|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 175-177
Telemental health – Is it “Virtually” perfect
Harpreet Singh Dhillon1, Shibu Sasidharan2
1 Department of Psychiatry, Level III Hospital, Goma, Congo
2 Department of Anaesthesiology and Critical Care, Level III Hospital, Goma, Congo
|Date of Submission||01-May-2021|
|Date of Decision||08-May-2021|
|Date of Acceptance||10-May-2021|
|Date of Web Publication||26-Jun-2021|
Dr. Harpreet Singh Dhillon
MD (Psychiatry), Level III Hospital, MONUSCO, Goma
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dhillon HS, Sasidharan S. Telemental health – Is it “Virtually” perfect. Arch Med Health Sci 2021;9:175-7
COVID-19 pandemic has compelled the world to bring a paradigm shift in global educational, economic, and health services from in-person to virtual platforms. This pandemic has posed a challenge but has also given an opportunity to reach the rural and underserved population through emphasis on the relevance of information technology. Pursuant to this, health-care provisions have shifted from in-person treatment to telemedicine. Although telemedicine was introduced in the 1960s, when physiological parameters of astronauts were transmitted from space to Earth during the National Aeronautics and Space Administration missions, it was majorly utilized to provide secondary- and tertiary-level medical care across long inaccessible distances under special circumstances such as space, naval warships/submarines. However, in order to provide continued health care to patients while ensuring safety from COVID-19 for both patients and health-care workers, telemedicine has become a norm during the current pandemic. This significant change in the practice of medicine has forced us to question our perception of ideal health care. In this short communication, we would like to deliberate on the pros and cons of this momentous shift with special reference to mental health services.
The formal introduction of telemedicine for clinical use in India was started on March 24, 2000, in Aragonda, Andhra Pradesh. Telemedicine apparently promised immense scope in a vast country like India, with acute shortage of trained health-care workers and vast urban–rural divide in health-care services, but the journey remained dormant since then. However, after COVID-19 was notified as a pandemic by the WHO on March 11, 2020, telemedicine became the buzzword with specific guidelines from the Ministry of Health and Family Welfare, Government of India, on March 25, 2020. These guidelines have also received the legal status under the National Medical Commission Act, 2019 and will be applicable not only during the pandemic but also will be relevant postpandemic, thus making telemedicine future proof. Health insurance companies in India have also recently recognized telemedicine services for reimbursement.
The demand for adequate telemental health services (TMHS) also increased in view of rising incidence of mental illness, especially during the pandemic, thus prompting the Indian Psychiatric Society to issue detailed practice guidelines for the same. TMHS can be defined as provision of valid and reliable psychological and mental health facilities utilizing Internet-based information technology tools such as telephone-delivered therapy, videoconferencing, Internet-delivered programs, and mental health apps., TMHS can be divided into synchronous or asynchronous services. Synchronous service is real-time, interactive communication over telephone and video conferencing and can be considered closest to a face-to-face scenario. Asynchronous treatments, on the other hand, include texts, E-mails, faxes, online programs, and smartphone-based apps. As per the telepsychiatry guidelines by the Indian Psychiatric Society, it is unethical to prescribe medicines in an asynchronous session. Although a psychiatrist can accept the recorded video evidence of seizures/symptoms of abnormal behavior, before prescribing the medicines, it is advised to verify the identity of the patient, during a live and interactive session in a real-time mode. Before generating an e-prescription, the psychiatrist needs to collate optimum and reliable information to arrive at a provisional diagnosis. The signed e-prescription needs to be sent to the patient through E-mail or any other messaging platform. However, for any injectable psychotropic medicine, the prescription can only be generated if the consultation is between a psychiatrist and a registered medical practitioner.
There is scarcity of mental health resources (eg. trained mental health professionals/institutions) in developing countries like India. COVID-19 pandemic has further amplified the burden of psychological symptoms such as stress, anxiety, burnout, depressive symptoms, hoarding, loneliness due to lockdown, paranoia about attending community events and diminished support from family and friends. Various countries have proposed and catered for counseling, supervision, training, and psychoeducation through online platforms to combat these symptoms. Internet-based TMHS have been shown to be effective in children, adolescents, and adults for anxiety, depression, adjustment disorders, and even posttraumatic stress disorder. Internet-based cognitive behavioral therapy (iCBT) has been the most studied modality for a variety of anxiety and psychosomatic psychiatric conditions and is paralleled with clinician-provided CBT., Other psychotherapy modalities such as interpersonal psychotherapy, acceptance, and commitment therapy and psychodynamic approaches have shown good efficacy when delivered online.,,
The attitude of clinicians for the TMHS (synchronous) was found to be largely positive, acceptable, and effective, especially in the COVID-19 pandemic settings. However, the advantages of TMHS were limited in patients with major psychiatric conditions (schizophrenia and neurocognitive deficits).
