Manipal model of telepsychiatry

ABSTRACT

Telepsychiatry can be understood as an interactive mental health service providing mode using information and communication technology. In recent decades, services provided under the umbrella term of telepsychiatry expanded to cater clinical services, diagnostic services, interventions, therapies, education, and research. Since telepsychiatry has been practiced in India for two decades, various models have emerged to meet the country’s demands and the logistics that are available. Both synchronous and asynchronous modes of telepsychiatry had been in practice in India depending on the availability of logistics. Most of the telepsychiatry services in India had focused on providing clinical care to reach the unreached population. Furthermore, telepsychiatry had been used to train mental health professionals and healthcare workers from other disciplines. However, not many models had incorporated the idea of hands-on training of the postgraduates/trainees of psychiatric social work (PSW) in telepsychiatry under supervision. This was addressed in the Manipal model of telepsychiatry. Manipal model of telepsychiatry has begun in 2016 with a novel idea to train mental health profession trainees in addition to cover other clinical services, research, and education. In the last eight years, four centers of Karnataka state have been covered under this model with progressive growth in a number of patients and this acted as a hands-on training model for the postgraduate trainees in starting telepsychiatry services independently. Furthermore, it provided an opportunity to develop the organization skills of trainees, improved their oratory skills, and improved their expertise in using information technology for mental healthcare delivery.

Mental healthcare delivery has various barriers, of which inadequate resources and distance feature prominently in developing countries. For mental illnesses, the treatment gap ranges between 70% and 92% in India.[1] To overcome barriers, technology is emerging as an important tool for the delivery of mental health care. There is evidence from other countries in support of telepsychiatry for mental healthcare delivery.[2]

Telepsychiatry can be understood as the use of information and communication technology to provide and support mental healthcare services. Dwyer was the first person to use the term telepsychiatry to describe interactive mental health services via television.[3] Subsequently, services provided under the term of telepsychiatry included clinical services, diagnostic services, interventions, therapies, education, and research.

World Health Organization had conducted global surveys on the availability of eHealth services among its member states before the coronavirus disease 2019 (COVID-19) pandemic. It showed that teleradiology services were available in 62% of member countries, whereas telepsychiatry services were available in 24% of countries only. of these 24% countries, only 13% of countries had established telepsychiatry services and the remaining were either in the pilot phase or in informal telepsychiatry services.[4] Furthermore, less than 10% of low- and middle-income countries had these established telepsychiatry services.[4] In the subsequent survey, 34% of member countries of the World Health Organization (WHO) had telepsychiatry services and out of this 25% countries had established telepsychiatry services.[5] Telepsychiatry is gaining momentum in developing countries also.[6]

Telepsychiatry services and models in India

Telepsychiatry in India is two decades old now. Both synchronous and asynchronous modes have been adopted in the Indian context. A live–real-time interaction between the mental health professional and the patient in a distant location using video calls and online platforms is known as a synchronous mode of telepsychiatry, whereas collecting the data (audio/video/summary) of the patient first and sending the data to the mental health professional via email and applications for reviewing later are known as asynchronous mode of telepsychiatry. Telepsychiatry in India was initiated by Schizophrenia Research Foundation (SCARF), Chennai, in 2004. SCARF had two models: mobile telepsychiatry model[7] and specialist–doctor–patient model.[8] Jan Swasthya Sahyog community health program used a synchronous mode of telepsychiatry to cater outpatient and emergency mental health services in Bilaspur and adjacent areas of Chhattisgarh.[9] In a project in Maharashtra, an asynchronous mode of telepsychiatry was effectively used where patient’s details were sent to a specialist by email.[10] Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, developed and validated a clinical decision support system/virtual psychiatrist model, which assisted nonspecialist doctors.[11-13] Another giant leap in telepsychiatry was by National Institute of Mental Health and Neuro-Sciences, Extension for Community Healthcare Outcomes (NIMHANS-ECHO) Project, which delivered various services: case-based discussions, didactic lectures, teleconsultations, tele-mentoring, and tele e-learning through virtual knowledge network—National Institute of Mental Health and Neuro-Sciences.[14]

Manipal model of telepsychiatry

Department of Psychiatry at Kasturba Medical College at Manipal in Udupi District of Karnataka initiated telepsychiatry services in 2016 and expanded it to four centers namely Primary Healthcare Centre (PHC), Kandlur; Community Health Care Centre (CHC), Byndoor; CHC, Hebri; and a private hospital in Basavakalyan.

Manipal model of telepsychiatry: Planning and implementation

A. Specifying the population in need

First step: Identification of the population that needed mental health services. To identify the population/place in need of mental health services, psychiatrists practicing in the district were approached to know the areas that they felt are unreachable. Then, the patients who availed services at Kasturba Hospital, Manipal, were approached who suggested that the remote areas, from where commuting was difficult and the areas that lacked service, needed mental healthcare services. With these inputs, the following places were identified.

Kandlur: It was selected in view of the location and the number of psychiatry patients in the locality.

Hebri: It was a Naxal-affected area located in the foothills of the Western Ghats.

Shirur/Byndoor: Here, mental healthcare services were inadequate.

Basavakalyan, Bidar: It was identified in view of lack of awareness, stigma, lack of mental health services, and poor socioeconomic status of people (one of the backward districts of India, located 800 km from Manipal).

