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. Copyright:

INTRODUCTION

Telemedicine is not new to India. The Indian Space Research Organization had initiated Telemedicine Pilot Project in 2001, which was embraced by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, in 2005,[1] and the Schizophrenia Research Foundation by 2008.[2] Over the years, telepsychiatry services have also expanded in many other institutes. Telepsychiatry services are provided both synchronously with hub and spoke model,[34] telepsychiatric on-consultation training model,[56] tele-after-care model,[78] and asynchronously in India. However, before the COVID-19 pandemic, there was lack of legal backing for the practice of telepsychiatry.[910]

Telemedicine Practice Guidelines (TMPG) were released by the Government of India on March 25, 2020[11] that provided ethical and legal background to telepractice in India. However, one should remember that it is part of the Medical Council of India regulations, not an act or rules. The Indian Psychiatric Society (IPS) and Telemedicine Society of India with NIMHANS were the first professional bodies to bring out Telepsychiatry Operational Guidelines (TPOG) on May 26, 2020.[12]

The guidelines have been received by the fraternity with a mixture of apprehension to practice telepsychiatry, relief to have a guiding document, and dissatisfaction on the list of drugs provided in Lists O, A, B, and C. Some feel that there should be no first telepsychiatry consultation and hence List A is not needed, while others feel that it is beneficial to have first telepsychiatry consultation and List A is unduly restrictive. This was noted in the comments, question and answer session of the online program held to update the IPS members on the guidelines, and personal communications of psychiatrists across the country with the authors.

List O contains over-the-counter drugs. List A contains list of psychotropic drugs as listed under Essential Drug List under subsection 10 of Section 18 of the Mental Health Care Act, 2017, notified as per letter F. No. V. 15012/04/2019-PH-I dated August 16, 2019.[13] List C contains prohibited drugs under Schedule X of Drugs and Cosmetics Act, 1940 and Rules, 1945 and narcotics and psychotropic substances listed in the Narcotic Drugs and Psychotropic Substances Act, 1985. List B contains rest of the psychotropic drugs.

Except for the fact that some of the medications which were deemed to be essential under the law were included in the List A, there is no other logical way in which the list can be formulated. The authors are aware, by their personal experience in the practice of psychiatry, that there are many medications which have equal effectiveness and cost, which are not included in List A at present. Many psychiatrists have raised the issues of having a consensus in the formulation of List A. Hence, it has become imperative to collect the data on the medications that most psychiatrists feel that they should be present in List A, if there is a logical reasoning behind the selection. This list would at least serve as Level-5 evidence when we strive to reach higher levels. In this background, this survey aimed to draw consensus on the medications that can be listed in Lists O, A, B, and C in TPOG-2020 and understand the current telepractices in India.

In this paper, we discuss the consensus on lists of medications in TPOG, 2020.

METHODOLOGY

This was online survey, conducted using SurveyMonkey platform.

The survey was granted ethics approval by the IPS Ethics Review Board instituted by Research, Education and Training Subcommittee of IPS.

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. The data collected were anonymized before analysis.

Assessment tools included opinions on Lists O, A, B, and C of TPOG-2020 (whether the respondents agree with the sufficiency of the medications listed in the Lists O, A, B, and C), suggestions on Lists O, A, B, and C of TPOG-2020 (what medications are to be added to the Lists O, A, B, and C), reasons for the suggestions, and sociodemographic details (age, gender, years of practice, type of practice – teaching hospital and private practice, type of telepsychiatry practice – informal and formal, and years of informal and formal telepsychiatry practice).

The participants were sent the survey link and the cover letter provided the outline of the purpose of the survey and stated that, participation in the survey implied consent.

Statistical analysis

The data were analyzed using the PSPP (not an acronym).[14] Frequency, percentages, mean, and standard deviation (SD) were calculated. Independent t-test was performed to see the influence of age, years of practice, and years of informal and formal telepsychiatry practice. Chi-square was performed to see the influence of gender, type of practice, and type of telepsychiatry practice.

RESULTS

The survey was sent to 6383 E-mails, of which 324 eligible participants opted out and 878 E-mails bounced back. Accordingly, out of the 5181 valid E-mails addresses, 354 psychiatrists responded, making a response rate of 6.83%.

Out of these 354 responses, 13 did not provide consent and one was not a clinician. The responses from the rest 340 responders were analyzed. The responders had a mean of 17.37 years of clinical experience (SD 12.2), 286 (84.4%) of the responders were practicing teleconsultation informally for 4.96 years (SD 7.81), and 246 (73.2%) of them were practicing teleconsultation formally for 1.65 years (SD 4.75). The responders were from both teaching hospitals (n = 171, 51%) and private practice (n = 164, 49%).

