INTRODUCTION
Telepsychiatry has been around for decades now.[1] However, it shot to prominence during the pandemic-related lockdown, when face-to-face consultations became largely unavailable. Psychiatric consultations by various modes like voice or video calls, text messages, and emails became a quickly accepted solution.
During the pandemic and in the post-pandemic period, many studies have attempted to evaluate the perception of mental health professionals concerning the advantages and disadvantages of telepsychiatry, current telepsychiatry practices, and the views about the recommendation of the list of medications that can be prescribed over telepsychiatric consultations.[2–4] Studies from across the world that have assessed the attitude of psychiatrists towards telepsychiatric consultations suggest that clinicians mostly believe that telepsychiatry is useful for providing mental health services in remote locations, reducing the consultation waiting time, and facilitating subsequent follow-up and refill of medications. However, most psychiatrists feel that teleconsultations will not replace face-to-face consultations, but can act as an adjuvant mode of care delivery. While the overall attitude towards telepsychiatry has been positive from the clinicians, some of their concerns have been about the extent of a therapeutic relationship that can be established over video consultations, the lack of physical examination, the possibility of online data leakage and loss of confidentiality.[5–8]
Though some of the surveys have attempted to understand the clinicians’ perception of telepsychiatry care, there is a lack of data on the experience and perception of the recipients of telepsychiatry care. A study from the United States that evaluated the experience of 3070 respondents on an 11-item self-report questionnaire reported that the majority of the recipients (82%), reported the experience to be excellent or good, about two-thirds (63.6%) either agreed or strongly agreed that remote treatment sessions were as helpful as in-person treatment, and two-thirds (64.2%) of the participants “agreed or strongly agreed” to consider telepsychiatric care in the future. However, one-fourth (24.6%) reported not feeling connected to their doctor/nurse/therapist as a negative aspect of receiving teleconsultation.[9] A small study from Denmark and Sweden that included 23 patients reported that all the respondents reported a high level of acceptance and satisfaction and were willing to use it again or recommend it to others.[10] A study from Canada that evaluated 230 respondents on a self-report questionnaire found that 89% of the participants were satisfied with the service and 96–99% were satisfied with the equipment and the room.[11] However, it is important to note that two of these three studies were conducted during the pre-pandemic period when the telepsychiatry services were not widely available and patients received the telepsychiatry services from a designated place outside their home.
A study from India evaluated the perception of patients and clinicians about the home-based telepsychiatry services, both before the COVID-19 pandemic and during the early part of the pandemic. About two-thirds of the patients reported a little difficulty in participating in the videoconferencing (VC) sessions during the COVID-19 pandemic, whereas before the COVID-19 pandemic only a small proportion of patients (16%) reported little difficulty in participating in the VC sessions. Similarly, 64% and 23% of the patients reported that video consultations were just acceptable during the COVID-19 pandemic and before the COVID-19 pandemic, respectively. Only one-third (36%) of the patients reported overall satisfaction to be good during the COVID-19 pandemic, whereas 71% of the patients reported overall satisfaction to be good during the pre-pandemic period. In terms of future use, 57% and 30% of the patients reported that they were less likely to prefer VC in the future during the COVID-19 pandemic and prior to the pandemic, respectively.[12] Overall, the satisfaction with all aspects of VC was higher during the pre-pandemic period than during the pandemic period.[12] These differences in the pre-pandemic period and during the pandemic can be understood from the perspective of selection of the patient for telepsychiatry consultation; that is, during the pre-pandemic period, it was offered to a select group of patients, whereas during the pandemic period, it became the only modality of providing care. However, this survey involved talking to patients on phone to receive the feedback that can at times lead to providing socially desirable responses.
As the data on the perception of the patients and caregivers is limited, there is a need to expand the knowledge in this area. In this background, we attempted to assess the patient and/or caregiver perceptions about telepsychiatry consultations from a tertiary care hospital. We also tried to understand the factors that might impact the experience and perceptions.
MATERIALS AND METHODS
This cross-sectional online survey was undertaken in a tertiary care hospital in Northern India by using Google Forms. Approval for the study was taken from the institutional Ethics Committee (INT/IEC/2021/SPL-953). The study involved assessment of clinicians’ satisfaction and also patients’ satisfaction with the teleconsultations. Additionally, an independent clinician who was an observant of the teleconsultation also rated the behavior of the clinician while the teleconsultation was being done. The papers related to clinicians’ satisfaction have been published earlier.[13,14] The patients and/or caregivers were informed by the clinicians about the details of the study at the beginning of the consultation, and a verbal consent was obtained from them. The patients and/or caregivers were informed that they would be sent a Google Forms link after the consultation, and they can respond about their experience with the video consultations and level of satisfaction. They were also informed that irrespective of their response, and their future care will continue as per the clinical requirement. The data was collected between April 2021 and December 2021.
