|Ahead of print publication
Profile of patients attending telepsychiatry unit and its usability and satisfaction during pandemic in South India - A retrospective study
Vishnupriya Veeraraghavan1, Krishnan Srinivasan2
1 Department of Psychiatry, Marwari Hospitals, All India Institute of Medical Sciences, Guwahati, Assam, India
2 Department of Physiology, All India Institute of Medical Sciences, Guwahati, Assam, India
|Date of Submission||27-Dec-2021|
|Date of Decision||09-Feb-2022|
|Date of Acceptance||06-Mar-2022|
|Date of Web Publication||12-Sep-2022|
Department of Psychiatry, Marwari Hospitals, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic is an unexpected event that has led to a drastic shift in the practice of medicine around the world. Currently, not many studies are available in India regarding the role of telepsychiatry and no study has been done to assess the usability and satisfaction scores of patients who undergo a telepsychiatric consultation. Aim: The aim of the study is to find the profile of patients attending the telepsychiatry Unit and its usability and satisfaction during the pandemic in South India. Setting and Design: The study was conducted on patients attending telepsychiatric consultation from a period of March 25, 2020, to September 2020. Materials and Methods: A retrospective chart analysis of patients attending telepsychiatry consultation from March 25, 2020, to September 2020 was made. Patients who underwent video consultation were asked to fill out the telehealth usability questionnaire scale through Google Forms. The usability of the telehealth system was assessed using a Likert Scale and scoring was done. Statistical Analysis: Descriptive statistics were used to characterize the study population. Statistical significance was set at P < 0.05. The design and findings of this study were written in accordance with SQUIRE 2.0 guidelines. Results: Twenty-two percent of the study population had consultation for more than fourtimes. Around 78% of the study population had online consultation for less than four times. More than 74% of the study population had video consultation and 26% of the study population had audio consultation. The total average Telehealth Usability Questionaire score was 5.3. The usefulness score summary was found to have a low score of 5.2 ± 0.6, whereas the satisfaction scale summary was found to have the highest score of 5.3 + 0.9. Conclusion: Profile of patients who attend a telepsychiatry unit during the crisis and their satisfaction helped us to know the pros and cons of online consultation and the ways to improve telemedicine in regard to psychiatric patient care. Our study shows that majority are satisfied with telepsychiatric consultation.
Keywords: COVID-19, lockdown, telepsychiatry
|How to cite this URL:|
Veeraraghavan V, Srinivasan K. Profile of patients attending telepsychiatry unit and its usability and satisfaction during pandemic in South India - A retrospective study. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Jan 31]. Available from: https://www.anip.co.in/preprintarticle.asp?id=355944
| Introduction|| |
Coronavirus disease 2019 (COVID-19, also known as 2019-nCoV), a cluster of acute respiratory illness with unknown causes, has occurred in India since January 20201. In addition to physical damage, COVID-19 also has a serious impact on the mental health of the public. Mental health services were affected during the lockdown like consultation-liaison psychiatry services, electroconvulsive therapy, brain stimulation services (such as repetitive transcranial magnetic stimulation and transcranial direct stimulation).,,, The COVID-19 pandemic is an unexpected event that has led to a drastic shift in the practice of medicine around the world. In an effort to balance the ongoing need for patient care with the risks to patient and staff safety, the Center for Disease Control have issued recommendations to consider telephone or video-based alternatives. The World Health Organization defines telemedicine as the “delivery of health care services by all health-care professionals using technology for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries.” Telemedicine guidelines were released on March 25, 2020, by the Board of Governors in India in association with NITIAyog. It defines telehealth as “the delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies.” The various types of telemedicine are live (synchronous), two-way, interactive, audio, and video-based communication between the patient and the clinician to deliver care at a distance. Literature says that information communication tools have been used in the field of