Telepsychiatry during COVID-19 - A brief survey on attitudes of psychiatrists in India.

Sir,

Worldwide more than 10-million people are confirmed to have Coronavirus disease (COVID-19) while the pandemic continues to progress rapidly (Coronavirus Update (Live), 2020). Management of COVID-19 cases remains the focus of health-care facilities. But, we cannot discount the psychological devastation caused by the pandemic. ”At-risk” individuals are likely to face serious psychological consequences of COVID-19 (Das, 2020; Vindegaard and Benros, 2020). Psychiatrist and other mental health professionals need to step-up to provide psychological support and due mental health care (Das et al., 2020; Tandon, 2020). Telepsychiatry can be useful in that aspect during COVID-19 (Corruble, 2020; Grover et al., 2020a). In low and middle-income (LAMI) countries like India, where the number of mental health professionals is already very low, the role of telepsychiatry can prove to be the right fit (Grover et al., 2020b; Singh, 2018).

Telepsychiatry services can serve in many ways, such as –

creating general awareness and providing the right health information to reduce the panic and wide-spread stigma in society,

promoting the ways of endorsing a healthy lifestyle, practising relaxation exercises to deal with the stress during COVID-19,

providing online psychological support and trauma preparedness training to at-risk individuals to reduce the hazard of long-term psychological adversities,

addressing the psychological issues of special populations like women, elderly, students, healthcare workers, soldiers and sportspersons,(v)‘tele-triaging’ of cases to provide care according to the nature of an emergency and the site of referral (tertiary care vs local facilities),

continuing psychiatric follow-up services to already registered patients without any need to visit hospital in-person (thus not further increasing the risk of COVID-19 transmission). This is essentially needed because the added stress of COVID-19 may worsen the pre-existing mental illness,

offering crisis-intervention and positive mental health promotion in the aftermath of the pandemic.

Despite many positives, the popularity of telepsychiatry in LAMI countries, in general, remained low, for reasons like lack of awareness, poor accessibility, and negative attitude of patients and treatment providers (Chellaiyan et al., 2019; Naskar et al., 2017). Unlike India, most resource affluent countries like China, United States and Australia have well-established nationwide telepsychiatry settings and, they have actively used this platform amid COVID-19 outbreak to deliver mental healthcare services (Kavoor et al., 2020; Li et al., 2020).

In 25th March 2020, the Government of India has acknowledged the need for telemedicine services in the country and has published a national guideline for the same (MoHFW, 2020). It was therefore interesting to find out the attitudes of Indian psychiatrists towards telepsychiatry during COVID-19. We prepared a 25-item semi-structured questionnaire using google form and was circulated among the psychiatrists across India using Email, WhatsApp, Facebook, LinkedIn and other social media applications via snow-ball sampling technique. The data collection was done from 12th April 2020 to 5th May 2020. All questions were in simple English language. The questionnaire was consisting of four parts: ‘Consent form’, ‘Socio-demographic details’, ‘Positive aspects of telepsychiatry’ and ‘Negative aspects of telepsychiatry’.

A total of 105 responses were obtained in the stipulated time. The final analysis was done on 102 completed responses (two responders did not give consent and one response was incomplete, and thus not included in the analysis). Mean age of the responders was 30.8 (±4.1) years with predominantly male (60 %), postgraduate (57 %), resident doctors (67 %). Almost half of them were from Delhi (49 %) and more than 86 % had prior experience of teleconsultation in some form. Voice call was the commonest mode of teleconsultation (Table 1 ).

Table 1

Summary of the survey (N = 102).

