Hussam Jefee-Bahloul

Mental health and psychosocial wellbeing of Syrians affected by armed conflict

AIMS This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees. METHODS We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed. RESULTS Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored. CONCLUSIONS Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

Telemental health in the middle East: overcoming the barriers.

The Middle East (ME) is a heterogeneous part of the world with variations in mental health services. The spectrum includes countries that have well (e.g., Israel), fair (e.g., Turkey, Iran, Saudi Arabia), or poor (e.g., Iraq, Syria) services according to the data provided by Jacob et al. (1) (number of psychiatrists per 100,000 population: Israel, 13.7; Bahrain, 5; Qatar, 3.4; Kuwait, 3.1; Lebanon, 2; UAE, 2; Iran, 1.9; Oman, 1.4; Saudi Arabia, 1.1; Turkey, 1; Jordan, 1; Iraq, 0.7; Syrian, 0.5; Yemen, 0.5; compared to USA, 13.7; Canada, 12; UK, 11). Given the disparities in mental health services there is a need to implement telemental health (TMH) in the ME. This article will discuss barriers of TMH in the ME and propose recommendations for implementation based on published studies and the author’s experience.

Using a Store-and-Forward System to Provide Global Telemental Health Supervision and Training: A Case from Syria

Not only in humanitarian conflict settings but throughout the globe, the provision of mental health services has always faced practical difficulties, such as the availability of flexible manpower of supervisors on the ground. Telemental health offers an alternative way to provide clinical supervision and services globally [1]. The use of videoconferencing-based clinical supervision has been reported in studies involving the teaching of medical students [2], psychiatry residents and fellows [3], and psychoanalysis candidates [4]. In addition, telemental health educational programs for psychologists and medical professionals are now being proposed [5]. In this report, we present a global telemental health system that provides clinical consultations and supervision to health care providers in the Syrian humanitarian setting, using storeand-forward technology, as an alternative to videoconferencing. Store-and-forward telemental health utilizes the indirect transmission of electronic text or recorded audio-visual material between parties. The Syrian TeleMental Health Network [6] uses a store-and-forward platform to provide training and education for health care workers, as well as clinical consultations, in Syrian conflict settings. The store-and-forward platform we use (Collegium Telemedicus) [7] is also used by nongovernmental organizations such asMédicines sans frontières to provide advice and consultations to their physicians in the field [8]. The platform is based in the UK and consists of a safe server through which referring providers can send clinical material about certain cases to specialists within the network. Collegium Telemedicus complies with European standards of information security by ensuring that “data traffic” from the user to the server is encrypted, in addition to an encrypted database and two firewalls to protect the server. The software is available on a secure server and can be accessed using any Internet browser. It provides “non-live” (i.e., asynchronous) means of communication, for transmitting clinical material and educational responses. The purpose of our network is to help health care providers (e.g., physicians, psychologists, nurses, and non-specialized health care workers) to obtain specialized consultation and then supervision about their cases. Many specialists of Arabic background (e.g., Syrian and Lebanese) are recruited from academic centers in the US, Canada, UK, and Middle East to provide the consultations and training. Clinics recruited for this network are either primary care centers staffed with physicians and nurses or mental health clinics staffed with Bachelor’s degree-level psychologists and psychiatrists. The medical director’s approval from each center is obtained prior to implementation. A needs assessment form is then filled out by the center’s coordinator, detailing the general capacity of the center, team members, their specialties, available medications (if any), and so on; this information will be available later to the specialists who will provide the consultations. Next, whenever possible, an initial meeting takes place via videoconferencing, during which all team members being recruited will meet with the network coordinators and some of the specialists to obtain an overview of the network and * Hussam Jefee-Bahloul hussam.jefeebahloul@gmail.com; hussam.bahloul@yale.edu

