with local providers and other professionals, preferably in hospitals or psychiatric/medical clinics. They should also consider how local resources can be developed over time to provide services that are first delivered internationally. One factor to consider from an international context is the experience of humanitarian crises that span different countries (Mesmar et al., 2016). For example, recent global events prompted a mass influx of refugees into Europe. Natural disasters, such as the earthquake in Haiti in 2010 and the 2017 hurricane in Puerto Rico, cause distress, displacement, and despair in many communities. Mesmar and colleagues (2016) investigated the ways that digital technologies were used to improve health and mental health assistance. They found that technology facilitated multiple and varied humanitarian actions to help remote communities prepare for, respond to, and recover from natural disasters and conflicts. In these situations, professionals used various technologies to facilitate communication, coordinate services, collect data, and enable timely responses to the crises. Electronic technologies, such as electronic health records, helped to track physical and mental health needs and connect individuals to services. An additional component of telemental health services in an international context is the use of shared electronic health records. Electronic health records are digital records that can be updated in real time and that are secured for privacy and confidentiality. In a survey of 53 European countries, 59% of member states reported having a national electronic health record system, and 69% had legislation that supported the use of national electronic health records (WHO, 2016). Many countries that use a national system of electronic health records link their records with laboratories, pharmacies, medical billing systems, and e-prescriptions. Shared electronic health records create a structure for professional collaboration and case coordination, which can help to improve clinical outcomes. War can have destructive and devastating effects on a country’s citizens. The effects of living in communities engaged in war can be both acute and long term (Ghumman et al., 2016). International conflicts can have chaotic and disastrous effects on individuals who not only face the loss of loved ones but also are victims of war crimes such as torture, rape, and kidnapping. Telemental health services may be one way to help individuals who experience posttraumatic symptoms in conflict-ridden territories. An advantage of telemental health services in these conditions is that they can reach more individuals in need compared with conventional face-to-face treatment. Professionals located in other areas of the world can provide assistance and expertise in an individual’s native language without having to go into areas of conflict or disaster. Providers can work with local nongovernmental organizations (NGO), hospitals, medical and mental health clinics, and pharmacies to provide the services individuals need. Naskar, Victor, Das, and Nath (2017) reviewed telepsychiatry programs across several countries, including South Africa, Australia, and India. International models of telemental health services were found to include several phases: (1) Identifying the target population that is at risk or underserved; (2) assessing the areas of service delivery needed; (3) partnering with local organizations for collaborative work; (4) training local individuals and professionals to serve as role models, outreach coordinators, external consultants, and providers; and (5) integrating the service-delivery system into the communities. An important aspect of providing global telemental health services is recognizing that individuals’ cultures have a great influence on the delivery and success of mental health
services. A clinician providing telemental health services or consultation in an international context needs to be familiar with symptom manifestation and the connection to culture, background, language, body language, and social mores to render an accurate diagnosis. For example, in some cultures, it is culturally inappropriate to open up to a stranger and discuss family concerns outside of the family. In those settings, it may be necessary to allow for several sessions of rapport building prior to discussing any clinical problems. Further, certain gestures and cultural practices in the U.S. may be insulting in other cultures. Therefore, it can be invaluable to employ a consultant who is an expert in the culture of the individuals receiving treatment. This can not only help with understanding cultural norms, but it can also allow for an understanding of any important historical contexts that could influence symptom presentation, treatment adherence, or ability to actively engage in specific treatments. Case Study: Telepsychiatry in India One telepsychiatry service established in India provided mental health services across the country under the auspices of an Indian NGO (Naskar et al., 2017). Using local cultural artifices, the staff in this program created outreach and awareness campaigns in the forms of street theater, folk songs, and film screenings. The goal of these outreach activities was to raise awareness about mental illness and a new telemental service, including teleconsultations. Providers in this program coordinated telemental health treatment with access to free medication at local access points. Based on the response of the community to the telemental health services, the team created a mobile telepsychiatry unit in one area of the country. The mobile telemental health unit was contained in a bus-type vehicle and included a teleconsultation room with a flat-screen television, a camera, and a pharmacy consultation room. The mobile unit had an onboard pharmacy so that medications could be dispensed immediately following psychiatrists’ orders through teleconsultation. Both the telemental health consultation and the medication were provided free of cost. Providers also provided emergency services via telemental health. The mobile unit also provided psychoeducation to caregivers to help remove the stigma of mental illness of their family members. They provided information about job opportunities. The prerecorded street performances and films with mental health workers were broadcasted on a television screen mounted on the back of the mobile bus. In addition, health workers distributed posters and pamphlets about mental illness and the telemental health services provided. Because of the scarcity of mental health professionals in India, nonpsychiatric professionals were also recruited to help (Naskar et al., 2017). General practitioners and paraprofessionals participated in the provision of service. The telepsychiatry program also provided services in tribal and rural areas in central India. In many areas, especially among industrialized countries around the world, telemental health programs are moving from the pilot phase of implementation to a more permanent infrastructure. In a 2015 survey of 53 European countries conducted by the WHO (2016), 84% of the respondents (38 member states) reported that their national universal health coverage policy includes language that supports technology-based health and communication. eHealth is a broad term that refers to the use of electronic technologies to deliver health-related information and can include telemental health. Most respondents (70%) had a national eHealth policy that included specific policies for eHealth. The majority of those that had a national eHealth policy (69%) reported having financial support available
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