Training and education in digital psychiatry: A perspective from Asia‐Pacific region

Abstract Background Digital mental health interventions and digital psychiatry have been rapidly implemented over the past decade, particularly with the intent to offer a cost‐effective solution in those circumstances in which the current mental health services and infrastructure are not able to properly accommodate the patients' needs. However, mental health workforce is often poorly theoretical/practical trained in digital psychiatry and in delivering remote consultations safely and effectively, not being common to own curricula‐specific training requirements in digital psychiatry and skills. Methods A web‐based international cross‐sectional survey was carried out by a working group constituted by one or two national representative(s) of each WHO South‐East Asia and Western Pacific Regions (APAC), with the aim to evaluate the level of training, knowledge, experience, and perception regarding the topic of digital psychiatry in a sample constituted by medical students, psychiatry trainees, and early career psychiatrists from APAC. Results An overall lack of theoretical and/or practical training on new digital tools and digital health interventions in psychiatry was observed. The level of training influences knowledge background, which, in turns, influences young professionals' perceptions and opinions regarding digital psychiatry and interventions in mental health. Conclusion Implementing psychiatry training programs may significantly improve the level of knowledge and use of digital tools in mental healthcare. Moreover, mental health services and infrastructures should be properly adapted to the digital era, considering the overall weak and heterogeneous technical support and equipment, issues of internet connectivity, and other administrative‐related challenges observed in APAC.


| INTRODUCTION
Digital health technologies typically refer to any form of remote/ online platform or mobile device that can be used or designed to deliver a health intervention, including smartphone-based apps, text messaging, telemedicine, telepsychiatry, wearable devices such as smart watches and online platforms and programs (Lipschitz et al., 2019;Wasil et al., 2020). Digital mental health interventions and digital psychiatry have been rapidly implemented over the past decade, particularly with the intent to offer a potential solution in those problematic circumstances and logistic issues for which the current mental health service infrastructure is not able to adequately accommodate to the needs of most patients (Husain et al., 2021;Lipschitz et al., 2019;Torous et al., 2019Torous et al., , 2020. In fact, digital psychiatry can be ideally widely disseminated with virtually no marginal cost, not requiring patient's transportation, and incentive patient autonomy, accessible in every moment when patient most needs support and with an efficacy comparable to traditional in-person interventions, despite different existing country-specific rules and laws in the field of digital psychiatry (Apaydin et al., 2018;Ng, 2020;Wells et al., 2018;Wright et al., 2019).
The need for implementing mental health services with digital psychiatry interventions mainly reside in the existing mental health care gap between the burden of mental disorders and the lack of appropriate resources and services necessary to treat them, particularly in the low-income and middle-income countries (LMICs) in which with up to 90% of people with mental disorders do not adequately receive treatment and follow-up (Carter et al., 2021;Merchant et al., 2020;Pathare et al., 2018). The digitalization of mental health care may offer direct support to individuals affected with mental disorders, by improving the quality of services provided and making evidence-based interventions more widely available (Bhugra et al., 2017). In fact, the supply of mental health care may be hampered by the limited numbers of mental health professionals and inequitable distribution of providers in some countries belonging to the APAC region. For example, in India, there is approximately one trained psychiatrist for every 250 000 people and the total mental health workforce available is less than one provider per 100 000 people and many of them are mainly resident in major cities (Lahariya, 2018). In the Indian Kashmir region, there are around 41 psychiatrists and 12 clinical psychologists of a Kashmiri population of approximately 12.5 million (Shoib & Yasir Arafat, 2020a). The situation in other APAC countries may largely vary, despite the lack of specialty physicians in each remote area appearing to be a condition frequently present. Therefore, implementing and facilitating the digitalization of mental health services may represent an opportunity to enable individuals to access adequate mental healthcare in communities where mental health services may not be otherwise available and connecting patients with remote services delivered by non-specialized providers (Carter et al., 2021;Pathare et al., 2018).
However, most mental health workforce does not own an appropriate theoretical either practical training in digital psychiatry and in delivering remote consultations safely and effectively, particularly among those coming from LMICs mainly due to technological and economical barriers encountered in applying digital psychiatry. Most countries do not have curricula-specific training requirements, either at core or higher specialty level, for psychiatry trainees to demonstrate competence in digital skills that may be considered essential to good clinical practice, including abilities and competencies needed to provide and deliver mental health intervention by using digital tools (Bhugra et al., 2017;Dave et al., 2020).
The present study aimed to evaluate the level of knowledge, training, and experiences on digital psychiatry and related disciplines (e.g., e-health, e-mental health, telemedicine, telepsychiatry) in a cohort of medical students, psychiatry trainees, and early career psychiatrists (ECPs) coming from WHO APAC, in order to evaluate which needs and implementing strategies should be addressed in APAC countries to increase access to digital mental health interventions and care.
2 | METHODOLOGY 2.1 | Study design and sample recruitment strategy A web-based international cross-sectional survey was carried out by using Google Form ® in the timeframe from May 22, 2021 to July 23, 2021 by a working group constituted by one or two national representative(s) of each WHO South-East Asia and Western Pacific Regions, with the aim to evaluate the level of training, knowledge, experience, and perception regarding the topic of digital psychiatry in a sample constituted by medical students, psychiatry trainees, and ECPs from APAC. National representatives were recruited through a link to a Google Form™ specifically designed to collect preliminary data (i.e., contact details including email address and affiliation, country/WHO region of residency and work, employment status, the average number of completed surveys able to be collected in a period of around 3-4 weeks) as well as the interest and availability in actively participating in the data collection. The link was disseminated within the WhatsApp ® group of the ECPs of the World Psychiatric Association (WPA) in the timeframe from April 9, 2021 to May 20, 2021. The countries not included in the survey were those in which it was not possible to identify a national coordinator who would take over the responsibility of the study (e.g., Bhutan, Maldives, Myanmar, Timor-Leste, Brunei, Darussalam, Cambodia, China, Cook Islands, Fiji, Kiribati, Lao People's Democratic Republic, Marshall Islands, Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Solomon Islands, Tonga, Tuvalu, Vanuatu, and Vietnam) or those countries in which the national coordinator (even though initially selected and invited to join the project, e.g., Bangladesh, Sri Lanka, Philippines, Malaysia, Republic of Korea, Singapore, Australia, and New Zealand) was unable to collect questionnaires for each of the above mentioned three categories from their own country. All respondents who met the following inclusion criteria have been included in the analysis of our study: (a) subjects belonging to the above-mentioned categories (e.g., medical students, psychiatry trainees or ECP); (b) subjects belonging to one of the above-mentioned WHO regions (i.e., South-East Asia or Western Pacific Regions); (c) all subjects who agreed to participate to the study; (d) all subjects who authorized the treatment of sensible and personal data for research purpose. While all subjects who disagree to participate in the study or who did not fill out all sections of the survey have been removed by the dataset.

