Bridging the Mental Health Treatment Gap through Tele-psychiatry - 'REACH' a Formative Research Project from Goa, India.

Lead Research Organisation: Sangath
Department Name: Research

Abstract

India has a significant burden of mental illness with almost 70 million people having some form of mental illness. This problem is compounded by an acute shortage of trained specialist manpower to provide mental healthcare to those who require it. The existing manpower can only provide care for one third of the mental health needs. Furthermore, 70% of this manpower is inequitably concentrated in urban areas while 70% of the Indian population lives in the villages. This mismatch is a great public health challenge and there is an urgent need to look at innovative ways to overcome this barrier to access. Affordable technology, which is easily accessible in India today, might provide the turning point in the field of mental healthcare delivery. In this project we plan to use videoconferencing technology to provide mental healthcare for patients attending primary care clinics. We plan to discover whether such an innovation is feasible and safe to deliver, acceptable to the various stakeholders and has a positive impact on the mental health of the people. Videoconferencing facilities will be established between District Hospital and Primary Health Centres, where most patients access health care. Patients with Depression, Alcohol use disorders and Severe mental illness will be identified by research workers, who will be offered consultations with a psychiatrist based in the District Hospital via videoconferencing. Medication and follow up services will be provided in the primary health centres. Before-after assessment will measure change in symptoms and disability level. Since the service is delivered in the community we expect better compliance rates. In-depth interviews will be conducted with all stakeholders including service delivery agents, patients and their families to determine the acceptability of tele-psychiatry. Demonstrating that delivering mental health care through tele-psychiatry is feasible and acceptable has significant policy implication. Tele-psychiatry can then play a transformational role in mental health delivery in low resource settings.

Technical Summary

The treatment gap for mental illness is as large as 75% in India. One of the reasons for that is the severe deficit of trained mental health professionals to deliver evidence based treatments. This proposed proof of concept study aims to increase access to mental healthcare through the innovative use of tele-psychiatry. We aim to offer remote consultation services using tele-psychiatry for those identified with depression, alcohol use disorders and severe mental illness in primary care attendees. The package of care will be developed through a formative phase using mixed methods; we plan to then test whether tele-psychiatry is feasible, acceptable and safe through an uncontrolled treatment cohort with a before-after design. Assessments at three months will evaluate key outcomes such as symptom burden, compliance rates and disability levels along with user and service provider experiences. If this test is positive, we will then plan an RCT (to follow from this project) to test this more rigorously.

Planned Impact

Tele-psychiatry, if found to be feasible and effective, will have major policy implications for generalising and improving psychiatric care in India. 70 million people in India are in need of mental health (MH) care and, using the traditional models of healthcare delivery, the existing MH manpower can provide it to only 29% of this population. Scarcity of MH resources in primary care leads to people with MH problems not being identified, inadequately treated or being referred to distant tertiary care centers, the remoteness of which precludes sustained follow up care. The use of technological innovation as proposed in our research project will help mitigate this public health crisis. At the end of this project we will have evidence to know whether it is feasible to integrate TP into public health systems. If feasible, this model will allow large sections of population to access scarce MH resources thus having a multiplier effect. Our research thus has the potential to impact the lives of millions of people who are in need of MH care in India and also inform mental healthcare delivery systems in similar settings in other LMIC. Further, if this project provides preliminary evidence of both feasibility and effectiveness, this could support replication in other settings especially where there is limited mental health care. Tertiary care institutions could use this model to provide satellite mental health clinics to increase penetration and coverage of mental health services.
Besides psychological morbidity, people with mental illness also have high medical morbidity and mortality compared to the general population. Providing access and care to timely and sustained mental healthcare within an environment of primary health system will directly impact the overall health as well as quality of life of those with MH problems. As a society this has significant social, health and economic benefits.
Government of India through its National Mental Health Program (NMHP) has been providing MH care to some districts in the country; although this programme started in 1980, the NHMP has so far been able to provide coverage to only 127 out of 626 districts across the country. Among others, one of the main reasons for the poor success of this program has been MH manpower shortage. Integrating TP into the NMHP would enhance the scale and reach of the program. Delivery of MH services through primary care is a goal envisaged in the National Mental Health Policy. TP may play a pivotal role in realising this goal.
At a local level the small state of Goa (current location of the study) would be an ideal case study to demonstrate the integration of TP into public health system, and we plan to recruit the State Government as our partner in implementing a TP programme following the next phase of the research: the definitive RCT.
We also plan to engage the national government in the definitive RCT which will follow from this present feasibility study. The outcome of our research project would thus have further impact by way of translational research; providing a promising option in a country with a looming MH crisis.

