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 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 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 Schizophrenia Research Foundation (SCARF), technical partner 
Organisation Schizophrenia Research Foundation
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
 
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 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