Lebanon: mental health system reform and the Syrian crisis.

The Lebanese Ministry of Public Health has launched a National Mental Health Programme, which in turn has established the Mental Health and Substance Use Strategy for Lebanon 2015-2020. In parallel, research involving refugees has been conducted since the onset of the Syrian crisis. The findings point to an increase in mental health disorders in the Syrian refugee population, which now numbers more than 1 million.

In the light of significant contextual political and structural difficulties, substantial reforms to Lebanon’s mental health system are underway, accompanied by a strategic research agenda.

Contextual challenges

Lebanon is a small middle-income country with a long history of war and political unrest. It has a population of about 4 350 000, including 400 000 Palestinian refugees, but in addition Lebanon is currently hosting more than 1 million registered Syrian refugees (World Bank, 2014).

Before 2013, due to the history of the state’s instability, the mental health system was still mostly led by the private sector. Local and international non-governmental organisations (NGOs) working in the humanitarian field had been functioning parallel to the government, and this contributed to a duplication of services and a lack of sustainable planning (Karam et al, 2008).

A national study carried by the Institute for Development, Research, Advocacy and Applied Care (IDRAAC) (Karam et al, 2006, 2008) had found alarmingly low rates of help-seeking among Lebanese people with mental disorders: only 11% of people with a chronic disorder had sought any help in the past 12 months. These extremely low rates contrasted with the apparent theoretical readiness of the Lebanese to seek help if needed: in a recent study led by the first author (yet to be published), 49% said they would definitely or probably consult a professional. Further analysis of our national data shows that the low rate of help-seeking seems to be mostly due to lack of awareness about mental disorders and only partly to unavailability of services or stigma.

The Mental Health and Psychosocial Support Task Force

In response to these needs, the Ministry of Public Health (MoPH), in partnership with the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and International Medical Corps (IMC), established the National Mental Health Programme (NMHP) (El Chammay & Ammar, 2014). In May 2015, after a process involving all key local and international stakeholders, that Programme launched the Mental Health and Substance Use Strategy for Lebanon 2015–2020 (Ministry of Public Health, 2015) with the vision: ‘All people living in Lebanon will have the opportunity to enjoy the best possible mental health and well-being’. In line with this vision, the MoPH established a Mental Health and Psychosocial Support Task Force (MHPSS TF), co-chaired with WHO and UNICEF.

The MHPSS TF coordinates the work of more than 62 mental health and psychosocial support staff actors working within the Syrian crisis response in Lebanon through a common annual action plan for all. For 2016, this action plan included, among other activities:

the development of protocols for crisis management for non-health front-line staff to help them manage persons with agitation or suicidal ideation

training more than 600 front-line staff on psychological first aid for persons in distress

agreeing on a set of mental health and psychosocial indicators for all actors to report

publishing a harmonising and unified evidence-based psychotropic medication list for specialists to ensure rational prescribing and continuity of medication supply for persons with mental disorders (this allowed a purchase order to be made, to cover the needs for 2017).

A main challenge remains building a solid referral system between all levels of care to ensure timely access to adequate out-patient and in-patient services for persons with mental disorders.

Moreover, the NMHP is implementing several cost-effective and evidence-based strategic interventions, such as:

integration of mental health into primary healthcare using the WHO mhGAP Action Programme in more than 75 primary care centres

development of community-based multidisciplinary mental health teams

training of trainers on interpersonal psychotherapy (IPT) with the aim of scaling it up to all professionals working in the humanitarian response

piloting of a guided self-help e-mental health service based on the WHO Problem Management Plus programme.

Many other actors are working closely with the NMHP towards strengthening the mental health system in Lebanon. This collaborative model has led to the selection of the NMHP as an innovation in the meeting held in April 2016 by the World Bank and the WHO on mental health. The success of this model was achieved through three main strategic decisions taken by the Ministry:

to merge the humanitarian and the development agendas

to maximise resources by creating synergies between different stakeholders and agendas through a national task force and participatory process

to streamline evidence-based mental health policy in all sectors.