| The structure of the survey
An ad hoc questionnaire constituted by four sections, was self-administered anonymously to all subjects recruited in the present study, after asking to give informed consent as legally and ethically required. The third section also included one question (C8) which is a multiple answer question. The sum of each item except C8 was built to create a continuous variable named knowledge score (K) ranging from 0 to 18. The fourth section was made of 33 questions, of which 29 questions with a dichotomous answer and 4 questions with an increased five-item Likert scale, to investigate the participants' opinions, experiences, and perceptions regarding the telemedicine, telepsychiatry, and digital psychiatry.

| Data collection
National representatives facilitated the delivery of the English version of the survey across all APAC countries, through an online data collecting system. No translation in other languages was deemed necessary, as participants were deemed by their national representatives to have sufficient command of English to reliably answer the questions.
Among South-East Asia and Western Pacific Regions invited to take part in the survey, the following countries actually participated to our survey: India, Indonesia, Japan, Nepal, Pakistan, and Thailand.

| Statistical analysis
A preliminary descriptive analysis was carried out by using the Software Statistical Package for Social Sciences (SPSS) for MacOS (version 26.0, IBM Corp., Armonk, NY). All categorical variables were summarized as frequencies (n) and percentages (%), while all continuous variables have been summarized as means (m) and standard deviations (SD) or median (M) and 95% confidence interval (CI), where appropriate. Pearson' χ 2 test was used to compare sociodemographic features and categorical variables, such as the level of training in digital psychiatry. The normality of the K score was confirmed by using the Kolmogorov-Smirnov and Shapiro-Wilk normality tests. Independent student's T-test and two-tailed Mann-Whitney test, were performed, when appropriate, to compare K scores according to the following dichotomous variables: gender, WHO Region (residency), WHO Region (birthplace), opportunity to have received a practical/theoretical training and to have applied it in the clinical practice (B22 item), modules/topics of digital psychiatry taught within the Faculty of Medicine and Surgery (from B26 to B31 items) or within the psychiatry training program (from B32 to B37 items) and all dichotomic items of section regarding participants' attitudes and beliefs regarding digital psychiatry-related contents (from D1 to D22 and from D28 to D34).
The analysis of variance (ANOVA) was used to perform all comparisons between the groups identified through K scores with respect to the main socio-demographic characteristics (i.e., marital status, country residency, country of origin, ethnicity, WBI, current professional/ academic role, country of Medicine Faculty, country of psychiatry training program, working country as psychiatrist). Moreover, ANOVA was performed to compare K scores and the level of participants' training and opinion regarding the efficacy of digital interventions versus the efficacy of face-to-face modality. The significance level was set a priori at p ≤ .05, two-tailed.

| RESULTS
The survey was filled out by 221 respondents, 5 of which were excluded in the analysis due to their subsequent refusal to participate in the study, and 24 as they did not belong to WHO South-East Asia or Western Pacific Regions. The total number of questionnaires correctly filled during the collection process and finally included into the downstream analysis was of 192.  Table 1).

