Mental Health and Psychosocial Support for the Internally Displaced Persons in Bannu, Pakistan

Humayun et al.

Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan

Asma Humayun, Nadia Azad, Israr ul Haq, Faisal Rashid Khan, Ambreen Ahmad & Rai Khalid Farooq

Following armed con£ict in the North Waziristan Agency, a mental health and psychosocial support Key implications for practice initiative was launched for internally displaced per- Humanitarian crises provide oppor- sons in Bannu, Pakistan. This was convened by tunities for collaboration between volunteer mental health professionals, in collabor- mental health professionals and ation with a variety of agencies (provincial govern- humanitarianagenciestostrengthen ment, military, humanitarian agencies) in a existing services security compromised region. As part of the initiat- Estimates of common mental dis- ive, monthly camps were held for a period of six orders in an IDP population have months. Mental health needs wereassessed. Amulti- been found, with 60% of this mor- disciplinary team (psychiatrists, psychologists, psy- bidity existing before displacement chiatric nurses and psychosocial workers) o¡ered There is a dire need for a public mental health care to 680 people who attended the mental health approach to address camps, of which 28% were under the age of18 years the existing burden of mental dis- old. Twenty-one percent returned for follow-up, orders while others were followed-up in the community by psychosocial teams. Estimates of common mental disorders were found. Both pharmacological and and Afghanistan on the other. It is part of a psychological treatments were o¡ered, according to Federally Administered Tribal Agency existing guidelines. Active e¡orts were made to (FATA), which refers to a semi-autonomous conduct holistic assessments and avoid a pure region under the control of the federal gov- biomedical approach. This also provided an ernment through a special law called Fron- opportunity for training non specialist sta¡ and led tiers Crime Regulations (FCR). This to formal (World Health Organization) mental region is known for its di⁄cult terrain and healthgapactionplan training forprimarycaresta¡. old, virtually unchanged tribal lifestyle termed as pashtunwali, where a jirga is Keywords: internally displaced persons, consulted for disputes. Parochial structures mental health, Pakistan and arcane traditions have tended to disre- gard health needs, especially for vulnerable segments of the population, such as women Introduction and children. As a result, formal health Background facilities are scarce, which barely cover basic Pakistan has had its share of con£ict related healthcare needs. (United Nations O⁄ce trauma. This is especially true for the North for Coordination of Humanitarian A¡airs Waziristan Agency (NWA) in the north wes- (OCHA), 2014). Traditionally, the majority tern part of Pakistan, adjoining the province have been highly sceptical and sometimes of Khyber Pakhtunkhwa (KPK) on one side hostile in terms of western medicine,

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.33 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

particularly vaccines. The impact of such contributed signi¢cantly towards mental hostility is re£ected in the fact that NWA health problems in Afghanistan, a neigh- reported the highest number of polio cases bouring tribal region (Miller, et al., 2008; among all the districts of the world in 2014 Panter-Brick, et al., 2009). Additionally, a (USAID, 2014). However, there has been a high prevalence of common mental dis- growing awareness and acceptance of wes- orders has also been reported in the tribal tern medicine in recent years, with most regions of Pakistan and Afghanistan people beginning to travel to other cities in (Cardozo, et al., 2004; Scholte, et al., 2004; KPK for specialised care. Mufti, et al., 2005; Hussain, Chaudhary, Due to a non existent, non functioning border Afridi,Tomenson, & Creed,2007.These rates with Afghanistan and a predominantly are nearly twice as high as reported else- Pushtun population, NWA and its adjacent where in Pakistan (Mirza & Jenkins, 2004) territories have su¡ered over two decades of and much higher than other developing incessant con£ict, social service neglect and countries facing con£icts andtherefore, need unmitigated humanitarian fallout. Militants to be interpreted carefully (Bolton & Betan- frequently spill over from adjoining areas of court, 2004; Ventevogel, 2005). Similarly, a Afghanistanintotribalagenciestotakerefuge, high rate of psychiatric morbidity have also and vice versa. The unending nature of the been reported in Afghan refugees (Kassam armed con£ict and violence has led to pro- & Nanji, 2006; Naeem, et al., 2005. A found adversity with reference to mental previous armed con£ict with the Taliban in health care inthe region (Khalily,2011).From 2009 displaced three million people in 2007,untilquiterecently,therewasanongoing KPK, Pakistan. Mujeeb (2015) found signi¢- armedcon£ictinNWAthatwas¢nallyhalted cant levels of psychological distress in that by a military operation started in June 2014. population, but the estimates of common Operation Zarb-e-Azb led to mass civilian mental disorders in internally displaced evacuation so that terrorists could be ident- persons (IDP) in Pakistan have not been i¢ed and targeted through land and air documented. attacks. As a result, over one million people (74% women and children) were displaced into the neighbouring district of Bannu, in Mental health care in Bannu KPK (United Nations High Commissioner The district of Bannu had an indigenous for Refugees, (UNHCR),2014) population of one million. For the two million people now residing in Bannu, current mental health services are limited to a Mental health and displaced single psychiatrist, with mental healthcare populations in the region not prioritised in Pakistan, as in many other A consequent rise in common mental dis- low and middle income countries (LMIC) orders in post con£ict/displaced populations (Saxena, Thornicroft, Knapp, & White- around the world is well established (Salah ford, 2007). Additionally, the country lacks et al, 2013; Turnip, Klungsoyr, & Hau¡, a mental health policy since the devolution 2010; de Jong, Komproe, & van Ommeren, of health responsibility to the provincial 2003). At the same time, the lack of capacity governments in 2011. Despite repeated of over burdened countries to respond to emergencies, only fragmented and sporadic mental health needs of con£ict related, dis- e¡orts have ever been made in terms of placed populations is also well documented developing an emergency mental health (Quosh, Eloul, & Ailani, 2011). Evidence response, disseminating training, involving suggests that in addition to war related con- stakeholders or advocacy at a national level. £icts, daily stressors and traumatic events The disaster/emergency preparedness plan

