Beyond the COVID-19 Era: An Exploration of Mobile Healthcare Technology and Telepsychiatry in Developing Countries

Mobile healthcare and tele-psychiatry is an important strategy that has been deployed as a major approach in mitigating mental health crises in the ongoing Covid-19 pandemic in many countries. This is because resources involved in catering to mental health needs have either been reduced or re-deployed to the infectious disease-covid-19 itself.

While the pandemic is a physical health crisis, it has put a significant strain on the mental health care services of diverse populations. However, before the covid-19 pandemic, global statistics and the latest reports on mental health disorders were already alarming and potentially disastrous. For example, in low and middle-income countries, between 76% and 85% of people with mental health conditions received no treatment for their disorders, about half of all mental health conditions start by age 14, and suicide was reported as the second leading cause of death in young people aged 15-29.¹ With the effect of the pandemic causing substantial levels of stress, uncertainty, and fear, mental health disorders are bound to increase exponentially if not given proper intervention. A recent systematic review of the prevalence of anxiety and depression among general population in Africa observed high prevalence of anxiety and depression caused by the COVID-19. This is consistent with similar studies that have observed the increased prevalence of mental health disorders that are as a result of the pandemic; especially in African countries where health systems are likely weakened ^2,3,4

Similarly, a study conducted in Nigeria demonstrated increased depression, inability to sleep, and anxiety among the surveyed participants.⁵ The reported reasons for these observed psychopathologies included loss of jobs, isolation of both young and old, loss of loved ones, and increasing fear of contracting the virus. Likewise, it is essential to highlight that while studies report an increase in mental illnesses during the lockdown, mental illnesses’ impact and burden are not new. A 2017 Global Burden of Disease study reported that over 260 million people suffer from depression, 45 million from bipolar disorder, and another 20 million from psychosis.⁶ These statistics indicated that mental illnesses are chronic and it requires continuous treatment for a long period. It may well be argued that the need for mental health professionals will increase significantly post covid-19 lockdown, and mental health care delivery should increase concomitantly to match the demand.

Despite the alarming number of people with mental  health conditions, mental health care services are still significantly neglected in developing countries. Furthermore, reports have shown that only 25-34% of people needing mental health care have received some form of treatment in low-and middle-income countries.⁷ With essential gaps in providing support and treatment of people living with mental conditions created by the inadequate mental health services, online provision of mental health services as either an alternative or support seemed to have been inevitable. The use of online mental health services as a means of providing care and support is not a completely new development. As the numbers of infected persons increased during the covid-19 pandemic, mental health services in hospital and care centers  incorporated the use of telemedicine, specifically telepsychiatry, to provide mental health services to various types of populations.⁸ In the treatment of psychiatric disorders like Depression, Obsessive Compulsive Disorder and Post Traumatic Stress Disorder, telepsychiatry has been involved in not only improving symptoms but overcoming barriers like shame, fear of stigmatization ⁹ and logistics barriers.¹⁰ It has shown to further increase patient satisfaction in patients with movement disorders like Parkinson’s disease and has even been suggestive to be more preferable for patient with anxiety disorders. Clinicians are also not left out in this advantage as telepsychiatry provides flexibility in scheduling appointments and time, the risk of patient aggression and possible violence during evaluation is greatly reduced and consultancy with other colleagues is also enhanced.¹¹ The World Health Organization has defined telemedicine as “the delivery of health services, where distance is a critical factor, by all healthcare professionals, using information and communication technologies.” Telepsychiatry is, therefore, the infusion of psychiatry specialty into telemedicine. It involves communication and interaction between a patient and the psychiatrist using telecommunications technology, usually video-conferencing.

As countries continue to carry out preventive measures, vaccination exercises, and other mitigating strategies against the covid-19 infection to possibly reduce the secondary effects across all sectors, it should be noted that mental health disorders and their complications will exist beyond the lockdown since the number of people with mental health illness keeps rising and is projected to increase even further due to the pandemic effect.

In addition to causing severe impairments to the affected person and their family, mental ill-health has been shown to impact society negatively; from tremendous economic costs, increased productivity losses to negative impact on economic growth.¹² The decline in optimum mental health of populations is because the COVID-19 crisis has further heightened the risk factors. Risk factors which are associated with poor mental health include financial insecurity, unemployment and fear¹³ Despite several reports on the current and potential impact of mental ill-health, mental health service delivery is still severely lacking especially in developing countries. Some of the challenges regarding mental health services during lockdown include: low funding of mental health, the scarcity of human resources, infrastructure, and burn-out of mental health workers, impact of misinformation, lack of access to mental health services and lack of access to support systems. These challenges are bound to be even more significant in the post-COVID-19 pandemic era. Millions of people have lost their loved ones, are grieving, and faced different levels of violence and trauma. To accommodate and provide adequate services for the resulting mental health crisis in these regions, mental healthcare and resources have been stretched too thin.

Before onset of the pandemic, there was already a rising trend of online mental health services as a means to address the increasing mental health need among the general populace. Telepsychiatry, which was incorporated to provide some relief during the lockdown, should continue to be a mental health service delivery approach post-lockdown. This integration of digital health interventions has shown several benefits which include the increased access to care, as barriers such as distance, stigma, time constraints, and safety will be eliminated. Additionaly, patients would not be out of work to assess mental health care and support. Another benefit is the increased convenience it has brought. For example, healthcare workers and patients can participate by simply using a laptop, a portable tab, or an android telephone handset. Similarly, mental health experts can render services from any part of the world. This addresses the limited mental health care professionals available in these parts of the world. Increased treatment of peculiar mental disorders such as social anxiety and agoraphobia, prompt treatment interventions, in the cases of emergencies such as suicide and reduced burnout of mental health professionals are also significant advantages that has been noticed in the use of this.

Studies have reported positive outcomes in telepsychiatry to treat disorders such as psychosis, bulimia nervosa, depression, and PTSD.^{14, 15, 16} These studies have also reported high positive telepsychiatry satisfaction among providers and patients (children, elderly and ethnic minorities).) In addition, in the elderly population – who often have other chronic comorbidities- studies have shown video-conferencing-based assessment to be comparable to that of physical interviews even with those with cognitive impairment. ¹⁶

Even with the numerous benefits of telepsychiatry, it is still not without its challenges. One of which could be its high cost. Some studies on cost-effectiveness have, however, been contradictory. While some studies have shown telepsychiatry to be similarly or even more cost-effective, ^{17, 18} others have reported it more expensive.¹⁹  Other possible challenges are technological barriers, legal concerns, expensive telecommunication data and connectivity issues, concerns about confidentiality, and privacy, and worries about establishing effective therapeutic rapport or alliance. However, with adequate funding, implementations of favorable policies, awareness, and training, some of these challenges can be tackled adequately. To further bolster the need to fund mental and developmental health services, a study by the WHO showed a $4 return on investment for every $1 invested. ²⁰ This gain is due to increased productivity which is a product of good mental health cultures across all sectors and in all age groups.

The challenges regarding mental healthcare and delivery are expected to increase after the lockdown. It is only plausible that the status quo of providing access to online mental health services be maintained to reduce mental health problems. As some countries begin to recover from the lockdown, telepsychiatry should not be neglected in these times; instead, it should serve as a springboard and an opportunity to fully incorporate it into mental health services especially in primary healthcare in developing countries.