Mental Health Research in the Syrian Humanitarian Crisis

In areas of armed conflicts, efforts to provide mental health services for refugees and internally displaced populations (IDPs) generally lack measures of effectiveness, and the gap between research and practice is significant (1). The Syrian Crisis has been described by the United Nations High Commissioner for Refugees (UNHCR) as “the great tragedy of this century” (2). The UNHCR reports at least 24 agencies currently providing mental health and psychological support to Syrian refugees (3). The actual interventions provided vary considerably among the agencies, which complicates the implementation of academic research and mental health services in humanitarian settings (4). This is further challenged by the limited academic publications on the matters of Syrian refugees’ mental health beyond basic needs assessment (3, 5–7). In an effort to standardize mental health interventions in humanitarian settings, the Inter-Agency Standing Committee (IASC) had published standardized guidelines for provision of mental health services, but had not addressed the role of academic research (8). Creating a research agenda for mental health in the less-resourceful settings has been emphasized (9). However, there are barriers to establish academic research in emergency humanitarian settings. Those barriers have been identified before (8), and we will mention few examples here in relevance to the Syrian scenario. The research conducted in conflict settings is often designed and executed by “foreign” institutions outside the area of the conflict or disaster (8), and the Syrian Crisis is no exception (5, 6, 10). This is likely to affect the efficacy and sustainability of interventions. Incorporating local institutions and humanitarian workers in designing and conducting the research would likely foster a sense of ownership in the locals and ensure sustainability. For instance, thousands of educated Syrian youth have sought refuge in the neighboring countries since the beginning of the conflict (11). Incorporating this educated population as research assistants and cultural brokers in mental health research projects would enhance ownership, sustainability, and efficacy of such projects. Another obstacle for academic research is reaching the non-refugee; i.e., displaced populations. The internally displaced living within the battlefields inside Syria, is an example (10). Additionally, mental health research in refugee camps across the borders requires availability of basic needs such as shelter, food, water, and basic medical services which are not always secured, or stable (12), and can interrupt research efforts. Hence, initiating needs assessment, intervention implementation, and effectiveness studies in the relatively more stable areas such as Turkey (13) can allow for manageable pilot research projects. In the future, those studies can be replicated and tested in less stable areas. In a recent study (currently in press and detailed elsewhere), one of us (Hussam Jefee-Bahloul) and colleagues surveyed a sample of Syrian refugees in a busy refugee primary care clinic in Kilis Turkey (6). The assessment used a standardized and validated tool that can reflect psychological stress. In brief, a significant number of refugees (41%) met the cut off criteria for needing further psychological assessment; however, less than a half had a perceived need to see a mental health specialist, and less so was open to mental health services provided via technology (telepsychiatry). The example of telepsychiatry here is relevant to the topic of this article as it represents an example of mental health innovative interventions that require testing in humanitarian settings. Conducting a sufficient basic needs assessment in a very busy primary care refugee clinic had mandated administration of a simple, time-efficient, and non-threatening questionnaire rather than standard psychological stress test batteries. Recruitment process was received with mixed reactions by the refugees; either desperation to seek help or suspiciousness of the foreign workers (even though our data collection was done by an Arabic speaking Arab-American medical student). Also, subjects of the study were hesitant to cooperate given the stigma surrounding mental illness in the Syrian culture. Nevertheless, this kind of needs assessment studies can be replicated and used as cornerstones for interventions effectiveness studies in the unstable conflict areas of Syria. Here thereafter, a philosophical gap lies between the academic “perfectionistic” views on research and the “practical” perspectives of humanitarian workers (e.g., the focus of humanitarian workers on immediate short-term-outcomes rather than long-term-outcomes) (8). This gap is justified by the emergency context of these situations. Refugees fleeing conflict areas may exhibit acute symptoms of psychological stress that require immediate attention by the humanitarian workers. The application of academic research in these acute settings may not guarantee immediate effective remedies for people under duress. Humanitarian workers may also have concerns that application of research designs will interrupt the flow of humanitarian work. This can explain the hesitance to incorporate research in conflict settings. On the other hand, the expansion of this gap will prevent field-based humanitarian interventions from catching up with evidence-based medicine. Hence, the need to bridge this gap and address these valid concerns has never been more imperative. Incorporating thoughtfully designed interventions and standardized outcome measurements into the routine humanitarian protocols and training manuals may help solve this problem. It is worth mentioning that some academic projects had successfully incorporated academic research into humanitarian settings in the past (14–19) and more is hoped to be accomplished on mental health of those affected by the Syrian Crisis. Finally, the schism between the academic and the humanitarian platforms and audiences adds to the observed gap. The academic literature and the humanitarian platforms rarely merge. Some academic journals have designated certain issues to humanitarian causes (4), however, this does not guarantee delivery of this information to the target audience, i.e., humanitarian organizations, workers, and policy makers. Unifying the academic and humanitarian platforms, can allow audiences from both fields to interact, share experience, and collaborate on much needed mental health research in areas of conflict.

