Abstract
Telepsychiatry has been used to increase access to mental health services for underserved populations (including ethnic minorities, immigrants and refugees) within-borders1–7 and across borders.8,9 However, telepsychiatry is underutilized in conflict or disaster areas. 10 For the last three years, the Syrian conflict has produced increasing numbers of refugees and there are now some two million. In December 2013, there were over 560,000 Syrian refugees registered in Jordan, spread over refugee camps and urban areas. 11 Little is known about the mental health services available to Syrian refugees in Jordan, especially to those who are not living in government or UN-funded camps.
The Syrian American Medical Society (SAMS) is a humanitarian organization which provides support for Syrian refugees and health care providers in Jordan. In 2013, I was asked to assist a Syrian-trained psychiatrist supported by SAMS and working in Jordan. We used telepsychiatry between the US and Jordan to assist with refugee mental health.
All cases for teleconsultation were selected by the treating psychiatrist based on treatment resistance. The purpose of the teleconsultations was to increase the local provider's capacity to manage treatment-resistant psychiatric cases. There were no direct patient encounters between the consultant and the patients, except in one case where a family member (husband) requested permission to participate in order to provide essential information about a female patient. The teleconsultations were conducted via Skype, and were done in Arabic. Each session lasted an average of 50 min, during which the local psychiatrist presented a case to the consultant, which was then discussed. In each case, a multiple consecutive evidence-based treatment plan was established (e.g. if plan A does not work then try plan B, and so forth). Some cases required more than one teleconsultation session. The work during the sessions was collaborative where the local psychiatrist provided explanations and descriptions of the logistics, barriers to providing proper care (e.g. limited referral resources, limited numbers of mental health providers, lack of the basic psychotropic medications), and the overall nature of cases seen in his work. In addition, the consultant provided supervisory educational remarks on each case. This supervision covered psychiatric diagnostic skills, effective and culturally specific supportive psychotherapy techniques, and evidence-based psychopharmacological or psychotherapy-based approaches.
Over a three month period a total of six treatment-resistant cases were completed, concerning children (n = 2) and adult patients (n = 4). The diagnoses were mood disorder not otherwise specified, schizoaffective disorder, bipolar disorder, major depression with psychotic features and post-traumatic stress disorder. Only one of the cases was for a post-traumatic stress disorder that had resulted from a trauma related to the current conflict. This is not surprising as the majority of mental illness post-conflict arises from existing or previous psychopathogies rather than new traumas. 12
Obstacles and proposed solutions
Although the teleconsultations were felt to be clinically useful by the treating psychiatrist, the telepsychiatry sessions suffered certain difficulties:
Bandwidth. The Internet connection was of modest quality which resulted in poor-quality videoconferencing and multiple disconnections. In some sessions the videoconferencing was substituted by audio-conferencing due to the slow connection. A potential solution to this problem would be to employ store-and-forward telemedicine, also referred to as asynchronous telepsychiatry. This has been shown to be cost-effective when compared to real-time telepsychiatry.
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Availability of the local psychiatrist. The treating psychiatrist was not available on every occasion, given the time demands and the nature of his work. An integrated-care model, where local clinic workers are trained to case-manage and coordinate the case-presentations or the store-and-forward consultations, would reduce the time demands on the treating psychiatrist. Remuneration. The lack of remuneration for the local psychiatrist in our collaborative work may make the work unsustainable in future. Demonstrating the effectiveness of telepsychiatry might encourage local governments or NGOs to increase remuneration for mental health providers.
Conclusions
Telepsychiatry using low-cost technology can be useful in providing supervision, education and consultations to mental health providers in conflict areas, such as in the Syrian conflict. The present work appears successful, although the outcome of the consultations on both patient care and the capacity building was not measured. In future studies, telepsychiatry may be valuable in capacity-building for the primary care providers who manage patients with mental illness in conflict settings.
Footnotes
Acknowledgments
I thank Dr Yassar Kanawati and Dr Andres Barkil-Oteo for their help in this work.