Correspondence
Telepsychiatry in using a quality of life scale. One of the Dow Medical College, Dow University of Health
Pakistan after natural
disasters
Despite recent advances, access to
mental health care is still restricted in
some low-income and middle-income
countries because of limited availability
Tony Craddock/Science Photo Library
of health facilities in rural areas,
reluctance to seek psychiatric help
because of cultural considerations, and
other factors.1
Therefore, there is an urgent need for
innovative methods to deliver mental
health services, particularly in remote
areas. Telepsychiatry, which includes
the use of video-based conferencing
to deliver mental health services, has
vast potential to bridge this gap.2 In
Pakistan, where about 160 000 people
experience mental health problems,
and 34% of population is affected by
anxiety and depression, telepsychiatry
can ensure that high-risk patients
receive timely help.3,4
Recently, telepsychiatry was used to
treat post-traumatic stress disorder
(PTSD) in a rural setting in northern
Pakistan. The village of Charun Oveer
experienced two consecutive natural
disasters in 2015; it was hit by floods
in March, followed by an earthquake
measuring 7·5 on the Richter scale in
October, which demolished 89 of the
140 houses in the region.
Unsurprisingly, many people
experienced psychological disturbances.
Since the closest health-care facility
was situated 3 h away by road, tele-
psychiatry was the only viable option
for providing sustainable psychological
and psychiatric treatment.
The required facilities were set up by
the medical corps arm of Karachi Relief
Trust, an organisation specialising in
disaster relief, headed by Dr Naseer
Mehmood and Dr Nuzhat Faruqui.5 It
was assisted by mental health experts
who volunteered for the project. They
diagnosed PTSD and other disorders
among survivors, who reported
a variety of symptoms including
insomnia, nightmares, and flashbacks,
1016
authors (MHU) volunteered in the
project and witnessed it first-hand.
Initially, two community-based
sessions were held in which 160 people
attended, with 60 men in one session
and 100 women in the other session.5
The people of the village allowed the
team to conduct all activities at the
local community spiritual centre.
These were a combination of visual,
oral, and interactive sessions aimed
at destigmatising and spreading
awareness regarding mental health
problems among the local population.
After the initial sessions, translators
were employed to further engage
the local villagers. The villagers were
taught breathing exercises, and art
and music therapy was introduced at
the community spiritual centre in the
village. Additionally, 18 community
members were given intense three-day
training sessions as mental health
workers; obtaining histories and
screening the community members
for anxiety, depression, and PTSD
only. 500 adults were screened and
57 were diagnosed with symptoms
of PTSD or depression. These were
then shortlisted for the telepsychiatry
sessions, and each patient was given a
prearranged hour-long appointment
with a trained psychiatrist at least once
a week. The intervention was delivered
to the patients in this manner for the
following ten months after which the
project came to a close. Outcomes for
the project are not available as yet.
While concrete evidence regarding
efficacy of telepsychiatry is still being
assessed, it is definitely beneficial
when in-person interaction between
doctor and patient cannot occur.2
Telepsychiatry has great potential to
deliver effective help to those who are
isolated from expert mental health care,
thereby reducing the treatment gap.
We declare no competing interests.
Tooba Fatima Qadir, Huda Fatima,
Mohammed Hadi Usmani,
*Syed Ather Hussain
drsahussain121@gmail.com
www.thelancet.com/psychiatry Vol 3 November 2016
Sciences, Karachi 74200, Pakistan
1 WHO. Mental health action plan 2013–2020.
2
Geneva: World Health Organization, 2013.
Hubley S, Lynch SB, Schneck C, Thomas M,
Shore J. Review of key telepsychiatry
outcomes. World J Psychiatry 2016; 6: 269–82.
3 Pakistan Association of Mental Health. Why do
we act. http://pamh.org.pk/why-do-we-act/
(accessed Aug 27, 2016).
4 Ghazal H. Telepsychiatry: the way to
reconceptualise access to psychiatric care in
Pakistan. J Pak Med Assoc 2013; 63: 1080.
5 Usmani H. Chitral quake survivors recover
from trauma through online clinics. Dawn
(Karachi), July 23, 2016. http://www.dawn.
com/news/1270809 (accessed Sept 19, 2016).
NICE guidelines for
schizophrenia: can art
therapy be justified?
NICE guidelines1 for schizophrenia
recommend that art therapies
are offered to all people with
schizophrenia, particularly for
the alleviation of negative
symptoms. In their narrative review
of art therapy for people with
psychosis in The Lancet Psychiatry,
Angelica Attard and Michael Larkin2
found little quantitative evidence
for its effectiveness, and only a few
qualitative studies qualitative studies
suggesting that it could be beneficial.