Copyright34 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al.

for mental health has also been defunct considered unsafe. As a result, community since 2006 (World Health Organisation based activities were extremely hard to (WHO),2009). coordinate/conduct. As a result, mental health services in Bannu While it was clear that such an emergency are typical of those o¡ered in most other situation required immediate attention peripheral districts in Pakistan (Bolton, in order to address mental health care 2013). The role of a psychiatrist tends to be needs, the key question remained: whose narrowed down to clinical responsibilities responsibility was it to coordinate any even in a tertiary care hospital. That, too, initiatives? The government (Health focuses mainly on a biological model of prac- Department & Provincial Disaster Man- tice of psychiatry. Bannu had a teaching agement Authority) was struggling to pro- hospital comprised of one professor of psy- vide basic needs to IDPs, so any additional chiatry with no other faculty to support agenda was a burden beyond their capacity. him. Despite an academic title, the job Mental health professionals have no pre- description is very much non academic, with scribed responsibility beyond their depart- pronounced administrative and medico^ ments. The military had the expertise, but legal responsibilities that compromises had no precedence to provide psychosocial clinical care. Additionally, there were few support to a civilian population. National teaching/training activities conducted by nongovernmental organisations (NGOs) the department. do not have the capacity, nor the expertise, Therefore, most people with mental to address the issues, while international disorders sought private consultations (pro- NGOs tend to focus on general health care vided largely by the same psychiatrist, after needs only. working hours). Limited in-patient facility was available for female patients only, especially for those who had travelled a long Mental health and psychosocial distance. There was a psychologist engaged support initiative at the psychiatry department, but who had It was under these di⁄cult conditions that a been working without pay for seven months. mental health and psychosocial support All cases of drug dependence were referred (MHPSS)initiativewasdesignedon humani- to a private facility nearby, which was not tariangroundsbyavolunteerteamofmental supervised by quali¢ed sta¡. Despite the health professionals from Islamabad, the humanitarian crisis, the medical college in capital of Pakistan (distance 298 kilometres, the city remained shut for summer holidays with a travel time of ¢ve hours by road). All and no medical students were involved in e¡orts were made to collaborate with the health care. Provincial Disaster Management Authority Another major barrier to mental health (PDMA) KPK, Army Field Hospital, care delivery to IDPs in Bannu was that the Department of Psychiatry at the teaching district is a highly sensitive and security hospital, national and international NGOs. compromised zone, as the Pakistan Army The initiative included monthly mental had taken control as soon as IDPs began to health camps at the teaching hospital in arrive. Even the hospital was considered a Bannu for six months, conducting mental soft target and was guarded round the clock, health gap action plan (mhGAP) training with armed guards present inside the emer- (WHO,2010) for primary care sta¡ and psy- gency room. It was not possible to execute chosocial training for community health any (humanitarian) interventions without workers (CHW). (This article describes security clearance from the army. In the experience of the mental health camps addition, travelling within the district was only.)

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.35 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

Methods health professionals (including nurses) and The objectives of these camps were to: obtaining essential medicines. Multiple consultation rooms were set up 1. Assess mental health needs of the IDPs; in the department of psychiatry. Each person 2. Provide psychosocial support to the dis- was registered and their demographic placed families; details recorded. Active e¡orts were made to 3. Identify and treat those su¡ering from conduct holistic assessments by small teams mental disorders; consisting of a psychiatrist, a psychologist/ 4. Assess needs and provide specialist care social worker and a nurse. A separate clinic to children; for children and adolescents was held by the 5. Dispense essential psychotropic medi- child psychiatrist, a psychologist and a nurse. cation; The displaced population spoke a di¡erent 6. Provide hands-on training to the health dialect of Pashto and for most, this was their care and psychosocial sta¡. ¢rst-evercontactwithanallopathic(modern) health service. Fortunately, all psychologists These camps were actively advertised and nurses were able to converse directly through banners, and noti¢cations were and interpret for the psychiatrists where sent to all health facilities in the area. necessary. In the ¢rst two camps, clinicians Pamphlets and hand-outs were distributed conducted assessments while other team in the outpatient department (OPD) of the members observed, interpreted and helped hospital, mobile unit announcements were to reinforce instructions and advice. This made in the city, and announcements were method of working also provided a huge also made on radio and in local mosques opportunity for hands-on training of nurses after the Friday prayers. A small media con- and ¢eld sta¡. Later, joint assessments ference was also held in order to raise aware- were conducted where any one member ness of the prevalence of mental disorders (depending on the problem) could lead the and the need to provide mental health care interview and others would intervene where to IDPs. needed.The average duration of joint consul- Volunteers included ¢ve psychiatrists tations varied between 15 to 20 minutes, but (including a child psychiatrist) and a psy- detailed interventions were continued by one chologist. The local psychiatry team member, when required. In many cases, included a psychiatrist, a psychologist, a the teams were able to o¡er follow-up within medical o⁄cer, four nursing sta¡ and aphar- the community. In other cases, follow-ups macist. International Medical Corps’ were organised at the department of psych- (IMC) ¢eld sta¡ included three psycholo- iatry. Supervision was o¡ered for complex gists and two psychosocial workers. Both casesby the (two) senior clinicians. genders were equally represented in the multi-disciplinary team in order to address Consultations and treatment any potential barriers for IDPs. The Army The consultations were not conducted on a Field Hospital provided logistical support (pure) biomedical model, but a more holistic, for the camps. bio-psycho-social approach, was followed. In most cases, more than one member of the family or even the whole family presented as Assessment procedures a‘case’. This caused some di⁄culty for the Although assessment was an ongoing pro- psychiatrists who appeared keen to identify cess, the ¢rst two camps focused more on the ‘most unwell’ person in the family to treat, assessing needs and resources, developing but the child psychiatrist and ¢eld sta¡ systems, engaging hospital sta¡, training seemed quite comfortable with approaching

Copyright36 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al.

the family as a whole. Similarly, the ing guidelines (WHO, 2010; WHO, 2013a). expectations of the families were not always A list of medicines was prepared for the ‘medical’. Most seemed content leaving the camps by modifying WHO’s EDL (WHO, room without a prescription. There were 2013b). Consensus was developed through other expectations however, for example, one discussions at a specialist forum (50þ person asked if milk was also being o¡ered. specialists), through Facebook, which is an Nearly all families were keen for a nutritional accessible and commonly used medium for supplement for their children, therefore this professional communication in Pakistan. was later added, although it is not part of The criteria used to deviate from the EDL WHO’s Essential Drug List (EDL). included: availability, tolerability and cost Since all cases were seen by quali¢ed mental e¡ectiveness. As cheaper versions of com- health professionals and clinically managed, monly prescribed newer drugs were easily clinical diagnosis was recorded according available, and considered to be better toler- to the International Classi¢cation of Disease ated, Risperidone and Escitalopram were (ICD10), instead of recording the symptoms also added. The ¢nal list included anti- only (WHO & UNHCR,2012).The primary depressants (Clomipramine, Dothiepin and diagnosis was selected according to Foulds’ Escitalopram), anti-convulsants (Carbama- hierarchy (organic: epilepsy,dementia, men- zepine and SodiumValproate), Risperidone, tal retardation and drug dependence took and Bromazepam. The required drugs for precedence) (Foulds & Bedford, 1975). the ¢rst three camps were funded by infor- A diagnosis of physical illness was also mal donations, with the IMC providing a recorded when required, and the patient large supply su⁄cient for six months. No referred appropriately. donations from the pharmaceutical industry Both pharmacological and psychological were accepted.The psychological treatments treatments were o¡ered according to exist- commonly o¡ered are described in Box 1.

Box 1: Components of psychological interventions offered

Intervention Components

1 Psychoeducation Explain the nature of problem/symptoms/ disorder/ treatment Avoid using drugs to cope with distress/ symptoms Behavioural activation: continue normal daily routines as far as possible; culturally appropriate relaxing activities; regular physical exercise; regular sleep cycles 2 Supportive counselling Address psychosocial stressors Help ventilate Reassure, where needed Problem solving Identify and enhance coping mechanisms Mobilise social networks

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.37 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

Intervention Components

3 Behavioural therapy (Instructions Make a list of problems for the parent/carer) Identify the most important problem behaviour to start with Give clear, simple and short commands that emphasise what the child should do, rather than not do All family members should be consistent about rules Be consistent about what the child is allowed/ not allowed to do Focus on praise or reward desirable behaviour Do not punish (hit the child), instead withhold rewards (e.g. treats or fun activities) Use a short and clear-cut ‘time out’after the child shows problem behaviour, instead of punishment Puto¡ discussionswiththe childuntilyouare calm Avoid severe confrontations or foreseeable di⁄cult situations 4 Stress management Progressive muscle relaxation Breathing exercises 5 Psychosocial support for Listen without pressing the person to talk. bereavement Assess needs and concerns Explore the meaning of grief Encourage culturally appropriate mourning and adjustment Provide or mobilise psychosocial support

Results and adolescents, 65% were male and 35% Demographic details were female. Only 1.6% were reported to A total of six camps were held at monthly be over the age of 65, while 64% of cases intervals. The total number of patients were adults between the ages of 19 and 50. assessed in the camps was 785. One hundred Sixty-¢ve percent of index cases were IDPs, and ¢ve cases were follow-ups, so index cases while 27% were residents of Bannu. With were 680. Out of the index cases, 55% were regard to marital status, 56.5% were mar- male and 45% were female, while 24.3% ried, 15% widowed and only 1% divorced. were under the age of 18. Of the children A higher percentage of single men (46.5%)

Copyright38 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al.

presented in the camps than single women (35%).Polygamy was noted to be quite com- (%) N mon in men, but the exact ¢gures are unknown as this detail was not recorded. Two-thirds of those assessed were illiterate and could only speak Pashto. All literate

individuals could speak Urdu as well. Men (%) Total

were four times more likely to be literate N and able to speak Urdu than women. These demographic details are shown inTable 1. Fol low-up pat ients Diagnostic categories Of IDPs,60% (259 out of 434 cases) reported (%) Female onset of symptoms before displacement, i.e. N preexisting mental illness, 18.7% reported symptoms following displacement and for 21.3% onset of symptoms were not recorded.

Nearly 13% cases received a dual diagnosis (%) Male

and 7.6% did not receive an ICD diagnosis. N A majority of those adults who received a diagnosis of ‘behavioural and emotional disorders’ su¡ered from mental retardation. Co-mor- bid physical illnesses were also recorded in 14.68% of the cases. (%) Total N The top six disorders were ranked according to their total occurring frequencies (obtained by adding primary and secondary diagnoses), with 82.5% of adult diagnoses and 77.5% of under-18 diagnoses included in these categories. Table 2 shows the (%) Female diagnostic categories. N

Tre at me nt s Both pharmacological and psychological treatments were o¡ered. Seventy-¢ve pro- 12 66(9.7) 33(4.8) 99(14.6) 7(6.7) 2(1.9) 9(8.6) 65 6 (0.9) 5 (0.7) 11 (1.6) 0 (0) 1 (0.9) 1 (0.9) < cent of the drugs prescribed were anti- > 13 ^ 17 43 (6.3) 23 (3.4) 66 (9.7) 4 (3.8) 4 (3.8) 8 (7.6) 18 ^ 35 167 (24.6) 145 (21.3) 312 (45.9) 26 (24.7) 26 (24.7) 52 (49.5) 50 ^ 65 33 (4.8) 33 (4.8) 66 (9.7) 7 (6.7) 3 (2.9) 10 (9.5) depressant drugs,10% were anti-psychotics, 36 ^ 50 59 (8.7) 67 (9.9) 126 (18.5) 12 (11.4) 13 (12.3) 25 (23.8) and 8% were anti-convulsant medications. Of the 1.9% cases prescribed Benzo- diazepines, most were already dependent on the drug. Only 6% cases received more than one drug. 28% of cases were not prescribed any drug. Table 3 summarises pharmacological treatments. The majority of cases (60%) were o¡ered both pharmacological and psychological Ages (years) Total 374 (55) 306 (45) 680 (100) 56 (53.3) 49 (46.7) 105 (100) treatments. Nineteen percent were only Table1. DemographicIndex cases detailsVariable Categories Male

