INTERNATIONAL CONTEXTS
Telemental health services can have a worldwide application, especially in areas that are underserved, under-resourced, and geographically remote. Accessible behavioral health care may be limited in low-, middle-, and even some high-income countries (Bischoff et al., 2017; World Health Organization [WHO], 2009, 2016). Barriers to mental healthcare include resource scarcity, inequity, and inefficiency. Additional barriers, such as stigma, discrimination, and marginalization, can also affect whether one seeks mental health services. Traditional therapy offered by trained professionals is often not available in many international communities. Thus, unconventional models of healthcare are needed to address the diversity and cultural needs of local communities. Telemental health services can improve the quality of care to individuals, increase care coordination among providers, improve care management, and overcome physical distances between providers and their clients (WHO, 2016). In low-income countries and regions that have limited infrastructure, telemental health services are primarily used to link physical and mental health providers with specialists, hospitals, and medical clinics (WHO, 2009). International telemental health programs have the potential to reduce the variability of diagnoses as well as provide vital healthcare services by increasing access, efficiency, and cost-effectiveness. However, barriers such as distrust by local residents, linguistic and cultural differences, differences in mental health and treatment frameworks, and lack of technological experience can affect whether telemental health services are used. In addition, there is no international legal framework to guide telemental health service delivery. The lack of policies and laws to oversee patient and client privacy and confidentiality can increase the risks and liabilities for professionals offering telemental health services. Implementing unconventional treatment in under-resourced international communities requires creative thinking and flexible interventions. Simply offering telemental health services without proper community support is a recipe for failure. A successful design for telemental health services in an international setting involves several components, including (1) involving community stakeholders, such as local providers, clients, and/or family members; (2) expanding community capacity to develop local resources; (3) designing plans of intervention that include both conventional and unconventional strategies; (4) delivering interventions in unconventional settings; and (5) ensuring the use of family-centered practices (Bischoff et al., 2017). Integrating specific strategies to incorporate comprehensive approaches to mental health services can help to sustain the intervention in the long term. Clinicians who provide telemental health services internationally should partner 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.
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