Publications

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Title Project introduction video 
Description We created a video recording of the study psychiatrist in which he describes the background of the project, give general information on mental health, and information on what does the treatment in the project includes. It is a brief video which was recorded and included in the study protocol during recruitment stage. Once a participant gives his/her consent to be a part of the study, the health assistants shows this video to them in order to introduce them to the doctor himself as well as give them a sense of familiarity with the doctor for the next time when they come for the first tele-psychiatry session. 
Type Of Art Film/Video/Animation 
Year Produced 2019 
Impact During the recruitment stages, we were facing a significant proportion of drop-outs from the study. After careful discussion among the research group, it was suggested that one of the primary reasons for this high drop-out rate is that when the patients are recruited till the time when they receive their first tele-psychiatry session, the patient don't seem to have a connect with the doctor. A video of the doctor himself telling the patients of what the treatment will include will help patients to connect with the doctor and help us reduce the drop-out rates in the study. We got a positive response from the patients regarding the video and patients were able to connect with the doctor better when they saw him for the first time during the tele-psychiatry session. 
 
Description 1. The preliminary analysis have shown a positive response towards tele-psychiatry as a platform for delivering the psychiatric treatment to the study participants. The participants gave their feedback on the treatment package that they don't feel much difference in talking to a doctor over a screen or in-person as long as they are receiving regular care.
2. The preliminary results show that the impact of intervention is positive on various outcomes which can be seen by the statistical significant reduction in the average scores of GHQ and WHODAS 2.0 from 5.9 to 3.4 and 23.75 to 19.25 respectively.
3. The initial analysis of the results show that counselors play an important role in the treatment package and act as a bridge between the doctor and the patient for effective communication. The presence of a counselor on the ground is found to be essential for regular follow-up with the patients. Apart from this, the counselling sessions provided as a part of treatment play a big role in improved outcomes and have been recognized by both the patients and the doctor.
4. We found that there is a huge gap in access to medicines for mental health problems in the government healthcare system and as a result the patients have to buy these medicines as a part of their out-of-pocket expenditure.
5. Preliminary analyses have shown a positive influence of home based care (provided as a part of the treatment) on the health seeking behavior of the participants.
Exploitation Route The outcomes of this feasibility and acceptability study will inform the design of a treatment package to be tested in a Randomized Controlled Trial. The intervention will be tested and a standard package of care will be generated which can be scaled-up across the state of Goa in the primary healthcare centers (which are the first point of contact for the population to receive care). The intervention, if implemented, will use the resources of the the government healthcare system including the staff (who can be trained), equipment and medicines to provide these services and improve the access of psychiatric services in the state. Later, this can be replicated nationally to different regions to be tested and implemented.
Sectors Communities and Social Services/Policy,Healthcare

 
Title Capacity to consent protocol 
Description We developed a checklist for assessing the capacity of the patients to give their consent during the recruitment process. All persons in the age group of 18 years or above are presumed to have capacity to give informed consent to research. In the absence of any indication to the contrary, such capacity can be assumed without further evaluation or documentation. In accordance with standard clinical procedures, a subject may be determined to lack capacity if the individual is unable to understand and appreciate the nature and consequences of enrolling in research, including the benefits and risks, the meaning of personal participation in the study, and cannot reach or communicate an informed decision. We decided on certain criteria to decide whether the person can be assessed for the capacity to consent. Based on this criteria, the health assistants will implement a checklist following the procedure for giving information to the participant but before taking the consent. If the participant is able to fulfill all the items on the checklist, he/she will be said to have the capacity to give consent. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2019 
Provided To Others? No  
Impact The project is catering to the population who are suffering from common and severe mental health disorders and providing them with psychiatric treatment. While most of the participants we recruit suffer from common mental health disorders like depression, we have come across a number of participants who are suffering from severe mental health disorders such as Dementia. The nature of the mental health problems sometimes render these patients to be unable to make an informed decision about themselves. Hence, this capacity to consent protocol is important to identify people who might not have this capacity to give their consent to be a part of the study. Those who do not have the capacity will not be included in the study but will be referred to a healthcare facility. 
 
