Enhancing mental health services for capacity building: The Afghan support program telepsychiatry initiative

Abstract

This research paper examines the impact and effectiveness of the Afghan Support Program’s (ASP) innovative telepsychiatry initiative in addressing the mental health challenges faced by Afghan refugees and communities enduring complex emergencies, and it also plays a crucial role in capacity building of Afghan refugees by providing training and support to local healthcare workers in that region. The study utilizes a mixed-method longitudinal design to analyze data collected from 1,000 patients. The result indicates that ASP’s telepsychiatry program plays the significant role in improving mental health care for Afghans, offering a range of interventions, including medication management and crisis intervention. The positive outcomes highlight the potential of Telepsychiatry to provide effective and accessible mental health services during a humanitarian crisis.

Telepsychiatry is an innovative approach to mental healthcare that leverages technology to provide psychiatric services remotely. It offers the potential to expand the reach of mental health services, improving access to treatment for individuals experiencing a wide range of mental health issues. Telepsychiatry has been proven to enhance the availability of specialized services, improve access to treatment, and reduce distress for patients and their families. Numerous studies have indicated that Telepsychiatry has the potential to prevent psychiatric admissions by offering earlier care in regions, where access to psychiatric services is limited.[1] An ambitious step as Telepsychiatry sponsored by world psychiatric association (WPA), Horizon Non-governmental organization (NGO) Peshawar in collaboration with Pakistan Psychiatric Society and Fountain House Lahore was launched at Ibadat Hospital, Peshawar, as an Afghan Support Program. This ground-breaking program leverages Telepsychiatry to enhance the specialized mental health services, improving access and reducing distress for patients and their families. The project includes equipping healthcare providers to handle mental health in complex emergencies and disasters, particularly for Afghan refugees. This study was conducted in the Pashtun language, as both participants share a similar cultural heritage.

Afghanistan’s in-country and refugee populations have been significantly impacted by four decades of conflict, political unrest, economic hardship, and forced relocation. Afghanistan has seen decades of conflict, social unrest, and extreme poverty for more than a century. Many people in the population suffer from a range of mental health issues as a result. Afghanistan, with a population of about 40 million, faces a complex health and social fragility, as identified by the compassion, assertive action, pragmatism and evidence (CAPE)Vulnerability Index.[2] The ongoing conflict and instability in Afghanistan have resulted in significant mental health challenges for its population, including high rates of post-traumatic stress disorder (PTSD), depression, and other mental health disorders. Afghans’ mental health problems are not just caused by war-related violence. Everyday pressures associated with human insecurity, such as poverty, forced relocation, the breakdown of family and community support, and the loss of home and means of subsistence, also lead to mental health issues.[3] Telepsychiatry, an innovative approach, offers the potential to expand mental health services, especially in areas with limited access to psychiatrists and mental health professionals.[4] This study assesses the impact and effectiveness of the Afghan Support Program’s telepsychiatry initiative in providing mental health care to Afghan refugees and communities affected by complex emergencies. It also plays a crucial role in the capacity building of Afghan refugees by providing training and support to local healthcare workers in Afghanistan.

MATERIALS AND METHODS

This Telepsychiatry study was sponsored by WPA, Horizon NGO Peshawar, in collaboration with Pakistan Psychiatric Society and Fountain House Lahore at Ibadat Hospital, Peshawar, as an Afghan Support Program. The study began after obtaining institutional ethics committee approval.

Sample design and procedure

A mixed-method longitudinal design was employed, and data was collected online with the assistance of psychologists and psychiatrists. The ICD-10 diagnostic system was used for diagnostic purposes. Proper training was provided to the team, which included psychologists, psychiatrists, and non-medical personnel in IT. Data was collected through online interviews on Zoom platform. A total of 1,000 patients were interviewed after obtaining their consent, between October 2021 and Dec 2023.

Statistical analyses

Quantitative data were analyzed using SPSS 20 (IBM, Armonk, USA). The sociodemographic variables, psychiatric and comorbid disorders, were tabulated in the form of frequencies and percentages.

RESULTS

Of the 1,000 patients interviewed, 536 (53.6%) were adult male, 374 (37.4%) were adult female, and 90 (9.0%) were children [Table 1].

Table 1.

