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A retrospective chart review of clinical profile of patients utilizing telepsychiatry services during COVID-19 pandemic at a tertiary care centre


 Department of Psychiatry, PCMC's PGI YCM Hospital, Pimpri, Pune, Maharashtra, India

Date of Submission24-Nov-2021
Date of Acceptance20-Apr-2022
Date of Web Publication04-Jan-2023

Correspondence Address:
Manjeet S Santre,
Department of Psychiatry, PCMC's PGI YCM Hospital, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_241_21

   Abstract 


Background: Telepsychiatry as a vehicle for delivering mental health services became evident due to outburst of mental health issues during coronavirus disease 2019 (COVID-19) pandemic and it was found useful in providing mental health care while maintaining social distancing norms and lockdown guidelines. Aim: To study clinical profile and sociodemographic profile of patients utilizing telepsychiatry services during COVID-19 pandemic. Materials and Methods: Total 70 old follow-up and 42 new patients were consulted on telepsychiatry, as per Indian Telepsychiatry Operational Guidelines 2020 given by NIMHANS, during 1st and 2nd wave of COVID-19 pandemic from June 2020 to May 2021. Sociodemographic and clinical data was extracted from all patients who utilized our telepsychiatry services in a semi-structured proforma for retrospective analysis using frequency tables. Results: A total of 102 patients benefitted from our telepsychiatry services. Out of which, 66.7% were adults between 21 and 40 years, with slight female preponderance (55.9%) and majority (78.4%) participants living in urban areas. About 70.6% were graduates with 41.2% participants belonging to either private or public service. One-third of the participants were IT professionals. Around 59.8% participants had past history of psychiatric illness and 40.2% had new onset illness. The diagnostic distribution included depressive disorder (28.4%), anxiety disorder (26.4%), psychotic disorder (21.6%) and obsessive compulsive disorder (9.8%) and others (13.8). Conclusion: Telepsychiatry has emerged as an important consultation modality in this COVID-19 pandemic. Its future use seems promising, which will require mental health practitioners to develop their skills while interacting digitally, conducting assessments, and therapy.

Keywords: COVID-19, mental health, retrospective, telepsychiatry



How to cite this URL:
Raidurg KA, Wadgaonkar GP, Panse SN, Santre MS, More JB, Karad AV. A retrospective chart review of clinical profile of patients utilizing telepsychiatry services during COVID-19 pandemic at a tertiary care centre. Ind Psychiatry J [Epub ahead of print] [cited 2023 Jan 27]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=367029



Telepsychiatry, the application of telemedicine in the field of psychiatry, is defined as the use of electronic communication and information technologies to provide or support clinical psychiatric care from a distance.[1] Importance of telepsychiatry as a vehicle for delivering mental health services is becoming increasingly relevant as the burden of psychiatric illnesses is increasing[2] and human resources are consistently inadequate to handle the same.[3] Psychiatric illness is the second leading cause of disease burden in the recent Global Burden of Diseases, Injuries, and Risk Factors Study, and it is estimated to affect about one in every seven individuals.[4]

Epidemiological studies in India, report prevalence rates of mental disorders to be 13.7%, with only 0.75 Psychiatrists per 1,00,000 populations.[5] About 83% of patients do not receive basic evaluation and treatment for any mental disorder in India.[4] Apart from scarcity of mental health professionals, other possible reason can be inadequately trained primary healthcare professionals, who seem reluctant or unable to evaluate, diagnose, or treat common mental health disorders. Thus, telepsychiatry seems like a promising approach especially for a developing country like India, with limited resources.

Telepsychiatry, both in synchronous and asynchronous modalities, can help in reducing patient's symptomatology, increasing regular follow-up and improving patient's adherence to treatment, given the chronicity of mental illnesses. Its covert and confidential nature also aids to overcome stigma and discrimination about mental disorders. Studies have shown telepsychiatry to be similar to face-to-face care with no difference in accuracy or satisfaction between the two modalities.[6]

