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Mental Health in Syria Mohammed Abou-Saleh1 and Mamoun Mobayed2

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Mental Health in Syria Mohammed Abou-Saleh1 and Mamoun Mobayed2 international standards, to replace the malpractice stopped and it is given now only with general of restraining patients who had become aggressive. anaes thesia. Guidelines on the use of seclusion and The establishment of several new departments restraint have been drawn up. Seclusion rooms has solved some of the problems of service provi­ have been introduced, based on international sion but has also created pressure because of the standards, to replace physical restraints. need to staff these units. The problem was partially Patient complaints are now collected and addressed through the employment of 50 new review ed by dedicated staff. nursing staff and more than 50 new care assist ants. A community-based approach The capacity-building programme to services The hospital recruited 23 new doctors, who signed Teams at the hospital supported the launch of contracts and started working as trainees in psy­ the first psychiatric out­patient department at the chiatry. Five have gone on to pass the first part of Tripoli central hospital. Outreach services have the Arab Board examination in psychiatry. been started to support local prisons, as well as An agreement was made to link to regional ex­ centres for people with intellectual disabilities and cellence centres for capacity­building programmes, a nursing home for elderly people. which support study tours in neighbouring coun­ In order to open up the hospitals to the commu­ tries. A programme of twinning Libyan hospitals nity, a day care unit has been established. This is with other psychiatric hospitals in the region has designed to provide services for in­patients; here, now been running for over 6 months. they can learn new skills away from the hospital Visiting professors and trainers were invited culture. Other service users from the community back to the country, including expatriate Libyan together with family members will become in­ mental health professionals. The World Health volved too, thus bridging the former gulf between Organization has supported training within the the community and the hospital. hospitals. Short courses have been established both for general doctors and for the team working at Conclusion the hospital, to bridge the gap in human resources. In order to get psychiatrists from all over the All these reforms at the hospital are associated country together, the hospital has supported the with a larger and more ambitious reform process establishment of a professional organisation, in the national mental health system in Libya, the Libyan Psychiatric Association; previously which is supported by the World Health Organiz­ psychiatrists came under the Libyan Neurol­ ation in partnership with the Libyan Centres for ogy Association. Furthermore, the Libyan Board Disease Control and Ministry of Health. This for Psychiatry Training is now in the process of process was initiated in late 2011, and includes the establish ment and official training in psychiatry is introduction of capacity­building programmes for expected to begin in 2014. multidisci plin ary professionals, initiating com­ munity mental health services, supporting mental Introducing a rights-based approach to health and launching advocacy and awareness mental health practice programmes for mental health such as ongoing The malpractice of administering electrocon­ training for general practitioners, psychologists vulsive therapy (ECT) without anaesthesia was and social workers. CONFLICT AND mental health IN North AFRICA AND THE MIDDLE EAST THEMATIC PAPER Mental health in Syria Mohammed Abou-Saleh1 and Mamoun Mobayed2 1Chief Executive Officer, Naufar (Qatar Addiction Treatment and Rehabilitation Centre) , This paper begins by outlining the nature of the The Syrian conflict Doha, Qatar; and Professor present conflict in Syria. It goes on to describe Syria has been in a state of conflict for over 2 years. of Psychiatry, St George’s, University of London, UK, the psychological consequences of this conflict What started as a civil protest against decades of op­ email [email protected] and the present state of the mental health pression and human rights violations by the Syrian 2Senior Consultant Psychiatrist, services in the country. regime rapidly escalated into a humanitarian and Al-Aween Social Rehabilitation Centre, Doha, Qatar 58 INTERNATIONAL PSYCHIATRY VOLUME 10 NUMBER 3 AUGUST 2013 public health catastrophe. The brutal actions of the 61.9%. Exposure to fighting and hostility and a Syrian regime have continued since March 2011, history of trauma before the current conflict were with the United Nations (UN) reporting in January the main predictors of current symptoms of PTSD. 2013 that there