Sociodemographic characteristics of the patients

Category	Sub-category	Frequency	%
Sex	Male	536	53.6
	Female	374	37.4
	Children	90	9.0
Age	0–14	90	9.0
	14–30	315	31.5
	30–40	266	26.6
	40–50	198	19.8
	50–60+	131	13.1
Status	Single	323	32.3
	Married	677	67.7
Education	Illiterate	828	82.8
	Literate	172	17.2

According to ICD-10, large numbers of patients from Khost Province (that is the Southeastern part of Afghanistan and to the south and east of Khost lie Waziristan in Pakistan) are suffering from recurrent depression (40.3%) and stress-related disorders (10.4%) [Table 2].

Table 2.

Psychiatric diagnosis of the patients

Diagnosis	Frequency	%
Stress-related disorder	104	10.4
PTSD	12	1.2
Dementia	42	4.2
ADHD	30	3.0
Recurrent depression	403	40.3
Bipolar disorder	78	7.8
OCD	43	4.3
Mental retardation	34	3.4
Schizophrenia	53	5.3
PPP	09	0.9
Disorder due to substance abuse	10	1.0
Epilepsy	76	7.6
Sexual dysfunction	24	2.4
Movement disorder	19	1.9
Disassociation disorder	56	5.6
Cerebral palsy child	07	0.7

Different comorbidities were observed during the interview process, for example, diabetes, hypertension, ischemic heart disease, and bronchial asthma [Table 3]. These comorbidities can contribute to the exacerbation of mental illness through various mechanisms like biological and social factors.

Table 3.

Comorbid disorders of the patients

Comorbidities	Male n (%)	Female n (%)	Total n (%)
Diabetes mellitus	70 (7%)	99 (9.9%)	169 (16.9%)
Hypertension	110 (11%)	90 (9%)	200 (20%)
Ischemic Heart Disease	18 (1.8%)	6 (0.6%)	24 (2.4%)
Bronchial Asthma	3 (0.3%)	2 (0.2%)	5 (0.5%)

The ASP introduced various interventions, including stress management, anger management, thought-stopping techniques, psychophysical exercises, and drug counseling.

Trends observed in mental health included issues related to aggression, assertive expression, somatic complaints, mind-body connection, domestic violence, and death wishes.

DISCUSSION

Over the last three decades, Afghanistan has seen both natural calamities and internal wars. At some time in their lives, most Afghans have experienced unimaginable tragedies and bloodshed. Because of this, mental health issues in Afghanistan are far more severe than those in other nations.[5] These kinds of events are linked to several mental health issues. Approximately 60% of Afghans, according to researchers, suffer from mild to severe mental illness.[6] Over the last two decades, novel attempts have also been made to create care systems to serve the mental health needs of these Afghan communities. The results of the Afghan Support Program Telepsychiatry Initiative highlight the critical need for readily available, culturally appropriate, and specialized mental health services for Afghan refugees and internally displaced people. The ASP’s telepsychiatry initiative enhances service delivery in areas with limited resources, enhancing the capacity of local healthcare practitioners. It provides remote medication consultations and manages prescriptions for the Afghan population, ensuring uninterrupted access to essential medications and improving patient wellbeing.

In locations with limited resources and a history of war, Telepsychiatry has been universally acknowledged as an efficient way to provide mental health care. Several research studies support its ability to surpass geopolitical and geographic barriers to care.[7,8] Telepsychiatry is a life-saving invention when it comes to Afghan refugees, whose access to in-person psychiatric care is frequently restricted by infrastructure and security concerns. According to our research, the high rates of stress-related illnesses (10.4%) and recurrent depression (40.3%) among ASP patients reflect comparable patterns observed in communities impacted by protracted violence and forced migration. Research by Steel et al.[9] found that the prevalence of PTSD and depression frequently surpasses 30% in populations affected by conflict and refugees. According to another research, Afghan women in Kabul and refugee settings in Pakistan also had significant rates of depression and post-traumatic stress disorder (PTSD), which were associated with family member deaths and injuries during the conflict, forced relocation, and persistent poverty.[10] Another study found that the 12-month prevalence of major depressive episodes was 11.7%, PTSD was 5.3%, and generalized anxiety disorder was 2.8%.[11] The cause of the low frequency of PTSD in our study (1.2%) may be related to underreporting because of cultural stigma or diagnostic difficulties in teleconsultations. Hassan et al.[12] also highlighted the significance of culturally relevant diagnostic methods in humanitarian contexts. Future research should explore the specific cultural expressions of trauma, among Afghan populations to refine diagnostic approaches in telepsychiatry settings.