During the COVID-19 pandemic, from mid April 2020, the preexisting telepsychiatry services of the department were utilized to substitute the routine outpatient services. During the COVID-19 pandemic, the telepsychiatry services replaced the in-person outpatient services and the telepsychiatry services were modeled in line with the in-person services.[13,14] All these services were managed online by using audio and video calls (via Zoom or WhatsApp). Accordingly, after the initial evaluation by a senior resident, the patients (with or without caregiver) were assessed in detailed by a junior resident, who spent 60–90 minute with each patient and their caregivers. This was followed by discussion with a consultant or occasionally with a senior resident. This discussion allows an opportunity to the junior residents to seek supervision and learn from the faculty. After the discussion, the patient and the caregivers were also interviewed by the faculty for 15 to 30 minutes for clarification of issues, interviewing the patient and/or caregivers, and finalizing the diagnosis and management plan. Since detailed work-ups involved the maximum amount of time spent by the faculty and involved video communications, this was chosen to assess the satisfaction of the patients/caregivers. This paper focuses on the experience and the level of satisfaction of the patients and/or caregivers who responded back to the Google Forms sent to them.
After every consultation by the participating consultants, during the study period, patients/caregivers (N = 430) were sent a Google Forms questionnaire (Trilingual—English/Hindi/Punjabi) on their registered mobile number to report their degree of satisfaction. For this assessment, a specific self-report questionnaire was developed, which included basic information about the mode and quality of receiving the telepsychiatry services (the platform and equipment used for consultation, connectivity, time spent, etc.) and a 10-item questionnaire covering various aspects of the teleconsultation, that they could mark on a 6-point Likert scale ranging from “Very dissatisfied” to “Very satisfied.” At the end of the questionnaire, there was an option for the respondent to give a descriptive comment regarding their experience of the consultation. For each of these consultations, the consultants noted down their level of satisfaction during the interaction, and also the level of functioning of the patients by using General Assessment of Functioning (GAF) Scale,[15] immediately after each call ended. Patient’s sociodemographic details were collected in a standard manner. The questionnaire was evaluated for the face validity by sending it to five psychiatrists, and their suggestions were included. The Google Forms were circulated along with the e-prescription after the detailed evaluation by the faculty member.
The data collected via the Google Forms was combined with the data entered by the consultant and the sociodemographic variables. The combined data was analyzed using the SPSS-14 software. For continuous variables, mean, median, standard deviation, and range were calculated, and frequencies were calculated for the categorical variables. Comparisons were made by using Chi-square test, and P value of ≤ 0.05 was considered significant.
RESULTS
Out of the 430 patients to whom the Google Forms was sent for feedback, 129 [30%] participants (either the patient or their caregiver) responded. The mean age of the patients who responded was 45 (SD: 17.5) years, with more than half of them were males (53.5%). Most of the participating patients were married (64.3%), educated beyond or up to class 10th (70.6%), and were Hindus (62.8%) by religion. Half of them belonged to joint family setups (50.4%) and were employed (53.1%). The mean distance of the patient’s locality from the hospital was 150 (SD: 260) kilometer. Majority of the responders were diagnosed with a mood disorder, and half of them (48.8%) also suffered from one or more physical comorbidities. The mean GAF scores for the responders, as rated by the consultant psychiatrists, was 43.1, indicating a level of poor functioning [Table 1].
;)
Table 1: Sociodemographic and clinical profile of patients who responded and who did not respond to the survey
When the sociodemographic details, the mode and details of consultation, the extent of technical difficulties, the psychiatric diagnoses, the GAF score, and the extent of clinician’s satisfaction with providing the consultations were compared for the patients/caregivers who responded and those who did not respond to the feedback form, it was found that 21.3% of the patients who had been assessed through WhatsApp video call responded to the Google Forms, while 35.7% of those assessed on voice call and 43.6% of those assessed on Zoom video call responded. There was significant difference between the response rate between the patients accessed via these three different modes (P < 0.001). No significant difference could be found between the respondents and non-respondents for other variables [Supplementary Table 1].
Supplementary Table 1: Comparison between respondents and non-respondents
Most of the respondents had the consultation over Zoom video call (53.5%), and the majority used a mobile phone (71.4%) to attend the call. For the feedback, more than half (57.4%) of the responses were filled by the caregiver accompanying the patient in the consultation. Almost two-thirds of the responses were in English (69.8%), but 23.2% and 7.0% responses were in Hindi and Punjabi, respectively.
