|Year : 2020 | Volume
| Issue : 2 | Page : 138-142
Telemedicine for mental health during COVID-19: Need and accessibility by patients of community outreach clinics
Ajeet Sidana, Abhay Raj Singh, Jaswinder Kaur
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Submission||06-Sep-2020|
|Date of Decision||04-Oct-2020|
|Date of Acceptance||12-Dec-2020|
|Date of Web Publication||23-Feb-2021|
Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh - 160 030
Source of Support: None, Conflict of Interest: None
Background: In the unprecedented times of the COVID-19 pandemic, majority of the outpatient departments have been closed including psychiatry community outreach clinics (COCs). The only way to reach out to these patients has been the newly evolved telemedicine services. Aim and Objectives: The aim of the study is to study the need and accessibility of telemedicine services among patients of COCs. Methodology: The case record files of patients who got them registered in the COCs during January to March 2020 were taken out and sociodemographic, clinical, and contact details were retrieved. A 12-item questionnaire was prepared to know the current status of these patients and information about need and accessibility of telemedicine service for mental health over phone. Results: A total of 78 patients were interviewed. Mean age of the respondents was 43.90 years. The most common clinical diagnoses were neurotic, stress-related, and somatoform disorders followed by substance use disorders, mood disorders, and schizophrenia, including other psychotic disorders. About two-third of the respondents reported that their condition worsened over a period of 4 months after closure of COCs, while one-fourth patients could not purchase medicines due to nonrenewal of prescription. Only 2.4% of the respondents were aware about the existing telemedicine services in the hospital and 100% of the respondents agreed to consult telemedicine services after imparting the information and scope of telemedicine services. Conclusion: Sudden closure of COCs led to worsening of mental health status of already registered patients in the clinics. There were poor knowledge and accessibility of telemedicine service by the respondents. Information, education, and communication about telemedicine services increase the feasibility, acceptability, and accessibility of services.
Keywords: Accessibility, community outreach clinics, COVID-19, mental health, telemedicine
|How to cite this article:|
Sidana A, Singh AR, Kaur J. Telemedicine for mental health during COVID-19: Need and accessibility by patients of community outreach clinics. J Mental Health Hum Behav 2020;25:138-42
|How to cite this URL:|
Sidana A, Singh AR, Kaur J. Telemedicine for mental health during COVID-19: Need and accessibility by patients of community outreach clinics. J Mental Health Hum Behav [serial online] 2020 [cited 2022 May 20];25:138-42. Available from: https://www.jmhhb.org/text.asp?2020/25/2/138/309963
| Introduction|| |
More than 70% of population of India lives in villages. The services and infrastructure for mental healthcare in the public sector are not only inadequate but are also confined to bigger cities and hospitals. Various epidemiological studies from India have estimated that the prevalence of mental disorders between 5.82% and 7.3% and the resources available to manage the huge burden of these disorders are insufficient, inequitably distributed, and used inadequately, which leads to treatment gap of more than 75% of the patients.,, A study by Reddy et al. has found various reasons for not seeking help, which were further grouped under the following factors: lack of awareness about the illness, religious beliefs, lack of family support, financial constraints, family dynamics, family's tolerance about symptoms, lack of insight about illness, families resilience, community beliefs regarding mental illnesses, and others.
The only way to reach this unreached underprivileged population is to provide services at their door steps through the community outreach program. Community psychiatry means providing community mental health services to the persons and families with mental illness within the community using various community resources. The community settings may be any religious place, i.e., Dharamshala, Gurudwara, or any other place in the community, or it can be even persons own house. This has been proven in various studies that community outreach services (COSs) are as effective as tertiary care outpatient department (OPD) services and it is the first step to bring the patients in to treatment.,,
The patients in COSs are dependent on the community outreach team (COT) for all treatment-related decisions, including referral to other departments. The patients registered in COCs get all service under one roof, and they get medicines, counseling sessions, investigation, and referral to other departments without any charges. In a way, the patients are solely dependent on the community clinics for continuation of treatment, and in case, if any medicine is not available in the community clinic, then it is very likely that either the patient would not buy the medicine or stop coming to the clinic.