Psychiatry since 1960. Telepsychiatry has been used for the treatment of various mental illnesses such as depression, panic disorder, posttraumatic stress disorder, bulimia nervosa, and schizophrenia. Internet-based psychotherapies have also been tried for anxiety disorders. In 2002, the mental health resource mapping in India revealed that 2219 psychiatrists were available nationwide,,,, while the more recent estimates a figure of 2800 – a marginal increase. This is in stark contrast to the estimated requirement of 9696 professionals. Furthermore, the stigma in Indian society, as well as the mental health gap, warrants the need of a telepsychiatric consultation setup. In India, telemedicine commenced in 2000, when Aragonda a village in Andhra Pradesh was linked via a distant telecommunication device set up in Chennai, which was 200 km away. It brought together diverse agencies like the Ministry of Health and Family Welfare, the Department of Space, and the Indian Space Research Organization. Schizophrenia Research Foundation (SCARF) a Nongovernmental Organisation provided teleconsultation to patients among the tsunami in 2004. But soon after the Telemedicine Guidelines release by the Government of India in 2020, telepsychiatry use has widened. Patient satisfaction is a pivotal part in the success of telemedicine programs and is required for telehealth to occupy a vital place in the existing health care strata. Currently, not many studies are available in India regarding the role of telepsychiatry and no study has been done to assess the usability and satisfaction scores of patients who undergo a telepsychiatric consultation.
The aim of the study is to find the profile of patients attending telepsychiatry unit and its usability and satisfaction during the pandemic in South India.
| Materials and Methods|| |
Telemedicine guidelines of India in association with the NITI AYOG were released on March 25, 2020, during the COVID lockdown. According to the guidelines, telemedicine can be practiced through video (Telemedicine facility, Apps, Video on chat platforms, Skype/Face time) Audio (Phone, VOIP, Apps etc.,), Text-based, telemedicine chat-based applications (specialized telemedicine smartphone Apps, Websites, other Internet-based systems) Asynchronous (email/Fax, etc.,). Soon after the guidelines, in our Psychiatry outpatient department, telemedicine option through audio, video, and chat modality was given to patients. Helpline numbers were given to patients. The electronic medical records of patients aged 18–75 years recruited from April 2020 to September 2020 were recruited after obtaining the Ethics Committee Approval.
This study was reviewed by the Institutional Review Board (IRB) and was determined to be a quality improvement initiative that was exempted from further IRB review. A retrospective chart review of telemedicine outpatient encounters by Psychiatry department faculty from March 25, 2020, to September 2020 was conducted. All patients aged 18 years old or older seen via a telephone or video-based encounter were included. Demographic data were collected including age, sex, place, nature of consult, education, occupation, marital status. details about diagnosis, number of online follow-ups, initiation of consult, mode of consult, substance use, comorbid illness, patient preference/reason for online consult. Diagnosis of psychiatric illness was in accordance with the International Classification of Disease's tenth edition. Patients were contacted to complete the patient satisfaction survey and all participants provided verbal consent to participate. Patients who were consulted through video consult alone were contacted and they answered demographic questions and questions regarding telemedicine visit characteristics (platform and device used, whether assistance was required for set up) [Figure 1]. A structured, Likert-scale based survey consisting of the telehealth usability questionnaire (TUQ) was administered. The TUQ scale assesses patient satisfaction with video-based telemedicine visits. The TUQ is a comprehensive and validated survey tool that includes questions in the domains of usefulness, ease of use, interaction quality (effectiveness), reliability, and satisfaction. It address changes in telehealth service delivery, use of different platforms or devices, quality of the telemedicine interaction, and patient satisfaction with the encounter. The TUQ was developed from existing telehealth questionnaires and has good independent content validity and internal consistency. Patients who had online video consultations were requested to fill out the TUQ scale which was prepared using Google Forms.