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.39 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49 (%) N (%) Total N Fol low-up pat ients (%) Female N (%) Male N (%) Total N (%) Female N 20 (5) 27 (6.8) 47 (11.8) 3 (3.29) 5 (5.49) 8 (8.79) 198 (49.7) 200 (50.3) 398 (100) 56 (36) 49 (35) 105 (91) Pashto 182(26.8) 39(5.7) 221(32.5) 41(39) 8(7.6) 49(46.7) þ No 186(27.4) 263(38.7) 449(66) 20(19) 41(39) 61(58.1) þ 9 1^45^8 81(20.4) 80(20) 70(17.6) 79(19.8) 151(37.9) 159(39.9) 13(14.2) 16(17.5) 15(16.4) 12(13.1) 28(30.7) 28(30.7) Widow 1 (0.3) 14 (4.6) 15 (2.2) 0 (0) 0 (0) 0 (0) Issueless 16 (4) 16 (4) 32 (8.0) 4 (4.39) 3 (3.29) 8 (8.79) Married 198 (29.1) 180 (26.5) 378 (56.5) 36 (34.2) 32 (30.5) 68 (64.8) Divorced 1 (0.1) 6 (0.9) 7 (1) 0 (0) 3 (2.9) 3 (2.9) Non-IDPs 95(14) 96(14.1) 191(28.1) 19(18) 17(16.2) 36(34.3) Not known 40 (5.9) 15 (2.2) 55 (8.1) 0 (0) 1 (0.9) 1 (0.9) Not known 1 (0.3) 8 (2.0) 9 (2.3) ^ ^ ^ Not known 24 (3.5)Not known 15 (2.2) 22 (3.2) 39 (5.7) 13 (1.9) 2 (1.9) 35 (5.1) 0 (0) 1 (1) 2 0 (1.9) (0) 1 (1.0) Pashto only 168 (24.7) 252 (37.1) 420 (61.8) 13 (12.4) 41 (39) 54 (51.4) (married cases only) IDP statusTotalMarital status IDPsTotalNo of children Single 239 (35.1) 195 (28.7) (25.6) 174 434 (63.8) 106 (15.6) 374 (55) 37 (35.2) 280 (41.2) 306 (45) 20 (19) 31 (29.5) 374 (55) 680 (100) 68 (64.8) 14 (13.3) 306 56 (45) (53.3) 34 (32.4) 49 680 (46.7) (100) 56 105 (100) (53.3) 49 (46.7) 105 (100) Language Urdu Index cases Variable Categories Male TotalLiteracyTotal ExactNote: ages, especially in case of women and older people were not known. Yes 166 (24.4) 374 (55) 30 306 (4.4) (45) 374 (55) 680 196 (100) (28.8) 306 (45) 56 (53.3) 35 (33.3) 680 (100) 49 (46.7) 8 56 (7.6) (53.3) 105 (100) 49 (46.7) 43 (41.0) 105 (100)

Copyright40 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al. Combined Frequencies % N diagnosis Secondary % Primary diagnosis N Frequecies Combined % diagnosis Secondary N % Primary diagnosis N Adults Under 18 The top six categories for the under18 age group.The term mental retardation is used according to ICD10. þ . Depressive episodeAdjustment disorderMental retardationEpilepsy 212 41.2 62 21 18 12.0 34.4 4 3.5 3 6.55 233 23 4.91 66 13 4.5 21 7.9 ^ 15 ^ 2 52 9.1 31.5 1.2 1 23 8 0.6 15 27 4.8 16 16.4 60 ^ ^ 27 Behavioural and emotional disordersDissociative disorder 2 0.4 9 14.75 11 2.1 11 9 17 14.75 10.3 20 12 6 7.3 3.6 29 1 0.6 7 þ Recurrent depressive disorderþ þ þ Drug dependence 71 13.8 8 13.11 79 26 5.0 1 ^ 0.6 ^ ^ 26 ^ 1 1 0.6 ^ ^ 1 þ þ Total 515 100 61 100 543 166 100.0 26 ^ 191 The top six categories for adults 1 3 78 Bipolar a¡ective disorder9 1011 Anxiety disorder12 Schizophrenia13 Obsessive^compulsive disorder14 Psychotic episode 2015 Dementia16 No ICD10 3.9 diagnosis 10 Not recorded 1 1.9 1.63 11 2 2.1 9 3.27 21 4 2 1.7 31 0.8 ^ 3.27 12 1 6.0 3 2 ^ ^ 0.6 2 13 1 0.6 3.27 ^ 0.4 ^ ^ 0.6 ^ 2 9 6 ^ ^ ^ ^ 1.2 ^ ^ 3 ^ 1 3 21 1 1.8 ^ ^ 12.7 0.6 ^ 1 1 ^ ^ 6 ^ 3 0.6 3.6 ^ ^ ^ 4 ^ ^ ^ ^ ^ ^ Table 2. Diagnostic categories (ICD 10) Notes: 2 4 5 6

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.41 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

o¡ered psychological interventions, while 13% of the patients were given pharmacological treatments only.Table 4 shows a sum- mary of the psychological interventions o¡ered.

Follow-ups After the ¢rst two camps, follow-up cases were also noted. It was encouraging that 21% of cases (in the last four camps) were reviewed at least once on follow-up. Half of the patients who did follow-up only spoke Pashto. Similarly, over 60% were illiterate, and their demographic details are also shown in Table 1. Sixty percent of follow-up cases were diagnosed with depression, and 14.2% of cases had not received any medication, but were still followed-up.

