For Andres Barkil-Oteo, MD, and Hussam Jefee-Bahloul, MD, the strong desire to help refugees of the Syrian Civil War greatly outweighed the challenges posed by their living continents away from the humanitarian effort.
Barkil-Oteo, who recently left the Yale Department of Psychiatry faculty to join Doctors Without Borders to work with refugees in Greece, and Jefee-Bahloul, a former advanced clinical fellow in the department, two years ago devised a way to teach and train health care workers who provide mental health services to Syrian refugees in the Middle East.
Taking advantage of technology, they co-founded the non-profit Syrian TeleMental Health Network, a secure online platform based in the United Kingdom that enables clinicians in humanitarian settings to ask questions about their patients, and to receive general mental health training and supervision from specialists in North America, Europe, and the Middle East through electronic text or recorded audio-visual material.
The intent was to help health care workers in refugee camps provide better services to people who have endured the horrors of having to flee their homes, or, in the most extreme cases, watched their loved ones die or be tortured. It also enabled academic professionals to offer clinical guidance in areas of the world where there is a lack of supervision and training from qualified mental health experts.
The network has signed up non-governmental organization (NGO) health care providers mostly in Turkey, where close to 3 million refugees have settled since the war in Syria began five years ago, but also in Jordan and Lebanon, where 1.5 million and 1.25 million refugees, respectively, are now living. To participate in the network, each center’s medical director must complete a needs assessment to explain the facility’s capacity to treat patients, its team members’ specialties, and its access to medication, if any.
“The clinics are grateful. They are under a lot of pressure,” Barkil-Oteo said. “Some of them took this, believed in it, and we saw how their capacity developed. That led them to ask for more training.”
He said the network consults on about 15 cases a month, although the number fluctuates. The site coordinators receive an alert when someone logs in and requests a referral. Users can either provide information about their patient in writing, or upload audio-visual materials – such as patient interviews or family information. They must pose at least one clinical question about their case to the network.
Barkil-Oteo and Jefee-Bahloul – who is now faculty at the University of Massachusetts Medical School in Worcester – work with others to review the cases, then refer the information to a specialist they feel is best positioned to help.
“The advice given is a mixture of clinical impressions and educational materials, such as available resources and published articles on the subject. The specialist is then assigned to this case as a resource for future questions, ongoing conversation, and supervision about the progress of the case,” Jefee-Bahloul, Barkil-Oteo and three other authors wrote in the paper, “Using a Store-and-Forward System to Provide Global Telemental Health Supervision and Training: A Case from Syria.”
The paper, published in 2015 in the journal Academic Psychiatry, provides an overview of the network, which is translated in both English and Arabic, and explains its purpose in helping the displaced Syrians.
The network launched in June 2014 with one mental health clinic and four bachelor’s level psychologists referring patients. The system was improved as more field clinicians were brought on, and the site coordinators learned how best to interact with their counterparts in the Middle East.
Jefee-Bahloul and Barkil-Otelo wrote in Academic Psychiatry that based on feedback, they learned they needed to provide more detailed clinical advice to the field workers.
“This feedback allowed for an iterative process of refinement of the procedural instructions to help referring health care providers to provide sufficient clinical materials, and specialists to provide the needed consultation and education,” they wrote in the paper. “One major change was the creation of a specific ‘mental health history’ template, allowing the clinician to provide a complete history and mental health exam, which led to better clinical questions and better responses from the experts.”
Clinician training is an important component of the website, Barkil-Oteo said, and teaching videos are available.
There have been plenty of patient success stories, he said. In their paper, the authors wrote about a 15-year-old Syrian boy who was referred to the network for a consult. He had been living in a refugee camp in Turkey for three years, and was exhibiting behavioral and social problems. Eventually, he withdrew from the camp school.
A health care worker at the refugee camp diagnosed the boy with attention-deficit/hyperactivity disorder and autism. The boy was referred to the network because he continued to exhibit aggression and social isolation despite being medicated.
Site coordinators directed his case to a child and adolescent psychiatrist at the University of Massachusetts, who made a provisional diagnosis of post-traumatic stress disorder. A treatment plan was prepared, which included trauma-focused cognitive behavioral therapy and group support. A plan was put in place to help the boy return to school.
Barkil-Oteo said stories like this motivate him to keep the network active so more refugees like the teenage boy can be helped.
“It’s really hard to see all of this and to think what can I do?” he said. “We are as effective as what’s happening on the ground.”