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Table of Contents
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 66-70

Use of store-and-forward tele-mental health for displaced Syrians

1 St Andrew’s Healthcare, Northampton, UK
2 University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
3 Howard University Hospital, Washington, D.C., USA
4 Yale School of Medicine, New Haven, Connecticut, USA

Date of Submission28-Aug-2019
Date of Decision06-Mar-2020
Date of Acceptance16-Mar-2020
Date of Web Publication29-May-2020

Correspondence Address:
FRCPsych Nadim Almoshmosh
Consultant Psychiatrist, St Andrews Healthcare, Cliftonville Road, Northampton, NN1 5DG
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_53_19

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The Syrian conflict has resulted in the worst humanitarian crisis of the 21st century with millions of people displaced inside Syria or in neighbouring countries. Severe shortages of mental health professionals in the area have created many challenges in addressing the mental health needs of this vulnerable population. In response, the Syrian Tele-Mental Health (STMH) Network was established in June 2014 following evidence gathered through a pilot survey. Using a ‘store-and-forward’ type of telemedicine, the STMH network was able to provide psychiatric consultations to 19 primary care centres serving 123 Syrian patients over a period of three years. In this article, we report and comment on the data obtained during this period including the strengths, limitations and challenges of such an approach.

Keywords: displaced Syrians, store-and-forward, STMH, tele-mental health

How to cite this article:
Almoshmosh N, Jefee-Bahloul H, Abdallah W, Barkil-Oteo A. Use of store-and-forward tele-mental health for displaced Syrians. Intervention 2020;18:66-70

How to cite this URL:
Almoshmosh N, Jefee-Bahloul H, Abdallah W, Barkil-Oteo A. Use of store-and-forward tele-mental health for displaced Syrians. Intervention [serial online] 2020 [cited 2023 Jun 3];18:66-70. Available from: http://www.interventionjournal.org//text.asp?2020/18/1/66/285313

  Introduction Top

Since the start of the Syrian crisis, over 5.6 million people have fled Syria, seeking safety in neighbouring countries and beyond. Millions more are displaced inside Syria according to the United Nations High Commissioner for Refugees (UNHCR, 2018). Making matters worse, there is a severe shortage of mental health professionals in the area to offer assistance related to the psychological consequences of this crisis. Even before the conflict, mental healthcare was in short supply in Syria, whose 21 million people were served by only 65 psychiatrists (Assalman, Alkhalil, & Curtice, 2008).

The World Health Organisation (WHO) estimates that approximately one in five people in conflict affected settings has a mental disorder (Charlson, van Ommeren, Flaxman, Cornett, Whiteford, & Saxena, 2019). Research has shown that current mental health needs of Syrian refugees range from the general negative effects of hardship and emotional adjustment difficulties to the most severe end of the spectrum, including complicated grief reactions, complex posttraumatic reactions, depression and anxiety (Almoshmosh, 2015; Karaman and Ricard, 2016; Barkil-Oteo, Abdallah, Mourra, & Jefee-Bahloul, 2018) and manifestation or exacerbations of pre-existing mental disorders (Almoshmosh, Jefee Bahloul, Barkil-Oteo, Hassan, & Kirmayer, 2019).

Tele-mental health (TMH) is a form of telemedicine that provides mental health assessment and treatment at a distance and can provide valuable assistance in the light of extremely limited mental health services on the ground. Studies show that TMH is effective in the diagnosis and assessment of a range of populations and settings (emergency, home health) and appears to be comparable to in-person care (Hilty, Ferrer, Parish, Johnston, Callahan, & Yellowlees, 2013). TMH has been successful when used in various clinical services and educational initiatives. It enables specialty consultation, allows reliable evaluation and generally satisfies patients and providers (Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004). Other studies have confirmed and found TMH to be cost and clinically effective (Hyler & Gangure, 2003; Garcia-Lizana & Munoz-Mayorga, 2010) in increasing access to care. It can also provide effective and adaptable solutions to the care of mental illnesses universally (Langarizadeh, Mohsen, Tabatabaei, Tavakol, Naghipour, & Moghbeli, 2017).

There are two main types of communication technologies in implementing TMH which are ‘synchronous or interactive’ and ‘asynchronous or store-and-forward’. Synchronous services provide live, two-way interactive transmission between patient and provider at distant locations. The store-and-forward (S&F) mode of communication involves acquiring data and then transmitting this clinical information via e-mail or web applications for later review by a specialist. Unlike synchronous forms of communication, asynchronous communication does not require the presence of both parties at the same time. The information can be transferred in the form of data, audio/video clips or recordings (Chakrabarti, 2015).