Majority of the responders agreed that List O (277, 85.5%), List A (162, 50.3%), List B (263, 82.4%), and List C (223, 69%) are apt [Table 1].

Table 1

Sufficiency of the medications in the lists that can be prescribed in telepsychiatry

Lists	Sufficient, n (%)	Not sufficient, n (%)	Others/not decided, n (%)
List O*	277 (85.5)	35 (10.8)	12 (3.7)
List A**	162 (50.3)	145 (45)	15 (4.7)
List B#	263 (82.4)	46 (14.4)	10 (3.1)
List C##	223 (69)	82 (25.4)	18 (5.6)

*16 persons did not respond; **18 persons did not respond; #21 persons did not respond; ##17 persons did not respond

Forty-eight participants disagreed with the number of medications available in the List A and suggested additions to the list [Table 2].

Table 2

Opinions on additions to list A

Opinions	Number of respondents
All medications should be available in list A, without any justification	15
Methylphenidate should be added to list A	10
Injectable antipsychotics should be made available in list A	3
Named the drugs without providing the reasoning	5
Did not answer the question appropriately	2
Other justifications	13
The moral and ethical responsibility should be on the practitioner as telepsychiatry consultation is equal to in-person consultation legally in all the other aspects
Newer medications with equal or better efficacy with better side effect profile can be added
The medications that can be used in special populations like elderly, pregnancy and lactating women can be added

Age, years of practice, years of informal telepsychiatry practice, and years of formal telepsychiatry practice, measured by independent t-test, did not have a significant variation on concurrence of Lists O, A, B, and C. Gender, type of practice (teaching hospital and private practice), and type of telepsychiatry practice (informal and formal), measured by Chi-square test, also did not have difference on concurrence of Lists O, A, B, and C. The details of these tests are provided in the supplementary material [Tables 3 and 4].

Table 3

Influence of age, years of practice, and years of telepsychiatry practice on the concurrence of the lists

Variables	List O			List A			List B			List C
	n	Mean (SD)	T (df), S	n	Mean (SD)	T (df), S	n	Mean (SD)	T (df), S	n	Mean (SD)	T (df), S
Age
Agreed	271	44.44 (12.13)	1.088 (304), 0.278	160	43.21 (12.29)	−1.495 (299), 0.136	259	43.98 (12.33)	−0.814 (301), 0.417	218	44.07 (12.20)	−0.648 (297), 0.517
Not agreed	35	42.06 (12.83)		141	45.34 (12.36)		44	45.64 (13.16)		81	45.12 (13.10)
Years of practice
Agreed	272	17.59 (12.10)	0.996 (305), 0.320	160	16.57 (12.23)	−1.283 (300), 0.200	260	17.03 (12.13)	−1.127 (302), 0.261	219	17.22 (12.04)	−0.865 (298), 0.388
Not agreed	35	15.43 (12.26)		142	18.37 (12.07)		44	19.29 (13.31)		81	18.60 (12.89)
Years of formal telepsychiatry practice
Agreed	242	1.56 (4.64)	−0.999 (274), 0.319	143	1.57 (4.90)	−0.731 (269), 0.466	240	1.75 (5.21)	0.403 (273), 0.687	199	1.83 (4.91)	0.573 (267), 0.567
Not agreed	34	2.46 (6.52)		128	2.01 (5.06)		35	1.39 (2.31)		70	1.43 (5.19)
Years of informal telepsychiatry practice
Agreed	267	4.77 (7.95)	−0.698 (300), 0.485	156	4.43 (7.99)	−1.193 (295), 0.234	254	4.69 (7.72)	−1.170 (297), 0.243	215	4.56 (7.29)	−1.608 (293), 0.109
Not agreed	35	5.76 (7.95)		141	5.54 (7.97)		45	6.19 (8.93)		80	6.25 (9.75)

The total number would vary as the options “others” and “not answered” were not considered for calculations. SD – Standard deviation; S – Significance

Table 4

Influence of gender, type of practice, and type of telepsychiatry practice on the concurrence of the lists