Other ¢ndings Special issues relating to women Con- trary to commonbelief that the female population might not be encouraged to access healthcare, 45% of all cases were women. However, in the under-18 sample, the male to female ratio was 2:1. Divorce is uncommon, as it is considered dis- honourable, but polygamy is common. As a result, nearly all women facing mental health issues live with persistent insecurity and the threat of their husbands’ re-marry-

ing, and thereby continuously compromise Primary prescription Additional prescription frequency Total in marital con£icts. Another sensitive issue relates to contraception, which is largely considered prohibited in Islam. If a woman is reluctant to have more children, the hus- band is more likely to re-marry. In our sample, nearly half of all married patients had ¢ve or more children, and 47 patients had more than nine children. Special issues relating to children Children can be seen to fall into one of three

categories, listed below. Drug No % No % No %

1. Childrenwith pre-existing, undiagnosed disorders that may need further investi- gation, regular medication and follow-

Nteodd 0.15 up (such as epilepsy). Table 3. Pharmacological Treatments 12345 Anti-depressant6 Anti-convulsant7Notrecorded1 Anti-psychotic8 Mood stabiliser Benzodiazepine Nodrugprescribed 387 45 189 Total 40 17 1 56.91 27.79 6.62 5.88 2.5 12 0.15 680 ^ 17 ^ 29.27 12 100 ^ 41.46 399 29.27 ^ 41 57 45 75.14 13 17 100 10.73 8.47 2.45 3.20 531 100

Copyright42 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al.

Table 4. Psychological interventions Intervention N %

1 Psychoeducation 207 30.4 2 Supportive counselling 158 23.2 3 Stress management 92 13.5 4 Behavioural therapy 38 5.6 5 Psychosocial support for bereavement 34 5.0 6 No intervention 148 21.8 7 Not recorded 3 0.4 Total 680 100.0

2. Children with pre-existing, but diag- Authority), mental health professionals nosed conditions that do not necessarily (volunteers/departments), military and need regular medication nor immediate humanitarian agencies, in an insecure and professional psychiatric care (such as challenging context, and without commer- mental retardation). cial sponsorship. The initiative aimed 3. Children with no pre-existing problems, beyond just providing immediate mental but whohave developedbehaviouraland health care to IDPs by strengthening local mild psychological problems due to services (Epping-Jordan et al., 2015; Pe¤rez- displacement. Sales et al., 2011). To our knowledge, this is the ¢rst instance in Pakistan where estimates Special issues relating to minorities for common mental disorders, both for According to military sources, there were adults and children, were identi¢ed in an 22 Hindu and 24 Christian families among IDP population from a tribal region. These IDPs who were not integrated into the com- camps helped in engaging local services munity for their protection. The Hindu and provided an impetus for setting up a families were housed on the top £oor of a mental health agenda in the region. It was Hindu temple, and the army had made encouraging that during this initiative, the special arrangements to deliver rations at humanitarian forum formed the ¢rst ever their doorstep in order to avoid incidents. MHPSS taskforce in the province (Humani- None of these families were represented at tarian Response, 2015). the hospital, so their access to health care remains a matter of concern. About the camps In view of the high security restrictions, geo- Discussion graphical distance, dearth of mental health Although other MHPSS initiatives in hu- resources locally and lack of an institutional manitarian settings have been reported from initiative, convening these camps was the Pakistan (Budosan & Aziz, 2009; Humayun, only viable option to support IDPs. In our 2008; Shah et al., 2014), this is likely experience, these camps were helpful in to be the ¢rst intervention in a highly assessing needs, providing direct care, en- secured military zone in Pakistan. These gaging local agencies, developing referral camps demonstrate an e¡ective model links and initiating capacity building. We for emergency mental health response found that presence of experienced pro- via collaboration between government fessionals in the ¢eld was highly valuable agencies (Provincial Disaster Management in terms of setting practice trends and

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.43 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

providing direct supervision, more so than need assessment from the camps. The local the usual trend of deputing junior psychia- department of psychiatry set up a helpline trists/psychologists (even with long distance for GPsto enable themwith a referral system. supervision) into a humanitarian setting. In addition, psychosocial trainings for Unlike traditional ‘medical camps’,active community workers were conducted by col- e¡orts were made to conduct multi- laborating NGOs who continued to provide disciplinary assessments in order to avoid a support for another six months after the purely biomedical approach and avoid risk camps. of over-medicalisation (Ventevogel, 2014). Considering the strongly ingrained biological model of medical practice, both from Findings from the camps a clinician’s perspective and consumer 1. This initiative o¡ered an opportunity to expectations, it was encouraging that at least assess mental health care needs in a 28% of those attending the camps were not con£ict hit area. A vast majority of the prescribed any drugs, and 15% of these also IDPs (at least 60% cases) had pre-exist- returned for a follow-up. ing mentaldisorders. About15% ofcases Another objective was to encourage task were residents of Bannu seeking second sharing by involving non specialists, as this opinions. Since these camps were organ- hasbeen established as an e¡ective approach ised in a tertiary care hospital, mainly for providing mental health care in resource advertised through local health facili- poor settings (van Ginneken, et al., 2013). ties, and referred to as a specialist Initially, it was time consuming to supervise activity for mental health problems, it other members (including psychologists, was unsurprising that most people were psycho-social workers and nurses) and over- found to be su¡ering from mental see their involvement in the consultation disorders. process. However, this proved to be a worth- 2. Althoughthe diagnosis of depressionwas while investment, as delegating tasks used for moderate and severe cases only, allowed clinicians to focus on the more the high prevalence might still be an severe cases. This also o¡ered a valuable indication of a trauma reaction. It is opportunity for training the mental health known that expression of trauma care team in the hospital and psychosocial symptoms is culturally-tied, and some ¢eld sta¡. posttraumatic stress disorder (PTSD) Through advocacy, the provincial govern- symptom clusters, including avoidance/ ment agreed to appoint another psychiatrist numbing, have been found to have at Bannu, but unfortunately no appropriate £uctuating salience depending on cul- candidate was found during that period. tural factors (Hinton & Lewis-Fernan- However, the psychologist in the department dez, 2011). In our experience, symptoms began conducting independent clinics of PTSD were frequently reported by afterwards. IDPs, particularly the sounds of ‘rumbling The need for training primary care sta¡ airplanesin[their]heads’,butnoneful¢lled following a humanitarian emergency in the full diagnostic criteria. For example, Pakistan is known (Budosan & Aziz, 2009; £ashbacks were usually £eeting and Budosan, 2011). Alongside the camps, not repetitive. Symptoms of hyper-arou- mhGAP trainings were conducted in the last sal were common, but pronounced three months (will be described in an emotional detachment or numbness was upcoming article). These were attended by not reported. One 4-year-old child a total of 58 primary care sta¡.The training screamed for an hour at the sight of army modules were prepared according to the personnel (in uniform) while waiting,

