Digital psychiatry in low- and middle-income countries post-COVID-19: Opportunities, challenges, and solutions

Abstract

Health systems are adapting to the unique challenges posed by the COVID-19 pandemic. Social distancing has forced clinicians to provide their services through online platforms in high income countries. Similar trends have been noticed in Low and middle-income countries (LAMIC). Digital health can help LAMIC address traditional barriers to care by overcoming issues related to stigma, discrimination, staffing, and physical and geographical resource constraints. Mobile phone subscriptions exceed 80% of the population in many LAMICs. Mobile platforms represent a viable resource in overcoming the significant mental health gap in LAMIC. This paper discusses the enormous potential that digital health has to transform healthcare delivery in LAMICs, as well as numerous challenges to implementation. We also discuss the need to develop national digital health strategies and suggest solutions to some of the barriers.

Since the end of 2019, the coronavirus disease (COVID-19) pandemic has spread from Wuhan, across China[1] and over the world. It is now on course to affect the largest number of people globally since the Spanish Flu in the early 20^th century. The direct morbidity and mortality associated with COVID-19 have taken a toll on both health-care providers and the general public. There are emerging reports of the mental health sequelae of COVID-19, including stress, anxiety, and depression.[2] Without evidence-based treatments, isolation strategies have been used throughout the world to limit the spread of the virus. While these strategies are essential in protecting the population, isolation has contributed to stress and is highly likely to lead to emotional and mental health problems.[3] There are concerns that isolation and physical distancing strategies may exacerbate existing gaps in access to mental healthcare,[4,5] particularly in low- and middle-income countries. Three-quarters of the global burden of mental, neurological, and substance use disorders lie in LAMIC, yet 90% of this population does not have access to mental healthcare,[6] or mental health research, which builds the foundation for evidence-based person-centered care. It is difficult to predict the long-term physical and mental health consequences of COVID-19; however, an economic crisis is likely to follow that may worsen mental health and emotional well-being worldwide.[7]

Health systems are adapting to the unique challenges posed by the COVID-19 pandemic. Social distancing has forced clinicians to provide their services through online platforms. In high-income countries, there has been an acceleration in the shift toward telemental health. We have seen changes in legislation and policy to promote the use of telemedicine in North America.[8] These changes have encouraged health providers to embrace telemedicine, overcoming barriers to implementation that have existed prepandemic. There has been a dramatic increase in the number of health-care providers using virtual platforms to deliver care.[9] The potential for digital health is yet to be realized fully. Benefits to digital health include significant cost savings; for example, Canada registered cost savings from investment in digital health of US$11.2 billion since 2007.[10] Beyond the economic advantages, health services can also function more efficiently through digital platforms, overcoming geographical and practical barriers to engagement, allowing patients to receive clinical care faster.

LAMIC have seen an increase in the use of digital medicine (personal communication). Digital health can help LAMIC address traditional barriers to care by overcoming issues related to stigma, discrimination, staffing, and physical resource constraints. Mental health services are available mostly in big cities in many LAMICs, and the use of digital technology can play a pivotal role in overcoming this barrier. Mobile phone subscriptions exceed 80% of the population in many LAMICs, including Africa, Central America, and South Asia.[11] The proportion of individuals with broadband Internet access is lower than those with the Internet through mobile phones, with traditional Internet access rates ranging from 27% of the population in South Asia to 60% in South America. However, nearly 40% of the world's Internet traffic comes from mobile devices, highlighting that more and more individuals are finding alternative ways of accessing the Internet. Mobile devices account for 66% of web traffic in India, 70% in Indonesia, 82% in Nigeria, and 75% in South Africa.[11] Mobile platforms represent a viable resource in overcoming the significant mental health gap in LAMIC. Evidence suggests that psychological interventions delivered on digital platforms are as effective as those offered in-person, and the use of such platforms has been endorsed by national guideline developing bodies such as the National Institute of Health and Care Excellence (NICE) in the UK.[12,13]

Despite the enormous potential that digital health has to transform health-care delivery in LAMICs, there are numerous challenges to implementation. The 2019 Global Digital Health Index assessed the state of preparedness and adoption of digital health in 22 countries at various stages of economic development.[14] It also measured the readiness of the wider health systems to adopt and deploy digital health interventions successfully. The findings indicated that while many countries have national digital health strategies, most lack digital health architecture, health information exchange, and data standards, all of which undermine the potential benefits of digital technologies. In addition, most LAMICs fall behind in the development and implementation of data governance frameworks that balance data privacy and protection with innovation. Training and education to use digital technologies are critical, but few LAMICs have integrated digital skills into their health-workforce training.[15] While mobile phone and Internet access are high in LAMICs, the number of individuals with computers and access to broadband Internet is very low.[16] Furthermore, all mobile phone users are not using smartphones with high-speed Internet capability. There is also a marked urban-rural divide in access to technology and education. Other barriers include low rates of education and awareness, and people demanding face-face care. Finally, improving access may go some way in reducing the mental health treatment gap. Still, it may not be sufficient until the numbers of practicing mental health professionals in LAMICs are increased.

The uptake of digital health worldwide has been remarkable in the context of COVID-19. However, to realize the full potential of digital health in improving access to mental healthcare in LAMICs, many steps need to be taken. There is an urgent need to develop national digital mental health policies and procedures that take into account local population needs. The use of digital technology needs to be incorporated into the education and training of health-care professionals. Digital health awareness campaigns need to be delivered, targeting the general public through the use of media and social media platforms. Digital health in high-income countries is provided through a public-private partnership, and this model can also be incorporated in LAMICs. There is also a need to improve access to smartphones and the Internet. Internet cafes are ubiquitous in LAMICs and can be used as access points for the public to reach health-care providers. Psychosocial interventions can be provided through web-based platforms, for example, YouTube and WhatsApp. Information technology is affordable in LAMICs and can be engaged to provide solutions to local barriers and to develop cost-effective platforms to deliver telemental health. Our group is currently in the process of feasibility testing a mobile application-based psychosocial intervention for psychosis in South Asia (TechCare-P) and a mobile application-based intervention for maternal depression (TechMotherCare; NCT02526355). Clinicians, academics, funding bodies, software developers, and policymakers need to collaborate to ensure that health-care provision in LAMICs moves from the analog to the digital world. The future of digital care should allow patient-centered access to real-time interventions that are cost-effective, clinically useful, and accessible. Progressively reduced costs of mobile devices and widespread acceptability of mobile health interventions offer a pragmatic solution to addressing the mental health treatment gap in LAMICs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.