Introduction
Armed conflicts and natural disasters cause significant challenges to the long-term mental health and psychosocial well-being of the affected population. Millions of people in many countries of the world experience war and conflict, and flight and displacement, over long periods of time and are severely affected by these experiences. This state of crisis also leads to intergenerational changes in traditional family and social structures. This often leads to severe emotional instability and a rapid increase in mental disorders such as trauma, anxiety, and depression. State professional mental healthcare services are rarely available in crisis countries. Even if they do exist, people who need psychological care are often not recognized as being in the need of help. Consequently, they are not referred to these services. There is an urgent need for high-quality mental health services and psychosocial support in crisis areas.
In 2019, the United Nations refugee agency (UNHCR) registered 70.8 million people who had been forcefully displaced. Of these, 25.9 million people were classified as refugees who had been forced to leave their homeland on account of persecution, war, or violence.
In 2014, people in Iraq and Syria, in particular, were subjected to considerable stressors owing to “Islamic State” terror, when the Islamic State of Syria and Iraq (ISIS) overran vast areas of Syria and Iraq. They used severe brutality, especially against long-established peoples and religious minorities in the countries, particularly the Yazidis. Huge numbers of men were executed, and thousands upon thousands of women and children were kidnapped and deliberately subjected to sexual violence. This situation led to massive movement of refugees. The Duhok region in Iraq was one of the areas most affected by this movement. It borders Turkey in the north and Syria in the southwest and had a population of approximately 1.5 million in 2015. This area took in the vast majority of the internally displaced persons (IDPs). In the Duhok region alone, there are currently (2019) 350,231 IDPs and 21 refugee camps. Throughout Iraq there are 2,045,718 IDPs in such camps.
Above all, it has been shown that the experience of violence and torture can increase the risk of developing a mental disorder, especially an affective disorder or posttraumatic stress disorder (PTSD). , The life of many refugees is characterized by competition when looking for work, a difficult living situation in the camps, rejection in the homeland, the experience of sexual and physical violence, and cultural uprooting. This, in turn, leads to conflicts in the social environment and feelings of helplessness, worry, insecurity, and hopelessness. , ,
Prevalence
Several studies have examined the prevalence rates of psychological disorders among refugees and IDPs in 21 countries. These studies have found different prevalence rates of mental disorders. However, a systematic review points out that PTSD (3%–88%), depression (5%–80%), and various forms of anxiety disorders (1%–81%) are the most prevalent disorders. These and other studies have drawn attention to a process in which trauma caused by human action (torture and predominantly sexual violence) precede the emergence of PTSD , and comorbid depression.
The World Health Organization’s (WHO) review of 129 studies in 39 countries showed that among people who have experienced war or other conflicts in the previous 10 years, one in five people (22%) will have depression, anxiety, PTSD, bipolar disorder, or schizophrenia.
According to the WHO’s review, the estimated prevalence of mental disorders among conflict-affected populations at any specific point in time (point prevalence) is 13% for mild forms of depression, anxiety, and PTSD and 4% for moderate forms of these disorders. The estimated point prevalence for severe disorders (i.e., schizophrenia, bipolar disorder, severe depression, severe anxiety, and severe PTSD) is 5%. It is estimated that 1 in 11 people (9%) living in a setting that has been exposed to conflict in the previous 10 years will have a moderate or severe mental disorder. In conflict-affected settings, depression and anxiety increase with age. Depression is more common in women than in men.
These studies and the systematic review suggest that demographic and socioeconomic factors shaping the environment of displaced groups, for example, internal displacement, potentially influence psychological health significantly. For instance, the coincidence of living in a refugee camp, unresolved conflict issues, unpromising prospects, and financial and material insecurity is frequently associated with reduced psychological health. ,
People with severe mental disorders can be especially vulnerable during and after emergencies, and they need access to basic needs and clinical care. A review from 2014 analyzed health information systems from 90 refugee camps across 15 low- and middle-income countries. It found that 41% of healthcare visits for mental, neurologic, and substance use disorders were for epilepsy/seizures, 23% for psychotic disorders, and 13% for moderate and severe forms of depression, anxiety, or PTSD.