had been over 60 000 people killed The study also involved 129 Syrian children (including 4084 children, 3986 women, 1405 aged 10–16 years from two camps. The number protesters killed under torture, plus an unknown of traumatic experiences related to conflict was number of soldiers) (Price et al, 2013a; updated as positively correlated with PTSD symptoms, and Price et al, 2013b, with an esti mate of over 90 000 the prevalence of PTSD among the children was people killed). There are more than 60 000 people higher than among adults, at 41.3–76.4%. who are missing, over 200 000 who have been ar­ A survey of 300 Syrian refugees in four camps rested and over 137 000 who have been critically in southern Turkey reported the prevalence rate of injured or disabled. Two million people have been PTSD to be 61%, morbid anxiety 53% and morbid displaced, both within but especially outside the depression 54% (Marwa, 2012). These results are country, to camps in Jordan, Lebanon and Turkey, similar to the findings of studies of the mental with little prospect of returning soon. health consequences of conflict in Palestine and A delegation to Syria from the UN Office for Lebanon. For instance, a Lebanon study reported the Coordination of Humani tarian Affairs found that, 20 years after the war, PTSD­related chronic that 35% of hospitals, 10% of health centres and diseases and physical symptoms were associated 40% of the country’s ambulances had been severely with a greater engagement in risk behaviours damaged (Amos, 2013). In major cities such as (Saab et al, 2003). Aleppo, Hama and Homs, the public health It was distressing to learn that the main systems have collapsed: disease registration and psychiatric hospital of Ibn Khaldun in the suburb of vaccination programmes have stopped and many Nayrab in the city of Aleppo was bombarded on 25 qualified doctors have fled the country. Only very December 2012; patients fled and were abandoned basic health services exist in the refugee camps of to their fate. Some were subsequently killed by Lebanon, Jordan and southern Turkey, and some snipers, according to local reports (see http://www. camps have no health services at all. Journalists youtube.com/watch?v=_ynVqQ2vhuU). The Dar have reported children dying from exposure to al­Ajaza psychiatric hospital in the Old City has cold and a lack of medical care for physical injuries also been bombarded but remains in operation caused by armed conflict (Coutts et al, 2013). because of the dedication of its staff. The ancient A crisis report from the United Nations Chil­ mental hospital Bimaristan Argun dating to the dren’s Fund (UNICEF), Syria’s Children: A Lost 14th century AD, has also been damaged (see http:// Generation?, indicated that of the 4 million affected archaeolife.blogspot.com/2012/10/destruction­of­ people inside Syria, almost 2 million are children, bimaristan­arghun­of.html). and of the 2 million who have been displaced out­ side the country, 800 000 are children (UNICEF, Mental health services in Syria 2013). Children have been exposed to grave human Syria is considered to be a lower middle­income rights violations, including killing and maiming, country. It has predominantly residential mental sexual violence, torture, arbitrary detention, re­ health services, comprising two mental hospitals cruitment and use by armed forces and groups, in Damascus and Aleppo (1200 beds in total). In and exposure to the explosive remnants of war. addition, there is an addiction treatment centre in Basic infrastructure and public services are being Damascus (30 beds), mental health departments systematically destroyed. Families are struggling to in two military general hospitals and a psychiatric survive in increasingly desperate conditions. One ward (with 12 beds) at Damascus University Hospi­ in every five schools in Syria has been destroyed, tal. Syria has two small private hospitals (Assalman damaged or converted into shelters for displaced et al, 2008). Community mental health services families – disrupting schooling for hundreds of are rudimentary, comprising clinics in major thousands of children (UNICEF, 2013). cities, with the majority being private clinics. The There has been a tremendous amount of number of mental health professionals is low (1 destruc tion; reports say that some towns and vil­ per 100 000 population), with very few specialists lages have been completely demolished, and the in child and adolescent mental health and other economic cost of the conflict has been estimated at sub specialties. hundreds of millions of dollars. Because there have been both massive destruc­ tion of health service infrastructure, including The psychological consequences of the mental health services, and an increase in the conflict prevalence of mental health problems as a result There are no published studies on the impact of
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