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Practicing psychiatry in the COVID-19 era

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Should we trust telepsychiatry and is this method of delivery even efficacious? Telemedicine has changed practicing SOPs, but how will the doctor-patient be built, especially in initial appointments in a psychiatry practice, without a face to face interaction? Or will the anonymity help due to the stigma of psychiatric conditions? Dr Ranjan Ghosh, psychiatrist, Good Karma shares his experience on World Mental Health Day

 As the virus spreads rapidly and tears through our beloved country, the quandary is how do we safely see patients that desperately need it? In the COVID-19 era to limit the spread of the virus we need to be:

  • Wearing personal protective equipment (PPE)
  • Cleaning and disinfecting surfaces and frequently touched items
  • Practicing healthy hand hygiene
  • Asking health, exposure to COVID-19, and travel questions during check-in
  • Minimising physical contact
  • Following social distancing guidelines

The problem is in psychiatry the above necessary measures lead to a worsening of rapport and experience, especially with initial appointments. Not to mention the deadly potential of acquiring the virus during travel and visiting an overcrowded clinic.

Prior to the pandemic as I had already started work on my online model, I was a little bit ahead of the pack. I feel almost overjoyed when now the conversation in India is moving more towards space visible by camera, bandwidth strength, and camera quality, which toys/artwork to displayed, sound quality, and various apps and Picture in Picture modes. I wanted to badly change the behaviour but now we see that automatically changed due to the above threat. But should we trust telepsychiatry and is this method of delivery even efficacious?

It actually works

Telepsychiatry’s evidence base is substantial, and satisfaction is extremely high among adult patients, psychiatrists and other professionals.

  • The evidence base is formidable for children, adolescents and adults regarding assessment (diagnostic, cognitive, other) and treatment (medication, therapy).
  • Preliminary studies in geriatric patients and across cultures are positive. Indeed, it may facilitate cultural, ethnic and language matching between patients and providers.
  • The experience of other mental health clinicians using telemedicine (i.e., telemental health), is consistent with, and further substantiates the diagnostic, therapeutic and outcome evidence base.
  • The ability to establish a therapeutic rapport with youth and families through telepsychiatry are well established

Exceptions for a few populations in which it may be preferable to in-person care (e.g., autism spectrum, severe anxiety disorders, geriatric patients with physical limitations, those with significant geographical obstacles).

Telepsychiatrists adjust clinical care in a few ways to make it as personal as in-person care. If we are to follow the above safety standards than we cannot do the following in house.  These are three points to determine a patient’s mental status:

First, they may project a little more in terms of gestures, just as if one is giving a presentation to a large group. Second, it helps to check-in to see how the patient is experiencing it. Third, verbal communication may replace handshakes, handing a tissue box and such. If an examination item is difficult at a distance, another staff or accompanying person can help.

The studies of telepsychiatry have shown to have an excellent feasibility rating with some exception for low bandwidth or pixilation. Validity is almost the same with some minor exceptions in monitoring for extrapyramidal side effects and/or tremors. Diagnosis of various psychiatric conditions was shown to be made reliably with inter-rater reliability. Satisfaction along with cost-effectiveness was made to be markedly higher than normal sessions.

Telepsychiatry services offer significant financial savings to families and children in the form of direct cost avoidance, and fewer lost work/school hours. The families’ return on the system’s investment benefits both the family and their community.  It drastically decreases the overhead of any practice.

Uniqueness of telepsychiatry in India

All the studies you have seen quoted are US based studies. What are some unique challenges and benefits of telepsychiatry here in India?  When I came back to India two years ago I came up with a plan to decrease the suicide rate through the following objectives i) Reduction of stigma through clever branding ii) Awareness/ Prevention talks, programmes and lectures (This includes messages in arts and entertainment) and iii) Accessibility to mental health services.  Even though we have such a crisis when it comes to mental health, there is still a huge stigma associated with it. To reduce the stigma, I called my clinic, not by name but a different entity and decorated it as a peaceful haven.

Now you can imagine in telepsychiatry one does not even need to walk into the clinic or dwellings of a neuropsychiatrist, psychologist, or counselor. Now they can avoid stigma and shame by seeking care anywhere anytime. This is a huge factor for someone who faces judgment. Through telepsychiatry we see accessibility increasing exponentially.

I would be remiss to only highlight the positives. Besides the above technical glitches, changing the behaviour of going into seeing the mental health professional or physician is still going to require some change.  There are some discrepancies but is said that conservatively around 25 per cent of India’s population have smartphones. The problem is then teaching that population to access services and change the traditional behaviour is going to be difficult.

Once they can understand things like when their network is faster and how much money and hassle, they save by not travelling I think we will see a mass exit from traditional clinics. It will be predicated on this pivotal time of conversion when faced with this pandemic. Anyone who needs something with even an average connection can now get help if needed thus reducing the wait time and ensuring that in a crisis that someone is there. I truly do not know what happened to SSR but if he was indeed bipolar and on medication, he would have been able to follow up with a professional rather than abruptly stopping them or googling his illness and then succumbing to it. As when he would have pressed painless ways to suicide, he would have seen the thousands of mental health professionals that were there waiting for his call. The behaviour change is this and this only, understanding that mental health just like SAR-COV2 knows no gender, class, creed, status, religion or age.  Let us change. People are dying. #EnoughIsEnough.

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