but was successfullycalmeddown during psychological complexity and dissocia- the clinical intervention. tive disorder received little or no atten- 3. Some demographic ¢ndings are consis- tion. It was also apparent that there was tent with the trends of seeking mental wide variation in prescribing practices: health care previously studied in another trends of poly-pharmacy and use of district of the same province (Shah et al., multiple brands were quite common. 2014). For example, a majority of those There was also a tendency to order rela- who sought help were in the age range tively expensive investigations like EEG of 19^50, with a near equal representa- and CT scans/MRI without clinical tion of both genders. Inthat sample, only indications. The care o¡ered to the chil- 8% were under the age of 18, whereas dren, especially those su¡ering from ours had a much larger proportion of mentalretardation,was far fromsatisfac- children and young adults (over 24%). tory. One family with two children suf- It was encouraging that 21% of patients fering from mental retardation had returned for a follow-up visit in our spent Rs.1.8 million (over USD 28,000) monthly camp. on health care without much help. 4. The most commonly prescribed medi- 6. Another relevant ¢nding was that not all cationconsistedofanti-depressantdrugs. essential drugs were available in the dis- This is not surprising considering the trict, including depot anti-psychotic high prevalence of pre-existing depress- injections. There is little regulation by ive disorders. However,it is quitepossible the provincial government. What is that these medicines were also being pre- available, both in terms of the medicine scribed as a symptomatic treatment for anditsbrand, ispurelydeterminedbythe anxietyor insomnia (inviewofconscious marketing success of the pharmaceutical e¡orts by the team to discourage benzo- companies (Khan, 2006). diazepines). Additionally, it has also been shownthat longer-term psychologi- Major barriers/limitations cal interventions in similar situations The main limitation of this experience could actually help better in symptom was the obvious disproportionate amount reduction and enhancing coping strat- of resources compared to the population egies than medical treatments (Ayoughi, a¡ected. Also, since the camps were held at Missmahl, Weierstahl & Thomas, 2012). a tertiary care facility, access to the hospital In addition, low level psychological was a major barrier for many people. Time interventions developed in non con£ict was another major constraint during these a¡ected areas of Pakistan have also been camps as, due to security concerns, travel- shown to be e¡ective, and might be ling was not possible after dark. Also, over helpful withinthis humanitarian context 100 patients were seen at each camp, mostly (Rahman, Malik, Sikander, Roberts & without a break. Documentation was there- Creed, 2008). fore, sometimes impossible, which was the 5. The camp also provided insights into the primary reason for missing data. existing mental health practices of the Another barrier was that of language and region. Like other parts of the country, culture. There was a huge language barrier KPK o¡ers a purely biomedical as two-thirds of the patients could only com- approach towards mental health care. municate in Pashto. Even the Pashto speak- Routinely, dozens of patients are seen ing professionals had di⁄culty conducting every day by psychiatrists with no more interviews because of the dialect spoken by than a few minutes’ consultation. Pro- most IDPs. There were also limitations in tracted and untreated cases of exploring psychological processes or

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.45 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

delivering therapeutic interventions (some- Conclusion times through an interpreter). In addition, Ventevogel et al. (2012) described the chal- there were pronounced socio-cultural inhi- lenges of providing integrated mental health bitions, especially for women, to seek care in a much more fragile and resource medical attention and advice from a doctor, poor context covering a population of a especially if male. Most women had their million population. They also highlighted faces covered in the waiting area and some the need for investing funds towards achiev- remained reluctant to uncover, even during ing longer term goals. The Bannu initiative the consultation. A related clinical obser- was an encouraging experience in a highly vation was that most patients (especially secure, but not so resource poor setting. It men) were unable to discuss emotional di⁄- helped mobilise relevant resources in the culties. This could partly be because the tri- short term, but sustainable e¡orts are much bal culture does not encourage emotional needed for an e¡ective outcome. Generating expressions, although Pashtun women are political will be a key challenge in the region. known to express their feelings (Grima, The goal should be to set up a primary 1993). Sometimes, there was di⁄culty in health care system in NWA and strengthen obtaining detailed information or collateral the existing system in Bannu, so that mental accounts because close family members or health care could be integrated as an essen- key informants were not available. tial component (Saxena & Setoya, 2014). A Most members of the team shared their own paradigm shift towards a public mental limitations in o¡ering psychotherapeutic health approach is much needed for psychia- skills and dealing with stress related dis- tric departments throughout the country. orders. Clear gaps in knowledge and skills These would need to rede¢ne their roles to in child and adolescents’ mental health care integrate within community initiatives. The were reported, for example in Iraq (Ai- primarycare sta¡ mustbe trained according Obaidi, Budosan, & Je¡ery, 2010), were also to mhGAP guidelines as a priority in identi¢ed in our experience. The team all districts. travelled together for these camps, and that It is also advisable to make a mental time was also utilised to explore clinical health disaster/emergency preparedness needs and developing skills. One of the key plan for countries like Pakistan, so that challenges identi¢ed as a major obstacle to MHPSS initiatives can be promptly organ- implement psychotherapeutic interventions ised (van Ommeren et al., 2015; Ventevogel recommended by the WHO stress related et al., 2015). Following a humanitarian cri- guidelines was the limited availability of sis, and in the absence of local specialists, mental health resources in developing short term rotations should be considered countries (Tol, et al., 2014). What is not as to support clinical services. A monthly clearly documented is that sometimes the mental health camp, for at least six months, existing mental health resource might also can greatly help support local services. not be adequately trained for these interven- Opportunities for providing psychosocial tions. support in the community should be Lastly,despite our best e¡orts, long term sus- coordinated between di¡erent agencies tainability of these e¡orts is yet to be seen. including district health o⁄ces, academic Lack of political will and sustained e¡orts departments of psychiatry and humanitar- to reinforce training of health care sta¡ are ian agencies. major concerns. In addition, most humani- Lastly, extensive and robust advocacy for tarian agencies might be present in Bannu mental health needs and services at the for a limited time only. national and provincial levels is essential.

