June 2013, Volume 63, Issue 6


Tele-mental and behavioural health: implications in glocal context — a hope to meet the needs of the underserved

M. Iqbal Afridi  ( Department of Psychiatry, Jinnah Postgraduate Medical Centre, Karachi. )

The increasing need of health services globally and shortage of trained health professionals especially in mental health is a huge challenge in the evolving world.1 The situation is further complicated due to natural and man-made disasters, lack of law and order, and financial, socio-cultural and religious barriers in various countries/regions.
To overcome these hurdles, the present medical community needs to utilise internet and communication technologies like telepsychiatry (TP) or tele-mental health (TMH). It is an important concept that has made possible to achieve the goal of providing mental and behavioural health care to the distant and underprivileged areas, and also in sharing of knowledge amongst mental health professionals across the world about prevention, screening, treatment, and rehabilitative and managerial services.
Human-friendly and cost-effective internet and mobile technologies such as cellphone/mobile, tablet, notebook, laptop, Ipad, desktop, android etc are available to most of the global population. This technique can be used multi-directionally between health providers and the general population of the global community. There is evidence of successful use of TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress and panic disorders, substance abuse, eating disorders, and smoking prevention.22 These services will overcome the time and space constraints and can be used from any part of the world, considering the language, cultural3 and religious perspectives.
We have to match the pace of the developed world. This will serve the purpose for mental health in all the areas including promotion, prevention, screening, treatment and rehabilitative services to millions of Pakistanis and other Asians living globally particularly in main cities like Dubai, Jeddah, Qatar, London, Toronto, New York etc., in collaboration with local health providers in the form of glocal (local and global) health services. This will be mutually beneficial from financial and professional perspective. Webinars4 can be arranged for teaching and training and continual professional development keeping in mind the safety, time cost and travel cumbersome.
The conventional health model (sham, magic etc) can be improved collaboratively by TMH providers. TMH is benefits the individual, family, group and community.
This will provide an opportunity to integrate the wisdom and experience of seniors and the dynamic and mechatronic (A multidisciplinary field of engineering, combination of mechanical, electronic, computer, software, control, and systems design engineering in order to design and manufacture useful products) capabilities of juniors and trainees effectively beyond boundaries and at the same time develop a liaison to bridge the gap of knowledge and skills at different centres of the world. These latest techniques are more attractive and palatable to youngsters, yet, are very cost-effective. This liaison may be used according to the need assessment and policy development of countries, considering the global realities. The inadequate services in subspecialties such as forensic and child and adolescent psychiatry in our country and globally can be overcome in this way.5
Seeking consultation in areas having shortage of consultants (psychiatrist, neurologist) can be overcome in remote and rural areas6 by primary care physicians.
E-health and TMH will help in de-centralisation, de-institutionalisation and de-stigmatisation of mental health in the remote and rural parts of the country and world. These services will provide an opportunity to reach beyond the door steps of the people where they live and work, rather than coming to the medical hospitals.
TMH will be a great source of liaison within and with other specialties such as maternal and child (post-partum depression); medicine(anxiety and depression in relation to CVS); surgery; ICU etc.
The global financial crises, uncertainty, fear of war and nuclear threat, the natural and man-made disasters like bomb blasts, target killings, recent earthquake-2005 and flood 2010-11 and of the regions-Afghanistan and Iraq may further warrant modification in our approach in providing medical and psychiatric services using e-health and TP without time and distance constrains.
For the best ethical and moral e-health and TMH, Standard Operational Practices (SOP), guidelines7 should be formulated considering the local and global context and looking at its outcome glocally.
TMH and telepsychiatry can be recommended in some of the following areas:
Removing stigma in mental illness and discrimination.
Prevention of suicide in suspected and chronic mental disorders.8
Identifying and screening of mental health issues among children and adolescents by developing school and college.
Behavioral interventions to reduce risk of communicable and non-communicable diseases and disorders.
Advocacy for the mental disorders person/patients globally.
Awareness and education on mental disorders to healthy humans and care givers of sufferers.
Respect and dignity of patients/persons rights.
Cost-effective interventions exist to promote mental health, even in poor populations by early childhood interventions, socio-economic empowerment of women, social support to old age populations, mental health interventions at work and violence prevention programmes.
Research can be another area for the effective utilisation of tele-health services.
Achieving and maintaining quality of teaching and training at different centres as per requirement of the community, yet maintaining ethical standards.
Despite the potential of emergency telepsychiatry, the literature has been fairly limited in this area.9
This is high time to discuss and formulate the ethical and legal guidelines in the glocal context of educating and practicing tele-mental and behavioural services, considering the issues of consent, confidentiality, cost, age, sex and prescription of medicine.
The government and NGOs must come forwards to integrate TMH and behavioural health in the existing health care in such a way to ensure component cost effective, comprehensive and sufficient services to meet the mental health care needs of the underserved population.
Considering the current generation of medical students and junior doctors who wish to become more mobile, a career as a "trans-national" doctor, could be in the making, hence European Network of Medical Competent Authorities was set up that has European legislation concerning mobility of healthcare and other professionals, it is proposed similar to the WHO, WPLO (World Physician Licensure Organizations) for fair, rationale and judicial usage of TMH and TP globally.10


1. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; published online Sept 4. doi:10.1016/S0140-6736(07)61239-2 http://www.aacap.org/cs/developmentor/telepsychiatry
2. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008 ; 53: 769-78.
3. Shore JHSDS, Novins D, Manson M. Cultural Aspects of Telepsychiatry. J Telemed Telecare 2006; 12: 116-21.
4. (Online) (Cited 2012 January 10). Available from URL: http://www.caltelehealth.org/event/webinar-best-practices-successful-legal-and-ethical-telemental-health.
5. (Online) (Cited 2012 January 12). Available from URL: http://www.aacap.org/cs/developmentor/telepsychiatry.
6. Gibson KL, Coulson H, Miles R, Kakekakekung C, Daniels E, O\\\'Donnell S. Conversations on telemental health: listening to remote and rural First Nations communities . Rural and Remote Health 11: 1656. (Online) 2011.
7. (Online) (Cited 2012 January 13). Available from URL: http://www.americantelemed.org/files/public/standards/PracticeGuidelinesforVideoconferencing-Based%20TelementalHealth.pdf.
8. De Leo D, Dello Buono M, Dwyer J. Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. Br J Psychiatry. 2002; 181: 226-9.
9. Sorvaniemi M, Ojanen E, Santamaki O. Telepsychiatry in emergency consultations: a follow-up study of sixty patients. Telemed J E Health. 2005;11: 439-41.
10. (Online) (Cited 2012 January 11). Available from URL: http://ec.europa.eu/internal_market/qualifications/policy_developments/index_en.htm.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: