According to the National Mental Health Survey 2016, 10.6% of India’s adult population suffers from mental disorders with 83% of them being inadequately treated or not treated at all (treatment gap). The treatment gap is expected to be higher in rural and tribal areas. The journey from developing a mental illness to seeking care is challenging and can span over months/years or maybe a lifetime in several cases. There is a sharp contrast in the utilisation of mental health services with the urban elite seeking preventive services such as stress management workshops, resilience coaching, etc. whereas the poor and marginalised (tribals, urban and rural poor) do not access care even for severe mental disorders such as psychosis. With only 318 psychiatrists in the Gujarat state (more than 60 million population) of India, mainly practising in urban locations, it is difficult to meet the mental health needs of the rural and tribal communities of the state. Two possible solutions to bridge this gap are integrating mental health care with primary care or providing care through telepsychiatry. While the former shall deliver results over the long term, telepsychiatry can provide results in the short term.
In the post-COVID world, telepsychiatry has emerged as an effective solution to provide mental health care in difficult-to-access tribal communities. Different telepsychiatry models have been successfully tested in India to bridge the treatment gap. A model of ‘Assisted Telepsychiatry’ was implemented in rural Goa, coordinated by lay counsellors trained in clinical assessment and follow-ups. In rural Tamil Nadu “Mobile telepsychiatry” model was tested where a bus equipped with video conferencing devices and a pharmacy, travelled to hard-to-reach areas where patients were mobilised and consultation occurred with a psychiatrist based in an urban centre. In Bengaluru, the “Telepsychiatry aftercare model (TAC)” has been operational since 2018, to conduct follow-ups of patients with mental illnesses registered at a tertiary care centre. The patients are contacted by hospital staff for video consultations following which a scanned copy of the prescription is sent to the patients.
While designing a telepsychiatry service, one must be conscious of the confounders and complexities prevalent, for better and effective utilisation and outcomes. Some of the barriers to delivering telepsychiatry services in tribal Gujarat include:
Faith, Stigma, and Awareness
Certain sociocultural and traditional beliefs such as witchcraft and black magic are strongly rooted in tribal culture, which leads to stigma and ostracization of individuals from society. These belief systems are created due to lack of awareness of mental illnesses, reliance on traditional healers and trust for community members rather than any outsiders. The fear of the disease status revelation (and its consequences) of the patient, further increases the gap in utilising any form of medical care with telepsychiatry being no exception. Additionally, since most tribals have their dialects which are significantly different as compared to most of the popular languages, involving a local person to facilitate the consultations remotely expedites the communication process. For telepsychiatry to succeed, building awareness and trust is a crucial step through collaborations with local leaders, community health workers, and traditional healers.
Logistical and Financial Barriers
Limited infrastructure, road connectivity, availability of public transport and remote locations create obstacles in delivering medications and attending consultation sessions for the patient which adversely affects treatment compliance and outcomes. Existing resources (if available) such as community health workers and mobile medical clinics can be utilised to address these logistic barriers effectively. Additionally, accessing healthcare entails direct (medicines, consultation charges, investigations, etc.) and indirect (transport, loss of wages, food, etc.) costs. The latter is seldom considered through external funding and thus, having telepsychiatry may help reduce the burden of some indirect costs such as transport and loss of wages.
Connectivity and Network Availability
Telepsychiatry heavily relies on network connectivity for effective communication between healthcare providers and patients. However, tribal areas suffer from limited or unreliable network infrastructure. Choosing common spots where individuals can assemble and connect from a single device and having a reliable network connection can be a promising solution. The use of audio calls in place of video calls in areas with poor connectivity can also be an alternative. Training community health workers and mid-level workers to facilitate the consultation process is essential to overcome this issue.
In conclusion, delivering mental health care through telepsychiatry in tribal settings comes with its unique challenges. One needs to effectively address the stigma and limited awareness and at the same time address logistical barriers and network availability to ensure improved access to mental health care. Through collaborative efforts and innovative solutions, telepsychiatry can play a transformative role in bridging mental health care gaps in tribal communities thereby making a positive impact on their quality of life.
About the authors: Dr. Vishal Karmani: A public health student, passionate about mental health care, and interning in a tribal district of Gujarat state in India. Email: firstname.lastname@example.org
Dr. Shyamsundar Raithatha: A community and family physician, working at a primary care clinic (Purna clinic) in a tribal village of Gujarat state in west India. The clinic is funded by Sarva Mangal Family Trust and managed by Bhanshali trust. Email: email@example.com
Competing interest: None
Handling Editor: Neha Faruqui