Descriptive statistics were used to characterize the study population. Data were analyzed with Mann–Whitney U test. Statistical significance was set at P < 0.05. The design and findings of this study were written in accordance with SQUIRE 2.0 guidelines.
| Results|| |
The age of the study participants was in the range of 18–71 years. Among the study participants, 32% were male and 68% were female. Among the study participants, 38% were new patients, whereas 62% were follow-up patients. 22% of the study population had consultation for more than four times. Around 78% of the study population had online consultation for <4 times. More than 74% of the study population had video consultation and 26% of the study population had audio consultation. Around 84% of the study population was from Pondicherry and 16% of the study population was from Tamil Nadu. 62% of the study population contacted for self consultation whereas 38% of the population contacted for consultation for family members. About 75% of the study population was having graduate educational qualifications and 25% had educational qualifications at the school level. Around 66% of the study population was not employed, whereas 34% of the study population was employed in various sectors. Eighty-two percent of the study population was married, whereas 18% of the study population was unmarried [Table 1].
Alcohol and nicotine intake is the main substance use from the participants. Diabetes, hypertension, and migraine are the common comorbid illness among the participants. Reason for online consult: Majority of the patient felt its time-saving. 20% said because of lockdown 25% because of stay in other states (lockdown restrictions). Diagnoses of the psychiatric illness were made in accordance with the International Classification of Diseases tenth edition. The most common mental health problem was panic disorder. The least common ones are dissociative seizure, somatoform autonomic dysfunction, nonorganic insomnia, and benzodiazepine dependence. Patients with the diagnosis of panic disorder, adjustment disorder, generalized anxiety disorder, obsessive-compulsive disorder, dissociative seizure, somatoform autonomic dysfunction were grouped as neurotic, stress related, and somatoform disorders. Patients with a diagnosis of bipolar affective disorder, moderate depression with the somatic syndrome, recurrent depressive disorder, severe depression with psychosis were grouped under mood and affective disorders. Schizophrenia paranoid and unspecified psychosis was grouped under schizophrenia, schizotypal and delusional disorders. Benzodiazepine use is categorized under Mental and behavioral disorders due to psychoactive substance use. Nonorganic insomnia was categorized under behavioral syndromes associated with physiological disturbance and physical factors.
Drugs used and their representation
Among antidepressants, fluvoxamine was widely used (36%) and the maximum dose used was 200 mg. The least used antidepressant was buspirone (2%) and the maximum dose used was 10 mg.
Among antipsychotics, quetiapine was the widely used drug (87%) and a maximum dose of 200 mg was used. The least prescribed drugs were aripiprazole and haloperidol (1%), each with a maximum of 2 mg.
Among mood stabilizers, lithium (71%) was the commonly prescribed drug with a maximum dose of 600 mg and the least prescribed was olanzapine + fluoxetine combination.
Among benzodiazepine, both clonazepam and etizolam had an equal contribution of 50% and the maximum dose prescribed was 0.5 mg in both the category.
| Discussion|| |
Telemedicine has gained importance over the past several years and even more so during the COVID-19 pandemic. Telemedicine provides an option for providers and patients to stay connected without getting exposed to virus. Previous research has highlighted that telepsychiatry is cost-effective. E-mail and telephonic consultations were identified as cheaper modes of telemedicine. In our study also patients gave higher score to questions under the usefulness subdivision replicating the results of previous studies. The commonest difficulty which was faced in our study was the network problem especially the connectivity in rural areas. Video call disruptions were encountered. This is in accordance with the previous research by Hilty et al. Accepting telepsychiatry as a substitute to in-person consultation was another challenge as this study was done in the primitive budding stage of telepsychiatry in India.
The TUQ was used to assess the usability of this telehealth system with patients using a Likert scale to rate responses:
- Strongly disagree
- Somewhat disagree
- Somewhat agree
- Strongly agree.
The total average TUQ score in our study group was 5.3. Previous telemedicine studies have revealed average total scores of 6.01. All 4 subheadings in TUQ had an average score above 5 and this shows better satisfaction across all domains of a teleconsultation.
