COVID-19 Innovations in Telemedicine-Telepsychiatric Service and Delivery through a Global Health Partnership in a rural health clinics in districts D1708 and D1709 of Metropolitan District of Quito, Ecuador
During the COVID-19 pandemic, through an ongoing international collaboration between Northwell Health and Universidad San Francisco de Quito (USFQ), a telepsychiatry program emerged in response to urgent mental health needs identified through rural health centers in Ecuador. Serving districts D1708 and D1709 of the Metropolitan District of Quito, the program supports neglected and underprivileged populations through integrated virtual mental health services for financially vulnerable individuals. Using telemedicine to deliver mental health services is an integral and innovative mechanism to improve access and reduce stigma. Average local income is less than $3 USD per day, and this program has expanded access for individuals who were not previously able to access mental health services. At no cost to the individual patient, the intervention includes graduate medical students from USFQ, psychiatry residents from Northwell Health, and a psychologist from each health center. The telepsych team collaborates to identify, refer and provide psychiatric consultation for patients. The telepsych program, instituted in January 2021 has been providing consultations for at least four patients once a week using the internet to expand equity and access to mental health services. The program comprises four main strategies: the identification and screening of patients that require a psychiatric evaluation by the health center psychologists; initial contact with patients for consent, coordination, and explanation of the program by the graduate medical students from USFQ; telepsychiatric consultation performed by the psychiatry residents from Northwell Health; and lastly the creation of an ongoing treatment plan and medication referral (if required) with the local health center in collaboration with graduate medical students from USFQ and the psychologist of the health center. Each task is carried out by a particular team member, adhering to a treatment
Support the Ministry of Public Health (MSP) at the local level with mental health management using the Telepsychiatry strategy targeted at vulnerable groups, through the collaboration of the psychology units of the health centers in rural areas and professionals from the Department of Psychiatry and Global Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Universidad San Francisco de Quito School of Medicine and San Francisco Mental Health Clinic.
3. Salud y bienestar
Objetivo 3: Garantizar una vida sana y promover el bienestar para todos en todas las edades
Mental health disorders are one of the main causes of disability worldwide, particularly in vulnerable populations (OMS, 2020). In Latin America, mental health diseases represent at least one-third of lost years due to disability, depression being one of the most common among them (Jiménez-Molina et al. 2019). It is estimated that in Ecuador the disability due to mental health disorders reaches 17% (PAHO, 2018). The root cause for it could be the limited access to mental health services in low-and Middle-Income countries (LMIC) due to low investment by governments, scant mental health professionals and exclusive health clinics for it, insufficient resources and expertise of the personnel in the health clinics, and poor promotion and prevention in mental health diseases. In Ecuador, these issues arise from the educational system with an almost nonexistent residency that offers the specific specialty, and not enough preparation during medical school. In Ecuador?s educational system only family medicine receives education regarding mental health, yet their capacity on managing diagnosis, psychotherapy and psychotropic medication is not as extensive as a specialist (Baena VC, 2018). As mentioned before, mental health is an enormous public health matter, and during COVID-19 pandemic it was deeply affected, especially in vulnerable populations in LMIC. A report using validated tools showed that during the COVID-19 pandemic in 2020 in 3 states in Ecuador, 59.2% individuals presented some level of anxiety and 54,8% individuals had depression (Velastegui et al. 2020). Having in mind that 80% of the worldwide live in LIMC, a solution for closing the gap treatment in socioeconomically disadvantaged groups had to be implemented (Jiménez-Molina et al. 2019). The most logical and viable solution during this time has been digital technology. Digital technology refers to services such as the internet, computers, mobile phones, tablets and/or text messaging. It is estimated that at least 80% of the individuals that reside in LMIC have mobile phones, yet only half of them have access to the internet (Fu, Z et al. 2020). In Ecuador, a report from the Telecommunications Ministry estimates that 60 from 100 individuals in 2012 had access to the internet, and that this number has increased much more during the last 3 years (Ministerio de Telecomunicaciones, n.d). Other reports showed the inequality in digital technologies access, indicating that not even half of the population have access to the internet in their houses; being the rural population the most affected. An interesting event is that even when they did not have internet in their homes, a growth in smartphones was seen in the population. Increasing a 4% in the urban area and a 5,5% in the rural area in Ecuador (Primicias, 2020). The rapid growth in technology enables the use of it in medicine, particularly in mental health services. Internet based interventions in rural communities and LMIC countries may be advertised due to its low cost, wide distribution, convenient time and reduction of transportation costs (Diwan, M.N. et al. 2021). This is primordial for rural populations in Ecuador, as a report estimated that 42% of the rural population lives with less than $3 dollars per day, and 19% of that group lives with less than $2 dollars per day (Revista Gestion, 2020). Many studies have arisen from this modality showing the viability of it in the child, adolescent and adult population not only for treatment but for promotion and prevention in mental health, yet its effectiveness is still questioned and needs to be proven. A study from Chile showed that even when digital mental health services had consistent acceptability, usability and adherence in the population, its effectiveness could not be proved due to low sample size and short follow-up periods mainly as a result from high attrition in the population (Rojas, G. et al. 2019). Meanwhile other studies reported that digital mental health services had almost equal results as face to face care, when using evidence based techniques and guided interventions employed in the traditional consultation. An example of this is a study that used video conferences once a month to treat depression, it had great outcomes regarding improvement in mental health status, satisfaction and adherence to treatment, equal to those treated in person. The same was for a study that used chat, audio or video conference to provide sessions to depressive individuals, that showed a decline in symptomatology within 16 consultations in a 6-month period (Jiménez-Molina et al. 2019). Finally, almost all studies from different reviews had a small sample size as mentioned before, and this limited to draw a definitive conclusion about a Telepsychiatry program. In Ecuador, during the COVID-19 pandemic few institutions like universities offered psychological consultations but neither provided a complete and/or unique Telepsychiatric program (Pacheco, M. 2020). The ministry of health tried to recruit personnel related to mental health to give consultations without any fee but there are no records if the program developed (UTPL, 2021). During this time, online psychiatric private practices were also installed but their fees exceeded the economic capacity many in our country have to deal with. For this reason, the development of a Telepsychiatry program was necessary, to provide mental health services implementing a collaborative multidisciplinary team that fill the socioeconomic gap in our vulnerable populations. Because there are not conclusive studies that show the effectiveness of a Telepsychiatry program in a rural population in Ecuador, it seems a great opportunity to assess the objectives of this program.
Serving districts D1708 and D1709 of the Metropolitan District of Quito, the program supports neglected and underprivileged populations through integrated virtual mental health services for financially vulnerable individuals. Using telemedicine to deliver mental health services is an integral and innovative mechanism to improve access and reduce stigma. Average local income is less than $3 USD per day, and this program has expanded access for individuals who were not previously able to access mental health services.; 1. To the patients to provide psychiatric treatment and/or follow-ups when they visit mental health departments in the health clinics of the Ministry of Health, and who under normal circumstances do not have access to appointments or follow-ups by a physician specialized in this area. 2. To the health clinics and the Ministry of Health to offer health services with an specialist that not available in this type of level of care.ls.
Achieved to attend to 160 patients from the health centers of El Quinche, Tumbaco, Yaruquí, Pifo, and Cumbayá, helping to reduce referrals to third-level centers to avoid saturating them. Electronic assistance was provided if necessary in cases where access to the same was impossible for teleconsultation in mental health.