During the coronavirus disease 2019 (COVID-19) pandemic, mental health of individualshas been as much affected as physical health, if not more, possibly because of the unexpected arrival of the illness, its explosive and rapidly spreading nature and most importantly uncertainty about the treatment and prognosis. Also, psychiatric patients were more likely to report moderate to severe worries about their physical health due to the concern that they might have unknowingly contracted the virus and perhaps less effective coping strategies.[7] In spite of the escalation of mental health issues, mental health care was immensely affected at the start of COVID-19 pandemic due to strict lockdown, fear of acquiring infection from visiting hospitals and mainly because maximum health resources were being directed towards treating COVID-19 affected patients. The paucity of mental health care was direly felt during these times. Thus, COVID-19 has served as a catalyst, accelerating the adoption of telepsychiatry across the country.[8] The commonest telepsychiatry services provided during the COVID-19 pandemic were mainly the psychological first aid, identification of mental health issues, screening of psychological symptoms, and their management.[9]

As our entire hospital was converted to a dedicated COVID-19 hospital (DCH), following the guidelines given by Ministry of Health and Family Welfare for COVID-19 dedicated facilities,[10] routine psychiatric OPD services were withheld with immediate effect from 1st April 2020. As the pandemic continued to run its long course with increasing mental health issues of old and new cases, a need for alternative psychiatric services was felt and hence Telepsychiatry services were started from June 2020 onwards. Here we present the findings of our retrospective study of the patients availing telepsychiatry services during COVID-19 Pandemic. This chart review elaborates the clinical profile of beneficiaries of telepsychiatry services at a tertiary care centre during the COVID-19 pandemic period.


   Methodology Top


Study design

One year retrospective chart review.

Study sample

All new and old follow-up patients who utilized our telepsychiatry services from June 2020 to May 2021, during both 1st and 2nd waves of COVID-19 pandemic, at a tertiary care centre.

Study tools

Diagnostic and statistical manual of mental disorders - 5th edition.

Semi structured proforma for sociodemographic and clinical data.

Modified Kuppuswamy's socioeconomic scale.


   Materials and methods Top


The COVID-19 Hospital Psychosocial Help Centre and telemedicine helpline run by the local municipal corporation were the referral channels through which patients having mental health problems were referred to telepsychiatry on-call psychiatrist. As per Indian Telepsychiatry Operational Guidelines 2020[11] given by NIMHANS, both old follow-up and new patients were consulted on video/audio call by the psychiatrist as per the requirement. Identity of patients was confirmed with Aadhar card copy. Verbal informed consent was obtained as per the guidelines. Sociodemographic data, clinical history details, MSE findings, and old documents wherever available were collected. Provisional diagnosis was given as per DSM-5 diagnostic criteria[12] and standard treatment was prescribed. Prescriptions were provided on WhatsApp messaging application.

The documented data was extracted and filled in a semi-structured proforma for this study with Ethics Committee approval (YCMH/IEC/KAVI/1/67/2021), while maintaining confidentiality of the patients. Socioeconomic strata was calculated using modified Kuppuswamy's socioeconomic scale.[13] The collected data was analyzed using frequency tables. The database managed in our study did not include any identifier or personal data that could be related to the identity of the patients.

Statistical analysis

Statistical Package for the Social Sciences (SPSS) version 27. The descriptive statistics are presented as percentages.


   Results Top


A total of 102 patients benefitted from our services with their sociodemographic and clinical profile as tabulated below in [Table 1] and [Table 2]. Out of which, 66.7% were adults between 21 and 40 years, with female preponderance of 55.9% and 78.4% participants living in urban areas. Among the participants majority (70.6%) were graduates and employed (46.1%). Maximum female participants were homemakers (39.2%). Seventy participants were patients who were taking treatment from our OPD on follow-up basis, rest thirty-two participants had newly approached to our facility. Forty-two participants belonged to either private or public service (41.2%), out of which, around 1/3rd were IT professionals. Twenty two out of all the IT professionals were working from home at the time of evaluation. The commonest diagnosis among those working from home was anxiety disorder (40.9%) and depressive disorder (36.36%). Sixty one participants had past history of psychiatric illness and positive Family history of psychiatric illness was found in (11.7%) participants, predisposing them to current illness with 3 of them having depressive (25%) and anxiety disorders (25%). Twenty-two participants had comorbid medical illness, diabetes mellitus and hypertension being the contributing illnesses. Around nine participants out of 102, had tested positive for COVID-19 at the time of their evaluation.
Table 1: Sociodemographic profile of participants

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Table 2: Clinical profile of participants

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The principal diagnostic categories found were of depressive disorder (28.4%), followed by anxiety disorder (26.4%), psychotic disorder (21.6%) and obsessive compulsive disorder (9.8%). While other diagnosis was of dementia, alcohol dependence syndrome, erectile dysfunction, etc., There was one interesting case belonging to a newer diagnostic entity of novel specific phobia- 'Corona phobia'. While, three cases of anxiety disorder were particularly related to COVID-19 being the precipitating factor. Comorbid addiction was present in (n = 10; 9.8%) of individuals, commonest being tobacco [Figure 1].
Figure 1: Diagnostic categories. *: As per DSM-5 diagnostic manual