As per the respondents, the average time spent by the residents during the detailed assessment was 42.2 (SD: 23.5) minutes, while that spent by the consultants was 27.9 (10.8) minutes. Slightly more than half (55.8%) respondents reported the quality of connectivity to be “very good” throughout the consultation, and another 38.8% reported the quality to be “good,” while 5.4% reported “fair” connectivity. Almost all (95%) of the responders reported good or very good clarity of voice and video throughout the consultation.
Slightly above two-thirds of the respondents were “satisfied to a large extent” with the assessment by the resident doctor, and 93.8% were “very satisfied” with the teleconsultation with the consultant psychiatrist. When the different domains of satisfaction were assessed, 91.5% of the respondents were very satisfied with the amount of time spent, 77.5% were very satisfied with the freedom they had to express themselves, 86% were satisfied with the behavior of the treating doctor, 81.5% were very satisfied with the amount of freedom they had in choosing their preferred type of treatment, and 64.3% were very satisfied with the information that was provided to them regarding their problem. About 72% were very satisfied with the prescription provided and the number of medications prescribed. About three-fourths (77.5%) of the respondents were very satisfied with the quality of care provided and the overall experience of the consultation. Majority (92.2%) of the respondents reported that they would “definitely” recommend the telepsychiatry service to a friend or relative in need of a psychiatric consultation [Table 2].
Table 2: Details of call and satisfaction parameters of respondents (as above)
When further analysis was done to understand the factors that might be contributing to the satisfaction of the patients/caregivers during the teleconsultation, quality of connectivity and clarity of voice during the whole duration of the consultation were found to be the most important determining factors.
To assess the impact of connectivity and the voice quality, the study sample was divided into two groups. Responses of “good” and “very good” connectivity and “good” and “very good” voice were combined into one group, and these were compared with the responses as “fair.” Better connectivity and clarity of voice were associated with satisfaction rating of “satisfied to large extent” or “very satisfied” regarding freedom to express oneself (P < 0.001), the amount of information provided (P = 0.03 for connectivity; P < 0.001 for clarity of voice), the prescription provided (P = 0.003 for connectivity; P < 0.001 for clarity of voice), and the number of medications prescribed (P < 0.001). Quality of clarity of voice, but not connectivity, was associated with freedom of choosing the type of treatment (P = 0.012).
To understand the relationship of overall satisfaction of the respondents with the quality of care received, first four responses (dissatisfied to large extent, dissatisfied to some extent, satisfied to some extent, and satisfied to large extent) were clubbed together and compared with those reporting overall “very satisfied.” It was seen that better overall-satisfaction was associated with the clarity of voice throughout the call (P < 0.001) and the connectivity during the consultation (P < 0.001). While the satisfaction with the assessment by the resident doctor was associated with the presence of a caregiver during the assessment (P = 0.008), the satisfaction with the assessment by the consultant was associated with the score of GAF (P < 0.001). Clarity of video was found to be associated with the satisfaction with the behavior of the attending doctor (P = 0.01).
Interestingly, the overall satisfaction reported by the patient or caregiver was associated with the overall satisfaction reported by the clinician in providing the teleconsultation (P < 0.001). Also, time spent in consultation did not seem to significantly affect the satisfaction reported.
When the responses provided by the patients themselves were compared with the responses provided by the family member or caregiver of the patient, no significant difference could be found for the demographic and diagnostic profile of the patients, various variables related to the video consultation, that is, type of consultation, duration of consultation, clarity of video and voice, etc., and satisfaction with the consultation. The only significant difference between the two groups of respondents was in terms of a lower GAF score among those whose responses were provided by caregivers (mean of 47.88 in the group of patients’ self-response versus 39.63 for caregiver responses, P = 0.02).
In the part of the Google Forms, where the respondents were allowed to leave comments in an open-ended manner, about 40 (31%) left responses. The overarching theme of this feedback was positive. Patients found teleconsultations to be a useful and necessary alternative to the usual treatment seeking, especially during an emergency such as the pandemic. Regarding negative experiences reported, one patient reported experiencing difficulty because valid forms for investigations like magnetic resonance imaging of the brain or electroencephalography could not be sent over phone. One caregiver wrote about the technological challenges faced by their elderly patient, and one of the patients experienced a dissonance between the discussion with the consultant and the prescription sent by the resident. One patient clearly mentioned that teleconsultation is better than a face-to-face consultation.