Announcement of sudden lockdown in the country by the Prime Minster of India on March 24, 2020, amid COVID-19 outbreak leads to the closure of OPD services of three major hospitals in the city as well as COSs. Since the patients registered in community outreach clinics (COCs) were exclusively dependent on the medicines supplied by the community team and they could not get the medicines from open market without renewal of prescription, it is very likely that it leads to discontinuation of treatment and recurrence of symptoms. To provide the medical services to the affected population without risking of COVID-19 infection, the Ministry of Health and Family Welfare, Government of India, in collaboration with the Board of Governors launched the telemedicine practice guidelines in India. Telemedicine is being perceived to be used by doctors to connect with their patients as well as by mid-level provider and health workers to connect patients with doctors without physical presence of patient in a hospital or clinic., However, there are very scarce Indian data or studies which explore the requirement, accessibility, and effective usage of the telemedicine services for mental health and substance use disorders (SUDs) by the patients registered in COCs. Thus, this study was planned to evaluate the need, knowledge, accessibility, and effectiveness of the telemedicine services in the community so that corrective measures may be planned to evolve these services as they are the future amid the times of pandemic.
| Methodology|| |
The Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India, is providing community psychiatry services (CPSs) in the adjoining villages of Chandigarh since more than two decades. Currently, the department is providing COSs to three adjoining places in and around Chandigarh, i.e., Dhanas, Khuda Ali Sher, and 26-police line dispensary on a weekly basis. The COT consists of a senior and junior resident of psychiatry, clinical, psychological, community nurse, and a medical social worker (MSW). All the members of the team sit in a single room for the assessment and dispensing of medicines. The medicines are dispensed by the team for a period of 1 week without any charges, and free physical and psychological investigations are carried out, if required. The patients with all types of mental health issues including SUDs visit these clinics, and diagnosis is arrived as per the ICD-10 criteria.
The case record files of patients who were registered from January 1, to March 19, 2020 (last day of COC) for the treatment of mental illnesses including SUDs in the COCs of department were retrieved. The sociodemographic and clinical information, viz., age/gender, occupation, education, income, diagnosis, and phone numbers, was gathered from the files.
Since there was no objective scale to measure the need and utility of telemedicine services for mental health issues, a 15-item questionnaire was prepared by three mental health professionals working in the community with considerable years of experience. Three questions were dropped after discussion and feedback from other mental health professional, and finally, a 12-item questionnaire [Table 1] was finalized and translated into Hindi and vernacular language to address the problems faced by the patients due to closure of COCs, if any. The MSW having experience of working in the community with these patients called up and explained them the purpose of survey. The prior consent for the enrolment in study was obtained over phone and included in the study. The appointment for interview was fixed as per the convenience of the respondent. The 12-item questionnaire was administered over phone by the MSW in the months of August–September 2020. It took 5–7 min to gather the responses from each respondent.
The study was approved by the institutional research committee.
The data were coded and analyzed using SPSS software version 22.0 (IBM SPSS Statistics for Windows, version 22.0 IBM Corp., Armonk, NY, USA). Categorical variables were reported as counts and percentages. Continuous data were given as mean ± standard deviation and range or median and interquartile range, as appropriate.
| Results|| |
A total of 97 patients were registered in the COCs between January 1, and March 19, 2020 (last day of community clinic). File records of all 97 patients were retrieved for the analysis for sociodemographic and clinical details. However, telephone numbers of only 88 patients could be retrieved from the file records. Out of these 88 patients, 10 patients did not pick up the phone. Therefore, the final sample consisted of 78 patients for the study.
[Table 2] shows the sociodemographic and clinical profile of the patients. Females outnumbered males; majority were homemakers, married, educated up to matric followed by illiterate, having income more than INR 7000 per month, and from nuclear families. The most common clinical diagnoses were neurotic, stress-related, and somatoform disorders followed by SUDs, mood disorders, and schizophrenia including other psychotic disorders.
Procurement of medicines and current status
When inquired about the visit to COC before lockdown, all the 78 participants reported that they were coming regularly and out of which 68 (87.1%) were taking medicines regularly till the last follow-up visit in community clinic. When asked about continuation of medicines after a gap of 4 months of disruption in COS, 58 (74.3%) were still continuing the medicines. When asked about procurement of medicines without renewal of prescription, 60 patients (76.9%) reported that they were able to procure the medicines whereas one-third could not procure the medicines. A total of 51 patients (65.38%) reported that their conditions worsened over a period of time, and out of which, 20 patients (25.6%) reported due to nonavailability of medicines as shown in [Table 1].
