A Resident-Based Telepsychiatry Supervision Pilot Program in Liberia

Worldwide, attention to mental disorders lags far behind the staggering morbidity attributed to them. The 2013 Global Burden of Disease study found that major depression and anxiety disorders were among the top 10 causes of morbidity worldwide, with major depression second only to lower back pain. In fact, eight of the top 25 causes were mental disorders (1). Yet, in low-resource settings, it has been estimated that 75% of people with serious mental illness go untreated, resulting in part from a worldwide shortage of 1 million mental health care workers in low- and middle-income countries alone (2). Closing this gap in mental health treatment will require a multipronged approach that includes improving mental health treatment and research capacity, reducing stigma, emphasizing prevention, and scaling up sustainable public mental health systems (3). In this column, we describe an innovative pilot program for increasing capacity to address mental illness in Liberia while potentially building up a cadre of future global mental health professionals.

Liberia and Mental Health

Located in West Africa, Liberia is one of the poorest countries in the world, ranked 177th of 188 countries on the Human Development Index, a composite reflecting life expectancy, access to education, and standard of living. Its more than 4.5 million people are still recovering from a brutal civil war and the deadly effects of the Ebola virus outbreak. Despite those traumas, Liberians have access to only two psychiatrists in the entire country, one a Liberian and one a Nigerian consultant.

The U.S.-based Carter Center has established a mental health program in Liberia that builds on local human resources to train nurses, registered midwives, and physician assistants as mental health clinicians (MHCs). A total of 166 MHCs have graduated in progressive cohorts from the intensive 6-month training program, the Carter Center’s only mental health program, and are now the de facto adult psychiatrists of Liberia. The Carter Center is now training MHCs who specialize in treating children and adolescents, and 84 have already been trained. The Mount Sinai Program in Global Mental Health has been working with the Carter Center and the Liberian Ministry of Health since 2011 to provide further training and supervision to the MHCs after they complete the program and return to their local communities around Liberia.

The MHCs tend to work in relative isolation in communities where mental health stigma typically prevails, with little or no access to supervision or professional development. The partnership between Mount Sinai and the Carter Center has historically involved a “couches-on-the-ground” approach, with residents from the medical school’s global mental health track flying in once a year for one month to either supervise or train MHCs. Typically, they are accompanied by attending physicians from the medical school, who spend the first week with them in order to help orient them. This partnership has involved helping to develop and supervise a mother-child consult service at a major hospital in the capital of Monrovia for several years prior to the Ebola crisis. Currently the residents are conducting annual training and in-clinic supervision of cohorts of the MHCs in an attempt to integrate cognitive-behavioral psychotherapy techniques into their practice.

The Telepsychiatry Supervision Program

More recently, the Mount Sinai Program in Global Mental Health has undertaken a telepsychiatry pilot program as a solution to the yearlong gaps in its presence in Liberia. Telepsychiatry increasingly provides a new avenue for extending mental health care into low-resource settings. Its use for bridging gaps in mental health treatment has been described in such far-ranging settings as India (4), Pakistan (5), and the United States (6). Published studies have generally described using telepsychiatry to extend the clinical reach of mental health professionals from their usual place of work, enabling them to diagnose and treat individuals in low-resource settings from afar. Less commonly described is the use of telepsychiatry for purposes of education and training, although there are exceptions, such as the work of the Chinese-American Psychoanalytic Alliance in providing Western-based psychoanalytic training and supervision to trainees in China (7).

For the Mount Sinai program, we opted to utilize senior psychiatry residents as the supervisors. Because of our experience working with them and with MHCs, we believed that they would have sufficient knowledge to provide general caseload supervision, the goal of the program. Several other reasons motivated this decision. First, residents’ final year of training provides an optimal time to help cultivate their identity as future supervising attending physicians. Second, we hoped the program would offer residents an international health experience without the challenges of overseas travel. Finally, there is an increasing call for formally training residents in the use of telepsychiatry (8).

We started the pilot program with the four residents who were already in our specialized global mental health track (one of the residents picked Liberia later in the PGY-4 year for his international field site and traveled there to meet his supervisee in person). However, in order to expand the scope of our program, we recruited five more residents outside the track. Our liaison in Liberia, the assistant director of the mental health unit of the Ministry of Health, then recruited nine MHCs according to her own judgment. We specified no particular criteria for their selection except that they be trained as MHCs by the Carter Center. We purchased nine laptops with Webcams and hand delivered them to Liberia during one of our CBT-focused trips. We also provided funding to rent an equivalent number of wireless hotspots and pay the monthly usage fee for a year. Finally, Vsee (www.vsee.com), a HIPAA-compliant teleconferencing platform designed for health care professionals, donated licenses for the nine residents.

Before the start of the program, the program’s Liberian liaison, who is herself an MHC, conducted an orientation session with the residents to orient them to life in Liberia and to the nature of the MHCs’ training and professional lives. Each resident also was assigned a “meta-supervisor” who was available to them on an as-needed basis. We also asked the residents and MHCs to write up and exchange brief biographies via e-mail. The residents and MHCs were then left to work out a mutually convenient time to try to meet weekly.

The residents and MHCs completed monthly surveys of the frequency, substance, and rewards and challenges of their meetings. We used this information to both assess the pilot’s impact and quality and troubleshoot issues in relative real time. The pilot program ran from July 2017 through June 2018, although data are available only through May 2018 because of resident graduation in late June 2018. The residents were less reliable respondents than the MHCs, for whom we usually had a 100% response rate.