DISCUSSION
This study looked at the experience and satisfaction of the patients and their caregivers regarding telepsychiatry consultations over Zoom or WhatsApp platform. The responses were collected via Google Forms after the end of the consultation. The response rate to the survey was 30% that can be considered to be a fair response rate. There was no significant difference in the profile of those who responded and those did not respond to the survey, suggesting that the study sample was representative of the whole patient population that was assessed as part of this larger study.
The mean age of the patients who themselves responded (or whose caregivers responded) was 45 years, and majority of them were married, employed, Hindu males, educated beyond or up to class 10th, and belonged to urban joint family setup. The mean distance of the patient’s locality from the hospital was 150 km. Majority of the responders were diagnosed with a mood disorder, and half of them also suffered from one or more physical comorbidities. This profile is comparable to the profile of patients included in other studies assessing telepsychiatry consultations.[9] This profile is also similar to the demographic profile reported for patients attending our outpatient services in general.[16,17] However, in terms of clinical profile, compared to the previous study that reported anxiety and neurotic disorders to be the most common diagnosis in patients attending our outpatient services, in the present study, the most common diagnosis was that of mood disorders. This difference could be due to the fact that although anxiety disorders form the bulk of the patients attending the walk-in services, majority of the patients who are evaluated in detail include those of mood disorder.
Most of the respondents had the consultation over Zoom platform (53.5%), and the majority used a mobile phone (71.4%) to attend the call. This was because Zoom had been subscribed as the primary platform of telepsychiatric care delivery at our institution. Only those patients who found it difficult to connect over Zoom would be transferred to a WhatsApp video call for the patient/caregiver’s ease of attending the consultation. In slightly more than one-fourth (29.5%) of the patient, the consultation had to be switched to the WhatsApp. About one-seventh (15%) of the consultations had to be given over voice call only, because of possible connectivity issues. These findings possibly suggest that connectivity issues remain a major limitation for practicing telepsychiatry in India. The previous study from India also reported similar connectivity issues during the COVID-19 pandemic.[12]
In the present study, more than half of the responses were filled by the caregiver accompanying the patient during the teleconsultation. It was noted that the caregivers sent the feedback for the more severely dysfunctional patients, as indicated by significantly lower GAF score of these patients. Overall the profile of the patients for whom responses were received and for whom the responses were not received did not differ significantly, suggesting that the study participants were representative.
In the present study, although two-thirds of the responses were in English, 23.2% and 7.0% responses were in Hindi and Punjabi, respectively. This indicates that inclusion of questionnaires in Hindi and other local languages improves the response rate to some extent. Hence, future survey’s should strive to collect responses in multiple languages and to improve the response rate and representativeness of the study sample.
Slightly more than half (55.8%) respondents reported the quality of connectivity to be “very good” throughout the consultation, and another 38.8% reported the quality to be “good,” while 5.4% reported “fair” connectivity. Almost all (95%) of the responders reported “good or very good” clarity of voice and video throughout the consultation. These findings should be understood in the light of the fact that a significant proportion of the patients required change in the platform to maintain the same. These findings suggest that clinicians often for the convenience of the patients and improving the video and voice quality shift from Zoom platform to other platforms. Majority (90%) of the respondents appeared “satisfied to a large extent” with the assessment by the resident doctor, as well as the consultant psychiatrist. When the different domains of satisfaction were assessed, the highest level of satisfaction was reported for the amount of time given during the consultation. Satisfaction with the behavior of the treating doctor, the amount of freedom in choosing the preferred type of treatment, the freedom to express themselves, the prescription provided, and the numbers of medications prescribed were quite high. Somewhat lesser satisfaction was reported with the information that was provided to them regarding their problem. About three-fourths of the respondents were very satisfied with the quality of care provided and the overall experience of the consultation. Majority (92%) of the respondents reported that they would “definitely” recommend the telepsychiatry service to a friend or relative in need of a psychiatric consultation. The high rates of satisfaction are comparable to the other studies that attempted to understand the patient perception of telepsychiatry consultations.[9,12] However, previous studies have not assessed satisfaction in details as done in the present study. Hence, it is not possible to compare the findings of the present study with the existing studies. The lesser level of satisfaction with the amount of information provided might be because of the fixed time limit of the consultations. It is also possible that the lower level of satisfaction may be due to the fact that these consultations mainly focus on clarification of diagnosis and drawing a management plan. Hence, enough time would not have been provided for imparting knowledge and information to the patient and caregivers at the initial sessions. However, it is important to keep this in mind from the clinician’s side for planning future teleconsultations.
