Telepsychiatry and mental healthcare referrals: Recommendations for low‐ and middle‐income countries

Dear Editor,

Low‐ and middle‐income countries (LMICs) struggle with the highest burden of mental health disorders, along with an often unequal distribution of resources, including specialist care. ¹ This situation can translate into unequal access to mental health care in different regions within these countries. Also, and due to a multitude of reasons, referral patterns in LMICs are often a barrier to the timely provision of care for people with a mental disorder. ² The early identification and initial management of a mental disorder plays a significant role in determining its prognosis; hence, it is vital to establish prompt access to specialist care whenever necessary. In this letter, we would like to emphasize the importance of establishing a strong referral system for people with a mental disorder and the pivotal role that telecare could play in this regard.

Telecare, in particular telepsychiatry, could assist with addressing existing mental healthcare access inequities in LMICs and prove useful in reducing time delays in the referral process. For example, eConsults or asynchronous electronic communications could allow specialized care to be relayed through the local healthcare provider (LHP) to the service user via electronic means. In an eConsult, the LHP sends the psychiatric provider a focused clinical question or a prerecorded video of an interview via email, which is then responded with a clear recommendation. This asynchronous electronic communication could reduce the gap between health professionals, assisting the LHP in providing mental healthcare locally, and expediting the referral process when necessary. Moreover, since patients tend to seek mental health care from their LHP, eConsults could improve the levels of adherence to this care. ³

In situations where the psychiatric provider must lead the provision of care, interactive videoconferencing—or synchronous communications—can further complement local healthcare services. Interactive videoconferencing can enable the provision of specialized mental health care at a distance. It could be provided to clinically supervised settings—like mental health units or primary care services—or not clinically supervised settings—like a service user's home—without the need for the service user to move great distances to access the needed care. This service, along with the eConsults, could expedite access to specialized care when required while also allowing service users to continue accessing their local support networks.

In summary, telepsychiatry could easily complement the existing network of mental healthcare delivery in LMICs and prove vital in reducing healthcare access inequities. ⁴ There are, however, some challenges that may need to be addressed first, such as confidentiality and security limitations. In addition, not everybody will have the necessary resources and digital literacy to liaise with a psychiatric provider. ⁵ It will be important to ensure the necessary technical conditions (e.g., internet, computer, or smartphone) are present. Funding also remains a challenge in LMICs, with many countries allocating less than 1% of their overall health budget to mental health. ¹ Also, providing mental health care that caters to the service user's cultural needs, particularly to the most vulnerable sectors of these countries, is of the utmost importance, and may require further training. ⁶ Thus, access to the necessary resources, including human and material resources, and appropriate formal training should first be ensured to avoid contributing to existing inequities.

To conclude, early diagnosis and treatment of mental health disorders is pivotal in mental health care. In contexts where there is unequal access to specialist care, as is often the case in LMICs, we recommend the adoption of telepsychiatry. Telepsychiatry, whether in the form of asynchronous or synchronous communications, could ensure easy access to specialist care and a swift referral process, thus securing timely access to specialized mental health care and reducing healthcare access inequities in LMICs.

IMPLICATIONS FOR PSYCHIATRIC NURSING PRACTICE

In LMICs, a high burden of mental health disorders is often met with an unequal distribution of resources, including psychiatric specialist care, a situation that translates into inequitable access to mental healthcare. Timely access to care has a substantial impact on the prognosis of a mental health disorder, and thus, it is imperative to address these inequities. Telepsychiatry could prove a valuable tool in this task, as it could help optimize resource allocation, enable access to specialist care at a distance, and allow a swift referral process. There may be some barriers ahead, such as access to funding and a need for further training in the use of telecommunication technologies and cultural responsiveness in the provision of telecare. Still, the integration of telepsychiatry in advanced psychiatric nursing practice could assist in reducing healthcare access inequities and improving clinical outcomes for the population.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.