Q&A: Managing the Middle East's mental health crisis

ABU DHABI — The Middle East is facing a mental health emergency as Iraqis, Syrians, Yemenis, and others cope with years of war, violence, and loss. The needs are presenting in countries with devastated health systems and only a limited medical workforce to address them. Iraq, for example, a country of 36 million, has just 80 psychiatrists.

The challenge is particularly acute for children, who manifest distress differently from adults. Their symptoms may be subtle — and easily missed without a properly trained eye. If they are able to receive prompt interventions, children prove remarkably resilient. But the needs are vast. In Syria alone, some three-quarters of children exhibit signs of psychological stress, a recent Save the Children report found.

Even in a sector that has grown used to describing its needs in superlatives — the largest displacements and needs in the past half-century — the scale of what’s at stake is astounding.

“When we have to focus on staying alive, it’s harder to focus on the emotional development of our children,” Dr. Gregory Keane, mental health referent in the Middle East at Médecins Sans Frontières, told Devex. “Our children become the teenagers and adults of the future, and people don’t necessarily learn the skills or as much of them as they could. That’s my worry. Communities that have been chronically damaged are communities that really struggle in terms of mental health presentation.”

Ahead of World Mental Health Day on October 10, Devex sat down with Keane to discuss how the humanitarian sector is coping with this mental health emergency, and what needs to be done better. The conversation has been lightly edited for length and clarity.

How have the emergencies of Syria and Iraq changed the way we think about mental health in humanitarian settings?

What the Middle East is really lacking is a mental health workforce beyond psychiatry. Iraq has a population of 36 million people. It has about 80 psychiatrists, so that’s about 1 or 2 per 100,000 people, compared to France or Australia or the U.S., where that number would be between 20 and 35.

In the Middle East, you have this big mental health crisis, and we just have psychiatrists managing it. And what are psychiatrists good for? They’re good for managing people with chronic, severe mental illness. And so if you have a mental health problem in the Middle East, you will go and see a psychiatrists, and because they are so few, it will be a short consultation and the range of treatments that are available to you are going to be much more narrow. Honestly, they’re going to be more medication focused because that's what you can do in a short period of time. People do know about therapies and are interested, but they don’t have that structure or training opportunities.

What MSF has done in Palestine, in partnership with Al-Najah University, is support a masters of psychology program, and we are a training base for their students. We bring in a few each year and support the clinical supervision of psychologists in our programs. I think humanitarian actors need to think a bit more long term about how we respond to this crisis. Because I think we have a responsibility if we’re here — as we have been for quite a few years — to think how can we invest more long term. What resources do we have that can help strengthen the mental health workforce in the region, with a greater focus on counseling and psychology, so doing talking therapy or counseling interventions.

We are always trying to think about creative ways to do training. You can’t just walk in and in two weeks train people to deliver a therapeutic intervention that is going to have quality to it.

We’ve seen the dramatic numbers describing the psychological needs in the region. But in clinical terms, how would you break down that need? How great is the need for simple counseling, compared with serious long-term psychiatric medical care?

I’d break it down into three groups. You can imagine Mosul was under Islamic State control since July 2014, and over that time, gradually, the health workforce has dissipated because people have left or been killed or they can’t work. Health systems and funding have collapsed, hospitals have been destroyed, and so that tertiary sector really wasn’t functioning until the beginning of 2017. We were seeing people coming out of East and West Mosul with relapses of severe mental disorder, because they hadn’t had access to treatment, and they had experienced the stress that triggers relapse, like schizophrenia.

While those numbers are very small, maybe 1 or 2 percent of the population, the burden for the families was enormous. You can think, you’ve got someone who's acutely psychotic, and you can’t send them to the hospital, you can’t get access to the medication you had, and there is daily stress, because people’s behavior is disordered. When we opened our activities in displaced people's camps between Mosul and Erbil, and south of Erbil in Qayarra, what we found is that people lined up with family members when we arrived and said please help us. We needed to have a strong psychiatric response. We needed medication, and we needed systems to support people.

We’re really lucky in MSF that we not only have a good expatriate staff, but we also had enough of a reputation that displaced psychiatrists from Mosul, when we advertised, came and worked for us. Up until a few months ago, we were the only NGO that employed Iraqi Arabic speaking psychiatrists, and one of the only NGOs that had been able to negotiate with Kurdish Regional Government to import medication.

