Health systems in many countries, including in the Middle East, have largely overlooked mental health. Despite the fact that mental disorders are found everywhere, affecting women, men and children, at all stages of life and all levels of society, people with mental disorders fail to receive the treatment and care they need and risk becoming marginalised from society. World Health Organisation, Improving Health Systems and Services for Mental Health, 2009, p. 9.
Mental health care provision is a complex issue. The fact that only a small number of people use mental health services is often related to a lack of understanding of mental health issues, the stigma surrounding mental ill-health or because it is a relatively new element in the international development arena. It is also a direct consequence of a lack of political support, inadequate management, overburdened health services and, at times, resistance from policy-makers. In conflict-affected countries such as Iraq and Lebanon, government systems are unable to meet the mental health needs of their own people, let alone those of refugees and the internally displaced (IDPs). Médecins du Monde (MdM)’s extensive experience in Iraq and Lebanon demonstrates that, while conflict negatively affects already weak health systems, it can also provide opportunities for humanitarian actors to encourage and support stronger and more sustainable government mental health and psychosocial support (MHPSS) systems.
Despite the differences in context, both Iraq and Lebanon face challenges affecting the quality, availability, appropriateness and timely delivery of mental health services, exacerbated by unrest and conflict. In both countries, the few resources that are dedicated to mental health and psychosocial support are often inappropriately deployed. A severe lack of human resources, lack of trained staff able to identify disorders and a shortage of hospitals and beds all undermine the quality and effectiveness of care. Even when services are available, the high costs of psychotropic medication Psychotropic drugs are ‘[a]ny medication capable of affecting the mind, emotions, and behavior’. Farlex Partner Medical Dictionary, 2012. hinders proper care. There is also no integration of effective treatment through primary healthcare, community-based care and short-term hospital care. According to the World Health Organisation (WHO), Iraq has fewer than four psychiatrists for every million people (0.37 per 100,000), and fewer than two nurses working in mental health per 100,000 population. WHO, ‘Global Health Observatory Data Repository’ (http://apps.who.int/gho/data/node.main.MHHR?lang=en). WHO also found that mental ill-health was the fourth leading cause of mortality amongst Iraqis over the age of five. In Lebanon prior to 2013, the mental health system was mostly led by the private sector and by local and international non-governmental organisations (NGOs) working in the humanitarian sector. According to WHO, in 2013 Lebanon had just 1.5 beds per 100,000 people for community mental health services in eight psychiatric wards at general hospitals and five specialised mental health hospitals with a capacity of 28 beds per 100,000 people. Psychiatric hospitals have a 97% occupancy rate. WHO, ‘WHO-AIMS Report on Mental Health System in Lebanon’ (www.who.int/mental_health/who_aims_report_lebanon.pdf).
The presence of large numbers of Syrian refugees has placed a huge strain on the Lebanese healthcare system. Only 10% of people in need of MHPSS services receive proper care and support. E. Karam et al. ‘Prevalence and Treatment of Mental Disorders in Lebanon: A National Epidemiological Survey’, The Lancet, 367, 2006. In Iraq, the population has lived under extremely difficult conditions for many years, including physical deprivation, political repression and prolonged conflict. An estimated 18% of the population in Lebanon and Iraq suffer from mental illness. Education for Peace in Iraq Centre (EPIC), ‘Mental Health in Iraq: Misunderstood and Marginalized’, 7 July 2014 (https://www.epic-usa.org/mental-illness). Colin Lee, ‘Addressing Mental Health Needs in Lebanon’, Humanitarian Exchange, 51, 2011 (available at https://odihpn.org/publication/addressingmental-health-needs-in-lebanon/). According to a survey conducted in Iraq in 2009, almost 20% of the population will suffer from a mental health disorder at some point in their life. The most common disorders were anxiety and depression. The survey also found that only 6% of people with mental disorders could access treatment. S. Alhasnawi et al., ‘The Prevalence and Correlates of DSM-IV Disorders in the Iraq Mental Health Survey (IMHS)’, World Psychiatry, 8, 2009. In an MdM assessment of the mental health and psychosocial needs of Syrian refugees in Lebanon conducted in 2013, 58% of interviewees exhibited fear, 64% anger, 62% lack of interest and 56% feelings of hopelessness; 65% were unable to conduct essential activities for daily living.
… and opportunities
Despite the critical context in both countries, recognition and awareness of mental health and the availability of international funds provide an excellent opportunity to lay the foundations for sustainable national mental health systems. Beginning in 2004 in Iraq and 2014 in Lebanon, significant efforts are being made by both governments to integrate mental health into primary healthcare in order to improve the prevention and detection of mental disorders, provide access to services and adequate treatment and reduce stigma.
