In an indication that cataclysm can be a catalyst for progress, Lebanon’s Health Ministry has used the momentum created by the Syrian crisis as an opportunity to reform the country’s mental health care system, aiming to provide services and coverage to all individuals in the country.
Mental health problems are fairly prominent in the Lebanese population. In 2008, a study showed that 12.6 percent of the population had a mood disorder, such as depression, and 16.7 percent had an anxiety disorder. A 2006 study revealed that 4.3 percent of Lebanese had experienced suicidal thoughts and 2 percent had attempted suicide. Substance abuse disorders are also on the rise.
This mental health situation in the country has been compounded by the ongoing Syrian conflict, which has resulted in an influx of Syrian refugees into Lebanon. UNHCR – the U.N.’s refugee agency – reported that just over 1 million displaced Syrians were registered in Lebanon at the end of 2016. Most of those people fled Syria to seek safety for themselves and their families.
Witnessing war and conflict can lead to many psychiatric disorders, including depression and anxiety disorders. “Invisible Wounds,” a recent study conducted by international NGO Save the Children, found that the grinding conflict has had a devastating psychological impact on the Syrian youth. “Toxic stress,” a result of the “prolonged activation of stress response systems in the body and brain,” (according to Harvard University’s Center on the Developing Child) is now widespread. Over 50 percent of the children interviewed by Save the Children said they never feel safe at school. Seventy-one percent of respondents said that children increasingly suffer from bed-wetting – a symptom of both toxic stress and post-traumatic stress disorder.
But Syrian refugees’ hardships are not limited to what they experienced in Syria. In Lebanon, they have to face the reality of living without many of their loved ones, who may have been killed in the conflict, arrested or displaced to other countries. Their living conditions are poor and the Lebanese government struggles to provide basic services such as food, shelter and education.
Based on World Health Organization estimates of the prevalence of emotional disorders in crisis-affected populations, up to 200,000 Syrians in Lebanon may be affected by mental health problems.
Mental health care services in Lebanon are predominantly provided by the private sector, which means such services are not easily affordable for the average-income person. The services provided also tend to be highly specialized outpatient and inpatient care; they have not been integrated properly into primary health care. In fact, general practitioners, nurses and social workers are not trained to recognize symptoms of psychological distress. Only 5 percent of the resources allocated to health services by the Health Ministry are directed to mental health services.
In 2013, UNHCR conducted an assessment of the mental health and psychosocial support provided to Syrian refugees in Lebanon. The report revealed that there was a lack of coordination between agencies on the ground, a lack of available services and weak referral systems to get the appropriate help.
As a consequence, the Health Ministry – which formerly covered only psychotropic medications and inpatient care in psychiatric hospitals – is taking steps to close the gap between the demand for mental health services and their supply.
In 2014, the ministry, in collaboration with the World Health Organization, UNICEF, International Medical Corps and humanitarian NGOs working on the ground, formed the National Mental Health Program. One year later, they launched the Mental Health and Substance Use Strategy, for the years 2015 to 2020.
These initiatives documentation says it aims to ensure that “all people living in Lebanon will have the opportunity to enjoy the best possible mental health and well-being.” The vision is inclusive: It does not discriminate against vulnerable groups – such as refugees and migrants – and is aligned with human rights. The ministry is targeting everyone residing in the country.
The ambitious objective, according to Health Ministry documents, is “to ensure the development of a sustainable mental health system that guarantees the provision and universal accessibility of high-quality mental health curative and preventive services through a cost-effective, evidence-based and multidisciplinary approach, with an emphasis on community involvement, continuum of care, human rights and cultural relevance.”
The program targets five domains, the first four of which are aligned with the WHO mental health action plan, while the fifth is somewhat specific to Lebanon.
The first is leadership and governance: Work is being done to establish a mental health department within the ministry in order to ensure the sustainability of the reforms that are set to take place. The laws regarding mental health and substance abuse are being revised to align them more closely with international human rights standards. All mental health professions and institutions will then be obliged to adhere to human rights standards when providing care to people in distress. The ministry is also working with the Justice Ministry to include courses on “mental health and law” into legal curricula.
Lebanon will also have its first independent “user association” – an association managed by people who have lived with mental health problems. The goal is to have this organization independently monitor the system and fight for the rights of people with mental disorders.
Second is reorientation and scaling-up of mental health services: Mental health service provision in Lebanon requires considerable reform; most of the services provided are specialized services in long-stay psychiatric wards. These services are expensive and most people do not need them.
The Health Ministry, in partnership with WHO, is piloting a publically available, online self-help intervention program that offers strategies to cope with distress. Efforts are being made to integrate mental health into primary care. Eight community health centers are due to open this year, which will provide additional primary care services. Their staff will be trained on proper referral for mental health issues.
Long-stay facilities are remote and not well supervised; their patients are therefore particularly at risk of mistreatment. The ministry has formed a national team that will assess these facilities’ compliance with human rights statutes and provide recommendations for improvement. The team will also push for a policy on staff care, through enacting legislation that would protect the well-being of employees.
The third area is promotion and prevention: In terms of the prevention of mental health problems, the Health Ministry is working with the Education Ministry to implement a “life skills” program in Lebanese schools that will equip students to cope with adversity.
The strategy will also push for legislation on maternity leave, in order to protect early childhood development. Childhood is a fragile period and maternal care is essential in promoting the well-being of children.
The fourth area is information, evidence and research: The Health Ministry is increasingly focusing on mental health research and is developing an electronic information tool to better assess the efficacy of various treatments. Culture is a key factor to take into consideration when determining what kind of treatment works best for a given population. It is not enough to implement evidence-based treatments that are effective in other cultures. In Lebanon, for instance, research is being conducted into the effectiveness of interpersonal therapy as a treatment for depression.
The fifth area is targeting vulnerable groups: The National Mental Health team at the Health Ministry is fighting to improve access to both preventive and curative mental health services for vulnerable groups. Vulnerable groups are people who, because of adverse circumstances, may be at higher risk of developing mental health problems and might need specialized care. These groups include persons with disabilities, children and adolescents, people living in difficult situations, older adults, persons receiving palliative care, prisoners, survivors of torture and their families, families of disappeared people from armed conflicts and wars, persons living with HIV/AIDS, survivors of sexual- and gender-based violence, the LGBTQ community, foreign domestic workers as well as Palestinian refugees and displaced populations.
For example, many female domestic workers from Ethiopia, the Philippines and elsewhere work in Lebanon. For these workers, leaving their home country and their families is a very difficult experience. Their working conditions are often hard. Many of them experience psychological distress and this often goes unseen. Seeking assistance can lead to deportation. The Health Ministry is working with the Labor Ministry to make sure that foreign domestic workers’ insurance covers mental health, and that they have access to mental health services without fear of deportation.
Stigma and awareness are crucial issues in the fight to promote mental health. In Lebanon, as in many countries, people tend to avoid seeking help because of the stigma surrounding mental health problems and a lack of awareness. Mental health problems can be disabling and, just as we make sure to preserve our general physical health, we also have to take care of our psychological health. A prime objective of the Health Ministry is to develop strategies to fight stigma and increase awareness, using the media and other tools. The effectiveness of policies and legislation must be measured by the impact on the population.
Hopefully these anticipated reforms and improvements in the mental health sector will afford Lebanon a prominent status among those countries upholding the values of mental health care. This is a worthy goal. And it is a bitter-sweet fact that the Syrian crisis has helped to trigger such a crucial strategy.