| Level of knowledge
The average mean K score was 7.9 (±SD = 2.9), with statistically significant higher scores among participants resident in WHO western pacific region compared to WHO south-east Asia region . Participants who declared a high WBI reported significantly higher K scores compared to lower middle (p = .021) and low income (p = .039; Figure 2). ECPs reported significant higher K scores compared to medical students (p = .015; Figure 3). Participants who attended the Faculty of Medicine in Japan reported significantly higher K scores, compared to those who studied in India (p = .006), Indonesia (p = .009), and Thailand (p = .030). Participants who studied in Nepal reported significant higher K scores compared to those studied in India (p = .038). Participants who studied their psychiatric training program in Japan also reported higher K scores compared to other countries (p = .004). Participants who currently work in Japan  (Gibson et al., 2011;Jameson et al., 2011;Whitten & Mackert, 2005).
Despite the limited training opportunities received, most participants declared the great need to implement digital psychiatry and related disciplines (e.g., e-health, e-mental health, telemedicine, telepsychiatry) since medical school and, subsequently, in dedicated modules/courses within psychiatry training program. In particular, the topic mainly suggested by participants to be included as an essential tool is telepsychiatry. Obviously, this increasing perceived need by clinicians may be also determined by the current COVID-19 pandemic and necessary restrictive measures and adaptations needed in the mental health services and infrastructures which indeed forced clinicians to reduce or discontinue in-person consultations (Unützer et al., 2020), access to mental health care and services by patients, despite an increasing demand and request for de novo psychiatric onset due to the COVID-19-related situation (Chen et al., 2020;D'Agostino et al., 2020;Fagiolini et al., 2020;Fiorillo et al., 2020;Giallonardo et al., 2020;Gorwood & Fiorillo, 2021;Li et al., 2020;McIntyre & Lee, 2020;Rojnic Kuzman et al., 2021). In fact, accordingly, our findings reported a moderate increase in the frequency use of digital psychiatry interventions (e.g., e-health, e-mental health, telemedicine, telepsychiatry, digital psychiatry, DHIs) by participants who reported an elevation up to 21%-50% compared to their previous clinical practice, after the COVID-19 outbreak (Stewart & Appelbaum, 2020). These findings are consistent with previous published studies carried out in India and Nepal (Li et al., 2021;Parikh et al., 2021;Rojnic Kuzman et al., 2021;Singh, 2021;Singh et al., 2021).
Furthermore, our sample showed an average K score very low which may be partially explained by the higher percentage of medical students recruited (54.2%), followed by ECPs (21.4%) and psychiatry trainees (19.3%). Therefore, we could argue that the lower K scores may reflect the fact that most participants have not already received their training in digital psychiatry and related disciplines, due to their medical student status and, hence, are not still able to correctly answer questions related to digital psychiatry and related disciplines.
Moreover, this sample distribution may also explain the low percentage of subjects who declared to have not received a theoretical and/ or practical teaching course in digital psychiatry and related disciplines (e.g., e-health, e-mental health, telemedicine, telepsychiatry) both within their medical school and psychiatry residency (Nagendrappa et al., 2021). However, in those participants who declared to have received some theoretical and/or practical training in digital psychiatry, even though at minimum extent, it was reported a higher possibility or likely a more positive attitude in applying it in their clinical practice. This evidence may also underline how extremely important is receiving, even though only at a basic level, digital skills and implementing digital competencies in the field of digital psychiatry as this may reflect a more positive attitude towards a digitally based clinical practice in mental health. In fact, in our sample, those who were trained in delivering digital interventions declared to be more ready and prone to apply them in their clinical practice.
