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. Copyright:

INTRODUCTION

Digital technology plays a large role in modern society. Assisting in day-to-day activities and communication to advanced research digital technology has its imprint on all aspects of our lives and the society has equally embraced it. Although advances in technology have not been translated into health care delivery, especially in the field of mental health, there has been a slow but steady movement toward the utilization of technology.[1] Consultations using technology and telemedicine were initiated in the early 2000s by the Indian Space Research Organization, National Institute of Mental Health And Neuro Sciences (NIMHANS)[2] and Schizophrenia Research Foundation (SCARF)[3] and many other institutes have taken up the same over the years. Telepsychiatry services are currently provided asynchronously as well as synchronously, i.e., tele-aftercare model,[456] on-consultation training model,[78] hub and spoke model[910], and collaborative model[11] to name a few.

Lack of legal backing was a major hindrance in practicing telepsychiatry before the Corona Virus Disease – 2019 (COVID-19),[1213] which was mitigated by the Telemedicine Practice Guidelines[14] and the Telepsychiatry Operational Guidelines.[15]

It is also important to understand the experience of the mental health professionals in providing telepsychiatry services. An understanding of the experience of the mental health professionals can help in refining the guidelines and also possibly help those already running the services or planning to start the telepsychiatry services. In this background, this survey aimed to understand the current telepsychiatry practices in India.

METHODOLOGY

Survey Monkey Platform was used to conduct this online survey.

Ethics approval was granted by the Indian Psychiatric Society (IPS) Ethics Review Board instituted by the Research, Education and Training sub-Committee of IPS.

All members of the Indian Psychiatric Society (psychiatrists) whose email address was available with the society were sent the survey link by email. The survey was conducted in June-July 2020. The data collected were anonymized before analysis.

Assessment tools, a semi-structured online proforma developed by the researchers, included demographic details of the respondents (age, gender, years of clinical experience, whether they are from teaching hospitals or private practice), information about existing telepsychiatry consultation practices in India (years of formal and informal telepsychiatry practice, hardware and software used for telepsychiatry practice, satisfaction of providing tele versus in-person consultations, preferred type of consultation – audio/audio-visual/text, comfort levels in providing consultation and prescriptions, their satisfaction of providing and perceived satisfaction of patients in availing different types of telepsychiatry consultations).

The participants were sent the survey link. The first page of the survey included the introduction and the purpose of the survey with an option of continuing on the questions of the survey if they wished to participate in the survey or leave the survey. The second page included an explicit statement of consent.

Statistical analysis

The data were analyzed by using the PSPP (a free software program for statistical analyses).[16] The frequency, percentages, mean, and standard deviation were calculated.

RESULTS

There were 6,383 email addresses available in the IPS directory and the survey link was sent to all. A total of 324 eligible members opted out of the study; 878 emails bounced back; 354 members responded in the remaining 5,181 valid addresses. Four remainder emails were sent. The response rate was 6.83%. Out of the 354 members, 13 who opted to take the survey on the first page of the survey marked that they did not want to provide the consent on the second page and 1 was not a clinician. The responses from the rest 340 responders were analyzed.

The mean age of the participants was 44.15 (SD 12.30) years with a range of 26 to 87 years. There were 90 females (26.47%) and 247 males (72.65%) and 3 participants did not disclose their gender. A majority of the participants were from Karnataka (51/340; 15%) and Maharashtra (50/340; 14.7%). The other states and union territories from where participation was recorded were Tamil Nadu (27/340), Uttar Pradesh (26/340), Chandigarh (21/340), New Delhi (19/340), Gujarat (17/340), West Bengal (16/340), Rajasthan (14/340), Kerala (13/340), Telangana (12/340), Andhra Pradesh and Odisha (9/340 each), Assam and Punjab (7/340), Jharkhand (6/340), Bihar and Madhya Pradesh (5/340 each), Chhattisgarh and Haryana (4/340 each), Meghalaya (3/340), Goa, Puducherry, Jammu and Kashmir (2/340 each), Himachal Pradesh, Nagaland, Sikkim, and Uttarakhand (1 each). Five participants did not mention the state/union territory to which they belonged to. The responders had a mean of 17.37 years of clinical experience (SD 12.2). The responders were from both teaching hospitals (n = 172, 51%) and private practice (n = 161, 47%). Nearly one-fourth of the responders (n = 46, 27%) were from central government-funded institutes. The majority from teaching hospitals (n = 55, 32%) were Assistant Professors. Half of the private practitioners (n = 87, 54%) were running their own single chamber practice. The majority (n = 286,84.15%) of the responders were practicing teleconsultation informally for 5.74 (SD 8.14) years ranging from 1 week to 45 years and 246 (73%) of them were practicing teleconsultation formally for 2 years (SD 4.75) ranging from 1 week to 40 years [Table 1].