The other group you can divide, first into those who need counseling — talking about day-to-day problems and how I deal with those. So it’s moms worried about where their kids are going to school; where am I going to get my next meal; maybe kids dealing with having left their friendship circles; dads not being able to work after losing that role as a breadwinner. People have these individual stresses, which are very relatable, and you can address them with relatively straightforward interventions: structured problem solving, active listening, simple interventions that help people solve their own problems, and giving them a sense of how to reframe their journey.

Then there’s another group of people that kind of sits in between, with traumatic disorders or severe depression. That requires a combination of talking therapy — either cognitive behavioral therapy or some other form of structured therapy. That requires training, supervision, that requires a lot of care. And that requires a really careful intervention. We are likely to have seen a lot more of those people than we would in most places, particularly coming out of Mosul, where people have experienced that really intense stress for weeks or months or years at a time, and that loss, violence and grief. The intensity of those symptoms and the access to treatment was not there.

This sliver of population is very challenging to treat because you need experts. We certainly have expatriate psychologists who can come and deliver some of that care, but it’s less ideal than having an Arabic speaker doing that. Here’s our gap. This is where we really need to improve — all humanitarian actors.

What are the specificities of those categories when it comes to children? What needs to be done differently?

This is the big challenge: how do we look after kids better? And there’s a real gap. Partly that’s because we don’t have child psychologists. MSF at the moment, in Northern Iraq, we have three expatriate child psychologists, who we’ve brought in because the need is so high, and we’re trying to train counselors in specific interventions.

The other issue that we face is that people in general don’t necessarily recognize the mental health symptoms that children experience. A child who’s bedwetting or refusing to go to school in the Middle East is naughty. That’s certainly one of our biggest presentations for children. Fortunately kids respond very well and generally quite quickly when we do things like education for parents. If the kid is still not responding, we might apply a more individual approach that might use play therapy or some other proven intervention that can be simple but is sensitive to a kid’s needs.

The sicker kids really need the clinic psychologists. We can train the counselors for these basic interventions, but you also have kids who have gone mute or have really disturbed behavior.

Within MSF specifically, and the humanitarian sector more broadly, what sort of sensitization needs to be done to raise awareness among staff about mental health issues? For example, do you train your trauma surgeons to pinpoint possible cases for mental health referral?

We’re really lucky that WHO has invested a lot of time and energy in creating WHO mhGAP, the Mental Health Gap Action Programme. There is a humanitarian module that is a week-long training for doctors and nurses and health professionals to upscale them on mental health presentation. We’re delivering what we call mhGAP plus, which will be two weeks in November in Iraq. We are recruiting doctors and nurses from departments of health in Kurdistan and Iraq, and also MSF doctors and nurses working in our hospitals, to be able to recognize and start treatment and make appropriate referrals to mental health services where they exist.

More broadly across sector, do you see a rising awareness about the need to consider mental health issues?

I think in the humanitarian sector there is an awareness. We’ve still got a ways to go with the medical workforce in the Middle East in general. I think there’s a perception and a sense of reality that spending that extra amount of time you need is sometimes just not available. We have to think creatively about how to help these health systems and also think that maybe spending those extra five minutes — getting the story rather than just treating the stomach ache or the headache — might actually save you time, because the patience isn't coming back five or six times.

These are the discussions that we have with doctors in the emergency departments and hospital wards: do we know enough about this person and situation? Could we consider mental health as a differential diagnosis? What brief interventions might I able to offer that person that could change their presentations? I think those somatic symptoms are very common — the headache, the stomach ache — what we would call conversion symptoms, maybe even panic. These are so common particularly in stressful situations. What are the briefings we can do to recognize those situations?

What is the prescription or best practice when there isn’t capacity to refer a serious mental health concern to a specialist for treatment?

We have to triage, first of all. We really need to improve medically the sense of placing mental health within that triage system, and recognizing that mental health problems are as in need of a serious medical response as any other presentation. An accurate and evidence-based approach is something we should be looking for.

In low-resource settings, there’s been a big movement in global mental health to try to improve the role out of proven interventions. There’s a lot of interventions that have been proven, but there’s not a lot of upscaling.

We need to really be examining those interventions that have been shown to be useful and see if they’re applicable in the sectors we are working in.