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   Discussion Top


To the best of our knowledge, this is one of the first studies in Indian context to describe the clinical profile of patients using telepsychiatry services during COVID-19 pandemic as per literature review. We found that, our telepsychiatry services were mainly utilized by adult age group of 21-60 years (82.3%) with slight female preponderance (55.9%). Services were also utilized by older adults above 60 years, but in a lesser amount (16.7%). The possible explanation could be that older adults may have lower cognitive and digital abilities needed to use technology, limited access to smartphones and internet, which is the basic necessity of telepsychiatry. Females are more vocal about their feelings and are more comfortable expressing their vulnerability.[14] This could be the rationale behind higher number of female participants in our study.

A similar Carribean study done in Dominican Republic by Peralta and Taveras[15] also found that, about 77.8% participants were between the ages of 18 and 59 years and 67.3% of the interventions were requested by women. Forty-six percent of the interventions were requested by people living in the local province of Santo Domingo. Our hospital belonging to urban conditions also had maximum participants from urban areas (78.4%). It can be because of greater probability of access to communication and information.

A nationwide survey done during COVID-19 pandemic in Austria by Traunmüller et al.[16] in general population found that, women and unemployed population experience elevated psychological symptoms, whereas self-employed individuals experienced less psychological impact. Similar to these findings our study had higher number of female patients and less number of people who were self-employed. This finding regarding employment could possibly be explained by the fact that self-employed individuals are routinely confronted with uncertainties in their business and have learnt to cope with it. They have also found that higher level of education was associated with higher psychological distress, similar to our study which had dominance of graduated individuals (70.6%). This preponderance of graduated participants can be attributed their knowledge and awareness about available facilities and having the resources and ability to use it.

Around 1/3rd of all the participants (33.3%) were IT professionals, for which the most likely explanation is having easier access to technology and internet facilities. These findings are similar to a study done in China by Xiao et al.[17] who found overall decreased physical and mental well-being status and an increased number of physical and mental health issues following the transition to work from home (WFH). The extended stay at home mandates during the pandemic may contribute to general depressed and anxious feelings, often leading to changes in routines and eating habits. These changes in physical activities and food intake can interact with other stress related to WFH that together will likely directly impact physical and mental well-being.

The commonest diagnoses in our study, among those working from home were anxiety disorder in nine and depressive disorder in eight participants. Depressive disorder was predominantly seen in seven out of ten females working from home. Our finding aligns with another recent survey conducted in Japan by Sato et al.[18] which noted, that female workers have a higher risk of depression while working from home during the pandemic. This could be because working from home may be more challenging for women, since females tend to be more responsible for household chores and other home activities, and working mothers can feel double the pressure at home due to lack of support with home schooling and taking care of children.[17]

A systematic review done by Banerjee et al.[19] in South Asian countries shows an increased prevalence of nonpsychotic depression, anxiety, somatic concerns, insomnia, and alcohol use disorders in the general population as an impact of COVID-19 and lockdown, mainly due to social isolation, misinformation, social media exposure, fear of infection, Xenophobia and stigma and uncertainty. Our study sample also reflects similar findings with commonest diagnosis of depressive disorder, followed by anxiety disorder, psychotic disorder, OCD and others [Figure 1]. Among anxiety disorders, three patients had 'Post COVID anxiety' symptoms and one patient was a case of 'Coronaphobia', a novel specific phobia. These findings are similar with a cohort study conducted in China by Huang et al.[20] who followed post-COVID patients over a period of six months and found that most patients endorsed at least one symptom, particularly fatigue or muscle weakness, sleep difficulties, and anxiety or depression, severity of which could be correlated with severity of COVID-19 infection. The underlying mechanism of the psychiatric consequences of COVID-19 is likely to be multifactorial and might include the direct effects of viral infection, the immunological response, corticosteroid therapy, ICU stay, social isolation, and stigma.