Parameters	Numbers (%) or Mean (SD)
Age (year)	30.8 (±4.1)
Gender
Male	62 (60.8)
Female	40 (39.2)
Academic degree
MBBS	36 (34.6)
MD	60 (57.7)
DNB	2 (1.9)
DM (Addiction, Child and adolescent psychiatry etc.)	4 (3.8)
Position
Resident doctor	70 (67.3)
Consultant	32 (30.8)
Affiliation
Tertiary care centre	74 (72.5)
Others	28 (27.5)
State/Union territory
Delhi	50 (49)
Others	52 (51)
If you had any experience of teleconsultation in past?
Yes	88 (86.3)
No	14 (13.7)*
If you kept a record of your consultation?
Yes	28 (27.5)
No	60 (58.8)
NA	14 (13.7)*
Mode of teleconsultation (several responders used multiple modes of teleconsultation)
Voice call	79 (77.5)
Video call	28 (26.4)
Messaging	52 (51.0)
Email	16 (15.7)
Established telepsychiatry set-up	8 (7.8)
NA	14 (13.7)*
How easy was it to understand patients problem over teleconsultation?
Not at all easy	2 (2.0)
Slightly easy	4 (3.9)
A bit easy	44 (43.1)
Moderately easy	34 (33.3)
Very easy	4 (3.9)
NA	14 (13.7)*
How difficult was it to share prescription with your patient?
Not at all difficult	12 (11.8)
Slightly difficult	6 (5.9)
A bit difficult	26 (25.5)
Moderately difficult	36 (35.3)
Very difficult	8 (7.8)
NA	14 (13.7)*
How likely would you recommend telepsychiatry, based on your experience? (n = 88)
Very unlikely	1 (1.1)
Unlikely	13 (14.8)
Neutral	24 (27.3)
Likely	38 (43.2)
Very likely	12 (13.6)
Do you believe telepsychiatry has any positives?
Yes, many	64 (62.7)
Yes, few	28 (27.5)
Maybe, not sure	10 (9.8)
None	–
Telepsychiatry will be able to provide quality mental healthcare to the far-reaching areas of the country
Strongly disagree	–
Disagree	14 (13.7)
Neutral	8 (7.8)
Agree	36 (35.3)
Strongly agree	44 (43.1)
Telepsychiatry will be able to reduce the overall cost of public health delivery
Strongly disagree	2 (2.0)
Disagree	8 (7.8)
Neutral	22 (21.6)
Agree	30 (29.4)
Strongly agree	40 (39.2)
Adequate implementation of telepsychiatry will reduce the waiting time of the patients
Strongly disagree	2 (2.0)
Disagree	4 (3.9)
Neutral	12 (11.8)
Agree	38 (37.3)
Strongly agree	46 (45.1)
Follow-up and refilling of medications will be easier with telepsychiatry services
Strongly disagree	2 (2.0)
Disagree	14 (13.7)
Neutral	16 (15.7)
Agree	40 (39.2)
Strongly agree	30 (29.4)
Do you believe telepsychiatry has any negatives?
Yes, many	14 (13.7)
Yes, few	76 (74.5)
Maybe, not sure	12 (11.8)
None	–
Lack of in-person contact will cost the doctor-patient relationship and the trust
Strongly disagree	4 (3.9)
Disagree	12 (11.8)
Neutral	20 (19.6)
Agree	46 (45.1)
Strongly agree	20 (19.6)
The digital record keeping will make patients' personal information more vulnerable to get stolen, pirated or hacked
Strongly disagree	6 (5.9)
Disagree	14 (13.7)
Neutral	24 (23.5)
Agree	38 (37.3)
Strongly agree	20 (19.6)
Absence of general and systemic examination would hinder clinical decision making
Strongly disagree	–
Disagree	6 (5.9)
Neutral	10 (9.8)
Agree	44 (43.1)
Strongly agree	42 (41.2)
Telepsychiatry will NOT replace the current pattern of patient care in the next 5 years
Strongly disagree	1 (1.0)
Disagree	13 (12.8)
Neutral	24 (23.5)
Agree	34 (33.3)
Strongly agree	30 (29.4)

DNB: Diplomat of National Board, NA: Not applicable.

Most responders believed that there are ‘’many’’ positive aspects of telepsychiatry (63 %), and were more likely to endorse the same to their colleagues. Most responders agreed that telepsychiatry will help catering mental healthcare in far-reaching parts of the country (78 %), it will reduce the cost of public health delivery (68 %), it will reduce the patients waiting time (82 %) and thus it will make the psychiatric follow-up services more convenient (68 %) both for the patients and the providers. Many responders agreed on several shortcomings of telepsychiatry, such as – (a) poor doctor-patient relationship (64 %), which can be very important in the field of psychiatry where empathy plays a significant role in healing; (b) risk of cyber theft (57 %), as sensitive personal details leak may pose a higher risk to the clients’ mental health and (c) inability to perform physical examination (84 %) can lead to misdiagnosis or missing a co-morbid illness. Because of these negatives combined with poor awareness, even now, after this COVID-19, rapid acceptance of telepsychiatry is unlikely. Maybe because of that, 62 % of the responders believed telepsychiatry will not be the primary modality of mental health delivery in recent future.

This survey has many shortcomings, such as small sample size, usage of a semi-structured questionnaire, and many resident doctors (post-graduate trainee and post-degree working residents) and therefore generalisability of the findings will be limited. Nonetheless, this survey provides the much-needed insight about the attitudes of psychiatrists from a low-resource setting, towards the usage of telepsychiatry in the era of COVID-19.

To conclude, telepsychiatry has many positives. Usage of digital media for public health delivery can be a game-changer for LAMI countries like India. COVID-19 increases the risk of mental health-related burden, but also provides scope for telepsychiatry to flourish as a model of service delivery in the coming future. Many young psychiatrists hold a positive attitude towards telepsychiatry, which can be considered as an optimistic sign for the future.

Ethical statement

This is a web based survey on doctors opinion about telepsychiatry during COVID-19. No personally sensitive questions were asked and no invasive procedure was done during the study. All informants provided informed consent in the digital data collection form (google form). Participants had a free choice to make changes or remove their submission at any point during the data collection time. All records were kept confidential. This study fulfills the criteria of Helsinki Declaration.

Funding

None.

Declaration of Competing Interest

None.