Variables	List O			List A			List B			List C
	Agreed (expected)	Not agreed (expected)	χ2 (S)	Agreed (expected)	Not agreed (expected)	χ2 (S)	Agreed (expected)	Not agreed (expected)	χ2 (S)	Agreed (expected)	Not agreed (expected)	χ2 (S)
Gender
Male	201 (201.2)	25 (25.4)	1.545 (0.956)	115 (117.7)	109 (105.3)	1.394 (0.845)	190 (191.1)	32 (33.4)	2.203 (0.699)	158 (162.0)	61 (59.6)	1.763 (0.779)
Female	73 (73.3)	10 (9.3)		45 (42.9)	35 (38.4)		71 (69.6)	13 (12.2)		63 (59.0)	20 (21.7)
Type of practice
Teaching hospital	136 (139.3)	17 (17.6)	4.797 (0.570)	86 (81.5)	62 (72.9)	9.124 (0.058)	133 (132.3)	21 (23.1)	1.158 (0.885)	112 (112.2)	41 (41.2)	0.728 (0.948)
Private practice	137 (133.6)	17 (16.9)		74 (78.1)	80 (69.9)		126 (126.9)	24 (22.2)		107 (107.6)	40 (39.6)
Formal telepsychiatry practice
Practicing	195 (200.4)	27 (25.3)	4.283 (0.638)	115 (117.2)	110 (104.9)	3.158 (0.532)	197 (190.3)	26 (33.3)	9.328 (0.053)	166 (161.3)	55 (59.3)	2.576 (0.631)
Not practicing	78 (73.3)	8 (9.3)		45 (42.9)	33 (38.4)		63 (69.6)	20 (12.2)		55 (59.0)	26 (21.7)
Informal telepsychiatry practice
Practicing	234 (233.0)	27 (29.4)	2.259 (0.894)	131 (136.3)	126 (122.0)	3.212 (0.523)	218 (221.2)	43 (38.7)	3.791 (0.435)	190 (187.6)	65 (69.0)	4.777 (0.311)
Not practicing	42 (43.2)	8 (5.5)		30 (25.3)	19 (22.6)		44 (41.0)	3 (7.2)		33 (34.8)	16 (12.8)

The total number would vary as the options “others” and “not answered” were not considered for calculations. S – Significance

DISCUSSION

Initially, when the task of classification befell upon the authors of TPOG 2020, there were two approaches that were available for the classification of the psychotropic medications into Lists A and B, including the first-line medications for various disorders or to include essential drugs in List A and all the others in List B. Both had their pros and cons.[15] After careful deliberation, the latter approach was followed to populate the lists.

The benefits of following this approach are as follows:

• The categories are easy and simple[15]

It provides a clear idea on which medications can be prescribed in the first consultation and which to be prescribed in the follow-up consultation[15]

Prevents indiscriminate prescription of medications by the registered medical practitioners[15]

Provides a legal safety net for the prescriber[15]

Prevents doctor shopping. Since it is easy for the patient to approach any doctor in the country for the prescription of medications, they may use this opportunity indiscriminately and consult multiple doctors, let alone psychiatrists, online. When all the medications available in the market are included in List A, the prescription will obviously differ from one doctor to another and lead to confusion among the patients and may increase litigations. Whereas when a particular list is available for the first consultation, all the doctors would have to prescribe from the same list, avoiding doctor shopping to a large extent. One may argue that the same is applicable to in-person consultations, but one has to be cognizant that it is difficult to consult many doctors to take opinions due to distance and travel in in-person consultations, and it is easy to take multiple consultations sitting at the comfort of one’s home. This list provides a balance between patients’ choices and indiscriminate use of it.

However, when the TPOG 2020 was released, many psychiatrists opined that the lists were too rigid and artificial. And hence, this online survey was conducted to collect opinions on the lists proposed by TMPG 2020 and TPOG 2020 and to gather evidence to modify the lists, if needed.

In the present survey, majority of the participants were satisfied with List O and List B; about two-third of the psychiatrists were also satisfied with the List C. However, only half the responders (50.3%) agreed to the List A. The ones who did not agree to the list did not provide a valid argument to consider other medications to be added to List A. The responders’ opinion on the lists of medications was not influenced by the demographics of the responders.

The lists could be revised from time to time based on the consensus of the IPS and the notifications by the governing bodies overseeing the medical practice in India. With the current results of the survey, it has become evident that although the majority agree with Lists O, B, and C, half the participants do not agree with List A citing many reasons. This can become an impetus to modify the list in the next edition of TPOG.

This survey has a few limitations, which must be kept in mind. The response rate to the survey was low, and hence, the findings cannot be generalized as opinion of all the psychiatrists in India.

CONCLUSIONS

TMPG, 2020 and TPOG, 2020 may become game changers in the way consultations are done in India. The guidelines have been received by the fraternity with a mixture of apprehension, relief, and dissatisfaction on the lists of medications included in the Lists O, A, B, and C. This online survey showed that majority of the responders agreed to the Lists O, B, and C, but not with List A. The approach taken to include the medications in list A, i.e., to include the essential drugs, has various benefits. However, the lists are not final and has a scope for modifications in the future. The results of this survey may become an impetus to modify the list in the next edition of TPOG.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.