The 2016 targets of the national strategy have been achieved. However, due to the fragile situation and ad hoc funding, the full implementation of the strategy remains threatened, despite political and administrative support from the MoPH.

The research agenda

In parallel, research involving Syrian refugees has been conducted since the onset of the crisis. In two studies (one yet to be published, the other reported by Fayyad et al, 2014) conducted by IDRAAC on a total of 3119 Syrian and Lebanese children and adolescents attending the same classes in schools in Lebanon (549 Syrian, 2570 Lebanese), childhood adversities were measured in both groups and war exposure in the Syrian children. The reported prevalence rates of depression, anxiety and post-traumatic stress disorder (PTSD) in both populations are presented in Table 1.

Table 1

Prevalence of mental health disorders among Lebanese and Syrian children and adolescents

Mental health outcomes	Prevalence (%)		P-value
	Lebanese	Syrian
Anxiety (SCARED rating ≥30)	50.7	56.0	0.031
Depression (CDI rating >20)	13.3	16.8	0.050
PTSD (RI rating >37)	5.7	4.7	0.351

SCARED, Screen for Child Anxiety Related Disorders; CDI, Children’s Depression Inventory; PTSD, post-traumatic stress disorder; RI, Child/ Adolescent PTSD Reaction Index.

Syrian students were exposed to a plethora of war events. Of the sample, 69.4% had experienced at least one type of war event, with 25.7% reporting up to three war events and 43.7% four or more. The ten most frequent war events reported by Syrian children were: destruction of homes of people they know (48.4%), inability to leave home because of bullets or bombing (37.0%), having a close person get injured because of the war (32.9%), seeing an injured person (not on television) (32.7%), witnessing explosions (28.6%), having a close person get killed (27.6%), having their home destroyed (partially or totally) (24.6%), witnessing someone getting beaten (22.3%), seeing a dead person (not on television) (21.0%) and seeing an armed person shooting at people (20.6%).

Interestingly and quite importantly for future research on disasters, the impact of childhood adversities seems to be much higher than that of war exposure in the genesis of PTSD, which may explain why the rates for PTSD were rather similar between the Syrian and the Lebanese students. Further analyses are underway to understand the interactions between childhood adversities, war exposure and mental health outcomes.

Additionally, a large-scale classroom-based intervention was conducted in 32 schools, targeting 3119 children to build resilience and coping strategies (results to be reported soon). The intention is also to unravel the role of biological markers.

In addition, a study by the Department of Psychiatry of the Lebanese University (Naja et al, 2016) assessing the relation of religiosity to depression in Syrian refugees in Lebanon, with a convenience sample of 345 adult Syrians, revealed a sharp increase in the prevalence of depression, from 6% before the war to 44%. Neither gender nor religiosity was found to affect the prevalence of depression.

The attitudes and perceptions of Syrian refugees concerning mental health, mental illness and mental health services are being studied by the Department of Psychiatry at Saint-Joseph University. A previous study conducted by this department focusing on in-patients had found that the number of Syrians who were admitted for treatment to a large psychiatric hospital from 2009 to 2013 had more than doubled in the 2 years since the start of the crisis compared with the 2 years before (106 versus 44), with an increase in suicidal ideation (Souaiby et al, 2016).

Conclusion

The Syrian civil war is one of the worst humanitarian crises since the Second World War; it has affected millions of people in Syria and neighbouring countries. The research findings from Lebanon point so far to a clear increase in mental health disorders in the young and adult Syrian refugee population in association with that crisis.

Despite the great strain on its health system, Lebanon has undertaken reform of that system through the implementation of a 5-year strategy. Stable funding, institutional support and research are still needed to ensure successful implementation. Nonetheless, other key social determinants, such as conflict and war, must be addressed by the international community as major factors leading to the poor mental health of the population.