Author: Thiago Lopes Genaro
Brazil is a giant country. It is the fifth largest country in the world, behind Russia, Canada, China and the United States. The Amazon region is immense. There are municipalities in the Amazon that are 7 days away by boat from the capital, Manaus. There are no roads, just rivers (with piranhas!).
In these municipalities, there are even more isolated indigenous communities. Some of them are also days away by boat from these small towns. Imagine, therefore, the challenge of bringing medical care to these municipalities and these communities. Imagine a young indigenous man with bipolar disorder experiencing mania. How to receive adequate care from a psychiatrist?
Let’s imagine another situation. An offshore oil platform. Workers on these platforms spend 2 to 3 weeks on board, without returning to land. One of the workers has bipolar disorder and is experiencing a manic episode. How to help him ? Should he be transported by helicopter back to land for evaluation by the psychiatrist?
Until the pandemic in 2020, I understood that Telemedicine would serve specific situations and in locations where there was no easy access to a doctor. In fact, in a recent discussion on Linkedin, psychiatrist and Yale professor Eric Arzubi highlights the importance of telemedicine in rural and remote areas. He points out that in two American states, Alaska and Wyoming, there is no medical residency in psychiatry, making it difficult for psychiatrists to be present and stay in these regions.
Currently, in Brazil, if you have bipolar disorder and want to be treated via telemedicine, there are some ways.
As I highlighted in a previous text here on the Blog, only 25% of Brazilians have access to medical insurance. Most of these healthcare companies already offer telemedicine consultations in various specialties, including psychiatry. Conexa Saúde is one of these companies. We already have several certifiers in Brazil that validate controlled prescriptions, through a link on the patient’s cell phone, facilitating the collection of medicines from pharmacies.
There are already initiatives even in emergency room environments. There is a large project at the company Hapvida in which emergency doctors in the emergency rooms of the network’s hospitals (there are more than 100 throughout Brazil) have support from a psychiatrist, via telemedicine, to treat serious mental health cases. Let’s imagine a patient with bipolar disorder, in a mixed depressive episode, unable to schedule an appointment with his psychiatrist (who is on vacation). In addition to sadness, anhedonia and emotional indifference, there is associated irritability, anger, agitation and impulsiveness. It’s difficult to wait for the assistant psychiatrist’s vacation to end, don’t you agree?
Through a consultation in the emergency room, the telemedicine back-up psychiatrist has access to the patient’s previous medical records and is able to not only assist them, but also adjust medication, guide family members and even discuss the possibility of hospitalization. All this with the psychiatrist being hundreds or thousands of miles away from the patient!
Still in the private sector, most psychiatrists in Brazil already offer private care via telemedicine. Some companies, including oil companies with offshore platforms, also offer telemedicine consultations (including emergency psychiatric consultations) to their employees.
For patients with bipolar disorder treated by the public health system, telemedicine is less accessible. Few states and municipalities offer this type of service. However, especially in the northern region of Brazil, the Amazonas region, there is a great partnership, called Proadi, between the federal government and reference hospitals in the country, such as Hospital Israelita Albert Einstein. Consultations with psychiatrists are offered, always in the presence of a local clinical doctor, to assist in the diagnosis and management of patients with various emotional health conditions, including patients with bipolar disorder. Complex cases are treated, such as pregnant women in mania or adolescents with severe depression. The reach of this program even involves local indigenous communities. For many of these Brazilians, it is the first consultation in their lives with a psychiatrist!
I feel comfortable providing telemedicine services as a psychiatrist.
– But Thiago, do you think it is different to treat a patient with bipolar disorder via telemedicine?
Yes, I think it’s different and I think it’s a contemporary way of being a psychiatrist!
In person or on the computer, I continue looking into the patient’s eye. I continue to identify irritability and restlessness suggestive of hypomania. I continue to see a sadder look, a lower tone of voice and more negative speech suggestive of a depressive episode. I continue to guide family members, alerting them to signs of attention and urgency (including faceto-face consultations in certain cases!). I continue to clarify doubts. I can visualize a side effect of a medication on a computer screen, such as tremors in the extremities or a skin rash! I’ve even been able to identify tongue tremor (associated with lithium).
Using telemedicine, I can send prescriptions and reports to patients across Brazil. The patient does not need to go to the office. Don’t waste time in traffic. It can be attended at more convenient times. He can include his brother who lives in Rio de Janeiro and his son who lives in Paris in the consultation. Everyone participates in the consultation. I’m just not going to say that telemedicine makes the patient’s life easier in a harsh winter, in a week of snowfall, because we don’t have snow in Brazil!
Telemedicine is not for everyone. But it is for many.
Telemedicine is not for all situations. But it is for many.
And you? How do you feel about telemedicine?
Thiago Genaro is a psychiatrist in São Paulo, Brazil. He is part of the clinical staff of Conexa Saúde, Hapvida, MentalMe, Hospital Nipo-Brasileiro and Hospital Israelita Albert Einstein
