Mental health in Syria.

This paper begins by outlining the nature of the present conflict in Syria. It goes on to describe the psychological consequences of this conflict and the present state of the mental health services in the country.

The Syrian conflict

Syria has been in a state of conflict for over 2 years. What started as a civil protest against decades of oppression and human rights violations by the Syrian regime rapidly escalated into a humanitarian and public health catastrophe. The brutal actions of the Syrian regime have continued since March 2011, with the United Nations (UN) reporting in January 2013 that there had been over 60 000 people killed (including 4084 children, 3986 women, 1405 protesters killed under torture, plus an unknown number of soldiers) (Price et al, 2013a; updated as Price et al, 2013b, with an estimate of over 90 000 people killed). There are more than 60 000 people who are missing, over 200 000 who have been arrested and over 137000 who have been critically injured or disabled. Two million people have been displaced, both within but especially outside the country, to camps in Jordan, Lebanon and Turkey, with little prospect of returning soon.

A delegation to Syria from the UN Office for the Coordination of Humanitarian Affairs found that 35% of hospitals, 10% of health centres and 40% of the country’s ambulances had been severely damaged (Amos, 2013). In major cities such as Aleppo, Hama and Homs, the public health systems have collapsed: disease registration and vaccination programmes have stopped and many qualified doctors have fled the country. Only very basic health services exist in the refugee camps of Lebanon, Jordan and southern Turkey, and some camps have no health services at all. Journalists have reported children dying from exposure to cold and a lack of medical care for physical injuries caused by armed conflict (Coutts et al, 2013).

A crisis report from the United Nations Children’s Fund (UNICEF), Syria’s Children: A Lost Generation?, indicated that of the 4 million affected people inside Syria, almost 2 million are children, and of the 2 million who have been displaced outside the country, 800 000 are children (UNICEF, 2013). Children have been exposed to grave human rights violations, including killing and maiming, sexual violence, torture, arbitrary detention, recruitment and use by armed forces and groups, and exposure to the explosive remnants of war. Basic infrastructure and public services are being systematically destroyed. Families are struggling to survive in increasingly desperate conditions. One in every five schools in Syria has been destroyed, damaged or converted into shelters for displaced families – disrupting schooling for hundreds of thousands of children (UNICEF, 2013).

There has been a tremendous amount of destruction; reports say that some towns and villages have been completely demolished, and the economic cost of the conflict has been estimated at hundreds of millions of dollars.

The psychological consequences of the conflict

There are no published studies on the impact of the conflict on mental health in Syria. A study by one the authors (Mobayed, in preparation) of a random sample of 228 Syrian men and women aged between 18 and 65 years, selected from two camps, who had been exposed to the conflict, reported prevalence rates of post-traumatic stress disorder (PTSD) across the camps from 36.3% to 61.9%. Exposure to fighting and hostility and a history of trauma before the current conflict were the main predictors of current symptoms of PTSD.

The study also involved 129 Syrian children aged 10–16 years from two camps. The number of traumatic experiences related to conflict was positively correlated with PTSD symptoms, and the prevalence of PTSD among the children was higher than among adults, at 41.3–76.4%.

A survey of 300 Syrian refugees in four camps in southern Turkey reported the prevalence rate of PTSD to be 61%, morbid anxiety 53% and morbid depression 54% (Marwa, 2012). These results are similar to the findings of studies of the mental health consequences of conflict in Palestine and Lebanon. For instance, a Lebanon study reported that, 20 years after the war, PTSD-related chronic diseases and physical symptoms were associated with a greater engagement in risk behaviours (Saab et al, 2003).

It was distressing to learn that the main psychiatric hospital of Ibn Khaldun in the suburb of Nayrab in the city of Aleppo was bombarded on 25 December 2012; patients fled and were abandoned to their fate. Some were subsequently killed by snipers, according to local reports (see http://www.youtube.com/watch?v=_ynVqQ2vhuU). The Dar al-Ajaza psychiatric hospital in the Old City has also been bombarded but remains in operation because of the dedication of its staff. The ancient mental hospital Bimaristan Argun dating to the 14th century AD, has also been damaged (see http://archaeolife.blogspot.com/2012/10/destruction-of-bimaristan-arghun-of.html).

Mental health services in Syria

Syria is considered to be a lower middle-income country. It has predominantly residential mental health services, comprising two mental hospitals in Damascus and Aleppo (1200 beds in total). In addition, there is an addiction treatment centre in Damascus (30 beds), mental health departments in two military general hospitals and a psychiatric ward (with 12 beds) at Damascus University Hospital. Syria has two small private hospitals (Assalman et al, 2008). Community mental health services are rudimentary, comprising clinics in major cities, with the majority being private clinics. The number of mental health professionals is low (1 per 100 000 population), with very few specialists in child and adolescent mental health and other subspecialties.

Because there have been both massive destruction of health service infrastructure, including mental health services, and an increase in the prevalence of mental health problems as a result of the conflict, it is expected that mental health conditions will overwhelm services. In the future, most Syrians with mental health problems can expect no treatment or care.

Discussion and conclusion

The conflict in Syria, which is now in its third year, is almost unprecedented in the magnitude of humanitarian and public health catastrophe. The Lancet stated in an editorial:

As if the direct effects of military force on Syrians were not enough, there has also been a full-scale assault on the health infrastructure. Even if Syrians are able to reach health facilities, which they often cannot because of ground fighting and erratic and unsafe transport, government forces have targeted health-care facilities, health workers, and patients intentionally, as described by independent observers such as Physicians for Human Rights, Amnesty International, and Médecins Sans Frontières. (Coutts et al, 2013)

It is very disturbing that the world has been witness to these atrocities but it has done so little to intervene. The Lancet rightly also stated:

A disturbing feature of modern conflicts and, indeed, the Arab uprisings, has been the flagrant disregard for the Geneva Conventions, including targeting of civilians, persecution of health workers, and attacks on hospitals, alongside the failure of the UN system to prevent these violations. The medical community may feel hopelessness in the face of these seemingly intractable situations. But there is much that it can do to monitor, report, and prevent the impact of conflict on the health of populations, as well as condemning attacks on civilians and breaches of medical neutrality. (Coutts et al, 2013)

The World Health Organization (WHO), as well as professional and humanitarian organisations, including non-governmental organisations (NGOs), has called attention to these challenges. The World Federation for Mental Health (WFMH), a global NGO, issued a statement in March 2013 on the mental health consequences of the complex emergency in Syria and made a call for action. Of major concern to the WFMH is that combatants on both sides of the conflict are generally ignoring the mental health consequences of the hardship and trauma created by violence and disruption. The WFMH called urgently for all parties involved, including the Syrian government and those contributing aid to support the conflict, to respond specifically to these issues and to consider the serious immediate and long-term mental health consequences of continuing armed conflict. Major humanitarian organisations that traditionally have not prioritised mental health should provide the means to support established organisations like the WFMH to expand training and services according to the Guidelines on Mental Health and Psychosocial Support in Emergency Settings produced by the Inter-Agency Standing Committee (2007).

The overriding priority for mental health in Syria now is to determine the mental health burden and consequent service response needs in relation to the conflict. A recent study in post-conflict Libya estimated the number of cases of severe PTSD and depression and related health-service requirements from the 2011 conflict there, and recommended mental health service targets (Charlson et al, 2012). When the conflict in Syria ends, what remains of the mental health services will be grossly insufficient to meet the predicted care needs. We call on national regional and international organisations to address these needs as part of the reconstruction of health services and to assist in providing skilled human resources for the suffering people of Syria.