Helping Syrians cope with depression

WHO/Laura Sheahen

A psychotherapist at a mental health centre near the Syrian border shows materials she adapts when working with Syrian refugees.

“We call depression the black snowball,” says B. Hussain*, a psychologist at a mental health centre in the southeastern Turkish city of Gaziantep. Hussain works with some of the nearly 3 million Syrian refugees that have escaped to Turkey and been granted shelter there since the crisis in their country began.

Like most refugees worldwide, Syrians now living in Turkey are under tremendous psychological stress. During years of conflict, many have lost loved ones, their homes, their livelihoods and certainty about their futures. After escaping bombs or sniper fire, they suffer from anxiety, post-traumatic stress disorder and other psychological illnesses.

But for some refugees, the suffering they have experienced builds up, and the black snowball gets bigger. It can lead to serious depression. For those who were already predisposed to depression before the crisis, the danger is even greater.

“Isolated and withdrawn.”

Hussain describes a Syrian man in his early 30s who arrived in Turkey alone. “He already had a tendency to be depressed,” says Hussain. “And he lost a lot of friends – they were killed in Syria. He found himself here with no friends, nothing. He became severely isolated and withdrawn.”

Somehow he made his way to the mental health centre where Hussain works. “He said, ‘I’ll give you 5 sessions. If it doesn’t work, I’ll commit suicide.’”

Helping troubled Syrians

Hussain and others have help from WHO to supplement their own education and experience. In Turkey and in northern Syria, WHO provides materials, training and other support to mental health groups and professionals.

“There are only 2 psychiatrists right now in northern Syria. It’s a huge gap,” says Dr Fuad Almosa, a psychiatrist based in Gaziantep who, like Hussain, is part of a WHO working group on mental health for Syrians. “So when you bring 37 trained doctors, it really helps.” Almosa is referring to 37 doctors in northern Syria who were trained last year in WHO’s Mental Health Gap Action Programme (mhGAP), a programme to identify and treat psychological disorders including depression. The trained doctors receive online clinical supervision and follow-up help.

WHO provides mhGAP training to Syrian doctors now living in Turkey. In parts of Turkey hosting many Syrian refugees, WHO is working to ensure that primary health care centres specifically created for the refugees are each staffed by 2 mental health experts.

“When patients come to me with psychological problems, I usually refer them,” says a family physician who works near the border with Syria and who was trained in mhGAP in March 2017. “But I know sometimes people can’t go to where I am referring them – they don’t even have the money to take a bus. After this training, I decided that I would try to help them.”

WHO also trains community members who can be a first line of defence in helping depressed Syrians. Community health workers in besieged areas of Syria have received online training in psychological first aid – in some cases, despite aerial attacks.

“With psychological first aid, the trainees are not providing therapy,” explains Almosa. “But they learn about the services available nearby, and link a person to those services.”

Almosa supervises mental health work in 8 clinics in northern Aleppo. For him, “the most valuable part of mhGAP training was that it ‘demedicalized’ mental health. We see the patient as not just a biological being, but a social one,” he explains. “This reduces stigma.”

Adapting mental health services to the culture

Almosa says that mental health workers in northern Syria are using approaches that are acceptable in their culture.

“Certain health approaches were not acceptable. For example, there was a mental health centre near a huge prison. That stigmatizes it. It’s better when you provide service near the people,” he says. “You become nearer to the community. It’s not like in the past, when mental health was isolated.”

As part of this approach, WHO plans to fund a mental health centre in a Syrian town called Sarmada in Idleb, as well as a mental health mobile clinic that “will reach far-flung villages”, according to Dr Manuel de Lara, Public Health Officer for WHO. The centre and clinic will be staffed by trained professionals from Hussain’s group, the Union of Medical Care and Relief Organizations (UOSSM), a WHO health partner. “It will be a mental health rapid response team,” explains de Lara. “If there are acutely ill patients, they can be taken immediately to the mental health centre in Sarmada, or referred into Turkey itself.”

In a city called Kilis, near the border with Syria, an organization that is part of WHO’s working group has 10 community mental health workers who conduct door-to-door outreach. The teams often start by simply saying, “Hello, how are you?”

Planning for the future

Mental health workers also vary their approaches based on other needs. Sometimes group therapy is effective. Therapy for children must be specially tailored. In Gaziantep, another UOSSM psychologist uses cognitive behavioural therapy (CBT) when working with some depressed Syrian refugees.

Despite immense obstacles, the members of WHO’s working group have been able to help thousands of people inside Syria and thousands of refugees in Turkey. The suicidal young man Hussain treated is “back to his normal life: he has plans for the future, new friends, a new job and fiancée,” according to Hussain.

Challenges remain, such as how to provide the best care for depressed Syrians who live in Turkey’s refugee camps. The toll of the Syrian conflict is immense and will be long-lasting, say experts. “Right now, Syrians are in survival and denial mode,” says Ms Hivin Kako of Bihar Relief. “After the conflict stops, we’ll need an army of psychological experts.”

De Lara agrees that the stakes are high for Syrians who have endured so much emotional suffering. “If no mental health services are provided now,” he warns, “we’ll lose the future.”

*Full name withheld on request.