Indeed, on the basis of their negative
findings, the investigators of a large
pragmatic trial of group art therapy
(MATISSE)3 rightly challenged the
NICE guidelines, 1 that clinicians
consider referring all patients with
schizophrenia for art therapies.
The Royal Australian and
New Zealand College of Psychiatry4
2016 guidelines for schizophrenia
note that art therapy is included in the
NICE guidelines, but conclude that the
evidence from randomised controlled
trials is inconclusive. On this basis,
they suggested more research and
assessment before art therapy could
be recommended. In fact, in Australia,
art therapy is not generally offered as a
therapeutic method for schizophrenia
in public mental health services.

From this Australian perspective,
it is surprising that art therapy can be
so definitively recommended in NICE
guidelines for schizophrenia, despite
the clear lack of an objective evidence
base. The UK implementation of NICE
guidelines will obviously have resource
and commissioning implications,
diverting scarce economic resources
from evidence-based options to
potentially ineffective options, on
the basis of the strong influence of
these guidelines. This implementation
therefore represents a substantial
opportunity cost to the National
Health Service (NHS), especially when
it is experiencing austerity measures.
It is concerning that the evidence-
based guidelines in the UK and Australia
reach such different conclusions on
the treatment of schizophrenia. This
contrast highlights the probable
differences in the methods and
committee structures of two major
national guidelines (UK and Australia),
and in particular, the interpretation
of non-randomised controlled trial
evidence-based data for psychiatric
disorders. It is probable that the onus
of proof for psychological therapies,
like art therapy, is much lower in the
UK than in Australia, and that NICE
www.thelancet.com/psychiatry Vol 3 November 2016
guidelines are incorrectly biased
towards psychological therapies for
mental health problems. Jauhar and
colleagues,5 expressed similar concerns
about the evidence base, methods, and
transparency that led to fairly definitive
recommendations for psychological
treatments in bipolar disorder. These
authors were clear in stating that
the NICE recommendations went
beyond the evidence and incorrectly
placed psychological therapies “on an
equal footing with pharmacological
treatments” for the treatment of
bipolar disorder.
NICE guidelines for schizophrenia
should adopt a much more cautious
and balanced view about the
widespread implementation of art
therapy for the negative symptoms
of schizophrenia, unless, of course,
objective evidence for its effectiveness
emerges. It is very important that
national guideline recommendations
are evidence based, otherwise the
credibility of these guidelines will
be questioned by policy makers and
clinicians, to the potential detriment
of overall patient care. At this stage,
using the principles of evidence-based
medicine, it is very hard to justify the
widespread implementation of art
Correspondence
therapy for schizophrenia within the
NHS or any other health-care system.
We declare no competing interests.
*Tarun Bastiampillai, Stephen Allison,
Arun Gupta
tarun.bastiampillai@sa.gov.au
South Australian Health and Medical Research
Institute, Adelaide, SA 5000, Australia (TB); South
Australia Health, Government of South Australia,
Adelaide, SA, Australia (TB); Department of
Psychiatry (TB) and Discipline of Psychiatry, School
of Medicine (SA), Flinders University, Adelaide, SA,
Australia; and Department of Psychiatry, Flinders
Medical Centre, Bedford Park, Adelaide, SA,
Australia (AG)
1 NICE. Psychosis and schizophrenia in adults:
the NICE guideline on treatment and
management. NICE Clinical Guideline 178.
2014. https://www.nice.org.uk/guidance/
cg178/evidence/full-guideline-490503565.
(accessed Sept 10, 2015).
2 Attard A, Larkin M. Art therapy for people with
psychosis: a narrative review of the literature.
Lancet Psychiatry 2016; published online
Aug 12. http://dx.doi.org/10.1016/S2215-
0366(16)30146-8.
3 Crawford MJ, Killaspy H, Barnes TR, et al.
Group art therapy as an adjunctive treatment
for people with schizophrenia: multicentre
pragmatic randomised trial. BMJ 2012;
344: e846.
4 Galletly C, Castle D, Dark F, et al. Royal Australian
and New Zealand College of Psychiatrists
clinical practice guidelines for the management
of schizophrenia and related disorders.
Aust N Z J Psychiatry 2016; 50: 410–72.
5 Jauhar S, McKenna PJ, Laws KR. NICE guidance
on psychological treatments for bipolar
disorder: searching for the evidence.
Lancet Psychiatry 2016; 3: 386–88.
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