Need and utility of telemedicine service
When asked about the other services rendered by the department which includes emergency services and indoor services during this time, 60 patients (76.9%) were aware about the other services, whereas 18 patients (23.0%) were just aware about COSs. When asked about the word telemedicine services, only 2 patients (2.5%) responded yes and majority have not heard this before. When enquired about the telemedicine services started by the hospital, only two patients (2.5%) responded in yes and majority of the patients (97.4%) were not aware about the telemedicine services even after 4 months of functioning. Out of these two patients, only one patient consulted the telemedicine service for mental health as depicted in [Table 1].
After giving the detailed account of information about telemedicine services by the MSW over phone, all 78 patients (100%) of the respondents reported that this new service will be very helpful during this COVID-19 period, all of them conveyed that now they will consult the telemedicine service, and all of them were satisfied with the information provided to them and scored the telemedicine services as 90%–100% useful as reflected in [Table 1].
| Discussion|| |
Probably, this is the first time in the history when all the OPD services in the major hospitals of the city and the COSs were closed suddenly. Since the department was providing the community psychiatry services for more than 20 years in the adjoining villages of Chandigarh and had developed a bonding with the community, therefore the department felt worried and was curious to know the effect of sudden stoppage of services on the mental health status of the population it had catered for the past so many years.
Moreover, there was a gap of around 3 weeks between closure of OPD and community service and establishment of telemedicine service in the hospital, and hence, it was pertinent to know that how they were managing themselves without medical help and also how they felt about the telemedicine services for mental health problems.
The index study was conducted after almost 4 months of starting the telemedicine service for mental health issues by the hospital and physical OPD in major hospitals, and COSs were still not restarted. We had the opinion that by this time, the community must have made some adjustments to continue with their treatment and started using the telemedicine services.
All patients were coming for follow-up for their regular medicines before lockdown which signifies the need and acceptability of the CPSs rendered by the department and described in other Indian studies as well., Generally, it has been found in previous study that large numbers of patients drop out during follow-up at hospital setting as the stigma associated with psychiatry and mental disorders also discourage many of the patients from seeking treatment.
About two-third of patients' condition worsened over a period of 4 months which signifies the need of regular consultation and nonpharmacological management along with psychotropic. Mental illnesses and SUDs have chronic relapsing and remitting course. Majority of the patients in index study had the diagnoses of neurotic and stress related disorders followed by SUDs and poor compliance to treatment can lead to re-emergence of symptoms including withdrawal symptoms and craving for the substance.
Almost one-fourth of patients could not procure medicines without renewal of prescription and led to discontinuation of treatment as these patients were exclusively dependent on the medicines supply by the community team and they discontinued the treatment after the closure of CPS. This has been seen earlier also that whenever there is short supply of any medicine in the community, either the patients will stop visiting the COCs or discontinue the treatment but not buy the medicines from open market. In addition, the chemists do not dispense the medicines without renewal of prescription in India as manufacturing and dispensing are strongly governed by the Drugs and Cosmetic Act, 1940; the Pharmacy Act, 1948; Indian Medical Council Act, 1956; and the Narcotic Drugs and Psychotropic Substances Act, 1985. However, a study from Central Saudi Arabia reported that people easily procure psychotropic medicines without prescription.
Majority of the patients were aware about the other services rendered by the department which shows the utility of COSs in spreading the information in the community regarding the treatment facility in the hospital. Contrary to this, about one-fourth of the patients were aware about only CPSs which denote that a subpopulation in the community which is exclusively dependent on community services and discontinuation of these services can lead to re-emergence of problems among this group.
On questioning about the word telemedicine service, only 2.4% of the respondents heard this word earlier and only these people called the telemedicine for consultation over a period of last 4 months, whereas 97.4% of the respondents were not even aware about the telemedicine services started by the hospital. When the information regarding the scope, utility, how to use it, how much time does it take for single consultation, free of cost, etc., was given to all the respondent over phone, 100% of the patients reported that this service will be very useful and now they will consult over telemedicine and also scored that information regarding telemedicine is 90%–100% useful. This clearly reflects the need of information, education, and communication about any new service in the local community in the vernacular language.
In index study, majority of the patients were illiterate or matric pass, homemakers, and poor socioeconomic status and had diagnosis of neurotic and stress-related disorders and SUDs, which are similar to earlier study from the same department. While a nationwide lockdown presents several difficulties, the index study also explores the difficulties experienced by the already enrolled patients in the COCs. The index study highlights the need of adequate information, knowledge, and scope of telemedicine services to this already vulnerable group of society. Telehealth/online services have been projected as one of the promising approaches for health service delivery during the COVID-19 pandemic. Indian Psychiatric Society and numerous other institutes have started reaching out to patients via telehealth services. However, a study by Arya and Gupta, 2020 concluded that while such initiatives are praiseworthy, there are concerns regarding feasibility and acceptability of such approaches in Indian Settings. The index study also found some major shortcomings in the feasibility and accessibility of the telehealth services among the study population.
