Neuropsychiatry: Advancing Individual and Global Impacts

When Neuropsychiatrist and Behavioral Neurologist Zeina Chemali, MD, MPH, came to Massachusetts General Hospital from Brigham and Women's Hospital in 2010, she drew upon her extensive training and experience as medical director and co-chief of their behavioral neurology unit to build Mass General's Neuropsychiatry Clinics and Training in the Department of Neurology and the Department of Psychiatry. Today, the neuropsychiatry outpatient clinics evaluate and treat more than 300 new complex cases each year and provide follow-up care for thousands.

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"The Neuropsychiatry Clinics are based on patients with neurological disorders that present with either cognitive or emotional disturbances," says clinic director, Dr. Chemali. "We grew from a clinic of me as the practitioner with one fellow to nine clinicians and two fellows."

Dr. Chemali's team sees complex patients throughout the lifespan including those with:

• Brain tumors
• Epilepsy
• Neuroinfectious and auto-immune disorders presenting with cognition, mood, anxiety and behavioral changes (e.g., impulsivity, apathy)
• Early-onset dementia (EOD)
• Genetic disorders, such as Down syndrome, Turner syndrome and Williams syndrome
• Neurodegenerative diseases
• Stroke and its associated comorbidities
• Traumatic brain injury

"Our clinical work is based on neurocircuitry—not directed towards one structure or location in the brain that's not working—but over the impacted neurocircuit that results in cognitive deficits and/or behavioral conduct problems," says Dr. Chemali.

As the outpatient clinics grew, they also developed a robust core training program for neurology and psychiatry residents and fellows in Mass General's Behavioral Neurology and Neuropsychiatry Fellowship (BNNP).

An important domain of Dr. Chemali's work is in training candidates, such as neurologists, psychiatrists, community health workers and nurses, on brain health for capacity building in local communities with low resources settings.

Dr. Chemali has also worked extensively abroad, including developing neuropsychiatric programs globally, creating a resiliency training program and battling physician burnout.

Implementing Education and Training in Global Psychiatry Work

Dr. Chemali travels globally to educate and train clinicians, neurology and psychiatry residents, community health workers and nurses at the interface of neurology, psychiatry and brain health. She has worked to develop clinical programs based around EOD and other neuropsychiatric programs globally.

She has carried out major educational training in brain health and brain studies in Ethiopia, South Africa, Uganda, Brazil and Lebanon and created neurology and psychiatry dual residency programs in Ethiopia and Somaliland.

"We're trying to do capacity building for health care workers in low-resource communities. They are seeing a lot of patients, and they need to know what they are seeing," Dr. Chemali says. "With a strong collaboration with the American University of Beirut in Lebanon, I added to their training so they could be ACGME International-accredited. They are the only program in the Middle East with this distinction and whose residents can come to the U.S. and do any fellowship they want."

Delivering Neuropsychiatric Services to Vulnerable Populations

Another focus of Dr. Chemali's work is giving vulnerable groups access to neuropsychiatric care.

"I grew up in civil war, so I try to provide help around war and structural violence," she says. "I work not only with refugees, but also with elders in the refugee camps because they are the most vulnerable of the vulnerable. My training and clinical work helps quite a bit."

Dr. Chemali was awarded the Anne B. Young Diversity Scholar Award in 2017 for her work with Syrian refugees in Lebanon. Her work not only focused on helping individuals, but also on bringing about systemic changes to better serve these populations.

"Some of my work has also been around empowering women, including an initiative to increase women's political participation in Lebanon. In Ethiopia and Lebanon, I've pushed for legislative change after actively listening and educating myself on the issues, including how to involve men to help women change domestic violence policy," she says.

Physician Burnout in Africa and the Middle East

In Africa and the Middle East, physician burnout can be profound due to resource and clinician shortages. In a 2019 BMC Public Health study co-authored by Dr. Chemali, investigators found that 40%–60% of physicians, nurses, health care workers and medical students in the Middle East experience burnout. In another 2019 BMC Public Health study, nurses and doctors showed the highest level of burnout in sub-Saharan Africa. Burnout was characterized as emotional and physical exhaustion from chronic exposure to emotionally demanding work.

"There are very few resiliency training programs to help. You don't have teams, so you're doing everything all the time. You are the social worker, the nurse and the doctor. And since you rarely take a vacation, it's 24/7," says Dr. Chemali.

"There is also the issue of violence in clinical care in low-resource settings because people come wanting immediate answers. If there is a delay, the physician might get assaulted. So physicians are on-guard and stressed out all the time. They have disrupted sleep and are answering questions at all hours because they are the only physician for hundreds or thousands of people."

Burnout affects job performance and satisfaction as well as psychological well-being. It also increases personal and professional depersonalization. Dr. Chemali says these health care workers are also less likely to speak up because of burnout's associated stigma. To combat this issue, she leads resiliency training programs around the world.

In Lebanese refugee camps, she trained 120 social workers and health care providers in mindfulness and resiliency techniques for personal use and to implement with Syrian refugees. She is also planning another resiliency program to attend to physician burnout in Ethiopia.

"I have used the Stress Management and Resiliency Training (SMART) program at the Benson-Henry Institute and translated it into Arabic for Lebanon. We've used the same translation to train cardiologists, physiologists, surgeons and medical doctors within a hospital in Kuwait," Dr. Chemali says. "We're also going to translate the SMART program into Amharic for delivery in Ethiopia."

Neuropsychiatric Impacts of the Pandemic

Dr. Chemali believes the COVID-19 pandemic will have neuropsychiatric effects that will require resiliency skills.

"The coronavirus affects people on multiple levels," she says. "Individually, the virus can affect the brain. There will be brain consequences and sequelae that we pick up two to five years down the line."

"There's also well-being. People were confined for long periods, often in addition to losing jobs and housing. There has been tremendous insecurity around food and stress from working while taking care of younger kids. It's taking a toll," she says.

On a community level, Dr. Chemali says the pandemic has brought about both positive and negative outcomes. Some people have come together to help each other, while others can't because of intense daily stressors. "They don't have much reserve to listen to other people, and then they participate in arguments and violence. It's the perfect storm."

In under-resourced areas, the problems are only compounding. There are fewer resiliency resources, money and people to handle these stressors.

"But what they do have is good social extended family ties. This is what creates resiliency," says Dr. Chemali. "So they stick together, and that cohesion might be a protective factor for them during the pandemic."

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