Digitally driven primary care psychiatry program is impactful in real-world scenario.

Sir,

We thank for the opportunity to respond (author/s)[1] on our work (2020).[2] Thanks for compliments on the public health module of the Diploma in Primary Care Psychiatry (DPCP) and to bring our notice about the missing information about translational quotient (TQ) assessment method. It may also be noted that DPCP offers the flexibility to customize the optional modules (of opioids and cannabis) for individual Primary Care Doctors (PCDs).[34]

We disagree that the title misleads as a system-wide intervention. We believe that title is a straightforward covering the impact of the training. Yes, it is possible for some readers to get mislead if they read only the title, but the majority will at the least read abstract.

It is clearly stated in the methodology section that it is a naturalistic study representing a real-world scenario where the scope of selection of doctors by authors is minimal. We, too, agree that deputed government may have selected doctors based on their interest in psychiatric care. The paradox may also be true that some doctors may not be interested in psychiatry but forced upon by deputation.

Authors comments on “observation of active participation and involvement of PCDs,” we believe that it is attributable to the impact of direct skill transfer accrued from Tele-psychiatric On-Consultation Training (Tele-OCT) modules where doctors exposed to reality check of their regular own clinical practice of many years.

The prevalence of common mental disorders in Nambi et al.[5] is based on pure research using research instruments. Please note that there is a glaring lack of prevalence data on psychosis, alcohol, and tobacco disorders at primary care of India. In this background, the Primary Care Psychiatry Quotient (PCPQ) was fixed at 30% based on the consensus of the team members. It is puzzling to see the recalculation of 3.8% of PCPQ by authors. It would be revealing if the authors explained their recalculation method.

Even we accept 3.8% figure, it is a good beginning in the public healthcare system in India. To gain further insight in this issue, we refined PCPQ as total and differential. The published data are the total PCPQ. The differential PCPQ is the proportion of individual psychiatric disorders seen to total psychiatric caseness.[6] We need systematic studies to calculate the more meaningful differential PCPQ.

TQ was assessed among the ten consecutive general patients for each PCD.[7] We agree with the author's expression that direct in-person evaluation may be better than Tele-OCT evaluation. However, Tele-evaluation was chosen as convenient and feasible to save resources. We disagree that we have not claimed its as online. We have used two synonyms to denote the “online” nature in “Tele-” prefix of “Tele-OCT evaluation” done by “Tele-psychiatrists.”

Tele-OCT evaluation conducted in a semi-structured 5-point Likert scale by evaluator-telepsychiatrists having the first-hand experience of primary care psychiatry, not by any random psychiatrist. We acknowledge that we have not done any formal inter-rater reliability of evaluators.

The bias of PCDs toward psychiatric diagnosis is abysmally low since Tele-OCT evaluation is done among ten consecutive general patients which ruled out the possibility of selection bias of patients.

We agree that there is a theoretical possibility of the Hawthrone effect. But in reality, Tele-OCT evaluator/telepsychiatrists had an opportunity to cross-check the diagnosis made by PCDs in live consultation. If PCDs overdiagnose, it naturally invites the negative score by evaluator. We disagree that the stability of TQ scores at 6 and 9 months is NOT because of biased evaluation or ineffective training. We believe it is suggestive of the robustness of Tele-OCT. As per the approved curriculum, all PCDs complete their three Tele-OCT sessions within the first 3 months of the course. In our understanding, TQ is more a reflection of Tele-OCT than other modules of DPCP. The sustained TQ scores reflect the sustained gain at 6 and 9 months of the Tele-OCT module, a desirable and influential outcome.

We attempt to simplify result that imagine each PCD is providing four psychiatric consultations per day amounting 1200 psychiatric consultations/year assuming 300 functional days/year. For 10 PCDs, it translates to 12,000 psychiatric consultations. We could imagine the positive impacts with these numbers on other outcome parameters including disability, cost-effectiveness, and savings of time.

To conclude, the results of our study are to be seen from optimistic and pragmatic points of view, not from the idealistic point of view, keeping in view of our resource constraint country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.