April 07, 2017
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Syrian Psychiatrists Far From Home Help Treat Refugees Online

The war has increased mental health problems while making it harder for displaced Syrians to access treatment. The Syrian Telemental Health Network lets psychiatrists outside the country provide remote support to colleagues on the ground.

By Charlotte Alfred


Two women from Syria sit facing the sea in Athens in March 2016. AFP/Angelos Tzortzinis

Two women from Syria sit facing the sea in Athens in March 2016. AFP/Angelos Tzortzinis

WHEN PSYCHIATRISTS ANDRES Barkil-Oteo and Hussam Jefee-Bahloul met at Yale University in Connecticut three years ago, they quickly realized they had a lot in common.

“You don’t see a lot of Syrian psychiatrists at Yale,” Jefee-Bahloul says, laughing. “We were basically the only two.”

They had also been grappling with the same dilemma – how to use their mental health expertise to help Syrians and Syrian refugees. Both had left their homeland before the 2011 uprising to do psychiatry training in theU.S. and their distance from Syria’s descent into war weighed heavily on them.

“You read the news, but you are sitting very far away, so you feel like you can’t do much and there is a big sense of hopelessness,” Barkil-Oteo says. “Either you try not to think about it, or you occupy yourself with different things, or you try to do something.”

The pair formed a close friendship and professional collaboration that led to the launch in 2014 of the Syrian Telemental Health Network, an online platform helping mental health workers treating Syrians to access training and supervision from specialists around the world.

Mental health workers in around a dozen clinics in Syria and neighboring Turkey, Lebanon and Jordan use the U.K.-based platform to request clinical guidance from a volunteer network of expert Syrian psychiatrists based in Europe, the U.S. and the Middle East.

They can upload case information, including video and audio recordings of their patients, to the secure platform in order to obtain direction and advice from psychiatrists. The network sees about 10–15 cases a month, although the number fluctuates as clinics become overwhelmed with refugees, or have to close or relocate owing to the fighting in Syria.

The consultations can be critical for the undertrained and overstretched health workers on the ground. In one case, a 15-year-old Syrian boy was being treated for autism in a refugee camp in Turkey, but remained uncommunicative and aggressive and was referred to the Telemental network. A child psychiatrist at the University of Massachusetts who reviewed the case, including a video of the boy, changed the diagnosis to post-traumatic stress disorder and recommended testing him for learning disabilities.

The network is trying to address two major repercussions of the war – the rise in mental health problems among Syrians, and the difficulties that Syrian mental health workers face in treating them.

For example, one of Syria’s two public psychiatric hospitals was forced to close early in the conflict because of fighting in Aleppo. Most of its patients fled across the border to Turkey, cutting their access to treatment at a time when stress was very likely to make their conditions even worse, says Jefee-Bahloul.

A 2015 survey by humanitarian organization International Medical Corpsof its Syrian patients revealed that 54 percent suffered from severe emotional disorders such as depression and anxiety, and 11 percent from psychotic disorders including schizophrenia.

Yet it is extremely hard for Syrians to obtain mental healthcare. Apart from the social stigma associated with psychological disorders, many Syrian refugees in Lebanon and Jordan are unable to afford the countries’ medical fees. While registered refugees in Turkey are entitled to free healthcare, there is a shortage of Arabic-speaking doctors, and psychiatrists in particular. In Syria, the entire health system lies in ruins after what Physicians for Human Rights describes as an “all-out assault on the country’s medical system” by government forces.

Meanwhile, humanitarian groups are not always well equipped to provide specialized mental healthcare, or even comfortable doing so, explains Barkil-Oteo. “The larger picture that many NGOs are trying to figure out is, what’s our strategy here? Are we in the business of saving people’s lives, or setting up primary care clinics that could be there for the next five years?”

In addition, there are simply not enough highly trained psychiatrists in the region – there were only 70 psychiatrists in Syria before the war broke out, according to the World Health Organization. Most Syrians now working in mental healthcare have an undergraduate degree in psychology, but very little advanced education or clinical experience, Barkil-Oteo says.

That is why the Syrian Telemental Health Network is designed to help build the skills of mental health workers through expert supervision, and has experimented with providing online lectures and training videos.

While the Syrian conflict “is an emergency situation, it is also not going to be solved anytime soon, so we are thinking five years ahead, and how to set up a system that will be sustainable,” says Barkil-Oteo.

Sustainability has been one of the network’s biggest challenges. On the one hand, using telemedicine – the remote delivery of medical care using technology – has helped sustainability, allowing a broad array of psychiatrists and clinics to become involved, and helping local staff develop their skills rather than become reliant on outside experts.

The network uses an online system called Collegium Telemedicus that is offered free to humanitarian agencies, and works with a local medical organization that is already well established in the region, called the Union of Medical Care and Relief Organizations (UOSSM).

But being a remote network also has its difficulties. The clinics’ involvement can fluctuate because of the precarious situation on the ground. Everyone from the supervising psychiatrists to the founders work for the network on a voluntary basis, squeezing it in alongside demanding day jobs. Barkil-Oteo and Jefee-Bahloul are currently looking for funding to put more resources into the platform.

They have both moved on from Yale. Jefee-Bahloul is now an assistant professor in psychiatry at the University of Massachusetts. Barkil-Oteo recently joined Médecins Sans Frontières (Doctors Without Borders), providing psychiatric care to refugees in Greece. They remain determined to help displaced Syrians and, ever psychiatrists, they are both quick to analyze their own motivations.

“Both Hussam and I are doing this as our own ways of coping with what’s going on,” says Barkil-Oteo. “Obviously, we haven’t solved the crisis, but you feel like you are doing your own little part.”

“I have learned a lot about myself and how I’m relating to what’s happening in Syria through this experience,” Jefee-Bahloul says. “The network is my anti-anxiety medicine.”

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