Title IMPACT Informed consent study Questionnaire 
Description Informed consent is the process by which potential participants are given the opportunity to make informed decisions about their participation in research. Yet, in many cases the participant does not fully understand the study before signing a consent form. A number of interventions have focused on modifying the typical informed consent process with the goal of increasing participants' comprehension of the information disclosed. In two systematic reviews of studies testing patient comprehension of the information conveyed in the informed consent process, interventions showed mixed results. However, several studies showed that modifications to the consent process such as adding multimedia elements or simplifying forms caused significant improvements in patient understanding. In addition, these modifications can decrease anxiety after consent, increase satisfaction and tolerability with the consent process, help increase retention of knowledge, and increase willingness to participate in the study. With some simple changes, the informed consent process can become much easier for participants to understand. We have incorporated a change in the informed consent process for IMPACT by including a video describing the study along with the usual paper consent form and explanation. The IMPACT video visually depicts the process of joining the IMPACT study and receiving a tele-psychiatry session, potentially allowing the participant to more fully understand the service they will receive as part of the study. In order to determine whether the addition of a video to the informed consent process significantly increases participant understanding, we have followed the usual consent process (an in-person explanation of the study along with a paper form) for the first three months of IMPACT, and then add the video component for the last three months of IMPACT. In each case, the consent session will be immediately followed by a short questionnaire (about 5 minutes) testing participant comprehension of the information discussed. The health assistant will administer the 13-item close-ended questionnaire, which has been derived from the UBACC, a reliable and valid short form adaptation of the MacArthur Competency Assessment Tool for Clinical Research (MacCAT-CR), widely accepted as the best assessment tool for measuring capacity to consent to research, as well as from tools used in several other informed consent interventions. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The informed consent process is a cornerstone of research. Yet, the academic community often spends little time on this important process and conveys information about the study or trial at a level too far above the understanding of the participant. As an innovator in this field, Sangath should be a leader in ensuring participants fully understand the study they are agreeing to participate in. Through this substudy, we can begin to understand how well the usual informed consent process works and whether simple enhancements can significantly improve participant comprehension. This study could lay the groundwork for future research on improving the informed consent process and lead to possible changes to usual consent procedures in projects running in Sangath and elsewhere. 
 
Title Qualitative questionnaire for outcomes assessment 
Description We developed a topic guide for recording the outcomes of the treatment intervention at the end of 3 months of the recruitment period from participants. This topic guide is aimed at recording the experiences of the participants of the intervention received as well as their perspectives on the acceptability and feasibility of the intervention. The topic guide is a qualitative outcome measure which consists of various sections focusing on different details including the details on recruitment, feedback on counselors and the tele-psychiatric sessions, and feasibility and acceptability of the intervention.The topic guide is administered to all the patients who consented for treatment along with those who dropped out before first session to record the reasons for dropping out. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2018 
Provided To Others? No  
Impact The topic guide helped in capturing the experiences of the participants on the intervention and in capturing the feedback on the primary outcomes of feasibility and acceptability from the participants. 
 
Title Electronic Records Management system 
Description We have developed a web-based platform to conduct the tele psychiatry service. This web interface allows video conferencing, and enables us to: 1) To maintain medical records (which are accessible to relevant project team members), 2) Have direct access to session notes and case history notes maintained by the psychiatrist and health assistant for every session, 3) Obtain reports on the relevant treatment indicators, 4) Maintain a schedule of appointments for each patients, 5) Allows the psychiatrist, patient and health assistant to chat (via call/message), 6) Allows the doctor to write a digital prescription which is printed at the tele psychiatry clinic. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact The ERM system allows for 1) improved sharing and accessibility to data across project team members located in different parts of the research site, 2) secure cloud server storage of the data, and 3) negates the possibility of physical damage of the data. 
 
Description Directorate of Health Services, Government of Goa 
Organisation Government of Goa
Country India 
Sector Public 
PI Contribution We provided mental health care via tele-psychiatry to the patients who visit Primary/ Community Healthcare Centers (PHCs/CHCs) where we have established our center. A comprehensive package of care was offered wherein the patient had access to: a psychiatric intervention offered by the psychiatrist (along with prescription of medicines) and psychological counselling offered by the trained Health Assistants who also facilitated the tele-psychiatric process. The Health Assistants are trained to offer step-wise care for Depression and Alcohol- related problems. They also provide basic counselling under the supervision of the psychiatrist. Depending on the need of the patient, the care was provided at the Clinic or at their home in different parts of Goa. The Health Assistants maintain regular contact with the patient to monitor treatment compliance and mitigate side-effects of medication.
Collaborator Contribution The management of the three PHCs/CHCs at Bicholim, Pernem and Sanquelim (all in Goa) provided our team a space to set up a tele-psychiatry Clinic. The doctors at the hospital regularly refer patients to our clinic, encouraging patients to seek mental health care.
Impact The patients are recruited from the PHCs/CHCs and are provided with tele-psychiatry services.
Start Year 2019
 