Acknowledgements deJong,T.J., Komproe, I. H. & van Ommeren, M. We would like to thank Major Gen Akhtar Jamil (2003). Common mental disorders in postcon£ict Rao, General O⁄cer Commanding,45 Engineers settings. Lancet, 361,2128-2130. Division & Temporarily Dislocated Persons Sup- port and Management Secretariat (TDP S&M) Epping-Jordan, J. E., van Ommeren, M., Ashour, for his keen interest and relentless support. We H. N., Maramis, A., Marini, A., et al. (2015). would also like to thankJaved Akhtar for o¡ering Beyond the crisis: Building back better mental the complete support of the Department of Psy- health care in 10 emergency-a¡ected areas using chiatry at Khalifa Gulnawaz Hospital, Bannu. a longer-term perspective. International Journal of We would like to acknowledge Rozan, Inter- Mental Health Systems, 9, DOI:10.1186/s13033-015- national Medical Corps and other NGOs for sup- 0007-9. porting this initiative. We are also very grateful Foulds, G. A. & Bedford, A. (1975). Hierarchy of to Mark van Ommeren for his constant encour- classes of personal illness. Psychological Medicine, 5, agement and valuable comments. 181-192.

References Grima, B. (1993). The performance of emotion among Ai-Obaidi, A. K., Budosan, B. & Je¡ery, L. (2010). Paxtun women: ‘‘the misfortunes which have befallen ChildandadolescentmentalhealthinIraq:current me’’. Karachi: Oxford University Press. situationand scope for promotionofchildandado- lescent mental health policy. Intervention,8,40-51. Hinton, D. E. & Lewis-Fernandez, R. (2011).The cross-cultural validity of posttraumatic stress dis- Ayoughi, S., Missmahl, I., Weierstahl, R. & order:implications for DSM-5. Depression and Thomas,T. (2012). Provision of mental health ser- Anxiety, 28, 783- 801. vices in resource-poor settings: A randomisedtrial comparing counselling with routine medical Humanitarian Response. (2015). Mental Health treatment in North Afghanistan (Mazar-e- and Psychosocial Support Task-forcejProtection sharif). BMC Psychiatry, 12,14. Cluster. Retrieved May15, 2015 from Humanitar- ianResponse.info: http://www.humanitarianre- Bolton, P.(2013).Mental health in Iraq: issues and sponse.info/en/operations/pakistan/mental- challenges. Lancet, 381,879-881. health-and-psycho-social-support-task-force.

Bolton, P.& Betancourt,T.S. (2004).Mentalhealth Humayun, A. (2008). South Asian earthquake: in postwarAfghanistan. JAMA, 2 92(5), 626-628. psychiatric experience in a tertiary hospital. East Medical HealthJournal, 14, 1205-1216. Budosan, B. (2011). Mental health training of primary health care workers: case reports from Hussain, N., Chaudhary, I. B., Afridi, M. A., Sri Lanka, Pakistan and Jordan. Intervention, 9(2), Tomenson, B. & Creed, F. (2007). Life stress and 125-136. depression in a tribal area of Pakistan. BritishJour- nal of Psychiatry,190,36-41. Budosan, B. & Aziz, S. (2009). A mixed methods ¢eld based assessment to design a mental health Kassam, A. & Nanji, A. (2006). Mental Health of intervention after the 2005 earthquake in Man- Afghan refugees in Pakistan: A qualitative sehra, North-west Frontier Province, Pakistan. rapid reconnaissance ¢eld study. Intervention, 4, Intervention, 7,265-283. 58-66.

Cardozo, B. L., Bilukha, O. O., Crawford, C. A., Khalily, M. T. (2011). Mental health problems Shaikh, I., Wolfe, M. I., Gerber, M. L., et al. in Pakistani society as a consequence of (2004). Mental health, social functioning and dis- violence andtrauma: a case forbetter integration ability in postwar Afghanistan. JAMA, 292(5), of care. International Journal of Integrated Care, 11, 575-584. e128.

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.47 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49

