Telepsychiatry in the Arabian Gulf region - Implications beyond the Covid-19 pandemic.

Coronavirus Disease 2019 (Covid-19) was declared as a public health emergency by the World Health Organization in March 2020 (WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020, n.d.). The State of Qatar confirmed its first positive case on 29thFebruary 2020, and by June we had the highest infection rate per million population (COVID19 Home, n.d.). This public health emergency prompted large-scale lockdown and home confinement to limit the spread of infection. The Ministry of Public Health in Qatar advised minimizing direct contact with patients for non-urgent care. These restrictions had a huge impact on provision of psychiatric services. As the pandemic was evolving, it became clear that mitigation strategies need to be put in place, and in March 2020, telepsychiatry services were introduced. These services used telephone or videoconferencing to limit face-to-face interaction in the delivery of outpatient psychiatric services. We analyzed the data on the number of new and follow-up cases and the rate of non-engagement (no-show rate) in the mental health outpatient setting in the four months following the introduction of telepsychiatry, and found that the total number of individuals accessing mental health services between March and June of 2020 increased by approximately 36.5 % compared to the same period in 2019, with a similar pattern following differential analysis of new and follow-up cases. In addition, a trend towards higher rate of engagement (less percentage of no-shows) was also observed when comparing the corresponding time periods. No discernible differences were found following gender stratification (Table1 ). Of note, the total population of Qatar is about2.79 million as of June 2020, compared to 2.63 million in June 2019, indicating that the significant rise in demand on mental health services was most likely due to COVID-related distress than would be expected from population growth alone (Monthly Figures on Total Population, n.d.).

Table 1

New and follow-up cases seen, and proportion of missed appointments between March and June of 2019 and 2020.

		Year	March		April		May		June
			Male	Female	Male	Female	Male	Female	Male	Female
New Cases Seen		2019	278	280	268	262	216	223	150	142
		2020	352	419	345	366	231	215	429	381
Follow-up Cases Seen		2019	1988	1860	1989	2080	1789	1720	1442	1488
		2020	2482	2333	2558	2510	1986	1850	2841	2788
Total Seen		2019	16,175
		2020	22,086
New Cases No Show		2019	33 %	37 %	30 %	36 %	35 %	37 %	42 %	43 %
		2020	34 %	29 %	17 %	16 %	17 %	15 %	8 %	11 %
Follow-up Cases No Show		2019	17 %	18 %	19 %	17 %	22 %	21 %	19 %	21 %
		2020	19 %	21 %	10 %	11 %	10 %	10 %	7 %	8 %

Qatar has a predominantly state-funded mental healthcare system (Saeed et al., 2020). Lack of engagement at psychiatry outpatient clinics stands as a crucial barrier to effective mental health care delivery and leads to waste of important resources. In 2019, the total psychiatric appointment default rate at HMC was 22 %, comparable to internationally reported figures (Adelufosi et al., 2013; Hull et al., 2002; Pang et al., 1995). The initial results of using telepsychiatry in Qatar are indeed promising, encouraging us to consider its implementation as an additional component of a mental health delivery system even after the pandemic. This is particularly important given the anticipated increase in demand on mental health services post pandemic, dearth of trained mental health professionals and reluctance of families to engage with mental health services due to stigma (Kehyayan et al., 2020). Telepsychiatry services have been implemented in many countries even before the pandemic and are shown to be clinically effective delivery methods of mental health services that enhance access to care (Hubley et al., 2016). However, given the wide disparity of this region’s sociocultural milieu in comparison to other countries where it has been assessed, it is paramount that the use of telepsychiatry in this region is evaluated for its feasibility, acceptability and effectiveness. In addition, the establishment of stringent governance mechanisms is necessary to ensure the protection of patient autonomy, confidentiality, and privacy. This is in keeping with the recommendation by the editorial of this journal (Tandon, 2020), which advocates service changes to be based on data to address the short and long-term impact of the continuing COVID-19 pandemic.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics consideration

Permission was granted to publish this anonymized aggregate data from hospital directors of the corresponding mental health services. No patient records were accessed, and hence IRB approval was not required.

Author contributions

All authors contributed to the conception, analysis and drafting of this letter.

Declaration of Competing Interest

The authors reported no declarations of interest.