The index study has few limitations that it includes small community population from a particular socioeconomic strata, responses were gathered as yes or no only, severity of worsening of problem could not be assessed, and hence, the results cannot be generalized to the whole community but has clearly stress about the information, education, and communication about the telemedicine service in the community for its larger use and accessibility. There is need to carry out the similar kind of studies on larger community population with different socioeconomic strata and using qualitative and descriptive responses and assessment of severity of recurrence of symptoms on standardized tools.
| Conclusion|| |
The COVID-19 pandemic has a profound effect on the health services delivery globally. There is an urgent need for treatment services to adapt to daily changing scenarios with emphasis on practical approaches to help people with mental illnesses. These times have warranted the use telehealth services to overcome the various hurdles faced by both clinician and patients; however, still, a lot of work has to be done on propagation, feasibility, and cost-effective usage of these services by the masses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian J Psychiatry 1998;40:149-57.
] [Full text]
Sidana A. Community psychiatry in India: Where we stand? J Mental Health Hum Behav 2020;23:1-11.
WHO Mental Health Gap Action Programme. Scaling up Care for Mental, Neurological, and Substance use Disorders. Geneva: World Health Organization; 2008.
Reddy SK, Thirthalli J, Channaveerachari NK, Reddy KN, Ramareddy RN, Rawat VS, et al
. Factors influencing access to psychiatric treatment in persons with schizophrenia: A qualitative study in a rural community. Indian J Psychiatry 2014;56:54-60.
] [Full text]
Van Citters AD, Bartels SJ. A systematic review of the effectiveness of community – Based mental health outreach services for older adults. Psychiatr Serv 2004;55:1237-49.
Pellegrin KL, Barbato A, Holuby RS, Ciarleglio AE, Taniguchi R. Cost-effective strategies for rural community outreach, Hawaii, 2010-2011. Prev Chronic Dis 2014;11:E215.
Srinivasa Murthy R, Kishore Kumar KV, Chisholm D, Thomas T, Sekar K, Chandrashekari CR. Community outreach for untreated schizophrenia in rural India: A follow-up study of symptoms, disability, family burden and costs. Psychol Med 2005;35:341-51.
Das N, Narnoli S, Kaur A, Sarkar S, Singh YP. Attitude to telemedicine in the times of COVID-19 pandemic: Opinion of medical practitioners from India. Psychiatry Clin Neurosci 2020;74:560-2.
World Health Organization. International Statistical Classification of Disease and Related Health Problems, Tenth Revision (ICD-10). Geneva: World Health Organization; 1992.
IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.; 2013.
Chandrashekar I, KapurR L, Parthasarathy R. Management of priority mental disorders in the community. Indian J Psychiatry 1981;23:174-8.
] [Full text]
Chatterjee S, Pillai A, Jain S, Cohen A, Patel V. Evaluation of a community based rehabilitation model for chronic schizophrenia in rural India. Br J Psychiatry 2003;182:57-62.
Patra S, Chavan BS, Gupta N, Sidana A. Clinical profile of patients seeking services at urban community psychiatric services in Chandigarh. Indian J Psychiatry 2016;58:410-6.
] [Full text]
Math SB, Manjunatha N, Kumar CN, Gowda GS, Philip S, Enara A, et al
. Sale of medicines by registered medical practitioners at their clinics: Legal and ethical issues. Indian J Psychiatry 2019;61:S786-90.
Alosaimi FD, Alruwais FS, Alanazi FA, Alabidi GA, Aljomah NA, Alsalameh NS. Patients reasons for obtaining psychotropic medications without a prescription at retail pharmacies in Central Saudi Arabia. Neurosciences (Riyadh) 2016;21:338-44.
Yao H, Chen JH, Xu YF. Rethinking online mental health services in China during the COVID-19 epidemic. Asian J Psychiatr 2020;50:102015.
Arya S, Gupta R. COVID-19 outbreak: Challenges for Addiction services in India. Asian J Psychiatr 2020;51:102086.
[Table 1], [Table 2]