As per CDC, telehealth consultations rose sharply by up to 154% in March 2020 as compared to the previous year. Recent US data suggest that the utilization of telehealth services increased from 11% in 2019 to 46% in 2020. Health-care providers also prefer telehealth consultations and are seeing 50–175 times the number of patients through telehealth than they did before. The regulatory authorities have also become more flexible in relaxing the restrictions on setting up facilities for telehealth. According to 2019 Health Center Program Data, the health centers capable of providing telemedicine rose steeply from 43% to 95% during the COVID-19 pandemic. The beneficiaries of TMHS also expressed satisfaction with respect to easy availability, convenience of timing, and perceived sense of privacy. A survey done across 25 Indian states (n = 3200) in August 2020 revealed that 72% of the participants preferred teleconsultation compared to regular outpatient department visits.
Few clinicians have expressed trepidations regarding the lack of humane approach, difficulty in establishing and sustaining rapport/therapeutic alliance, which are considered to be the mainstay in the management of mental health conditions. There are few other challenges such as ethical and cultural insensitivities, which might appear when health-care delivery is provided across geographies without any information about the native cultures. Second, telemedicine can potentially jeopardize the confidentiality and privacy of crucial medical and related information of the patients. Telemedicine can also result in conflicts related to ownership, accountability, documentation, and medicolegal cases, and since the medical services in India are covered under the Consumer Protection Act (1986), it could lead to increase in the legal suits on the doctors. Another challenge is that of sustainability, since telemedicine is clearly economical for the patient by saving money and time spent on traveling, the returns from health-care provider's perspective are uncertain, especially in developing countries. The clinical quality of the TMHS, nonavailability of prescribed medicines in the local area and few technology-related concerns (eg. data theft, payment and insurance-related issues) also need to be streamlined. There have been some unfortunate instances where health-care professionals, especially females, have experienced harassment due to telephone calls at odd hours or have been contacted for reasons other than therapeutic.
In conclusion, TMSH has a simple, effective, and valuable role in supporting psychological needs of patients as well as general population in these perilous times. Hence, it is imperative that we accept and adapt to this new normal.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bashshur R. Technology Serves the People: The Story of a Cooperative Telemedicine Project by NASA, the Indian Health Service and the Papago People. Superintendent of Documents. Washington, DC: US Government Printing Press; 1980.
Ganapathy K. Telemedicine and COVID-19. Apollo Med 2020;17:205. [Full text]
Nelson EL, Bui TN, Velasquez SE. Telepsychology: Research and practice overview. Child Adolesc Psychiatr Clin N Am 2011;20:67-79.
World Health Organization. Telemedicine: Opportunities and Developments in Member States. Report on the Second Global Survey on eHealth. Geneva, Switzerland: World Health Organization; 2010.
Cooper SE, Campbell LF, Smucker Barnwell S. Telepsychology: A primer for counseling psychologists. Couns Psychol 2019;47:1074-114.
Sasidharan S, Harpreet Singh D, Vijay S, Manalikuzhiyil B. COVID-19: Pan (info) demic. Turk J Anaesthesiol Reanim 2020;48:438-42.
Varker T, Brand RM, Ward J, Terhaag S, Phelps A. Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychol Serv 2019;16:621-35.
Vigerland S, Lenhard F, Bonnert M, Lalouni M, Hedman E, Ahlen J, et al.
Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clin Psychol Rev 2016;50:1-10.
Carlbring P, Andersson G, Cuijpers P, Riper H, Hedman-Lagerlöf E. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: An updated systematic review and meta-analysis. Cogn Behav Ther 2018;47:1-18.
Donker T, Bennett K, Bennett A, Mackinnon A, van Straten A, Cuijpers P, et al.
Internet-delivered interpersonal psychotherapy versus internet-delivered cognitive behavioral therapy for adults with depressive symptoms: Randomized controlled noninferiority trial. J Med Internet Res 2013;15:e82.
Ivanova E, Lindner P, Ly KH, Dahlin M, Vernmark K, Andersson G, et al.
Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial. J Anxiety Disord 2016;44:27-35.
Johansson R, Frederick RJ, Andersson G. Using the internet to provide psychodynamic psychotherapy. Psychodyn Psychiatry 2013;41:513-40.
Connolly SL, Miller CJ, Lindsay JA. A systematic review of providers' attitudes toward telemental health via videoconferencing. Clin Psychol Sci Pract 2020;00:E12311.
Santesteban-Echarri O, Piskulic D, Nyman RK, Addington J. Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. J Telemed Telecare 2020;26:14-20.
Koonin LM. Trends in the use of telehealth during the emergence of the COVID-19 pandemic–United States, January–March 2020. Morbidity and Mortal Wkly Rep 2020;69:1595.
Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post-COVID-19 reality?. McKinsey & Company. Published May. 2020 May 29;29.
Demeke HB, Pao LZ, Clark H. Telehealth practice among health centers during the COVID-19 pandemic-United States, July 11–17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1902-5.
Ganapathy K. Telemedicine: An integral part of clinical neurosciences. Neurol India 2021;69:352.
] [Full text]
Andrews G, Cuijpers P, Craske MG. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS One 2010;5:E13196.