In Iraq, efforts by the Ministry of Health (MoH) with the support of WHO have been directed towards establishing and launching a national mental health policy and legislation and increasing efforts to integrate mental health into primary care services, schools and other community services. While supporting mechanisms and funding are not yet in place, the MoH still views mental health as a priority area in its overall health agenda. The integration of MHPSS within primary care was included in the Basic Health Services Package for Iraq, developed and launched by the MoH in 2010, and piloted in some primary health care centres (PHCCs), but lack of funding has meant that no appropriate follow-up work has been done.
In Lebanon, MdM is working with the Ministry of Public Health (MoPH) on the integration of mental health services into primary healthcare at the PHCC level, as well as directly providing mental health support and treatment, both at the community level and through outreach activities in the Bekaa region and Beirut. Social workers have been providing psychosocial support sessions for men, women and children in need, home-based follow-up and access to other services (cash assistance, food vouchers, non-food items, shelter, legal protection, education, resettlement, etc.), as well as referrals to specialised mental health services provided by psychotherapists and psychiatrists. Since 2015, MdM has also been involved in a strategic partnership with the MoPH’s National Mental Health Program (NMHP). The NMHP aims to reform mental health care in Lebanon and provide services beyond medical treatment at the community level, in line with human rights provisions and the latest evidence on best practice. Ministry of Public Health, Republic of Lebanon, ‘The National Mental Health Program’ (https://www.moph.gov.lb/en/Pages/6/553/the-national-mentalhealth-program). The National Mental Health Strategy that emerged in 2015 integrates mental health services into primary health care and reinforces a community-based approach, whereby care and treatment are delivered first at primary level within the community, before ‘stepping up’ to more intensive and specialist services when clinically required. Ministry of Public Health, Republic of Lebanon, ‘Mental Health and Substance Use, Prevention, Promotion and Treatment’, Situation Analysis and Strategy for Lebanon 2015-2020 (https://www.moph.gov.lb/userfiles/files/Mental%20Health%20and%20Substance%20Use%20Strategy%20for%20Lebanon%202015-2020-V1_1-English.pdf).
MdM adopted this approach in a pilot intervention with partners in an MHPSS unit at Rafik Hariri University Hospital, the largest public hospital in Lebanon. The pilot includes the integration of mental health into primary care, the establishment of a community mental health centre, the integration of mental health within different departments of the hospital and the establishment of a psychiatric ward. The ultimate intention is to provide comprehensive, accessible, high-quality and evidence-based mental health and substance use services, with a continuum of care, and offered regardless of nationality, age or gender.
When the project started, the hospital was unable to care for people with mental disorders, partly because hospital staff had little or no knowledge of how to assess, diagnose and address disorders. To address this, a mental health team comprising case managers, psychologists and psychiatrists was set up in the primary healthcare centre. Training on mhGAP – an evidence-based guideline to facilitate the scaling up of care for mental and neurological disorders and substance abuse – was given to care providers from the hospital and primary healthcare centres. A referral system was established in 2017 between the primary health level, the specialist community mental health centre and in-ward intensive psychiatric care in the hospital. Individuals identified as having a disorder are cared for by a multidisciplinary team, including MHPSS case management, psychosocial support services, psychotherapeutic and psychiatric interventions at individual and group levels and awareness sessions on mental health issues. The observed positive impact on mental health has encouraged the MoPH to extend the model to ten other regions in Lebanon in coming years.
In Iraq, MdM provides curative and preventative care for IDPs in Dohuk and Kirkuk governorates in Kurdistan, designed to reduce the risk of emotional numbing, breakdown and self-damaging coping strategies. A team of mental health and social workers implemented psychosocial support and psychological first aid (PFA) activities. MdM then developed a pathway of care, including a strong network and referral and coordination arrangements, mainly with other international humanitarian agencies. Several challenges emerged during implementation, including having to deal with two different government systems in Iraq and Kurdistan. Unlike Lebanon, this meant that, instead of working within and supporting a national mental health care framework and structure, which would enable the sustainable provision of all levels of care, MdM and other international and local NGOs were only able to deliver short-term MHPSS services.
Mental health disorders and the burden they create are a public health problem. As a humanitarian health actor, MdM’s first priority was to respond to people’s immediate mental health needs. However, advocating and working closely with all stakeholders including the government health sector to build a national framework should be the next step to ensure positive impact and sustainability. MdM’s experience in these two crisis-affected countries is an explicit example of this. In both cases, the start up intervention was intended to provide direct psychosocial support and mental health services. However, in Lebanon, with the existence of a national strategy and attempts to build a national framework, MdM was able to develop a more rigorous model that is both comprehensive and hopefully more sustainable.
Marie Darmayan is MdM Mental Health Coordinator in Lebanon. Dia Abou Mosleh is MdM Mental Health Coordinator in Iraq.