Mental Health and Psychosocial Care
In Northern Iraq, for example, there are currently 28 psychiatrists and 26 licensed psychotherapists who work in three psychiatric institutions or for local nongovernmental organizations (NGOs), for 6 million people. Financial problems frequently represent an obstacle to psychiatric support. For instance, health insurance companies do not cover psychiatric outpatient support. Moreover, organizational difficulties hamper psychiatric support. For example, difficult and precarious conditions in refugee camps and a poor infrastructure in towns and rural areas cause difficulties in providing psychiatric care. Finally, up to now, the work of local psychotherapists and psychotherapists in general is not recognized professionally.
According to the WHO figures (2018), there are 22 international and 8 national NGOs focusing on healthcare work in Iraq at the moment, in addition to the meagre care structures mentioned above. Only nine of these are working in the Dohuk region. NGOs frequently work according to the Mental Health and Psychosocial Support (MHPSS) approach. MHPSS describes all types of support, local or otherwise, geared to protecting or strengthening psychosocial welfare. This includes consultations with trained laypersons and with specialized psychotherapists. In 2018, relief agencies were able to take care of approximately 1.3 million people in need. In this context, merely 10,294 people out of 360,000 IDPs were provided with MHPSS up to now. Insufficient healthcare structure, a low number of professional staff, limited financial resources, and other causes make an adequate professional and nationwide psychotherapeutic treatment system impossible.
Implementation of Programs in the Aftermath ofWar and Terror
Several programs have been designed and implemented, such as the Inter-Agency Standing Committee (IASC) by the heads of a broad range of United Nations (UN) and non-UN humanitarian organizations. The programs have highlighted that mental health with a psychosocial care program is highly relevant.
For example, the IASC incorporates the following into crisis prevention: (1) preexisting social problems (e.g., poverty, discrimination, ethnic and religious conflicts, domestic violence), (2) preexisting distress (e.g., grief, nonpathological distress and distress, substance abuse, psychological disorders), and (3) humanitarian aid (e.g., undermining of community structures or traditional support mechanisms, and lack of information about food distribution or poor management of the information that is provided).
Some studies show that it is not of primary importance to apply psychosocial interventions immediately after disasters. This approach is based on the principles of psychological first aid. ,
It is crucial primarily that people feel safe and that their anxiety decreases immediately after a disaster. This necessitates agents providing information, psychosocial support, and sufficient food, housing, and access to medical care if necessary or wanted, or accompanying those who are affected to a safe place ( Table 13.1 ). The philosophy of psychosocial and mental health interventions can be formulated as follows: based on their proximity, services should provide immediacy of response, expectancy of recovery, and simplicity.
| Intervention | Target Population | Examples of Interventions | Intervention Conducted by | |
|---|---|---|---|---|
| Finding people and protecting them from further threats | Most of the people who are affected | Professionals and any person who can help to protect them | Military Policy Community | |
| Take to a safe place if possible | Most of the people who are affected | Put in a safe place (house, building, tent, etc.) | Police Health staff | |
| First medical emergency aid | Most of the people who are affected | Physical examination, first treatment of injuries | Physician Aid workers | |
| Medical examination | Most of the people who are affected | Physical examination, outpatient or inpatient treatment | Physician | |
| Psychological first aid | Most of the people who are affected | Restoring immediate safety Restoring contact with loved ones | All responders and aid workers | |
| Psychological examination and diagnostics | People with first psychological symptoms, such as acute stress disorder (ASD) | Anxiety, seizures, state of shock, first depressive symptoms, sleep disorder, nightmares, social isolation | Psychiatrist Psychotherapist Clinical psychologist | |
| Psychological examination and diagnostics after one month | People who meet the criteria for posttraumatic stress disorder (PTSD) | Psychological screening and assessment | Long-term psychotherapy | |
| Skills for psychosocial recovery | People whose distress is sustained by bereavement or secondary stressors | Brief assessment of needs, problem-solving, social support | Healthcare practitioners and workers with expertise in the required skills and in conveying these skills effectively | |
| Psychosocial interventions for medium- and long-term problems Outpatient and/or inpatient psychiatric treatment | People whose distress is sustained and associated with functional impairment | Culture-sensitive adapted psychotrauma therapy | Staff of mental healthcare facilities Psychiatrist, Psychotherapists, Clinical Psychologist, Social workers specialized in trauma |
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