In our study as per the International Classification of Diseases-10, patients were categorized as neurotic and stress related, Schizophrenia, mood and affective disorders, Mental and behavioral disorders due to the use of psychoactive substances, and behavioral syndromes associated with physiological disturbance and physical factors. Except for the Behavioural syndromes associated with physiological disturbance and physical factors cluster, patients under the other four clusters were found to have a higher satisfaction with the teleconsultation evident by the negative correlation with the TUQ scores.
In our study, the TUQ usefulness score summary was found to have a low score of 5.2 + 0.6 whereas the satisfaction scale summary was found to have the highest score of 5.3 + 0.9. Previous studies of patient satisfaction with telemedicine across medical specialties have shown that patients are generally satisfied., The majority of patients reported high satisfaction with telehealth visits, with average scores higher than five in the majority of components of the survey. This finding echoes the results of previous telemedicine patient satisfaction. Patients also reported that telemedicine increased accessibility to health care services, saved time, and met their health care needs. Patients also frequently mentioned about cost-effectiveness [Table 2].
Among the individual items, “Telehealth improves my access to healthcare services” had the lowest score. This may be due to the fact that this study was done during the incipient stage of telemedicine in India. Furthermore, initially people were arduous to use telemedicine mode. Item 4 “It was simple to use this system” had the highest score among all other items. It might be due to the reason that the teleconsultation application option was given to the patients themselves. User-friendly applications such as Whatsapp, Google meet were widely preferred by the patients.
The reliability subsection, designed to assess if the telemedicine visit is as reliable as in-person service, had low score range. The range in this section was 3–7. This is in accordance with the previous studies., This could be explained by the same phenomena observed by the present study or related to other studies that introduced patients to new software that necessitated specific computers and fast internet speeds, which participants did not have. Patients found to have higher satisfaction with interaction quality, indicating that the telemedicine visit was effective for provider-patient interactions. Patients indicated that they were able to both easily talk to (Item 11) hear (Item 12), and see (Item 14) the physician. The score range for this group was also high (4–7) this is in contrast to previous work that has found the patient's ability to hear the physician is often poor., The most commonly reported issue with telemedicine visits was an issue with the audio. Once resolved, patients highly rated the quality of the audio component. Previous consumer market surveys have demonstrated concerns around the security of health information and the quality of care delivered through telemedicine modality. Such concerns were not found in the patients of this study. This shift could be due to increasing patient utilization and comfort with technology as it becomes more prevalent and vital during this pandemic. So far only few telemedicine-related studies have been done, that too in specialization fields like otorhinolaryngology. Studies done in other fields have small sample size, used single measures of satisfaction, have nonvalidated surveys or scales with poor validation. Studies assessing satisfaction in telepsychiatry are very rare.
| Conclusion|| |
Telemedicine is an increasingly important option for patient care during COVID-19 with implications for medical practice beyond the end of the pandemic. Telemedicine is an effective means to conduct a variety of outpatient counter types with high patient satisfaction, including new patient, return, and follow-up visits.
The results of this study are certainly influenced by the social context and implications of the COVID-19 pandemic. Additional limitations of this study include selection bias and response bias of those completing the survey. Only patients with video-based telemedicine visits were contacted to participate. Patients who did not have access to these platforms couldn't be recruited. Notably, successful use of a telemedicine platform requires a basic knowledge of technology and smartphone accessibility. Thus, this study could not capture the results of patients who due to socioeconomic status or low technology literacy were unable to have a video-based telemedicine visit. This study also yields to some of the inherent issues with telemedicine research. Generally, patients report high levels of satisfaction with their received health care.
The challenges in patient care created by COVID-19 have enabled more rapid integration of telemedicine into medical practice. The increased emphasis on telemedicine visits will likely shape the future of medicine due to increasing familiarity with telemedicine by both patients and providers. Many patients in the present survey stated they would continue to use telemedicine even after a return to normalcy and is evident in our results that nearly 22% of the population consulted the psychiatrist in the online mode more than once. Furthermore, training and education in telemedicine will need to be augmented at all levels of medical education as currently there is a lacuna in medical education for the same.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
COVID 19 Public Health Emergency of International Concern (PHEIC) Global research and Innovation Forum: Towards a Research Roadmap. Geneva: WHO; 2020. p. 1-7.