To express psychological anguish, Afghans often employ specialized language that draws on culturally relevant ideas about the link between the body and the mind. One significant advantage of this program was the ability to provide telehealth psychiatric services in the Pashtun language to practitioners with cultural backgrounds like those of the patients. It has been demonstrated that cultural alignment fosters a therapeutic connection and dramatically lowers resistance to mental health treatment.[13] This element most likely helped the program achieve accurate symptom reporting and patient participation. Additionally, the ASP effort helped eradicate the stigma associated with mental health among Afghan refugees. The mind-body interaction, which is sometimes overlooked in conventional healthcare models, was brought to light by the coexistence of diseases, including diabetes, hypertension, and heart disease. According to the research by Patel et al.,[14] integrated care improves outcomes when comorbid physical and mental health issues are addressed, particularly in areas with limited resources.

The past two decades have seen attempts to train psychosocial counselors, create community-based programs, and include mental health in the healthcare system. To lessen stigma and identify people, who need help early, it is crucial to increase community awareness and provide mental health treatment effectively. Achieving this aim also requires increasing the capacity of community-based healthcare professionals or medical institutions. This initiative’s combined goal of providing treatment and enhancing local capacity was one of its distinguishing characteristics. IT support staff and other non-medical professionals must be trained for the telepsychiatry platform to remain viable. One crucial tactic for expanding mental health treatment in low- and middle-income nations is task-shifting to non-specialist providers and developing local capacity, per WHO’s Mental Health Action Plan 2013–2020.[15] A thorough, biopsychosocial approach to care is demonstrated using cognitive methods, psychophysical exercises, and anger control approaches. This strategy is consistent with data from multidisciplinary research that demonstrates that in trauma-exposed populations, integrating behavioral and lifestyle treatments with psychiatric therapy improves results.[16]

Secure telepsychiatry platforms deliver real-time crisis support and interventions for patients experiencing acute mental health crises. A significant proportion of the patients (47.0%) proactively sought follow-up consultations after their initial telepsychiatry session, and 33.3% reported positive feedback. This highlights the acceptability and trust in telepsychiatry services among Afghan patients. Positive outcomes in recurrent depression treatment underscore the potential of Telepsychiatry as an effective mode of therapy.

Limitations

All data was collected, and interviews were conducted online, and patients were never seen face-to-face. This could potentially limit the depth of rapport building, the ability to observe non-verbal cues that are crucial in psychiatric assessment, and the detection of subtle symptoms that might be more apparent in an in-person setting. Data collected through online interviews primarily relies on patient self-report. This introduces the potential for self-report bias, where patients may underreport stigmatized symptoms (e.g. suicidal ideation, substance abuse) or overreport positive outcomes due to a desire to please the interviewer or maintain a positive self-image.

CONCLUSION

The Afghan Support Program’s telepsychiatry initiative has demonstrated its effectiveness in providing mental health care to Afghan refugees and communities facing complex emergencies. It highlights the value and use of technology in providing access to mental health care. Through medication management and crisis intervention, this initiative has enhanced the mental health services available to Afghans. The positive outcome highlights the potential of Telepsychiatry in addressing mental health challenges during a humanitarian crisis.

Implications and future research

This research contributes to the understanding of Telepsychiatry as a valuable tool for mental health care in conflict zones and complex emergency settings. Future research should focus on long-term outcomes and the sustainability of such programs to further improve mental health services for affected populations.

Disclaimer

This research study is provided for informational purposes, and the findings, interpretations, and conclusions presented in this research are based on available data and analyzed at the time of publication.

Authors’ contributions

Concept, design, literature search: KAM, AJ, AP data acquisition: KAM, AAM, ZS, MZ, NM statistical analysis: SS Manuscript preparation: SS, manuscript editing and manuscript review: AJ, MS, MMA, Guarantor: KAM. All authors have read and approved the final manuscript.

Ethical statement

Permission to carry out the study was obtained from the Institutional Ethics Committee (Letter no. PPRC/Telepsychiatry/1^st November 2022).

Conflicts of interest

There are no conflicts of interest.

Data availability statement

Data will be made available on reasonable request.

Funding Statement

WPA, Horizon, Fountain House Lahore, and Pakistan Psychiatric Society financially supported this project.