In 2020, an unprecedented roadblock hit humanity hard, shook its core and disrupted every form of human living. The Covid-19 pandemic has affected all physical forms of communication, brought healthcare down to its knees and left the world economy in an unabated free fall. The outbreak has also cast its dark shadow on the psychological front. Society was in a constant state of panic and fear, not knowing where and when Covid shall strike next. Its reign of terror was more evident.
in countries like India that struggled to handle the massive workload due to acute shortage of manpower and infrastructure. Our country, already reeling from the inadequate number of mental health professionals for its mammoth population, has received a body blow due to this pandemic. This is where telepsychiatry or e-mental health has a role to play, with its enormous potential and obvious promises.
Like most spheres of human lives, information and communication technology, due to its rapid strides in the last couple of decades, has breached the healthcare system too. The use of internet, TV, social media, etc., has started to play a significant role in day-to-day medicine and surgery in developed nations while telepsychiatry is also taking a front seat on the ride up. In India, though still in a nascent stage, telepsychiatry is the “new normal” and promises to bridge the huge mental health gap. Mental health workers can now seemingly do the impossible and reach faraway corners of the country to spread awareness, treat, and give psychotherapy and advice to whichever population is in dire need of it, which was not possible before. In the times of this pandemic as well as after, it has a definite role to play.
Based on the National Mental Health Survey of India 2015-16, one in six Indians suffer from some sort of mental disorder. The actual number could be still higher. This coupled with an acute shortage of trained professionals paints a poor picture of mental health in the country. It is estimated that only about 29% of mental health needs are met by the available manpower. This number could take a severe downturn, taking into consideration the pandemic and its ensuing aftermath. Also, there is a massive difference between the supply and utilisation of mental health services amongst the rural and urban areas, further compounding the problem. Telepsychiatry could well be the much-needed shot in the arm of the lumbering mental health services.
There are various methods of providing telepsychiatry to the masses. The most used have been consultation over telephone calls, emails, text messages, social media forums like special chat groups, websites, blogs, vlogs and via video conferencing. Out of these, video conferencing comes the closest to a real doctor-patient interaction due to its live, two- way and audio-visual interaction. It can almost obviate the need for a mental health expert in the vicinity. Overall, there are two main types of e-mental health technology—synchronous or interactive, and asynchronous or store-and-forward. Synchronous technologies provide real-time interaction, whether audio or visual, and have the advantage of immediate response. The quality, though, is limited by the nature of the technology provided. The asynchronous or store-and-forward technique involves non-real-time data transfer and interaction, mainly via e-mails and web applications for later perusal by the expert and does not require both parties to be present at the same time. But its major strength is also its chief drawback as real-time urgent resolutions are not possible.
Telepsychiatry can be utilised for conducting various kinds of real-time case managements and emergency as well as planned consultations for education, raising awareness, training and teaching and consultation liaison services. Various internet-based psychotherapies and neuropsychological assessments that would otherwise suffer from the lack of adequate manpower and infrastructure can also be provided.
The biggest challenges to this proposed mental health reform come in the form of lack of proper logistics and technology, delivery methods, cost effectiveness and trained staff. Although such e-mental health services would reduce the expenses incurred on things like travel, the cost of the best available technology and trained staff would levy a heavy toll, putting its promise of being cost effective under question.
Apart from the functional challenges above, various ethical and legal questions remain unanswered. The role and responsibility of a telepsychiatrist in an emergency condition like a suicidal or severely agitated patient can be called to question, but it can be mitigated to some extent in the presence of the primary care physician or other mental health professional. Another legal challenge is the privacy and confidentiality of the patient’s data and unwanted disclosure of clinical notes or mental health status to a foreign source. This can be overcome by the promise of encrypted software that doesn’t allow sharing of any data with third parties. But still, these threats cannot be taken lightly and cybersecurity needs to be ramped up.
In a landmark move, the Ministry of Health and Family Welfare, Government of India, released telepsychiatry guidelines last year in association with the Indian Psychiatric Society (IPS) and NIMHANS, Bengaluru. Also, very recently, the IPS started its first-ever suicide prevention helpline (1800-532-0807) for the public. These are welcome steps to digitise mental health for service delivery and training in our country. Even with its challenges, the transition of psychological health to a virtual platform has received a positive impetus during Covid. How it will stand the test of time remains to be seen.
Dr Mayank Rai
Psychiatrist, AIIMS Rishikesh
Dr Debanjan Banerjee
Consultant geriatric psychiatrist, Kolkata
(rai.mayank0@gmail.com, dr.djan88@gmail.com)