As the humanitarian situation inside Syria continues to worsen, mental health needs among refugees who have fled the country are steadily increasing. Ahead of World Mental Health Day on October 10, Doctors Without Borders/Médecins Sans Frontières (MSF) wants to highlight the plight of Syrians in northern Iraq’s Domeez refugee camp, where MSF’s counsellors and psychologists are seeing growing numbers of patients presenting with far more acute symptoms than a year ago.

In 2012, around seven percent of MSF’s mental health patients in Domeez displayed symptoms of a severe mental disorder. In 2013, this number has more than doubled, to 15 percent.

“The psychological situation in Domeez camp is an emergency in itself,” says Ana Maria Tijerino, an MSF mental health advisor. “Our team is increasingly seeing more complex reactions and symptoms among the refugees. Disorders such as schizophrenia and severe depression are becoming more commonplace, and we are seeing many patients who have suicidal tendencies.”

Acute psychological needs

MSF began general medical activities in Domeez in May 2012 and immediately saw the need to incorporate a mental health programme. Two months later, a team of trained psychologists and counsellors started providing individual, family, and group sessions.

The mental health team works alongside medical staff who help detect patients in need, then refer them for counselling. A team of community health workers also works within the camp to promote awareness about the services.

Since the programme began, MSF has conducted more than 2,600 consultations.

“The need for mental health care is immense and should be considered a vital component of medical response,” says Tijerino. “People who have just arrived to the camp have been exposed to a range of trauma: they may have directly witnessed violence or had their lives placed in danger, they may have lost their houses or family members.

“At the same time,” she continues, “people who have been living here for a year have a heightened sense of hopelessness. Nobody knows what is going to happen tomorrow, and when this conflict will end. This is having a huge effect on people’s psychological well-being. It has become a desperate situation.”

Caring for patients with severe mental health disorders

As the numbers of patients with severe mental disorders such as schizophrenia or depression has increased, MSF has adapted its approach. Some patients seek care at the clinic, but in many cases stigma around such disorders is a huge barrier to asking for help. When it’s necessary, MSF psychologists conduct home visits, ensuring contact both with the individual and the family.

Currently, MSF refers these patients to a nearby hospital if need be and is working with the Department of Health to expand psychiatric care within the clinic itself. This will reduce the need for referrals outside of the camp and allow patients to be treated and more closely monitored nearer to their home, temporary though it may be, and their family.

War’s impact on children

The war and its aftermath have had far reaching consequences for the mental health of children. Currently in Domeez, children and adolescents make up 50 percent of all MSF’s new patients. Every week, 15 to 20 children and adolescents are admitted to the programme.

One of the most common symptoms for children of all ages is bedwetting, a reaction to anxiety and fear. Other symptoms children display include behaving aggressively and isolating themselves from families and friends.

To address these symptoms, staff leads sessions that involve talking to the children alongside a family member and encouraging them to express themselves through drawing and playing techniques. The aim is to reestablish a safe environment and increase the coping skills of the children and their families.

Another vulnerable group: single men

In Domeez, a part of the camp has been designated for single men who arrive without family or wives. Living five or six to a tent and without the support of family members, their ability to cope has been greatly reduced, but the stigma related to seeking out mental health care is even more pronounced.

MSF therefore sends male counsellors directly to the tents and provides sessions there.

“Everyone here has a story,” says an MSF counsellor. “Some have escaped from the army, some have fled from Damascus where they witnessed the war. They always say they are neglected here in Domeez and that nobody takes care of them. When I speak to them, I hear their emotions, and I see their sadness, which manifests in anxiety and irritability. We also see some cases of post-traumatic stress disorder. These men have directly witnessed war and have seen people killed in front of them.

“There are many stories, but one which I remember is a case of severe self harm,” he continues. “This normally happens when people feel hopeless and want to gain some sense of control. This man was cutting his whole body and had severe scars everywhere. He was so frustrated and upset that he thought this was the only solution. He had to leave his business behind in Syria, he cannot find a job here, and he misses his family. He is living in complete isolation. He says he gets relief from seeing the blood.”

Restoring strength and control

MSF’s team aims to help refugees find healthy ways to regain some sense of control over their psychological well-being. “We aim to help give them back some of their strength,” explains Dr. Henrike Zellmann, the supervising psychologist for the programme.

“We are working to reinforce their coping strategies, and we give them a chance to talk openly and confidentially. It takes time, and the problems will not be solved in one session. We do not have the ability to make the situation go away. But our psychologists can help people make some sense of what they have been through and gain control of the unbearable symptoms they are experiencing.”

Since May 2012, MSF has been working in Domeez refugee camp in Dohuk governorate, home to more than 42,000 Syrian refugees. Teams provide around 2,500 general health care and mental health consultations each week.