Table 1

Profile of the clinicians who participated in the survey

Variables	n=340 (%)
Type of teaching hospital	(n=172)
Government Medical College (with no private practice)	40 (23.25)
Government Medical College (with private practice)	33 (19.18)
Central Government Funded Institute	46 (26.74)
Private Medical College	42 (24.42)
Others#	11 (6.4)
Designation in the teaching hospital
Professor	32 (18.60)
Additional Professor	5 (2.9)
Associate Professor	33 (19.19)
Assistant Professor	55 (31.98)
Lecturer/Senior Resident	34 (19.77)
Junior Resident	13 (7.56)
Type of Private practice	n=161
Consultant Psychiatrist, running own single chamber practice	87 (54.04)
Consultant Psychiatrist, running own hospital with inpatient facility	18 (11.18)
Consultant Psychiatrist, working in a corporate hospital, with no inpatient facility	20 (12.42)
Consultant Psychiatrist, working in a corporate hospital, with inpatient facility	25 (15.53)
Consultant Psychiatrist, working with an NGO	11 (6.83)
Commonly used hardware *
Simple Telephone with voice call facility	48 (14.12)
Smart phone	260 (76.47)
Tablet	16 (4.71)
Laptop	66 (19.41)
Desktop	28 (8.24)
Commonly usedmethod*
Text messages	104 (30.59)
Audio	196 (57.65)
Video	187 (55)
Email	44 (12.94)
A dedicated software	36 (10.59)
Prescription in teleconsultation
Text the name and doses of medications to patient	46 (15.49)
Provide prescription with your registration number and letter head in the form of an email/Text message	218 (73.4)
Others##	33 (11.11)

*The sum-total would be more than 100% as many practitioners use more than 1 method. #Others include autonomous tertiary care institute under government undertaking (n=1), DNB institutes (n=4), Private teaching hospital (n=4), retired professor from a private medical college (n=1), and State Government funded institute (n=1). ##Others include providing photograph/scanned PDF of written prescription (n=19), customized Adobe PDF format with signature (n=2), through apps and institutional software (n=5), over voice-phone (n=1)

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%), followed by WhatsApp (n = 9, 25%), Practo (n = 6, 16.67%), HealthPix, and Lybrate (n = 5, 13.89% each). Nearly three-fourths (n = 218, 73.4%) provided prescription with their registration number on the letter head in the form of an email or text message [Table 1].

Two-thirds of the responders (n = 228, 67.06%) felt that in-person consultation is better. Many of the responders who were practicing teleconsultation preferred a combination of voice, video, and text including emails (n = 134, 42.01%). Nearly half of the responders were comfortable to some extent in evaluating a patient for the first time by teleconsultation and not advising psychotropic prescription (n = 142, 44.1%), and nearly another half were comfortable to some extent in evaluating a patient for the first time and advising psychotropic prescription (n = 130, 40.5%). Nearly one-third (n = 99, 30.84%) were fully comfortable in evaluating an old follow-up patient whom they had seen at least once in-person for the consultation and not advising psychotropic prescription, and nearly half (n = 149, 46.42%) were comfortable to a large extent in advising psychotropic prescription for old follow-up patients. The responders were satisfied with the video consultations and had an impression that their patients also would be satisfied with video consultations and rated their own and their patient’s satisfaction as a median of 75, with a mean close to 70, on a Likert scale of 0 to 100 [Table 2].

Table 2

Preference, satisfaction, and comfort

Variables			Frequency (%)
Satisfaction of providing teleconsultation, when compared to in-person consultation
In-person consultation is better than teleconsultation			228 (67.06)
Teleconsultation is better than in-person consultation			3 (0.09)
Both are equally good			65 (19.12)
Preference of tele-consultations
Text Only including emails			6 (1.88)
Voice calls only			13 (4.08)
Video calls only			32 (10.03)
A combination of Voice and Video calls			90 (28.21)
A combination of Voice calls and Text including emails			19 (5.96)
A combination of Video calls and Text including emails			25 (7.84)
A combination of Voice and Video calls and Text including emails			134 (42.01)
Comfort level of evaluating a patient for the first time by teleconsultation and not advising psychotropic prescription
Not at all comfortable			72 (22.36)
Comfortable to some extent			142 (44.1)
Comfortable to large extent			63 (19.57)
Fully comfortable			45 (13.98)
Comfort level of evaluating a patient for the first time by teleconsultation and advising psychotropic prescription
Not at all comfortable			102 (31.78)
Comfortable to some extent			130 (40.5)
Comfortable to large extent			69 (21.5)
Fully comfortable			20 (6.23)
Comfort level of evaluating an old follow-up patient (whom you have seen at least once in-person for the consultation) and not advising psychotropic prescription
Not at all comfortable			57 (17.76)
Comfortable to some extent			81 (25.23)
Comfortable to large extent			84 (26.17)
Fully comfortable			99 (30.84)
Comfort level of evaluating an old follow-up patient (whom you have seen at least once in-person for the consultation) and advising psychotropic prescription
Not at all comfortable			8 (2.49)
Comfortable to some extent			68 (21.18)
Comfortable to large extent			149 (46.42)
Fully comfortable			96 (29.91)
Level of satisfaction
	Mean (SD)	Median	Mode
Patient
Voice	58.79 (21.89)	60	50
Text-based	44.52 (25.1)	42	40
Video	71.32 (20.95)	75	80
Mental Health Professional
Voice	56.65 (24.06)	59	50
Text-based	41.44 (24.71)	40	50
Video	69.45 (22.99)	75	75 and 80