Quality of connectivity and clarity of voice during the whole duration of the consultation were found to be the most important determining factors for satisfaction. The overall satisfaction reported by the patient or caregiver was associated with the overall satisfaction reported by the clinician providing the teleconsultation. Also, time spent in consultation did not seem to significantly affect the satisfaction reported. These findings suggest that therapeutic alliance possibly enhances the satisfaction for clinicians as well as the patient/caregivers.
The study has a few limitations that need to be considered for interpreting the findings of the present study. The study lacked a comparison group of patients who rated their satisfaction for in-person consultations. The study was conducted during the lockdown period when there was lack of access to the in-person consultation. Though the questionnaire was assessed for face validity, its psychometric properties were not assessed. The response rate of the patient/caregivers was only 30%, which left out a large proportion of the patients unrepresented among those who reported their satisfaction with the teleconsultations. Since this was an exploratory study, correction for multiple comparisons was not done.
To conclude, the present study suggests that overall satisfaction with teleconsultations was high among patients and/or caregivers for telepsychiatry consultations. The aspects of the consultation that seem to have maximum impact on clients’ satisfaction with teleconsultations are the connectivity and clarity of voice. However, many patients reported lesser degree of satisfaction was with the amount of information provided during the consultation. These factors can be important in guiding the development of future telepsychiatry services.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand?. J Family Med Prim Care 2019;8:1872-6
2. Basavarajappa C, Grover S, Dalal PK, Avasthi A, Kumar CN, Manjunatha N, et al. Current telepsychiatry practice in India-An online survey of psychiatrists. Indian J Psychiatry 2022;64:307-11
3. Basavarajappa C, Grover S, Dalal PK, Avasthi A, Kumar CN, Manjunatha N, et al. Perceived advantages and disadvantages of telepsychiatry –An online survey of psychiatrists in India. Indian J Psychiatry 2022;64:93-7
4. Basavarajappa C, Grover S, Dalal PK, Avasthi A, Kumar CN, Manjunatha N, et al. The prescriptions of psychotropic medications in telepsychiatry: An online survey of psychiatrists in India. Indian J Psychiatry 2022;64:159-63
5. Das N. Telepsychiatry during COVID-19 – A brief survey on attitudes of psychiatrists in India. Asian J Psychiatr 2020;53:102387
6. Donelan K, Barreto EA, Sossong S, Michael C, Estrada JJ, Cohen AB, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care 2019;25:40-4
7. Indria D, Alajlani M, Fraser HSF. Clinicians perceptions of a telemedicine system: A mixed method study of Makassar City, Indonesia. BMC Med Inform Decis Mak 2020;20:233
8. Olwill C, Mc Nally D, Douglas L. Psychiatrist experience of remote consultations by telephone in an outpatient psychiatric department during the COVID-19 pandemic. Ir J Psychol Med 2021;38:132-9
9. Guinart D, Marcy P, Hauser M, Dwyer M, Kane JM. Patient attitudes toward telepsychiatry during the COVID-19 pandemic: A nationwide, multisite survey. JMIR Ment Health 2020;7:e24761
10. Mucic D. International telepsychiatry: A study of patient acceptability. J Telemed Telecare 2008;14:241-3
11. Simpson J, Doze S, Urness D, Hailey D, Jacobs P. Telepsychiatry as a routine service –the perspective of the patient. J Telemed Telecare 2001;7:155-60
12. Chakravarty R, Chakrabarti S, Shah R. Home-based telemental health services for Indian
patients during the COVID-19 pandemic: A comparison with the pre-COVID phase. J Family Med Prim Care 2022;11:2507-15
13. Grover S, Naskar C, Sahoo S, Mehra A. Clinician's experience of telepsychiatry consultations. Asian J Psychiatr 2022;75:103207
14. Naskar C, Grover S, Mehra A, Sahoo S. Clinician's experience of telepsychiatry consultations with elderly
patients. J Geriatr Ment Health 2022;9:26-33
15. Hall RC. Global assessment of functioning: A modified scale. Psychosomatics 1995;36:267-75
16. Grover S, Kumar V, Avasthi A, Kulhara P. An audit of first prescription of new
patients attending a psychiatry walk-in-clinic in North India. Indian J Pharmacol 2012;44:319-25
17. Grover S, Rai B, Chakravarty R, Sahoo S, Mehra A, Chakrabarti S, et al. Suicidal behavior in new
patients presenting to the telepsychiatry services in a Tertiary Care center: An exploratory study. Asian J Psychiatry 2022;74:103152