Use of telepsychiatry in areas of conflict: the Syrian refugee crisis as an example

Telepsychiatry has been used to increase access to mental health services for underserved populations (including ethnic minorities, immigrants and refugees) within-borders and across borders. However, telepsychiatry is underutilized in conflict or disaster areas. 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. 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 50min, 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 psychotherapybased approaches. Over a three month period a total of six treatmentresistant cases were completed, concerning children (n1⁄4 2) and adult patients (n1⁄4 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 postconflict arises from existing or previous psychopathogies rather than new traumas.

Teaching psychiatry residents about culture-bound syndromes: implementation of a modified team-based learning program.

Diagnostic and Statistical Manual of Mental Disorders (DSM) IV defines culture-bound syndromes (CBS) as “recurrent, locality-specific patterns of aberrant behavior and troubling experience ... indigenously considered to be ‘illnesses,’ or at least afflictions ... generally limited to specific societies or culture areas.” [1] In DSM 5, the definition became “... a cluster or group of co-occurring relatively invariant symptoms found in a specific cultural group community or context (e.g., ataque de nervios).” [2] Psychiatry residents would do well to familiarize themselves with this important group of psychopathologies. For instance, vignettes related to CBS regularly appear on the American Board of Psychiatry and Neurology Board Examination as well as the Psychiatry Resident-InTraining Examination (PRITE®). The Accreditation Council for Graduate Medical Education (ACGME), responsible for accrediting the majority of graduate medical training programs in the USA [3], requires programs to improve residents’ understanding of how a patient’s culture and subculture influence psychopathology. The ACGME does not require a formal, CBS-specific curriculum and does not provide guidelines on how awareness of CBS may be achieved. To this end, we developed a pilot teaching seminar using a modified team-based learning (TBL) approach for psychiatry residents to increase their knowledge of these syndromes. Here, we present the details of this activity as well as the pilot data that we obtained after implementation. Traditional TBL has been used frequently in medicine and psychiatry teaching. It involves pre-class preparation followed by a structured component applying learned concepts into clinical cases [4]. This is accomplished by dividing students or residents into groups where each trainee will interact with others through an active-learning model. InMay 2013, a seminar created and administered by a chief resident (author) was presented to psychiatry residents (Post-graduate year 2, 3, and 4) at the University of Texas Southwestern Medical Center in Dallas. In 1h, 22 psychiatry residents were divided into four groups and presented with six culturally complex psychiatric vignettes. Attendance was voluntary. The vignettes presented patients with one of six different CBS (dhat, latah, pibloktoq, taijin kyofusho, koro, and susto). (The vignettes are available by communication with the author). Residents were asked to select the most likely CBS and associated country of origin from a multiple choice list (average of seven choices including distracters). The vignettes were timed, and scores were calculated after the seminar. The team members were encouraged to use electronic devices to access the internet to answer questions. The team that scored highest at the end of the activity won gift cards to a local coffeehouse to serve as an incentive during the TBL activity. The vignette portion of the exercise was followed by a discussion of each case in which the key symptoms of each CBS were highlighted and distracters addressed. In traditional TBL, there are three phases. Pre-group activities can include reading assignments and a readiness assurance test. The core group activity that follows allows for learned concepts to be applied [4]. In our module, the pre-assigned reading materials were replaced by allowing residents to use digital resources during the learning activity. Three tests were administered for each resident individually: (1) a pre-test before the activity, (2) a post-test administered immediately after the activity, and (3) a remote test administered electronically 4 weeks later. Tests were anonymous and H. Jefee-Bahloul (*) Yale School of Medicine, New Haven, CT, USA e-mail: Hussam.bahloul@yale.edu