Feedback From the Residents

The residents reported that they were able to schedule an average of 2.9±1.2 sessions per month but that 1.7±0.9 sessions actually took place. Issues with Internet access accounted for more than half of the missed meetings, whereas the remaining reasons were approximately equally divided between unspecified issues that arose on the part of the resident or the MHC. In only 13% of the monthly reporting periods were all scheduled sessions held. The average length of session was 0.60±0.23 hours. On a scale of 1 to 10, with 10 being the highest, the residents rated whether the program was rewarding (6.43±1.66), challenging (5.3±1.76), and educational (6.34±1.68).

The residents said that clinical matters encompassed 78% of the session time with MHCs, whereas personal support for the MHC accounted for 14%; administration, 5%; and advocacy or policy, 3%. When clinical matters were the focus, medication management took up 60% of the session time; case management, 13%; medical issues, 12%; individual psychotherapy, 11%; and family/couples issues, 4%.

When asked to elaborate on the most rewarding aspect of the experience, the residents consistently commented on how rewarding it was to be helpful. The biggest challenge with the sessions was the quality of the Internet connection, with problems from sound occurring 36% of the session time and problems from video occurring 31% of the session time. However, as one resident commented, “Its [sic] hard to meet up. Sometimes can be hard to find solutions to problems as we often run into barrier of lack of resources/money/people.” Otherwise, they had difficulty understanding the MHCs for 18% of the time and thought the MHC’s had difficulties understanding them for 7% of the time. Feeling unprepared posed a problem for 4% of the time, and believing that the MHC was not prepared was an issue for 4% of the session time.

Feedback From the MHCs

The MHCs’ overall ratings of the program were 6.75±2.81 for whether the program was rewarding, 6.21±2.56 for whether the program was challenging, and 7.05±2.95 for whether the program was educational. The clinical impact was rated 6.80±2.91. When asked to describe what was most challenging about the supervision, most MHCs commented on the Internet access or their lack of resources. Commenting on the learning experience, one MHC said, “It is most challenging because it is my first time during [sic] or discussing issues about patients with doctors or [a] supervisor but still we are getting there.”

Somewhat different from the resident reports, MHCs indicated that the focus of the supervision sessions broke down into the following proportions: clinical matters, 34%; advocacy or policy, 27%; personal support, 25%; and administration, 22%. Among clinical topics—again, in a departure from reports by residents—the relative focus of the time spent was estimated as follows: case management, 34%; medication management, 33%; individual psychotherapy, 31%; and couples psychotherapy, 22%. Although responses to these questions ultimately exceeded 100%, the relative proportions are none the less informative.

When asked about the challenges with the quality of supervision sessions, the MHCs overwhelmingly reported that 90% of the problems arose from Internet quality, whether of sound or video. They also reported that problems with the Internet were the major reason for missing weekly sessions. Finally, they reported problems understanding their supervisor for 2% of the time, whereas they felt their supervisor could not understand them for 3% of the time.

Discussion

We believe the Internet is an underutilized resource for addressing the worldwide mental health gap. In the case of the Mount. Sinai Program in Global Mental Health, the Internet seems like a natural way to multiply and sustain the program’s impact between trips to Liberia and possibly elsewhere. It also appears cost-effective. Personnel costs are minimized because the residents participate as part of preexisting elective time. Also, the primary nonpersonnel costs associated with the pilot—nine laptop computers plus nine hotspots with 1 year’s worth of Internet service—cost $6,208 for the entire year of the pilot program. In contrast, the 2-week trip by two psychiatrists to teach CBT and deliver the computers ahead of the pilot cost $7,600 in airfare plus accommodations.

Yet the Internet was both the platform for this program and its biggest liability. Problematic Internet connectivity was unquestionably the biggest drain on the quality and frequency of the supervision sessions. Attempts to find a better alternative have not been fruitful, with one Internet expert even asking whether the program should operate only in places with better Internet service. However, we feel our telepsychiatry approach is worth continuing, flaws and all. The resident-MHC pairs were also resourceful in finding alternative means of communicating as Internet vagaries dictated, including relying on what was often still very tenuous audio-only communication in Vsee, e-mailing patient material, and using communication applications such as WhatsApp (being mindful of how to easily avoid sharing identifiable patient health information).

The Ministry of Health has asked that we continue and expand the program. Aided by private donations, including a second round of crowdfunding, we are therefore about to expand the number of MHCs in the telepsychiatry program to 20. We anticipate that a more systematic expansion in year 3 and beyond would require grant funding. There are a few interesting and important areas we hope to improve on in the next program year. First, we will continue to explore better Internet options, however hard they are to envision. Second, we hope to explore whether there continues to be divergence between the resident and MHC assessments in what they focus on and, if so, to understand its basis and relevance. For now, we will no longer ask respondents to estimate percentage of time spent on each area of focus but instead will ask them to rank-order areas of focus to see if this approach permits more convergent responses. If convergence does not improve after several months, we will hypothesize that the divergence arose from differing or vague professional definitions of the areas of focus and will add definitions to the survey.

Third, we also need to better prepare our residents for helping the MHCs address general medical issues, especially treatment of seizure disorders, a major responsibility for mental health professionals in many low-resource settings and something far more removed from psychiatry residents’ expertise, especially when neurological resources are themselves scarce. Finally and most important, we need to ascertain the best way to measure the impact of the program on patient care rather than rely on subjective perceptions.

We also imagine that the Liberian telepsychiatry program could serve as a working model for recruiting psychiatrists-in-training and psychiatrists in high-income countries as mentors to mental health and other mental health–friendly health professionals around the world. It is an exchange where all stand to benefit. There is no substitute for the depth of in-person visits to low-resource settings and how they accelerate mutual learning and revitalize international relationships. But Internet-based assistance may be the best path to sustaining mental health outreach to low-resource areas.