Even though substance use disorders are one of the major diagnoses in routine OPD in India, there were only three patients who sought telepsychiatry treatment for Alcohol use disorder. A population survey of active drinkers in the UK identified that 21% increased alcohol consumption during the lockdown, while 35% reduced their alcohol intake.[21] Lockdown has caused different behavioural changes on alcohol intake. Although psychosocial distress has been well recognized as a risk of relapse and increased alcohol consumption, the reduction might be associated with decreased financial ability and the decreased availability of on-site alcohol areas (e.g., pubs or bars).[20]

In our study, patients having past history of psychiatric illness (59.8%) were found to be more in number as compared to newly diagnosed individuals. Similar results were found in a review article published by Li et al.[22] which suggests that due to traffic restrictions and isolation measures, patients with severe mental illness faced difficulties to receive maintenance treatment, and ended up in relapse and uncontrollable behavior. Hao et al.[7] in China, also found that psychiatric patients were at a higher risk of displaying higher levels of symptoms of PTSD, depression, anxiety, stress and insomnia, worries about physical health, anger and irritability and suicidal ideation as compared to healthy controls.

Strengths

Our study focused on telepsychiatry, an upcoming modality, and is one of the first studies to describe the findings of telepsychiatry services. The study highlights common disorders encountered in telepsychiatry practice and gives an idea about the accessibility of telepsychiatry services across the population. It conveys the possibility of mental health consequences of WFH in IT professionals, as an effect of the COVID-19 pandemic.

Limitations

Our study being a descriptive retrospective chart review, mainly focused on patient details from a diagnostic and treatment point of view, which could have led to missing out on other important associations. We did not measure severity of disorders using any rating scales. An analytical prospective study design with a larger sample size and predefined objective parameters regarding usefulness of telepsychiatry services can be done in future.

Implications

The clinical and sociodemographic findings of the study can help psychiatrists identify their target population and extend availability of mental health care to rural areas. The study can also be a useful guide for mental health professionals for setting up further telepsychiatry units across the country.


   Conclusion Top


A total of 102 patients benefitted from our services. Telepsychiatry services were more approached by young adults, having higher education, belonging to higher socioeconomic status, residing at urban areas and working in IT profession. Thus, it has emerged as an important consultation modality in this COVID-19 pandemic. Commonest psychiatric disorders treated were depressive and anxiety disorders with significant effect on mental health care of patients with pre-existing mental illness.

Telepsychiatry can also have application in the future, to provide consultation to those, who are unable to avail the in-person services (rural population, old patients, etc.) or when services are needed on a large scale. In a developing country like India, there will be challenges on the path ahead. Mental health practitioners will have to develop their skills while interacting digitally, conducting assessments, and therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Perera SR, Gambheera H, Williams SS. "Telepsychiatry" in the time of COVID-19: Overcoming the challenges. Indian J Psychiatry 2020;62:S391-4.  Back to cited text no. 1
    
2.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015–16 Prevalence, Pattern and Outcomes. Bengaluru: NIMHANS; 2017.  Back to cited text no. 2
    
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Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun 2020;87:100-6.  Back to cited text no. 7
    
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Yellowlees P, Nakagawa K, Pakyurek M, Hanson A, Elder J, Kales HC. Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19. Psychiatr Serv 2020;71:749-52.  Back to cited text no. 8
    
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El Hayek S, Nofal M, Abdelrahman D, Adra A, Al Harthi M, Al Shamli S, et al. Telepsychiatry in the Arab world: A viewpoint before and during COVID-19. Neuropsychiatr Dis Treat 2020;16:2805-15.  Back to cited text no. 9
    
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Telepsychiatry Operational Guidelines – 2020 by Indian Psychiatric Society, & Telemedicine Society of India, Math SB, Manjunatha N, Kumar CN, Basavarajappa C, Gangadhar BN, et al., 2020.  Back to cited text no. 11
    
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Wani RT. Socioeconomic status scales-modified Kuppuswamy and UdaiPareekh's scale updated for 2019. J Family Med Prim Care 2019;8:1846-9.  Back to cited text no. 13
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Banerjee D, Vaishnav M, Rao TS, Raju MS, Dalal PK, Javed A, et al. Impact of the COVID-19 pandemic on psychosocial health and well-being in South-Asian (World Psychiatric Association Zone 16) countries: A systematic and advocacy review from the Indian Psychiatric Society. Indian J Psychiatry 2020;62:S343-53.  Back to cited text no. 19
    
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Kim JU, Majid A, Judge R, Crook P, Nathwani R, Selvapatt N, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol 2020;5:886-7.  Back to cited text no. 21
    
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    Figures

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    Tables

  [Table 1], [Table 2]



 

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