An estimated 17% of Lebanon’s population suffers from mental health problems, yet almost 90% have no access to treatment. On the surface, Lebanon has made significant strides since the 2006 war, and is today a major financial and cultural centre in the Middle East. Economic growth for 2011 is forecast at 6%, a record 2 million tourists visited the country last year and Lebanon received $8.2 billion in remittances in 2010 from Lebanese nationals living abroad. At the same time, however, the country is gripped by political crises, threatening its financial and social fabric, and poverty levels in some parts of the country are stubbornly high. The health infrastructure is under severe strain, not least from the large numbers of Palestinian and Iraqi refugees living in this small country.
Mental health in Lebanon
Lebanon’s first large-scale psychiatric epidemiological study, part of the World Health Organisation’s (WHO) World Mental Health Survey Initiative, revealed that a shocking 49% of the population sampled had experienced a war-related distressing event of some type and the survey was compiled before the 2006 war. The precarious position of refugees in Lebanon leaves them especially vulnerable to mental health issues. According to a study in December 2010, conducted by the American University of Beirut and the UN Relief and Works Agency (UNRWA), 21% of the 270,000 Palestinian refugees in Lebanon suffer from some form of mental illness.
Lebanon has a predominantly private health care system, which relies heavily on the private sector and NGOs to provide mental health services. The country ranks high in the Middle East based on the number of mental health professionals, with 60 psychiatrists and 100 clinical psychologists for every four million Lebanese, and 274 general practitioners (GPs) per 100,000. Although its mental health expertise is internationally renowned, like many countries in the Arab world Lebanon does not have a national policy on mental health, and very little long-term planning is being done at the ministerial level. Budget allocations from the health sector for mental health average just 5%, lower than most European states but higher than the global average of 3.2%.
Like other Arab cultures, the Lebanese express their emotional concerns through somatic or physical complaints, as these are more socially acceptable. As a result, people suffering from common mental disorders such as depression may manifest their condition through stomach aches or migraines, making them more likely to visit their family doctor to seek treatment rather than a mental health professional. Family doctors or GPs, being unaware of the actual cause of the individual’s complaint, may resort to prescribing medication which does not address underlying mental health problems.
International Medical Corps in Lebanon
International Medical Corps has carried out training for health care workers including GPs and mid-level health staff in conjunction with the Order of Physicians and the Lebanese Psychiatric Society in Beirut. This training enables health professionals to identify, manage and refer people with mental health problems. Designed to address Lebanon’s specific needs, the training programme is pragmatic, and emphasises that psychotropic (mind-altering) medications should only be used as a last resort.
International Medical Corps trains GPs and nurses in the provision of mental health care because they are the frontline providers of general health services in Lebanon, and are therefore in a position to identify and address mental health problems. Participants were recruited from International Medical Corps-supported clinics in five of the country_s eight provinces. Over the past two years, 79 GPs and 35 mid-level staff (including nurses and social workers) have been through the training programme. Four sessions have been held, with 12 days of theoretical training on topics including depression, anxiety, schizophrenia, substance abuse, domestic violence, mental health in the elderly and medication management. A further three on-the-job training sessions complemented the theoretical work, involving supervision by a psychiatrist to check whether training participants were properly applying to their patients what they learned in class.
The International Medical Corps training manual was based on various sources, including “Where there is no Psychiatrist” by Vikram Patel, and adapted to the Lebanese context through the use of case studies. It was reviewed by several Lebanese psychologists and the head of the Lebanese Psychiatric Society. Having the buy-in of both groups and the Ministry of Health (MoH) ensured full attendance and high standards and encouraged greater participation. The Lebanese Order of Physicians provided Continuing Medical Education credits to the registered GPs. Involving the MoH has been instrumental in getting approval of training materials and certifying the training programme. The training programme also complies with Inter-Agency Standing Committee (IASC) guidelines on Mental Health and Psychosocial Support in Emergency Settings.
International Medical Corps emphasises a unified system of care within each clinic and centre, stressing the importance of referral both upwards and downwards. Staff were trained to detect symptoms of mental health disorders and establish where and to whom a patient should be referred. In addition, communication, building rapport and the importance of psychosocial interventions were all highlighted. Ideally, the patient would first be seen by either a nurse or a social worker, then referred to a GP trained in mental health. If the case was severe or out of the scope of the GPs training and qualifications, a mental health specialist would be consulted. However, all three would work together through collaboration and continuous communication in order to ensure the patient’s wellbeing and recovery.
Refresher training for previous participants began in late 2010. These sessions are based on previous evaluations of training gaps and are tailored to staff specialisations. For mid-level staff, training centered on using psychosocial interventions to help patients suffering from mental disorders. GPs were trained in how to use psychosocial interventions that rely on not overprescribing psychotropic medications. Further refresher training for gynaecologists took place in April, covering the detection, management and referral of cases of abuse. Pediatricians received in-depth instruction on child and adolescent mental health and signs of abuse and neglect that might be causal factors in children displaying somatic complaints that have no biological causes.
Iraqi refugees in Lebanon
Iraqi refugees arrive in Lebanon with all the problems that forced migration can inflict upon an individual, including loss of place, a profound sense of uncertainty and prevalent mental health issues.
International Medical Corps has worked closely with Iraqi refugees in Lebanon, Syria and Jordan as part of a regional initiative funded by the US Bureau of Population, Refugees and Migration since 2007. The agency has implemented a comprehensive health care programme throughout Lebanon targeting locations where Iraqi refugees reside, and serving them in addition to vulnerable Lebanese. The programme is divided into three main areas: support for eight primary health care centres; support for secondary and tertiary health care; and dissemination of health education. The programme also operates five mobile medical units, primarily serving new arrivals from Iraq and providing follow-up services. Since 2008, International Medical Corps_ main initiative has been the integration of mental health into primary health centres to promote the idea of a community-based mental health system that provides accessible, affordable and less stigmatising services.
Challenges and lessons learned
Mental health care provision is often viewed as a complex issue. This perception originates from the fact that it is a relatively new element in the international development arena. Integrating mental health care within general health care provision makes mental health services more accessible and facilitates the detection of people with mental health problems, who might otherwise remain without appropriate care. Psychotropic medication should be used only where it is routinely available and accessible at the local level.
In Lebanon, as in many other countries, individuals are reluctant to visit mental health care services because they are wary of being stigmatised. The family doctor remains the key in diagnosing and treating mental disorders, which means that training GPs in the detection and treatment of mental disorders is a necessity.
International Medical Corps’ programme involves formative research, continued programme modifications and close collaboration with the government and all other stakeholders. The agency will continue to focus on providing refresher training, strengthening referral systems and supporting the integration of mental health at the organisational level. It is vital that any form of training in mental health is followed up with on-the-job sessions. International Medical Corps is currently part of the technical committee set up by a WHO national consultant responsible for carrying out a national situation analysis on mental health, and producing a strategy with a three-year national mental health plan for the MoH. In this strategy, International Medical Corps’ comprehensive training package will be cited as a successful programme that aims to integrate mental health into primary health care, which is one of the main objectives of the three-year plan.
Lebanon will continue to lurch from crisis to crisis, putting further pressure on existing resources and making long-term planning in this sector very difficult. Mental health care is likely to remain in the hands of the private sector and NGOs. Although the MoH in Lebanon does not have a policy on mental health, it is vital that both the private sector and NGOs fully engage with the ministry. The delivery of community-based mental health care services in a country like Lebanon is the responsibility of everyone involved.