Bojdani E, Rajagopalan A, Chen A, Gearin P, Olcott W, Shankar V, et al.
COVID-19 pandemic: Impact on psychiatric care in the United States. Psychiatry Res 2020;289:113069.
D'Agostino A, Demartini B, Cavallotti S, Gambini O. Mental health services in Italy during the COVID-19 outbreak. Lancet Psychiatry 2020;7:385-7.
Kavoor AR. COVID-19 in people with mental illness: Challenges and vulnerabilities. Asian J Psychiatr2020;51:102051.
Xiang YT, Li W, Zhang Q, Jin Y, Rao WW, Zeng LN, et al.
Timely research papers about COVID-19 in China. Lancet 2020;395:684-5.
Telematics WGC on H. A Health Telematics Policy in Support of WHO's Health-for-All Strategy for Global Health Development: Report of the WHO Group Consultation on Health Telematics. Geneva: Telematics WGC on H; 1998.
Eleanor Layfield BA, Triantafillou V, Prasad A, Deng J, Shanti RM, Newman JG, et al
. Telemedicine for head and neck ambulatory visits during COVID-19: Evaluating usability and patient satisfaction. Head Neck 2020;42:1681-9.
Malhotra S, Chakrabarti S, Shah R. Telepsychiatry: Promise, potential, and challenges. Indian J Psychiatry 2013;55:3-11.
] [Full text]
García-Lizana F, Muñoz-Mayorga I. What about telepsychiatry? A systematic review. Prim care companion. J Clin Psychiatry 2010;12:2-6.
Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.
] [Full text]
Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian J Psychiatry 1998;40:149-57.
] [Full text]
Ganguli HC. Epidemiological findings on prevalence of mental disorders in India. Indian J Psychiatry 2000;42:14-20.
] [Full text]
Agarwal SP, editor. Mental Health: An Indian Perspective 1946-2003. In: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. New Delhi: Elsevier; 2004.
Naskar S, Victor R, Das H, Nath K. Telepsychiatry in India – Where do we stand? A comparative review between global and indian telepsychiatry programs. Indian J Psychol Med 2017;39:223-42.
] [Full text]
Langbecker D, Caffery LJ, Gillespie N, Smith AC. Using survey methods in telehealth research: A practical guide. J Telemed Telecare 2017;23:770-9.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25:986-92.
Hilty DM, Nesbitt TS, Marks SL, Callahan EJ. Effects of Telepsychiatry on the Doctor-Patient Relationship: Communication, Satisfaction, and Relevant Issues. Prim Psychiatry 2002;9:1-10.
Forbes RC, Solorzano CC, Concepcion BP. Surgical telemedicine here to stay: More support from a randomized controlled trial on postoperative surgery visits. Am J Surg 2020;219:880-1.
Serwe KM, Hersch GI, Pancheri K. Feasibility of using telehealth to deliver the “powerful tools for caregivers” program. Int J Telerehabil 2017;9:15-22.
Yulzari R, Bretler S, Avraham Y, Sharabi-Nov A, Even-Tov E, Gilbey P. Mobile technology-based real-time teleotolaryngology care facilitated by a nonotolaryngologist physician in an adult population. Ann Otol Rhinol Laryngol 2018;127:46-50.
Rimmer RA, Christopher V, Falck A, de Azevedo Pribitkin E, Curry JM, Luginbuhl AJ, et al.
Telemedicine in otolaryngology outpatient setting-single Center Head and Neck Surgery experience. Laryngoscope 2018;128:2072-5.
Waseh S, Dicker AP. Telemedicine training in undergraduate medical education: Mixed-methods review. J Med Internet Res 2019;21:e12515.
[Table 1], [Table 2]