Blog

Author: Sohail Sethi, Des Moines University, MS2

For those pursuing a career in medicine, it is common to fantasize about what your future will look like. The lengthy training path only exacerbates this of course. As premeds, we all knew of the undergraduate who aspired to be the future ‘pediatric cardiothoracic neurosurgeon.’ But, as medical students in the odd position of making it past the first hurdle but simultaneously just beginning the ‘race,’ the future seems just the tiniest bit closer and all the more scary.

With a year-and-a-half of medical school under my belt, I’ve spent more hours than I care to admit daydreaming about my future career. It should come as no surprise considering the namesake of this blog that I want to specialize in psychiatry. But, of course, my inner premed wants more. After some key experiences – before and during med school – I’ve decided that I do not want to be just a psychiatrist. I want to be a rural psychiatrist.

It is my hope that in writing this brief article, I not only convey why I am passionate about rural medicine, but also convince one of you reading to consider a career in rural psychiatry as well.

The primary motivator that draws me to practice in a rural area is undoubtedly the positive impact a physician can have. We all entered the medical profession to help people. This principle of commitment to others manifests itself throughout our education and training. And yet, there is a significant proportion of the population who go without medical care. Almost twenty percent of Americans have not seen a doctor in over five years. According to the American Journal of Preventive Medicine, nearly two-thirds of non-urban counties lack a psychiatrist. The CDC found that rural Americans are not just sicker on average, they also have poorer outcomes for the same pathologies as their city-dwelling counterparts. By practicing in a rural environment, you will not only be able to help people, you will be able to help people who need care the most.

As previously illustrated, there is a great shortage of psychiatrists in the country, particularly in rural regions. This means that for those who choose to work in underserved areas, you may be the only psychiatrist around, and herein lies another reason to choose rural psych. As a rural provider, you are able to practice at the top of your license. You can serve as coordinator for your patient’s healthcare team, work with local leaders to shape policy, identify and dedicate resources to community-specific issues, and expand mental health services as needed. The increase in autonomy also means that you won’t be beholden to hospital administrators and quotas as much as your colleagues. For those interested in a challenge, the opportunity is there in rural psychiatry.

Lastly, rural psychiatry deeply interests me due to the community you can foster. In smaller, less populated towns, you are more likely to know your fellow physicians better. This will surely lead to you better understanding the perspectives of your referring physicians, and they can better grasp your role as a psychiatrist and the benefits of specialized care. Furthermore, the chance to be a resident of the community you serve will grant a provider unique insight into the lives of their patients, culminating in a stronger doctor-patient relationship.

While rural psychiatry is not for everyone, it is the path I am most excited for as I advance through my medical training.

Authors: Yonis Hakim (1) and Yousef Raslan Hakim (2), Tulane University School of Medicine, M3 (1) and Geisinger Commonwealth School of Medicine, M3 (2)

Introduction

Children in warzones during armed conflicts face various difficulties. Currently, during the most recent and ongoing devastating war in Palestine, children have been deprived of school education, which has ceased since the beginning of the war that has lasted over 3.5 months up-to-date [1]. As of the middle of January 2024, around 26,000 Palestinians have been reported killed in Gaza, of which around 70% are children and women, and around 64,000 have been reported injured, of which around 11,000 are children. In the West Bank, around 100 Palestinian children have been reported killed [1]. Given the horrendous number of casualties and injured children, warzones have serious lasting effects on children [1].

Non-Psychiatric Effects on Children

Regarding non-psychiatric effects of warzones on children, it has been reported that Traumatic Brain Injury (TBI) is the most common cause of death [2]. Children also experience intracerebral and subdural hemorrhages and epidural hematomas [2]. These can be caused by blunt injuries due to explosives [2]. Additionally, children suffer from nutritional deficits and dental and dermatological pathologies [3]. Infections are also more likely to spread during these conflicts due to lack of clean water, nutrition, and immunizations [4]. These infections include measles, polio, diphtheria, tetanus/pertussis, varicella, COVID-19, among others [4]. Also, before and after birth, there are higher rates of mortality, stillbirths, and low birth weights in these populations [5].

Psychiatric Effects on Children

Regarding the psychiatric effects of these warzones and conflicts, children are at an increased susceptibility for the development of stress due to encountering the death of family members and other tragic incidents [3]. Anxiety disorders and major depression are 2-3 times more prevalent in conflict-affected populations than the general population [3]. Children are also susceptible to posttraumatic stress disorder (PTSD) [3]. Besides these disorders, children are at an increased risk for the development of immediate stress reactions, such as apathy and dependent behavior [5].

Management of Children’s Psychological States

Regarding the management of PTSD in these vulnerable children, there have been three psychosocial interventions shown to be promising [6]. These are Teaching Recovery Techniques, Writing for Recovery, and Advancing Adolescence [6]. Teaching Recovery Techniques are lessons given by professionals to teach children about trauma and ways to deal with loss and PTSD symptoms [6]. Writing for Recovery consists of allowing children to write about their emotions and describe their traumatic experiences, and it guides children to develop positive insights from their traumatic experiences [6]. Advancing Adolescence is a two-month program that revolves around providing a safe space to children, supporting them socially, allowing them to express themselves, and providing them with group activities [6-7]. These group activities include fitness, arts, and vocational and technical skills [6-7]. Out of those psychosocial interventions, only Teaching Recovery Techniques were shown to decrease PTSD scores [6].