  Syrian tele-mental health network Top

The team of authors considered the opportunity of developing a series of TMH interventions in the provision of mental healthcare services for displaced Syrians. Their aims primarily were to provide the needed psychosocial support (Almoshmosh, 2016) and, where possible, to advise on managing mild to moderate common mental health problems such as depression, anxiety and acute stress-related problems. They set up the Syrian tele-mental health network (STMH) to help provide mental health consultations, education and clinical advice to enhance capacity-building efforts in this conflict setting using the available technology.

Mental health workers in humanitarian settings may come across patients with severe stress, trauma or manifesting symptoms of mental illness. Managing cases in these settings can be challenging due to limited resources and lack of supervision and training. The STMH aims to provide ‘on the job’ clinical advice and provide specialised consultations and supervision for local health workers in relation to delivering appropriate mental health service to displaced Syrians.

Prior to establishing the STMH, one of the authors assisted local psychiatrists in the management of treatment-resistant cases among Syrian refugees in Jordan via online video consultations with the clinician, not the patient. Over a three-month period, six complex cases (including individuals with PTSD and resistant depression) were successfully treated (Jefee-Bahloul, 2014a). Significant barriers in using direct video supervision were noted at this time, including lack of appropriate bandwidth, unreliable connectivity, the time difference between different time zones and a lack of funding.

Later, a pilot assessment (the PASSPORT Study) was conducted with 354 Syrian refugees in Turkey who presented at primary care clinics. Of these, 42% screened positive in the HADStress screening tool which was found to be associated with PTSD. 45% of those who reported a need for psychiatric treatment were willing to consider TMH as an approach generally (Jefee-Bahloul, Moustafa, Shebl, & Barkil-Oteo, 2014). The impression was that Syrian refugees are more likely to go to primary care medical clinics to seek help and are less interested in direct encounters with mental health professionals through telemedicine. In fact, the cohort provided many reasons for not wanting TMH with video streaming, citing privacy and safety concerns.

Based on the results of the pilot assessment and to further gauge providers’ attitudes towards the S&F type of telemedicine, an electronic pilot survey was sent to Syrian healthcare providers affiliated with humanitarian nongovernmental organisations (NGOs) managing displaced Syrians (Jefee-Bahloul, Duchen. & Barkil-Oteo, 2015). S&F requires engagement and active participation from healthcare providers by submitting text or audio-video clinical material for consultations. The description of TMH and S&F was provided to participants who were asked about their attitudes towards such services. Half of the providers believed that mental healthcare could be delivered through S&F and that there would be benefits from such services (Jefee-Bahloul, Duchen, & Barkil-Oteo, 2015). With this collective evidence, the team produced an Arabic translation of the documents linked with the platform, including user guidelines, a referral process and a mental health history and mental state examination template created to improve clinical communications between referrers and responding specialists.

  Setting up the service Top

STMH decided to use S&F through Collegium Telemedicus which has a simple secure way of exchanging clinical information between field workers and specialists. STMH went through a process of recruiting specialists who could provide clinical advice and supervision through the network. Calls were made to identify specialist volunteers with Arabic backgrounds (who could read, write and speak Arabic) from various parts of the world. These specialists were identified and invited to volunteer through the authors’ professional networks and direct personal contacts. This went on in parallel to identifying suitable referral centres within Syria and its neighbouring countries, where there may be healthcare field workers but are in need of such remote capacity building and clinical supervision.

STMH collaborated with many Syrian expatriate organisations such as Union des Organisations de Secours et Soins Médicaux and the Syrian American Medical Society and other smaller NGOs using needs assessments to identify centres that would benefit from the network. Information about the resources within these centres was gathered as part of the process, looking at the staff complement to establish whether there was at least one trained psychologist or therapist and if there were a general practitioner or a pharmacist available, together with listing available psychotropic medications and other service supports.

Relevant demographics and essential electronic accounts for practitioners were created with instructional videos explaining the process and how to use the platform. A psychologist from one of the centres referring an already known patient would seek their consent and start a referral of a new case. This includes describing relevant clinical information in writing, based on the agreed mental health assessment template or upload audio-video clinical material (patient interviews, family member collateral information, etc.) and asks clinical questions about the case.

The STMH coordinator, who is a senior psychiatrist, would then review the case and allocate it to the most appropriate specialist in the network to provide advice. That person would in turn respond to the raised questions and provide ongoing supervision to the referrer of the case. Educational materials including the psychological first aid guide for field workers (WHO, 2011), the mental health gap action programme humanitarian intervention guide (WHO & UNHCR, 2015) and published articles on the subjects raised were shared when relevant. No direct interactions occurred between the STMH network specialists providing the advice and the patients. The network provided advice and support only to centres that were out of government control areas and wanted to cooperate.

