CMDs), dementias and substance use disorders. Mean (SD) number of patients seen per month before and after training was 1340.33 (86.73) and 1876.44 (236.51) (t =  - 3.5, p < 0.05) respectively. A hybrid model of training PCDs is feasible and can be effective in identification of persons with psychiatric disorders in the community. Prospective, well designed studies are essential to demonstrate the effectiveness of this model.

Video consultations from an Indian academic hospital: First 3 years of experience from telepsychiatric after-care clinic

Background Continuity of care for psychiatric disorders by conventional in-person consultation by psychiatrists is associated with several challenges. There is a need to develop alternative models of specialist care. We studied our 3 years' experience of live video consultations (VCs) from the tele after-care clinic to patients with psychiatric disorders at an Indian academic hospital. Methods We did a file review of 669 VCs provided to 213 patients in the first 3 years (2017-2019) from the telemedicine centre of a tertiary care academic hospital. We analysed details of sociodemography, clinical profile, tele after-care consultations and outcome. Results Two hundred and thirteen patients (55% men) were enrolled for the tele after-care clinic. The mean (SD) age of the patients was 42.2 (17.29) years and a majority were educated till high school and beyond. Patients with severe and common mental disorders constituted 60.1% and 40%, respectively. Among the total 669 appointments, 542 (81%) VCs were successfully provided; of the remaining, 125 were cancelled and 2 were aborted due to a medical emergency. Medication prescriptions were unchanged in 499 and modified/totally changed in 47 VCs. Conclusion Our large study shows that telepsychiatric after-care is a useful alternative method which can supplement in-person follow-up. Barriers such as distance, cost and medical illness can be overcome using tele after-care clinics for regular follow-ups in stabilized psychiatric patients. There is a need for prospective studies, preferably, randomized controlled trials comparing effectiveness of tele after-care with in-person consultations to assess treatment outcomes.

Virtual health care for adult patients with intellectual and developmental disabilities: A scoping review

Background

The COVID-19 pandemic led to an abrupt shift to virtual health care for many patients, including adults with intellectual and developmental disabilities (IDD). Approaches to virtual care that are successful for people without IDD may need to be adapted for adults with IDD.

Objective

The aim of this scoping review was to examine what is known about virtual health care for adults with IDD and in particular, the impact of virtual delivery on access to care for this population.

Methods

A comprehensive search was conducted of the academic and grey literature. A two-stage screening process was conducted by two independent reviewers and a structured data extraction template was populated for each included study. Findings were analyzed thematically using Access to Care Framework domains.

Results

In total, 22 studies met inclusion criteria. The majority were published in the past three years and focused on specialized IDD services. A subset of 12 studies reported findings on access to care for adults with IDD. Participants generally reported high acceptability of virtual care, though some preferred face-to-face encounters. Initial results on effectiveness were positive, though limited by small sample sizes. Challenges included internet quality and technical skill or comfort.

Conclusions

This review suggests that it is possible to deliver accessible, high quality virtual care for adults with IDD, however, relatively little research has been conducted on this topic. Due to COVID-19 there is currently a unique opportunity and urgency to learn when and for whom virtual care can be successful and how it can be supported.

Video teleconsultation services for persons with epilepsy during COVID-19 pandemic: An exploratory study from public tertiary care hospital in Southern India on feasibility, satisfaction, and effectiveness

PURPOSE

During the COVID-19 pandemic, there is a large unmet need for follow-up services, particularly for chronic diseases such as epilepsy. Alternative methods to reach these people have become necessary. We assessed the feasibility, satisfaction, and effectiveness of video teleconsultation using mobile phones for managing persons with epilepsy (PWEs) on follow-up at a tertiary care center in the southern part of India.