B. Policy Issues

After specifying the population, service delivery policies were made and memorandum of understandings (MoUs) were prepared and signed by all involved agencies. These MoUs were reviewed and renewed every year. The following points were part of the policy.

Finances: Patients were not charged for this model of mental healthcare delivery. No financial incentives for service providers and all these were considered as extension of existing community services by the Psychiatry Department of Kasturba Medical College, Manipal.

Technical requirements: Laptops, webcams, Internet services, and vans for travel were provided by the Manipal Academy of Higher Education, Manipal.

Investigations: When required as the standard of care, they were recommended and were done in government hospitals as per the procedure.

Medications: They are provided freely by the government hospitals in liaison with District Mental Health Program (DMHP) in three centers and by Chitta Sanjeevini Charitable Trust in one center. In addition, local panchayats and nongovernmental organizations (NGOs) donated medicines.

C. Integrator

An “integrator” is an entity that accepts responsibility for services for a specified population. The roles defined for integrator were as follows: 1) to link and coordinate with healthcare organizations (PHC and Manipal) and society with the mission of healthcare delivery and 2) to recognize and respond to the needs and preferences of population in general and of patient in specific with available resources. Here, the hospitals and the government doctor acted as integrators. Collaboratively, PHC doctor and psychiatry junior residents involved individuals and families and redesigned the primary care services and structure by keeping an exclusive day in a month for mental health services and streamlined patients to the particular day. In addition, the government doctor managed resources at their PHCs, segmentation of resources/services was done, and allocated finances were redistributed for effective implementation and coordinated and integrated at the macrolevel with DMHP and government.

The following models of telepsychiatry were implemented.

Collaborative care consultation model

The PHC chosen was Kandlur PHC, in Kundapura Taluk. Video conferencing applications such as Skype and Hangout (Google Talk) were considered. Internet connection at Kasturba Hospital Manipal and PHCs had good speed for videoconferencing. The trial run was done in April 2016, and both Skype and Hangout chat services were found to be of optimal use for the venture. Subsequently, services were initiated in two more centers in Udupi District: Hebri Taluk CHC in April 2017 and Byndoor CHC in September 2017.

Work pattern in these three centers: A team of three professionals (psychiatry junior resident (JR), psychiatric social work (PSW) trainee, and PSW faculty) would visit these centers on a designated fixed day (different for each center) of each month.

Under the supervision of PSW faculty, PSW trainee and JR would organize the camp and would coordinate with the doctor at the government center. Patients were interviewed in a designated room by JR and PSW trainees in front of a laptop (spoke), and this interview was supervised by a consultant psychiatrist in real time at Kasturba Hospital, Manipal (Hub). After this, the consultant psychiatrist would also interview the patient for further clarification. After discussion, a diagnosis would be made and medications were prescribed by the JR and dispensed by the hospital pharmacy. Necessary psychosocial evaluations and interventions were done by PSW trainees. During every visit, PSW trainee delivered a talk on mental health for all patients in the waiting area. In these three centers, hospitals and government doctors acted as integrators for this collaborative care model.

Direct-to-patient consultation model

The fourth center was in Basavakalyan in Bidar District of Karnataka. The primary author visited Basavakalyan on a monthly basis since January 2014 for delivering mental health services. This was converted to direct-to-patient model of telepsychiatry in September 2016. The treating psychiatrist visited the center once in 3 months. An MOU existed with the primary author, NGO, Nesara, for coordination and implementation, and with Chitta Sanjeevini Charitable Trust, Bengaluru, for the supply of medicines. For site and logistics, a private hospital, which had two pediatricians, was approached and liaised for the delivery of services free of cost. Patients would contact the NGO and would reach the center on the specified date. Then, the patient would be sent inside the telepsychiatry room, where a video interview by a psychiatrist at Manipal would happen and pediatrician would do a physical examination and prescription would be emailed. Psychotropics would be dispensed by the pharmacy of the hospital for free. Here, the NGO and pediatrician acted as integrator and looked after the service.

Progress and indicators

Initial apprehension of a new modality of mental health services decreased with regular use. Certain points that indicated the effectiveness of model were as follows: increase in a number of patients, tertiary care center was less often needed for admissions or follow-ups, demand-driven supply, JRs/trainees got trained in telepsychiatry and were confident of organizing camps independently, JRs/trainees were trained to work in liaison with public and private bodies, in delivering talks on mental health for public, and consultants were able to do supervised training of JRs/trainees in interview skills.

Hurdles

Hurdles encountered were as follows: network-related issues, limited availability of medicines at government centers, documentation process, rotation of JRs/trainees, language barriers, cultural differences, and time constraints.

CONCLUSION

The Manipal model of telepsychiatry is unique in terms of mental healthcare delivery in collaboration with the government and NGO with a focus on community care. In addition, the model explores a novel method of training JRs/trainees in aspects of community psychiatry, organization skills, interview skills, liaison skills, and public speaking skills. Despite the hurdles, the model is able to cater the mental healthcare needs of the defined population. The model can be considered for replication by psychiatry departments of various medical colleges for reaching the unreached and training of JRs/trainees in community psychiatry and equipping them with hands-on experience in telepsychiatry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.