  Results Top

Data were collected from July 2014 to April 2017. The total number of referrals was 123 including 73 males (59.35%) and 50 females (40.65%). The mean age of patients was 25.41 years with an SD of 12.88 and range between 4 and 60 years. Of these, 27 patients were less than 18 years old. The referrals were for a range of symptoms including stress and trauma related symptom, anxiety and depression, insomnia, bed wetting, along with exaggeration of pre-existing disorders such as schizophrenia and bipolar disorder.

The number of referrals from inside Syria was 95 (77.23%), including centres based in the towns of Obin, Qah, Ifreen, 26 (21.13%) referrals from centres based in Turkey (Gaziantep, Kilis, Rayhania) and two (1.62%) referrals from Lebanon. Ifreen and Obin Centres (both in the North West of Syria) made the most referrals, 49 (39.8%) and 27 (21.9%), respectively.

Of the 19 potential referring centres, 10 of them actively participated, with 18 referrers out of a potential 48 taking part. Some centres may have had other direct support provided to them by NGOs that were active in the area; hence, they did not seek further cooperation from the STMH network.

Questions asked by referrers covered various areas including management and treatment in 49 (39.8%) cases, clarifying diagnosis in 46 (37.3%) cases, questions on approach and assessment and in 10 (8%) cases and asking for clinical materials and resources in 15 (12%) cases. Questions related to treatment strictly depended on the specifics of the case and the centre resources. Advice on pharmacological management in 21 (17%) cases was given to practitioners by the Network psychiatrists on commencing and following up when required. 28 (22.7%) were cases asking about the nonpharmacological management and general approach of the case. Psychotherapeutic and counselling interventions were delivered by the centre psychologist in accordance with their level and skills set, with monitoring and guided supervision by the Network staff. Such cases remained open until improvement occurred or no further advice was needed by the practitioner.

In total, 20 specialists offered consultations. Senior psychiatrists/neurologists and senior psychologists in STMH were based and practising in various countries, with three in the UK, eight in the USA, two in Canada, four in Qatar, two in Saudi Arabia and one in Turkey. They covered many sub specialities in mental health including general psychiatry, trauma based psychotherapy, cognitive behaviour therapy, neurology and child psychiatry. Webinars were arranged with the specialists by the network coordinator for updates and progress.

Feedback about the service was sought from referrers. STMH received feedback in 35 cases from 10 referrers. Referrers generally gave positive feedback: They indicated that the consultations helped them to understand and confirm the diagnosis of patients, to gain confidence in the approaches used, to provide better management of cases and in offering specialist practical advice. This saved patients time and effort in finding a specialist, and reduced the cost of healthcare for both patients and referring primary care centres. Delay in response to queries and not having live interaction with specialists were deemed as restrictions.

  Discussion Top

There are three main barriers in implementing TMH in this area of the Middle East that are frequently observed including cultural, technical (technology, staffing) and financial factors (Jefee-Bahloul, 2014b). In this particular initiative, STMH strived to survey needs and cultural attitudes before embarking on the project. While patients were less likely to agree to a TMH encounter, STMH found encouraging support from providers to receiving S&F assistance.

The technical challenge of poor Internet connections made an S&F system more practical to use, despite the limitations of not having a ‘live’ interaction. A further technical challenge was the lack of availability of electronic medical records which increased the burden on referrers to document cases in a system that is separate from their paper-based files. In addition, the lack of trained technicians and medical support, such as lack of medications or available hospitalisation for severe disorders in emergencies particularly in remote settings, can be an obstacle in areas already suffering shortages of technical and medical services (Jefee-Bahloul, 2014b). In the future, allowing patients full access to their medical records enabling them to transfer them easily (as it is a highly mobile group) should be taken into account when designing TMH systems (Kluge, 2011). This may help in continuity of care across several providers.

Providing advice on patients’ care without face-to-face interviews and relying on insufficient information provided was challenging. On occasions, this required the exchange of multiple messages to understand the full picture. Time differences (6–8 hours) between the locations of specialists (US/UK/Qatar/Canada) and referrers (Syria/Turkey/Jordan) added delays in responding to referrals. As Arabic was the language used across the Network, this prevented us from recruiting other motivated specialists, therefore their potential input was lost. This could have impacted the involvement of non-Arabic speaking referrers, such as those who are Kurdish − a language spoken by many Syrians. The S&F method does not lend itself to providing psychotherapy from a distance, therefore there was reliance on the limited experience and skills of clinicians on the ground. Standards setting and quality control were therefore an issue being subject to the quality of symptom recognition, assessment and case presentation by the referrers.