One of the things that we are doing is we have developed a relationship with the German NGO IPSO. They have a lot of experience training counselors in Afghanistan and other places, and the founder has set up recruitment and training of Syrian refugees in Germany. We have developed a relationship to do internet-based therapy, as a pilot, to access Syrian counselors in Germany who have really good levels training, who are Syrian, to deliver care to Syrians in our burns unit in Atmeh, Syria. It’s looking really good. There are additional costs in some ways, but I would ask the question, what is the question of not providing Syrians with mental health care? We really need to be thinking about what the term “costs” means in that setting.

Syria is a black hole from a humanitarian perspective. Two other places that are humanitarian black holes are Yemen and Anbar Province in Iraq. There are hardly any humanitarian actors in either of those places. It’s easy to go to Erbil. But how many people are doing mental health care interventions in Yemen? Almost none. There’s a lot of good reasons for that, but I do think we need to be honest with ourselves. If we’re going to bring value as humanitarian actors, how are we going to do that with people who really need it?

You mentioned the need for rethinking what cost means in these settings. What is the cost if we don’t address these mental health challenges in the region now?

One of the things that we know from the natural history of mental health conditions is that the more violence, grief, and loss you’ve faced, and the longer that you’ve faced that, the more vulnerable you are to stresses. So Iraqis, despite their strength and dedication to moving forward, are likely to be more vulnerable as a result of the multiple stresses they have faced.

I think that has an impact on the structure of society. People who are constantly under attack are by nature going to want to focus inward on their families and make sure that they can keep safe from the danger around them. If you are sitting in Sydney or Ohio, your kids can run safely outside, and you have a job, your kids can go to school. You can focus on the emotional development of your child. But if you’re distracted by violence, by bombs, by some form of oppression, your focus is very different; it’s not on the emotional strength, it’s the food on the table, whether my child can get home safely tonight. I’m more likely to have a very low threshold for my child’s behavior, and maybe be less interested in listening to them, because I need to keep them alive.

That’s the damage that’s being done, that when we have to focus on staying alive, it’s harder to focus on the emotional development of our children. Our children become the teenagers and adults of the future, and people don’t necessarily learn the skills or as much of them as they could. That’s my worry. Communities that have been chronically damaged are communities that really struggle in terms of mental health presentation.

What other new innovative approaches is MSF working on in the region?

I think that we need to implement what we know works, and we need to implement it more broadly. There’s been a lot of innovation; let’s utilize some of that and scale it up. A lot of people keep innovating and innovating, and that’s great to an extent, but we already know what are quality interventions, what works, what has impact, and so we need to scale up those quality interventions — basic counseling approaching, basic MhGAP approaches, and a really good therapeutic approach as well. Of course we need to be sensitive to language and culture, but I think those can often become excuses for not rolling out something that you know will most likely work.

We often discuss displacement as a major psychological stress. What about return? As hundreds of thousands of Iraqis return to Mosul, for example, are there mental health risks?

One of the things that we see among people in IDP camps is that there are people who say I am never going back, and others who say I can’t wait to go back.

Among those who go back, the people who are focused on the here and now and getting through the day are more likely to survive. Because if you’re thinking about how to get through the day, you’re likely spending less time thinking about some of the bad things that might have happened to you in the past. On a day-to-day basis, the practical things people are facing are maybe a lack of running water and electricity, a lack of food, maybe being reminded of some of the bad things that happened there. Certainly some people don’t return for that reason. We’ve had a couple of patients with PTSD responses and their refusal to go back is part of avoidance.

Resilience is one thing we really observe, too. You would imagine that these people might have suffered to the point that you’d be really sick. But what we know about humans is that they have an incredible capacity for resilience. Certainly I think resilience can be negatively impacted by chronicity, but people still have it — and the same hopes and dreams about wanting their kids to be successful, building a home, those basic things that are about building security in the future.

How does this impact the NGO workforce that is on the ground, helping deal with this challenge?

When we have locally trained workforces, we need to make sure as NGOs that we are looking after their mental health. We’ve recruited a Jordanian, Arabic-speaking psychiatrist, and her job is travel between our projects and deliver mental health care for our staff members. We’re trying to build a network of Arabic-speaking psychologists to be able to do that, because if we don’t look after ourselves, how can we look after the people we work with?