PATIENTS AND METHODS

We included PWEs aged 18 years and over who have been evaluated in person within the past six months, with details available in electronic health records (EHRs), and advised regular follow-up after getting telephonic consent. We excluded those requiring emergency care and those seeking teleconsultation for new symptoms. Participants were sent a message in English and in the local language about the possibility of a video teleconsultation. If willing, they were informed about the date, time, and technical requirements such as smartphones, browsing facilities, etc. Feasibility and effectiveness were assessed. Satisfaction/acceptability was assessed using Telemedicine Satisfaction Questionnaire.

RESULTS

From June 2020 to October 2020, we selected 336 PWEs after screening 1100 records, and we tried video teleconsultation in 141 (41.8%) PWEs. We achieved successful video connections in 95 (28.2%) and audio consultations in 46 (13.6%). The median duration for calling the participants, making successful connections, and consultation was 8 (5-14) min. The majority required two (47.4%) or three (32.6%) attempts. Sixty-five PWEs (68.4%) used caretaker's mobile phones. We gave prescriptions to all, and 18 received new drugs. Out of 95 PWEs, 90% either 'agreed' or 'strongly agreed' on 12 out of 14 telemedicine satisfaction questions.

CONCLUSION

Although we need to make video teleconsultation more feasible, our synchronous mobile video teleconsultation model is an effective and acceptable method to follow up PWEs. This real-time model has the advantage that it does not require any mobile application to be downloaded and installed. Further studies are needed to evaluate methods to improve the reach of these services particularly to vulnerable groups of the population.

A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center

Background

Neurology services in rural and semi-urban part of India are very limited, due to poor infrastructure, resources, and manpower. Tele-neurology consultations at a non-urban setup can be considered as an alternative and innovative approach and have been quite successful in developed countries. Therefore, an initiative to bridge this health gap through Tele-Medicine has been taken by the Government of India.

Aim

To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Neurology consultations from the Tele-Medicine Centre, National Institute of Mental Health and Neurosciences, Bengaluru.

Methodology

We reviewed case files of such patients between December 2010 and March 2017. A total 189 collaborative tele-neurology outpatient consultations were provided through the Tele-Medicine Centre, located at a tertiary hospital-based research centre in southern India.

Results

The mean age of the patients was 39.6 (±19) years and 65.6% were aged between 19 to 60 years; 50.8% were male. The most common diagnosis was a seizure disorder in 17.5%, followed by cerebrovascular accident/stroke in 14.8%. Interestingly, 87.3% were found to benefit from tele-neurology consultations using interventions such as a change of medications in 30.1%, referral to a specialist for review in 15.8%, and further evaluation of illness and inpatient care for 7.93%.

Conclusion

This study has demonstrated the successful implementation of outpatient-based collaborative tele neurology consultation in Karnataka.

Telemedicine practice guidelines of India, 2020: Implications and challenges

Telemedicine Guidelines of India, 2020 promises to pave a road map for regularization and diversification of teleconsultation services across the country. This guideline is the need of the hour, especially during the current coronavirus disease pandemic. All modes of communications (text, audio, video, etc.) between the service provider and user are included in the broad rubric of the guidelines. Scope, inclusions, exclusions, and restrictions are clearly specified in the guideline. Medications are grouped and listed for the specific type of consultation, and restricted drugs are notified. This guideline especially helps mitigate the gaps in legislation and reduces the uncertainty while providing a practical, safe, and cost-effective framework to improve healthcare service delivery in this article; the authors discuss the implications of this new guideline and the challenges during the implementation of teleconsultation services across the country.

Setting Up and Providing Telepsychiatry Services in India

The exponential growth of technology in the past few decades has benefitted the healthcare sector. Telemedicine is a newer advancement which is making healthcare affordable and more accessible to the needy in recent times. This article discusses how to set up telepsychiatry services, the procedure of telepsychiatry consultation, how to record and maintain the electronic health records, the potential challenges, ethical and legal aspects concerning telepsychiatry while ensuring the good practice guidelines, medical ethics, patient rights, and the minimum requirements as established by the Information Technology Act and the telemedicine practice guidelines (TPG) 2020 issued by the Indian Medical Council.