DISCUSSION

The current study showed that many practitioners are utilizing technology for telepsychiatry consultations in the form of voice, video, text, and emails through their smartphones although they feel that in-person consultations are better. They were comfortable in consultations with or without issuing prescriptions.

Between 2016 and 2019, the usage of telehealth had doubled from 14 to 28% in the United States,[17] and between 2013 and 2018, telemedicine had grown by 44%.[18] An industry white paper in 2020 from the USA reported that there was an increase in the usage of telemedicine from 5% in 2015 to 22% in 2019.[19] The USA saw a rapid growth in telemedicine usage of about 50% during the first quarter of 2020 as compared to the same period of 2019.[20] Another study found that although there was an initial increase of about 32% teleconsultations in April 2020, the utilization later stabilized to about 13–17% across different specialties.[21] Another study from the USA found that during the pandemic, 30.1% of the consultations were provided via telemedicine and the usage ranged from 68% for endocrinologists to 9% for ophthalmologists. It also found that 53% consulted for depression.[22] The current study shows that about 84% of the responders were utilizing telepsychiatry in India as compared to 20-30% in the USA. One reason for the high numbers may be due to selection bias (tech-savvy responders who utilize telepsychiatry and answer an online survey). The numbers are akin to the United Kingdom (UK), which had established telemedicine services for many years and due to instructions by the UK’s Secretary of State Health to all the general practitioners to see all their patients remotely by default during the peak of COVID-19 crisis, the number of teleconsultations increased from 25 to 71%.[23]

A study from Bangladesh in 2015 on various models of telemedicine in South Asia found that most countries used the store and forward method, most models are on a project basis and their primary aim is to improve healthcare facilities.[24] The countries from the Southeast Asian region all have some kind of regulation on telemedicine practice.[25] This coupled with the need for reduced face-to-face contact during the pandemic has increased telemedicine usage in the Asia-Pacific region. Even before the pandemic, the Asia-Pacific region had about 22% usage for telemedicine which sharply rose by more than 100% in many countries during the pandemic.[26]

A survey conducted in India[27] between August and December 2020 on 154 healthcare providers (HCPs) found that about 38% had practiced telemedicine, and a majority of them did it due to COVID-19 (105/154; 51%) and patients’ request (39/54; 19%). Some (3/154; 2%) felt that patients would not be satisfied with teleconsultation. About 46% preferred WhatsApp as a telemedicine platform. Two-thirds of the HCPs felt that only about 20% of their patients would probably seek teleconsultation. This is in contrast to our study which found higher usage of telemedicine and a preference for audio calls. In-person consultation was preferred even in our study.

A cross-sectional survey conducted at the Massachusetts General Hospital in 2019, which included psychiatrists, reported that 59% of clinicians reported no difference in the overall quality of the visit between in-person and virtual video visits (VVV) and 52.5% opined more effective treatment with VVVs than in-person visits.[28] Another retrospective study from the Children’s Hospital of Philadelphia in 2019 found that 93% of the time clinicians considered telemedicine satisfactory.[29] The current study shows a preference of clinicians for in-person consultations, although utilizing telepsychiatry and being comfortable at the same time. One reason for the same might be that the practitioners were digital immigrants with more than 17 years of clinical practice rather than digital natives.

The available literature suggests that dedicated software is being used for telemedicine services. The current study shows the hardware, different methods utilized, and the way prescription is provided in telepsychiatry.

Limitations

The response rate was low despite multiple reminders. The survey was sent only to the members of IPS. There would be many psychiatrists who are not members of society and would be practicing telepsychiatry. Hence, the survey would not represent the general practices of the Psychiatric fraternity of the country. As with all the surveys, there could be a response bias. Telepsychiatry would have come to the forefront with the onset of the COVID-19 pandemic and the answers may reflect the trends post-pandemic.

CONCLUSION

The current study shows 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 tele-practice.

Financial support and sponsorship

Nil.

Conflicts of interest

Few authors (Suresh Bada Math, Narayana Manjunatha, Chethan Basavarajappa, Channaveerachari Naveen Kumar, Bangalore N Gangadhar) are the editors of the Telepsychiatry Operational Guidelines, 2020.