Tele-Mental Health: An initiative to bridge the gap between mental health care providers and their patients – Dr. Priyanka Shah

The COVID-19 health crisis has led to economic hardship, bereavement and social isolation which has affected the mental health of the people globally. But poor health resources, lack of Intensive care beds in hospitals, lack of ventilators, lack of oxygen cylinders, poorly equipped health system, and political instability in the country have intensified the overall impact and suffering of mental health of people in our country Nepal. ​

In the last decade, there has been a steady rise in the suicide rate (from 8 to 9 suicides per 100,000 people) in Nepal. The suicide rate has dramatically increased by 25% after the lockdown began. In 2020, Nepal Police data reported 16 to 18 cases of suicides every day in Nepal. The statistics are heartbreaking and it clearly shows the burden of mental problems due to COVID-19 in Nepal. In addition to this, unemployment, financial instability, and domestic abuse, which are some of the indirect consequences of the pandemic, have also resulted in increased suicide rates.

Amidst this crisis, Health Foundation Nepal (HFN), in collaboration with the Government of Nepal Ministry of Health and Population Services Epidemiology and Disease Control Division and Curative Service Division, and Nepal Institute of Mental Health (NIMH) launched a Tele-mental health project intending to improve the mental health of people affected by COVID- 19 infection in Nepal.

This one-month-long tele-mental health project commenced on 1st July 2021. COVID-19 affected patients who received care from HFN Tele-medicine services were contacted through phone calls and screened for depression, anxiety, stress, sleep problems, and suicide risk. The tool which was used for screening patients is Mental Health Questionnaire-5 (MHQ-5) consisting of two questions from Patient Health Questionnaire-9 (PHQ-9), another two questions from Generalized Anxiety Disorder-7 (GAD-7), and one question from Columbia Suicide Severity Rating Scale (C-SSRS). Before commencement of the program, training regarding symptoms of depression and anxiety disorder, suicide prevention, effective communication skill, questionnaire tools, and psychological first aid was provided to everyone working in the project, and the appropriate guidelines were set for everyone to follow. The workforce for the project was divided into two-tier groups. A first-tier group comprising medical officer doctors, counselors, psychologists, and psychiatric nurses. The second tier group consisted of psychiatric doctors. The first tier group was involved in screening the patients for mental problems and providing psychological first aid. Patients who suffered moderate to severe mental illness and suicide risk were referred further to a tier two group of health care professionals. The dedicated volunteers who helped this project come to life were from Nepal and the United States of America (USA). This project is the perfect amalgam of technology and modern medicine and an excellent example of how a coordinated strategic approach can make a difference in the life of people regardless of the distance between mental health care providers and their patients.

I had the opportunity to be a part of the Tele-mental health project team of Health Foundation Nepal (HFN) and contribute to uplifting the mental health of people affected by COVID-19. My personal experience working as the Coordinator and Psychological First Aid (PFA) provider in the tele-mental health project team of Health Foundation Nepal was quite fulfilling. In my role as a coordinator, I was responsible for coordinating the overall tele-mental health project and ensuring smooth functioning to achieve the objectives of the project. I directly reported to the founder member of the HFN organization and the tele-mental project. In the beginning, I was anxious about my role. However, as the project progressed, I felt more comfortable interacting with other members of the team and could confidently carry out the role that was expected of me, and help other members of the team. In our working team, we were easily able to share our experiences, ideas and openly discuss the issues that arose in our daily huddle meetings while providing services to the patients. Every member of the team was involved in problem-solving, and this made me realize how important teamwork is in the project, and how valuable each member of the team is. I can see that effective communication and active participation of all members of the team are essential to coordinate a project successfully. From a learning perspective, I was able to develop my leadership skills and exhibit them as well.

My role as Tele Psychological First Aid (PFA) provider was immensely satisfying and a unique experience for me. My first telephone conversation was with a 40 year female from Kathmandu which was fruitful and rewarding. The positive response and feedback I received from the very first call helped me build my confidence. It also motivated me even more to work on the project. It was reassuring to know that the training I received before the start of the project made the conversations with the patients easy. Although most of the patients were forthcoming to talk about their mental health, not all the conversations were productive. I encountered some patients who were not so keen on talking about their mental health and did not consent to participate in our mental screening program. Respecting their autonomy and privacy, I politely provided those patients HFN toll-free mental helpline phone number 1660-82-56003 and urged them to call us whenever they felt the need.

I also came across some difficult scenarios such as patients who were grieving the death of loved ones and patients struggling with suicidal thoughts. Talking to one of the patients who was grieving the death of a loved one, I sensed hopelessness, anger, and guilt about not being able to provide enough care to their loved ones. I tried my best in my ability to acknowledge their feelings and reassure them that the feeling they were experiencing was normal and a part of the grieving process. Dealing with the patients with suicidal ideation is a great responsibility and a serious mental health issue. While talking to patients who expressed suicidal intentions, we need to listen to them actively and give them the chance to talk about the issues bothering them. I learned skills on how to explore social situations, identify the patient’s protective and triggering factors, and even how to help mitigate the suicidal thoughts of the patient. This is something that cannot be fixed with one phone conversation. Therefore, those patients were referred to a consultant psychiatrist (Tier 2 workforce of HFN tele-mental health project) for further management.

As a young doctor, I will continue to work on my interpersonal communication skills to listen and holistically understand my patients and provide them better care.

Working in this HFN Tele-Mental Health Project has deepened my appreciation for the mental health care practitioners who are working to improve the mental well-being of people.  I have also learned to take care of my mental well-being and now I can identify the symptoms of depression, anxiety, the stress in others and provide the necessary support to those in need.

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