There was a high number of potential referring centres who initially agreed, but did not send any referrals. Although reasons for this were not specifically pursued, this could be due to insufficient training in recognising mental health symptoms, clinicians’ knowledge of the technology, patients’ resistance and perhaps the unfamiliarity of referrers with the specialists at the other end. The reduction in number of referrals received over time was associated with the significant shift in geographic territories in favour of government forces. This may explain why Ifreen centre − located in a relatively neutral area − sent 39.8% of referrals.

Unfortunately, the project was slowly underutilised over time and it appears that there may have been a few reasons. The changing scene on the ground due to war activities had a tremendous impact upon the sustainability of our work resulting in the last case being received in April 2017. The major two clinics that were active in the Network (Ifreen and Obin clinics in Idlib and Lattakia Provinces, respectively) were both affected by battles and this, along with the targeting of other mobile healthcare clinics, resulted in the discontinuation of our work. Volunteer coordinators and specialists who were all pro-bono primarily ran the Network without time to increase their availability. In addition, it was not possible to reach and recruit more referrers given the limited manpower and lack of resources in the STMH, along with the maturation effect as some referrers were learning and have needed less advice.

This model for a STMH network was enough to launch the service. However, for long-term sustainability it is important for the coordinator to be based near the clinics to help address some of the challenges preventing referrals and to be supported financially, possibly as a part time role.

Data were collected according to Collegium Telemedicus privacy policy that is fully compliant with the EU General Data Protection Regulation. The rest of the data were stored at the referring clinics in their regular archive.

  Conclusion Top

S&F TMH offers many benefits to patients and clinicians, including convenience, efficiency and practice improvement. S&F networks (which historically had been used in medical fields, radiology, etc.) can be expanded to tele-mental health and used in conflict settings. The STMH provides an example of how a free and accessible telemedicine platform can be adapted to provide capacity building and supervision for healthcare workers, and more specifically in our scenario for mental health workers in conflict zones who lack direct supervision and on-the-job training.

Lessons learnt from undertaking this project highlight the importance of early planning and discussion with organisations that have been involved or are interested in using TMH platforms. Furthermore, identifying NGOs on the ground with existing resources and qualified personnel would make it easier to set up clear goals and pathways for such work. Volunteers need to be adaptable, take into account the need for funding early on for sustainability and above all being patient. Taking these factors into account TMH can be cost effective, particularly with a sustained number of volunteers, and can lead to efficient and adaptable solutions to the care of patients with non-urgent mental health conditions. However, there are potential challenges to the implementation of this approach that need to be considered and covered. Further studies are required to evaluate the applications of S&F TMH and to explore its potential promises.


The authors wish to thank all specialist volunteers for their invaluable contribution to this project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


  References Top

Almoshmosh N. (2015). Highlighting the mental health needs of Syrian refugees. Intervention, 13(2), 178-181.  Back to cited text no. 1
Almoshmosh N. (2016). The role of war trauma survivors in managing their own mental conditions, Syria civil war as an example. Avicenna J Med, 6(2), 54-59.  Back to cited text no. 2
Almoshmosh N., Jefee Bahloul H., Barkil-Oteo A., Hassan G., Kirmayer L. (2019). Mental health of resettled Syrian refugees: A practical cross-cultural guide for practitioners. The Journal of Mental Health Training, Education and Practice, 15(1), 20-32.  Back to cited text no. 3
Assalman I., Alkhalil M., Curtice M. (2008). Mental health in the Syrian Arab Republic. International Psychiatry, 5(3), 64-66.  Back to cited text no. 4
Barkil-Oteo A., Abdallah W., Mourra S., Jefee-Bahloul H. (2018). Trauma and resiliency a tale of a Syrian refugee. American Journal of Psychiatry, 175(1), 8-12.  Back to cited text no. 5
Chakrabarti S. (2015). Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches. World J Psychiatry, 5(3), 286-304.  Back to cited text no. 6
Charlson F., van Ommeren M., Flaxman A., Cornett J., Whiteford H., Saxena S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis. The Lancet, 394(10194), 240-248.  Back to cited text no. 7
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Jefee-Bahloul H., Duchen D., Barkil-Oteo A. (2015). Attitudes towards implementation of Store-and-Forward telemental health in humanitarian settings: Survey of Syrian healthcare providers. Acta Informatica Medica, 22(1), 32-35.  Back to cited text no. 15
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