Grover 2020

Asian Journal of Psychiatry 53 (2020) 102429
Contents lists available at ScienceDirect
Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp
Letter to the Editor
Bridging the emergency psychiatry and telepsychiatry care: Will COVID-19 lead to evolution of
another model?
Telepsychiatry is understood, as a subset of telemedicine, which sitting at the remote place. The specialist is able to make his independent
involve providing a range of services including psychiatric evaluations, impression about the patient’s problem, advises the physician to carry
therapy, patient education and medication management through Tele out the physical examination as per the requirement, and advises for
psychiatry services (American Psychiatric Association, 2020; Chakra investigations. The patient is retained at the local health care facility and
barti, 2015). According to American Psychiatric Association, the term the patient is again reviewed by the specialist with the available
telepsychiatry should be limited to video conferencing (American Psy investigation findings and treatment plan is formulated, which is
chiatric Association and The American Telemedicine Association, 2018). executed by the physician seeing the patient locally. This ensures care at
The ongoing COVID-19 pandemic has brought the video-conferencing the local health care facility without having the patient to travel to long
based Telepsychiatry services to the forefront. The Government of distances. In the western countries, emergency Telepsychiatry services
India (GOI) notified the Telemedicine guidelines on 25th of March, 2020 have been growing steadily (Reinhardt et al., 2019). These services
(Medical Council of India and Niti Aayog, 2020). This provided a boost involve providing psychiatry services to various emergency set-ups
to the Telepsychiatry services. According to the Telemedicine Guide through video-conferencing. For this, a psychiatrist at the remote loca
lines, as issued by GOI, telemedicine services should be avoided for tion assesses the patient through video-conferencing, facilitated by the
emergency care, when alternative in-person care is available. Emer emergency physician. Based on the assessment, the advice is made for
gency telemedicine consultation should be limited to first aid, life-saving pharmacotherapy, discharge and admission to an inpatient facility. The
measure, counseling and advice on referral (Medical Council of India emergency Telepsychiatry services are considered to be acceptable,
and Niti Aayog, 2020). Further, these guidelines state that in all emer feasible, possibly cost-effective, and leads to a reduction in waiting time
gency cases, the registered medical practitioner (RMP) should notify the in the emergency for the patient (Reinhardt et al., 2019).
emergency to the patient and advise an in-person interaction at the At our centre, which is a tertiary care hospital, psychiatry services
earliest. However, during the Telepsychiatry consultation, the RMP is are provided to all the emergency set-ups (medical, surgical, pediatrics,
required to take adequate desired steps that could be life-saving. The trauma) by the consultation-liaison psychiatry team. This is a 3-tier
RMP is also required to provide guidance and counseling. system, in which the patient is assessed by a trainee psychiatrist, who
It is seen that, during the ongoing pandemic, there has been an up is present in the emergency setting (rather than being on call). This has
surge of mental health issues (Tandon, 2020a,b). However, due to ensured increase in overall referrals from various emergency physicians
lockdown various mental health services, such as inpatient, outpatient (Grover et al., 2015). Once the emergency trainee resident assesses the
and other services have been reduced; there was an expansion of the patient, the patient is seen by a senior resident, who is a qualified psy
Telepsychiatry services, both in the institutional set-ups and the private chiatrist, who carries out the further assessment. Finally, the patient is
practice set-up across the country (Grover et al., 2020a,b). In psychiatry, seen/discussed with the consultant and final treatment plan is made and
one of the major emergencies is the suicidal behaviour of the person. patient is managed in the emergency setting for duration varying from 2
Telemedicine guidelines have specifically not addressed this issue. h to 72 h, with occasional patient kept in emergency for longer duration.
Hence, psychiatrists are not clear, as to how to handle such a situation, During the ongoing COVID-19 pandemic, the routine outpatient
while providing Telepsychiatry services and there are no clear-cut an services have been substituted with the telepsychiatry services. Keeping
swers to the same. In general, it is suggested that, in case of emergency, the issue of suicidality in mind, we have tried to embed the emergency
the patient should be advice for in person consultation or should be and telepsychiatry services (Fig. 1). Accordingly, if any patient seen at
advised to seek help at the local medical facility. Keeping the issue of the telepsychiatry services requires an emergency care, patient and
suicidality, having two phone numbers of the patients (one of which is of family are encouraged to attend the emergency services, where the team
the relative of the patient, preferably staying with the patient) at the is already alerted about the patient’s possible arrival. Once the patient
time of registering the patient, and ensuring that someone is present arrives at the emergency, patient is evaluated by the emergency team,
with the person while providing Teleconsultation can help the psychi appropriate management is carried out and then patient is attached back
atrist in ensuring that the person is guided for the in-person consultation to the telepsychiatry services. On the other hand, when a patient directly
and first aid care is ensured. comes to the emergency, patient is assessed by the emergency team, and
An important aspect of medical practice is supervising or guiding the patient is attached with the telepsychiatry services for further
other colleagues in providing care to the patient. This can involve pa follow-up. This system of combining both the services has ensured that
tient to been seen by a local physician, who shows the patient to a patients, seen in the telepsychiatry services, can assess the emergency in-
specialist (in this case psychiatrist) through video-teleconferencing, person consultation and those directly seen in emergency are being seen
during which patient is also independently assessed by the specialist through the telepsychiatry services ensure continuity of care. However,
https://doi.org/10.1016/j.ajp.2020.102429
Received 30 August 2020
Available online 23 September 2020
1876-2018/© 2020 Elsevier B.V. All rights reserved.
Letter to the Editor Asian Journal of Psychiatry 53 (2020) 102429
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Financial disclosure sponsibility. Asian J. Psychiatry 50, 102100. https://doi.org/10.1016/j.
ajp.2020.102100.
We have no financial disclosure to make.

Sandeep Grover*, Subho Chakrabarti, Swapnajeet Sahoo, Aseem Mehra
Department of Psychiatry, Post Graduate Institute of Medical Education and
Declaration of Competing Interest
Research, Chandigarh 160012, India
The authors report no declarations of interest. *

Corresponding author.
E-mail address: drsandeepg2002@yahoo.com (S. Grover).
Acknowledgements
None.

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Asian Journal of Psychiatry 53 (2020) 102429

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

Letter to the Editor

American Psychiatric Association, n.d. What is Telepsychiatry? [WWW Document]. http

We have no financial disclosure to make.

The authors report no declarations of interest. *

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