Moreover, the levels of knowledge are not only influenced by the level of training and education in digital psychiatry but also by economic status, being higher among participants who own higher WBIs, probably due to the highest financial possibilities which may have individuals in buying digital tools and acquiring a better and more qualified education and training in the field of digital psychiatry.  (Chen et al., 2020;Feijt et al., 2020;Ghebreyesus, 2020;Hilty et al., 2013;Jameson et al., 2011;Wagnild et al., 2006). Furthermore, most of the sample declared advantages of digital psychiatry tools also in terms of financial and economic savings, by allowing a better rationalization of socio-health-financial processes, in terms of hospitalization rate reduction, travel cost reduction, and optimization of patient's waiting list. Therefore, digital psychiatry may potentially provide an advantage from an administrative and logistic perspective, especially to mental health infrastructures and national health organizations which are poorly organized or missing in the health workforce and specialty professionals. Moreover, in terms of efficacy and effectiveness, most participants believe that digital psychiatry interventions are comparable to those in-person ones and may potentially replace them, particularly in times of emergencies, even though most participants suggested that digital psychiatry should be preferred mainly to those pharmacologically stable patients and those who need follow-up visits. According to the respondents, digital psychiatry should not be recommended to those patients at their first consultation visit whereas it should be recommended a more traditional in-person consultation, as already previously underlined by a study (Gibson et al., 2011). In addition, most participants of our study did not report consistent findings regarding concerns and issues on privacy, data protection, and safety of digital tools in mental health, having our sample mainly reported an overall good opinion of digital tools also in these privacy and safety-related aspects, despite a previous study reported a negative perception by interviewed clinicians (Hale & Kvedar, 2014). However, regarding technical and clinical issues, participants mainly declared the need to preliminarily acquire an accurate and balanced assessment between risks versus benefits/ contraindications of digital psychiatry interventions in specific categories of patients, before offering the service. This evidence is in line with the American Telemedicine Association (ATA) guidelines (Turvey et al., 2013) which recommended to preliminarily identifying a supporting caregiver who should be called and alerted by the clinician in case of emergency during a digital intervention and/or consultation.
According to most of our sample, the identified caregiver should be warmly included in a structured and prevently agreed balanced plan for the management of a patient's crises during a digital consultation and/or intervention. Interestingly, despite not necessarily being a board-certified training and certification regarding digital competencies in mental health, most participants believe that clinicians should firstly obtain a certified theoretical and practical training in digital psychiatry, before allowing them to deliver a digital intervention and consultation in mental health.
Despite this promising evidence, our study presents a set of limitations as listed below. First, the sample size not being equally distrib- Therefore, further research and more longitudinal and case-control study designs are needed to evaluate the effect of COVID-19 pandemic on the level of education and training in digital psychiatry and related disciplines across APAC countries and how this may be influenced according to the different stages of academic progression and country digitalization. Moreover, further country-specific national-based studies should be carried out, and compare their findings to evaluate which is the best education and training strategy to ensure an adequate and homogeneous training in digital psychiatry and related disciplines across APAC countries, particularly those belonging to the LMIC. In fact, our findings demonstrated significant differences in those LMICs which implemented digitalization such as Nepal, in terms of education, training, and frontline experiences in applying digital psychiatry and related disciplines (e.g., e-health, emental health, telemedicine, telepsychiatry), by supporting the idea that incentivizing medical and psychiatry training programs in this field may potentially facilitate the digitalization process in LMICs.

ACKNOWLEDGMENT
Open Access Funding provided by Universita Politecnica delle Marche within the CRUI-CARE Agreement.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.