Even before the COVID-19 pandemic, telepsychiatry and remote tele-health and tele-psychiatry services have been an expanding field of practice in response to inadequate access and insufficient mental health workforce in rural areas of the United States. There is considerable evidence showing similar outcomes (diagnostic accuracy, care quality, efficacy, patient satisfaction) between in-person and tele-mental health services in the general population. A systematic review of 452 published research articles on telepsychiatry found that treatment outcomes were similar to in-person sessions and that both patients and providers felt satisfied with services.
Recently, researchers have begun looking at the use of tele-psychiatry for the purpose of conducting asylum evaluations in settings where in-person encounters are unavailable. Asylum evaluations are highly specialized medico-legal encounters whose purpose is to assess asylum seekers’ claims of persecution, torture or ill-treatment as part of a process to change their legal status for residence in a host country. Asylum evaluations can focus on physical evidence collection or on mental health evidence collection (in the form of psychiatric signs, symptoms or diagnoses related to the alleged trauma), or both. There is limited data from over 2 decades ago (when asylum grant rates were more favorable in general) showing that nearly 89% of those who had representation and received a medical evaluation gained asylum compared to the national average of 37.5% .
In FY 2018, the most recent year for which we have complete data, 38,687 individuals were granted asylum  with 325,514 cases pending by December . In 2019, just 31 percent of asylum seekers were granted asylum; grant rates vary greatly depending on the jurisdiction, individual judge, country of origin and whether or not the asylum seeker has legal representation .
Most asylum evaluations take place in the communities where asylum seekers reside while awaiting their immigration proceedings. However, some have to be conducted in detention facilities, which are often located in remote locations. Clinicians must travel several hours to perform exams, and the exams themselves can last several hours each, making the process of conducting asylum evaluations unfeasible for busy healthcare providers.
Since the implementation of the Migrant Protection Protocols (MPP, also referred to as “Remain in Mexico”), which has required asylum seekers to wait in Mexico during the duration of their immigration proceedings and to attend their hearings in courts along the southern US border, assessments have been complicated by the need to cross an international border to reach the clients and by physically insecure conditions in the open air encampments and informal shelters in Mexico where the asylum seekers are living. 
An option to conduct an evaluation remotely, enables clinicians and legal representatives to provide such services to clients who otherwise would not have access to an expert evaluation. Telephonic mental health evaluations, in particular, offer convenience, safety, and low cost for clinicians in comparison with paying and taking the time off for travel to those locations.
A recent comparison of 10 telephonic mental health asylum evaluations with 20 randomly selected in-person asylum evaluations found that telephonic and in-person evaluations were equally efficacious in over 26 clinically relevant areas, including obtaining a history of torture, psychiatric history, and reaching diagnoses . Clinicians performing telephonic mental health evaluations stated that they did not find a difference in their ability to accurately diagnose in comparison with in-person evaluations, which required the same clinical standards and skills.
At the same time, the clinicians reported some challenges building rapport with the client without access to nonverbal information conveyed through body language and facial expressions. They found that checklists and cognitive tests were logistically more challenging to conduct over the phone; they also found that the mental status exam was less comprehensive, since they could not observe the clients’ motor activity, appearance, and facial expressions . Another, albeit preliminary, study , reviewing 15 telephonic evaluations, reported that clinicians expressed increased comfort with telephonic evaluations following specific training.
In December 2019, we launched a collaborative pilot project offering remote mental health tele-evaluations -- with video-conferencing options -- to asylum seekers residing in an open-air encampment across the US-Mexico border, and set out to assess participating clinicians’ perceptions of the experience.
Physicians for Human Rights (PHR) -- a global non-governmental organization and a leader in capacity building for asylum evaluation programming and service provision -- launched the pilot program at the migrant encampment in Matamoros, across the US-Mexico border from Brownsville, Texas. As many as 3,000 asylum seekers have lived in the encampment at one time since July 2019, when the US government began implementing the Migrant Protection Protocol (MPP) policy in that sector of the border 
More than 62,000 asylum seekers have been returned to Mexico under the Migrant Protection Protocols or Remain in Mexico policy, requiring them to wait for months for intermittent U.S. immigration court dates. Less than 1 percent of asylum seekers are granted the chance to exit the program and less than 5 per cent have legal counsel . Many of the clients in Matamoros do not have access to medico-legal asylum evaluations or related declarations, which could bolster their cases. The pilot was a partnership of several non-profit civil-society organizations. PHR recruited experienced asylum evaluators, Lawyers for Good Government (Proyecto Corazón), Pro Bono Asylum Representation Project (ProBAR), Justice For Our Neighbors, and local immigration attorneys facilitated the client referrals, and Project Lifeline assisted with client intake, coordinated scheduling, interpretation, and delivery of evaluations to legal organizations or specific attorneys for reconciliation of medical and legal documents.
Protocol and setup
The pilot project provided both in-person and remote forensic and psychological evaluations and interpretation. A Project Lifeline intern coordinated all parties remotely and was physically present on site at the Resource Center Matamoros (RCM), where they could ensure connectivity between clinician, interpreter, and asylum-seeker, and that the privacy and confidentiality of the virtual encounters were established and maintained. The RCM provided private rooms and wireless internet access to support video tele-conferencing between the clinician, interpreter, and asylum-seeker via Skype or Whatsapp. At times, remote interpreters connected with the clinician and asylum-seeker, who were at the RCM for an in-person evaluation. Each encounter lasted between 2-4 hours.
PHR recruited experienced PHR-trained asylum evaluators via email request. Each evaluator was given a tip sheet with guidance on best practices for remote evaluations, a summary of the unique legal frameworks and an information sheet describing the local set-up. Project Lifeline coordinated with local attorneys and their clients, scheduled the evaluations, answered clinician questions before and after the interview, and connected clinicians to attorneys to deliver final reports to be reconciled with the asylum application.