In addition to these psychosocial interventions, there are general approaches in the management of conflict-affected children’s psychological states. Immediate approaches include distancing the child from the area of harm, providing basic health and safety needs, and assessing the child’s psychological state [5]. It is important to provide children with a sense of safety and security [5]. This sense of security, in addition to the other aforementioned approaches, should be performed in accordance with a trauma-informed care perspective [5]. This perspective provides children with safe places, positive social interactions and relationships, and the ability to express emotions and learn how to control them [5]. This perspective aims to re-establish children’s routines from prior to the conflict so that they can have stability in their daily lives [5]. Also, a psychological assessment should be performed, and it should be individualized and centered around the needs of the child, which may differ largely from the needs of another child [5]. Following the assessment, evidence-based interventions, such as the three psychosocial interventions mentioned above, should be applied [5]. If group-based interventions are used, the sessions should be fewer and have lower participation thresholds to decrease stress during sessions [5]. These interventions should aim to build the children’s resilience [5,8].

Social and environmental conditions should also be taken into account. Humanitarian aid and sufficient medical, cultural, and educational facilities are needed for the proper development of children [5]. The facilities can be established with the aid of non-governmental organizations and should have child-friendly spaces [8]. Psychological support should also be provided to parents, if an assessment illustrates the need for support [5]. It is also recommended that physicians keep parents involved in the care of their children [5]. Parents should be informed of the progress of their children’s treatment and play a part in the decisions pertaining to the treatment [5].

To ensure proper treatment of the children, clinicians should be culturally competent and medical interpreters should be used to provide children and their families with a culturally-centered care that will build rapport [8]. Clinicians should also undergo disaster training to be adept at treating children afflicted by conflicts [8].

Conclusion

Children in warzones experience psychiatric and non-psychiatric effects that range from anxiety and depression to traumatic injuries and mortality [2-3]. To provide the best psychiatric care to children, evidence-based interventions and trauma-informed care that aim to foster resilience should be used [5,8]. The care should not be restricted to caring for children but also include improving the environment, assisting parents, and ensuring the readiness of the medical team to help the children and their families in these situations [5,8].

References

1. UNICEF. UNICEF in the State of Palestine Escalation Humanitarian Situation Report No.16 [Internet]. Jerusalem: UNICEF; c2024 [cited 2024 Jan 29]. Available from https://www.unicef.org/sop/reports/unicef-state-palestine-escalation-humanitarian-situation-report-no16

2. Kocik VI, Borgman MA, April MD, Schauer SG. A scoping review of two decades of pediatric humanitarian care during wartime. J Trauma Acute Care Surg. 2023 Aug 1;95(2S Suppl 1):S170-S179. doi: 10.1097/TA.0000000000004005. Epub 2023 May 12. PMID: 37166192; PMCID: PMC10389486.

3. Klas J, Grzywacz A, Kulszo K, Grunwald A, Kluz N, Makaryczew M, Samardakiewicz M. Challenges in the Medical and Psychosocial Care of the Paediatric Refugee-A Systematic Review. Int J Environ Res Public Health. 2022 Aug 26;19(17):10656. doi: 10.3390/ijerph191710656. PMID: 36078371; PMCID: PMC9517743.

4. Ottolini M, Cirks B, Madden KB, Rajnik M. Pediatric Infectious Diseases Encountered During Wartime-Part 1: Experiences and Lessons Learned From Armed Conflict in the Modern Era. Curr Infect Dis Rep. 2021;23(12):27. doi: 10.1007/s11908-021-00770-1. Epub 2021 Dec 9. PMID: 34903952; PMCID: PMC8656442.

5. Bürgin D, Anagnostopoulos D; Board and Policy Division of ESCAP; Vitiello B, Sukale T, Schmid M, Fegert JM. Impact of war and forced displacement on children’s mental health-multilevel, needs-oriented, and trauma-informed approaches. Eur Child Adolesc Psychiatry. 2022 Jun;31(6):845-853. doi: 10.1007/s00787-022-01974-z. PMID: 35286450; PMCID: PMC9209349.

6. Alzaghoul AF, McKinlay AR, Archer M. Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review. BJPsych Open. 2022 Aug 8;8(5):e153. doi: 10.1192/bjo.2022.552. PMID: 35938530; PMCID: PMC9380009.

7. Panter-Brick C, Dajani R, Eggerman M, Hermosilla S, Sancilio A, Ager A. Insecurity, distress and mental health: experimental and randomized controlled trials of a psychosocial intervention for youth affected by the Syrian crisis. J Child Psychol Psychiatry. 2018 May;59(5):523-541. doi: 10.1111/jcpp.12832. Epub 2017 Oct 2. PMID: 28967980; PMCID: PMC5972454.

8. Kadir A, Shenoda S, Goldhagen J, Pitterman S; SECTION ON INTERNATIONAL CHILD HEALTH. The Effects of Armed Conflict on Children. Pediatrics. 2018 Dec;142(6):e20182586. doi: 10.1542/peds.2018-2586. Epub 2018 Nov 5. PMID: 30397168.