Geriatric Telepsychiatry: Promoting Access to Geriatric Mental Health Care Beyond the Physical Barriers

Psychiatric illnesses are an important contributor of morbidity and mortality in older adults. There is increase in older adults with psychiatric disorders paralleling their growth in absolute numbers. This leads to challenges in mental health care and service delivery. Several barriers that exists in our community hinder older adults from receiving mental health care. Additionally, lack of adequate human resources in geriatric mental health care compounds the problem. Telemedicine, though not new in other fields of medicine, is relatively new in the practice of psychiatry in India. This is probably due to lack of clear guidelines and regulations regarding the same in India. There is a recent increase in teleconsultations in India similar to other developed countries due to ongoing COVID-19 pandemic. The recent telepsychiatry operational guidelines have made telepsychiatry a legitimate and official practice in India. Challenges specific to older adults in the form of low digital literacy, sensory issues, and cognitive impairment can be overcome by adopting telepsychiatry services in coming years. Concerns related to security and safety of telepsychiatry require further evaluation.

Ethical and Legal Aspects of Telepsychiatry

Ethical and legal frameworks are essential components in mental health care, due to inherent nature of illnesses and practice modules. These serve to safeguard rights and privileges of patients and mental health professional. Gradual evolution of technology and its' application in assessments and interventions is making it as an essential part of mental health care delivery. This transition will bring innovative challenges for mental health care delivery in terms of practice, ethical and legal aspects. Existing ethical and legal frameworks are time tested for real time/face to face delivery of mental health care. Ongoing pandemic provided opportunity and necessitated use of technology for delivering health care needs. Newer operational and practice guidelines have emerged for practice of telemedicine in general and telepsychiatry in specific. These are in lines with existing ethical and legal frameworks. However, additional frameworks with specific definitions about what constitutes consultation, assessment methods, prescription modes and contents of prescription, documentation, certification, eligible platforms for telepsychiatry, need to be incorporated and observed. The article addresses these ethical and legal aspects in telepsychiatry practice with the background of existing practice guidelines and rules.

Evolution of Community Telepsychiatry in India Showcasing the SCARF Model

This review chronicles the origin of telepsychiatry services started by the Schizophrenia Research Foundation (SCARF) in the community and traces the birth of the Scarf Telepsychiatry in Pudukkottai (STEP) program at Pudukkottai in Tamil Nadu. This paper also examines the trajectory of STEP and highlights other relevant models existing in the country in the last decade.

Tele-mental health during the coronavirus disease 2019 (COVID-19) pandemic

This editorial highlights the origin of telemedicine in India, and discusses the present and explores the possibilities in the future in the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic.

Tele-psychiatric after care clinic for the continuity of care: A pilot study from an academic hospital

BACKGROUND

There is a need of continuity of care research in psychiatric disorders to deal two important issues such as accessibility of psychiatrists, and travel.

AIMS

This pilot was designed to evaluate the acceptability, feasibility, possible clinical effectiveness and cost benefit of video based tele-psychiatric aftercare (TAC) clinic from an academic hospital.

METHODS

Fifty selected patients were recruited to provide direct video-consultations (DVC).

RESULTS

This study shows higher score on acceptability, satisfaction and respect to privacy on these TAC.

DISCUSSION AND CONCLUSIONS

This is first pilot study as one of the patient friendly and less expensive continuity of care.

Symposium summary on "Community Psychiatry and DMHP-An update"

This summary provides details of a one-day symposium, titled 'Community Psychiatry and District Mental Health Program (DMHP)- An update' that was organized jointly by the Departments of Psychiatry and Epidemiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru in collaboration with the Department of Health and Family Welfare, Government of Karnataka on September 3rd 2018. This symposium was supported by Dr. Ramachandra N Moorthy, foundation for Mental Health and Neurological Sciences, NIMHANS, Bengaluru.