Khan, M. M. (2006). Murky waters: the pharma- Salah, T.T., Abdelrahman, A., Lien, L., Eide, A. ceutical industry and psychiatrists in developing H., Martinez, P. & Hau¡, E. (2013). The countries.The Psychiatrist, 30, 85-88. mental health of internally displaced persons: an epidemiological study of adults in two settle- Miller,K.E., Omidian, P., Rasmussen, A.,Yaqubi, ments in Central Sudan. International Journal of A. & Daudzai, H. (2008). Daily stressors, war Social, 59,782-788. experiences, and mental health in Afghanistan. Transcultural Psychiatry,45,611-638. Saxena, S. & Setoya, Y. (2014). World Health organization’s Comprehensive Mental Mirza, I. & Jenkins, R. (2004). Risk factors and Health Action Plan 2013-2020. Psychiatry and treatment of anxiety and depressive disorders in Clinical Neurosciences, 68, 585-586. Pakistan: systemic review. BMJ, 318(3), 794. Saxena, S.,Thornicroft, G., Knapp, M. & White- Mufti, K. A., Naeem, F., Ayub, M., Sai¢, F., ford, H. (2007). resources for mental health: Scar- Haroon,A.& Kingdon, D.(2005).Psychiatricpro- city, inequity, and ine⁄ciency. Lancet,878-889. blems in an Afghan village. Journalof Ayub Medical Scholte,W. F., Ol¡, M.,Ventevogel, P., deVries, College, 17,19-20. G.J.,Jansveld,E.,Cardozo,B.L.&Crawford, Mujeeb, A. (2015).Mental health of internally dis- C. A. (2004).Mental health symptoms following placed persons in Jalozai camo, Pakistan. Inter- war and repression in eastern Afghanistan. national Journal of Social Psychiatry. DOI: 10.1177/ JAMA, 292(5), 585-593. 0020764015573083. Shah, S., van der Bergh, R., van Bellinghen, B., Naeem, F., Mufti, K. A., Ayub, M., Haroon, A., Severy, N., Sadiq, S., Afridi, S. & Zachariah, R. Sai¢, F., Qureshi, S. M. & Kingdon, D.(2005).Psy- (2014).O¡eringmental health services inacon£ict chiatric morbidity among Afghan refugees in a¡ected region of Pakistan: Who comes and Peshawar, Pakistan. Journal of Ayub Medical College why? PLoS One, 9, DOI: 10.1371/journal.pone. Abbottabad, 17, 23-25. 0097939.

Panter-Brick, C., Eggerman, M., Gonzalez, V. & Tol,W.A., Barbui, C., Bisson, J., Cohen, J., Hijazi, Safdar, S. (2009).Violence, su¡ering and mental Z., Jones, L. & Van Ommeren, M. (2014). health in Afghanistan: a school-based survey. Lan- WHO guidelines for management of acute stress, cet, 374, 807- 816. PTSD and bereavement: Key challenges on the road ahead. PloS Medicine, 11, e1001769. doi:10.1371/ Pe¤rez-Sales, P., Fe¤rnandez-Liria, A., Baingana, F. journal.pmed.1001769. & Ventevogel, P.(2011).Integrating mental health into existing systems of care during and after com- Turnip,S.S.,Klungsoyr,O.&Hau¡,E.(2010). plex humanitarian emergencies: rethinking the The mental health of populations directly and experience. Intervention, 9, 345-358. indirectly exposedto violent con£ict in Indonesia. Con£ict and Health, 4,14. Quosh, C., Eloul, L. & Ailani, R. (2011). Mental health of refugees and displaced persons in Syria UNHCR. (2014). Emergency Response for IDPs and surrounding countries: a systemic review. from North Waziritan Agency. From http:// Intervention, 11, 276-294. unhcrpk.org/wp-content/uploads/2013/12/ UNHCR-2014-Supplementary-Budget-Appeal- Rahman, A., Malik, A., Sikander, S., Roberts, C. Emergency-Response-for-IDPs-from-North- & Creed, F. (2008). Cognitive behaviour Waziristan-Agency.pdf. therapy-based intervention by community health workers for mothers with depression and their United Nations O⁄ce for Coordination of infants in rural Pakistan: a cluster-randomised Humanitarian A¡airs (OCHA), 2014. Pakistan: controlled trial. Lancet, 372, 902-909. Type of Health Facilities in North Waziristan

Agency, FATA (27 January 2014). Retrieved from Improving access to mental health care and psy- ReliefWeb: http://reliefweb.int/map/pakistan/ chosocial support within a fragile context: a case pakistan-type-health-facilities-north-waziristan- study from Afghanistan. PLoSMedicine,9,e1001225. agency-fata-27-january-2014. Ventevogel, P., van Ommeren, M., Schilperoord, USAID. (2014, June 26). Pakistan^Complex M. & Saxena, S. (2015). Improving mental health Emergency,Fact Sheet, FiscalYear2014. Retrieved care in humanitarian emeregencies. Bulletin of the 4 October 2015 from USAID: http;//www.usaid. World Health Organization, 93, 666-1666. gov/sites/default/¢les/documents/1866/pakistan_- ce_fso3_06_26_2014.pdf. WHO. (2009) WHO-AIMS Report on Mental Health System in Pakistan. Pakistan: WHO. From http:// van Ginneken, N.,Tharyan, P., Lewin, S., Rao, G. www.who.int/mental_health/pakistan_who_aims_ N., Meera, S., Pian, J. & Patel, V. (2013). Non- report.pdf. specialist healthworkers interventions for thecare of mental, neurological and substance abuse dis- WHO. (2010). The mhGAP Intervention Guide orders in low- and middle-income countries. (mhGAP-IG) for mental, neurological and substance use Cochrane Database System Review,11, CD009149. disorders for non-specialist health settings.Geneva: WHO. van Ommeren, M., Hanna, F., Weissbecker, I. & Ventevogel, P. (2015). Mental Health and WHO. (2013a). Guidelines for the management of con- psychosocial support in humanitarian emergen- ditions speci¢cally related to stress. Geneva:WHO. cies. East Mediterranean HealthJournal, 21, 498-502. WHO. (2013b). WHO model List of Essential Medi- Ventevogel, P.(2005). Psychiatric epidemiological cines: 18th Edn. From http://www.who.int/medi- studies in Afghanistan: acritical reviewand future cines/publications/essentialmedicines/en/ directions. Journal of Pakistan Psychiatric Society, 2, index.html. 23-25. WHO & UNHCR. (2012). Assessing mental health Ventevogel, P.(2014).International Review of Psy- and psychosocial needs and resources: Toolkit for major chiatry. Integrationofmentalhealth into primaryhealth- humanitarian settings. Geneva:WHO. care in low-income countries: Avoiding medicalization, 26, 669-679. Asma Humayun is Consultant Psychiatrist in Ventevogel, P., van de Put, W., Faiz, H., van Islamabad, Pakistan. Mierlo, B., Siddiqi, M. & Komproe, I. H. (2012). email: [email protected]