Description Mental Health Clinic at Primary Care Facility in Mormugao, Goa 
Organisation Mormugao Port Trust
Country India 
Sector Private 
PI Contribution * We provided mental health care via tele-psychiatry to the employees of the Mormugao Port Trust and their families. A comprehensive package of care was offered wherein the patient had access to: a pharmacological and psychiatric intervention offered by the psychiatrist and to psychological counselling offered by the trained Health Assistants who facilitated the tele-psychiatric process. * The Health Assistants are trained to offer step-wise care for Depression and Alcohol- related problems. They also provide basic counselling under the supervision of the psychiatrist. * Depending on the need of the patient, the care was provided at the Clinic or at their home in different parts of Goa. * The Health Assistants maintain regular contact with the patient to monitor treatment compliance and mitigate side-effects of medication.
Collaborator Contribution * The management at the Mormugao Port Trust Hospital provided our team a room to set up a tele-psychiatry Clinic. * The pharmacy at the hospital provides medications free of cost to the employees of the Port Trust. The same facility was extended to the medications prescribed by our study psychiatrist at no cost to the patients. * The doctors at the hospital regularly refer patients to our clinic, encouraging patients to seek mental health care.
Impact * Significant contribution to the case load in the case series
Start Year 2018
 
Description Schizophrenia Research Foundation (SCARF), technical partner 
Organisation Schizophrenia Research Foundation
Country India 
Sector Charity/Non Profit 
PI Contribution The research team visited the sites of SCARF, which has a scaled up a tele psychiatry service in Chennai. The purpose of this visit was to share experiences of the SCARF scale up, exchange knowledge and gain input on testing a similar model in the formative work in Goa.
Collaborator Contribution SCARF has long-standing experience in implementing community health programs in urban and rural areas of the state of Tamil Nadu, in Southern India. The members of the organisation shared their expertise and experience of conducting tele psychiatry services, and helped formulate the protocol for the formative work in Goa.
Impact 1. The visit to the SCARF site led to the refinement of the tele psychiatry service which is being developed and evaluated in Goa.
Start Year 2017
 
Description Study psyhiatrist 
Organisation Antarman
Country India 
Sector Hospitals 
PI Contribution Our research team hired Dr. Akshada Amonkar, who is a consultant psychiatrist at Antarman, a local private mental health clinic, as the second study Psychiatrist. We recruited a second psychiatrist in order to manage the increasing patient case load in the Primary Healthcare Centers. She volunteered to be a part of the project and offer her services at no charge.
Collaborator Contribution Dr. Akshada Amonkar volunteered her services for free for nearly 6 months of the project's operation and is continuing be be associated with the project.
Impact The entire research study is contingent upon the psychiatric consultation services offered by Dr. Akshada Amonkar, along with Dr.Ravindra Agrawal, as we are able to connect the people of Goa, who live in different parts of the state, to a psychiatrist who is based in the state capital. Patients who are nearly 50 km away from the psychiatrist have been able to interact with her and avail her services.
Start Year 2019
 
Title IMPACT 
Description We are investigating the acceptability and feasibility of mental health care offered via video and tele-conferencing. 
Type Therapeutic Intervention - Psychological/Behavioural
Current Stage Of Development Initial development
Year Development Stage Completed 2019
Development Status Under active development/distribution
Impact The tele-psychiatry session is facilitated by Health Assistants that happen to be trained counsellors. We have observed that a collaborative relationship has developed between the study psychiatrist and the Health Assistants such that the patients are now receiving a comprehensive package of care that includes a pharmacological intervention and psychological counselling, maintained by regular monitoring and maintenance. 
 
Title Sangath IMPACT 3 AM Therapy: A compact web-platform that improves access to mental health care using tele psychiatry 
Description The e-platform that we developed exclusively for IMPACT, has the following features: 1. Appointment scheduler: The platform enables the user (patient/health assistant on one end and the therapist on the other) to create their own profile and book appointments for sessions with the psychiatrist. The platform sends an auto generated email to both the user and the psychiatrist when an appointment is confirmed and booked. It also lists the number of sessions conducted and scheduled, with detailed notes, date, time and duration of the sessions. 2. Electronic management of records: The platform enables the psychiatrist and health assistant to maintain medical records of the patient electronically. The records are saved on a password-protected cloud server to maintain data security and confidentiality. It also allows the health assistants to scan and upload any previous medical records while the session is being conducted so that the therapists can review them immediately. 3. Video conferencing: The platform allows for video conferencing, and also has an in-built chat messaging service. The video sessions are auto recorded and securely stored on a cloud server. 4. E-prescription: The platforms enables the psychiatrist to prescribe medication/s to the patient from this platform, and the prescription is printed at the user/health assistant's end. 
Type Of Technology New/Improved Technique/Technology 
Year Produced 2018 
Impact If feasible, this model will allow large sections of population to access scarce mental health resources thus having a multiplier effect. The technology used in the project has the potential to impact the lives of millions of people who are in need of mental health care in India and also inform mental healthcare delivery systems in similar settings in other low-and-middle-income countries. [Information on URL given below: this page is password protected and we cannot share the password as it would enable access to patient data] 
URL http://www.sangathimpact.com
 
Description Dissemination meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Activity: We organized a dissemination meeting with the staff of one of the recruitment sites- Mormugaon Port Trust (MPT) to present the findings of the program in that site.

Objectives: To disseminate the results of the project with the hospital staff and share a closure report.

What we did: We organized a presentation with the hospital staff at MPT to present the results of the project relating to that site and showed them the impact of the project in MPT. We also shared a printed report with the staff for their reference.

Outcomes: Around 40 hospital staff attended the meeting and discussed the project and the results with the research team and gave positive feedback on the project at the site.
Year(s) Of Engagement Activity 2020
 
Description Health and Wellness camps 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Introduction: We organized a series of 3 Health and Wellness camps in the month of April 2019 for the general public at one of the recruitment sites for the project- Mormugaon Port Trust (MPT).

Objective: The objective of the camps was to improve our reach to a wider population for creating awareness about mental health and addictions in the workplace.

What did the camp include: The camps were organized in MPT premises where the employees of the organization were invited to attend the event. The event included a plethora of engagement activities for the participants including:
1. An awareness talk on general mental health
2. Group activities for creating more awareness and for skill building among participants for identifying someone at workplace with mental health problems and the probable helping alternatives.
3. Interactive games and sessions on information about mental health.
4. Screening of the participants for recruitment in the study.

Outcome: We were able to reach out to approximately 100 participants in the course of these events. These participants were screened for the program using standardized questionnaires and the ones who were positive and consented were followed-up for treatment. We also published and shared a report with the organization giving them recommendations on improving workplace wellness.
We also came across a positive change in the views of the participants related to mental health and their own role in helping themselves and others.
Year(s) Of Engagement Activity 2019
 
Description Networking session for PHC staff 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Activity: We organised a presentation at three Primary/Community health centers (PHCs/CHCs) in Goa to introduce the study before starting the recruitment in these sites.

Objective: The Objective of these presentations were to create awareness about the project among the staff of the health centers and urge them to help us in recruitment and reaching to a wider population through referrals.

What we did: We introduced the study with objectives and the procedures that we will be implementing in the PHCs. We also distributed awareness materials to the staff for further referrals. We reached out to individual practitioners in the health centers as well to create awareness about the project and refer any patients that they feel require the services.

Outcome: Our presentation and continued efforts helped in creating awareness among hospital staff and helped us in recruitment by referrals.
Year(s) Of Engagement Activity 2019
 
Description Networking session for college students 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Undergraduate students
Results and Impact The project team members delivered talks at colleges focussed on mental health, mental health problems, and help-seeking, using audio-visual materials.
Year(s) Of Engagement Activity 2018
 
Description Networking session for community gatekeepers (community health workers) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other audiences
Results and Impact Our project team organised regular networking meetings with various stakeholders in the community. The purpose of these meetings was to build awareness on mental health and mental illness, and the services offered in the IMPACT project. Some stakeholder groups which were a part of these meetings were: 1) lay public, 2) Integrated Child Development Services (which falls under the remit of the Ministry of Women and Child Development*) workers who are also called community health workers, and 3) self help groups such as Alcoholics Anonymous. *(The Integrated Child Development services is a flagship program of the Government of India to improve maternal and child health outcomes at the village level).
Year(s) Of Engagement Activity 2017,2018
 
Description Networking session for community gatekeepers (self help groups) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Our project team organised regular networking meetings with various stakeholders in the community. The purpose of these meetings was to build awareness on mental health and mental illness, and the services offered in the IMPACT project. Some stakeholder groups which were a part of these meetings were: 1) lay public, 2) Integrated Child Development Services (which falls under the remit of the Ministry of Women and Child Development) workers, and 3) self help groups such as Alcoholics Anonymous.
Year(s) Of Engagement Activity 2017,2018
 
Description Networking session for medical professionals practising in the research site 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Dr Abhijit Nadkarni delivered a session on the importance of the project, its scope and opportunities for referrals into to the tele psychiatry service.
Year(s) Of Engagement Activity 2018