Mental health services in situations of conflict, fragility and violence: What to do?
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© UNHCR/Joel van Houdt
Armed conflict and violence disrupt social support structures and exposes civilian populations to high levels of stress. The 2015 Global Burden of Disease study found a positive association between conflict and depression and anxiety disorders. While most of those exposed to emergencies suffer some form of psychological distress, accumulated evidence shows that 15-20% of crisis-affected populations develop mild-to moderate mental disorders such as depression, anxiety, and post-traumatic stress disorders (PTSD). And, 3-4% develop severe mental disorders, such as psychosis or debilitating depression and anxiety, which affect their ability to function and survive. If not effectively addressed, the long-term mental health and psychosocial well-being of the exposed population may be affected.
In conflict or post-conflict situations like those currently faced in the Middle East, in some African countries, among refugees flowing into European Union countries, or the 7 million internally displaced population after 52 years of conflict in Colombia, one of the priorities is to develop programs to protect and improve people’s mental health and psychosocial well-being. In these situations, much-needed mental health care can be incorporated as part of humanitarian and development responses. Since affected populations are at an increased risk of mental disorders and psychological distress, inaction can severely overwhelm the local capacity to respond, particularly in settings where social networks and roles have been altered, and the health and social services infrastructure was already weak or rendered dysfunctional by crisis situations.
Is there a robust body of evidence to make the case for integrating mental health services in crisis response and addressing common skepticism at national and international levels? The simple answer is yes. Organizations such as the World Health Organization (WHO), the United Nations Refugee Agency (UNHCR), Partners in Health (PIH), International Medical Corps (IMC), Grand Challenges Canada, and the Mental Health Innovations Network have accumulated vast amounts of evidence about what to do in conflict and post-conflict settings. The 2016 Disease Control and Priorities report on Mental, Neurological, and Substance Use Disorders, which draws on the knowledge of institutions and experts from around the world, also provides a “gold standard” assessment and evidence on burden, interventions, policies and platforms, and economic evaluation.
The evidence is clear. Effective scaled-up responses to improve the mental health and psychosocial wellbeing of conflict-affected populations require careful adaptation to specific contexts of multi-layered systems of services and supports (e.g., provision of basic needs and essential services such as food, shelter, water, sanitation, and basic health care; action to strengthen community and family supports; emotional and practical support through individual, family or group interventions; and community-based primary care health systems). This allows a focus on affected individuals as a whole, addressing both their physical and mental health needs, while reducing the risk of stigma and discrimination among families and communities. This is important since mental disorders are highly co-morbid with other priority conditions (e.g., maternal and child health conditions, HIV/AIDS, and non-communicable diseases such as cancer and diabetes).
To inform the design of context-specific interventions in emergency settings, the mapping of the problem is of paramount importance, including assessment of mental health and psychosocial information about the affected population, covering both those with disorders induced by the crisis, and those with preexisting disorders. Such assessments can also clarify what is the current availability of mental health services in affected settings.
As illustrated by PIH experience in countries such as Haiti, Rwanda, Peru, and Liberia, many effective, evidence-based interventions are available and can be grouped into an essential package of interventions along a mental health value chain at community and facility levels, that includes prevention (e.g., community stigma reduction); case finding (e.g., psychological assessment, diagnosis); treatment (e.g., counselling, psychosocial interventions such as cognitive behavioral therapy, and treatment with essential medicines such as antidepressant and antipsychotic medications); follow-up (e.g., monitoring of symptoms); and reintegration (e.g., social and economic interventions). 
Are these interventions cost-effective? A WHO-led study prepared for the WBG/WHO global mental health event at the 2016 WBG/IMF Spring Meetings showed that the estimated cost of treatment interventions at the community level for moderate to severe cases of depression, including basic psychosocial treatment for mild cases and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases, is quite low: the average annual cost during 15 years of scaled-up investment is $.08 per person in low-income countries, $0.34 in lower middle-income countries, $1.12 in upper middle-income countries, and $3.89 in high-income countries. Per person costs for treatment of anxiety disorders are nearly half that of depression. In terms of the economic returns on investment, benefit-to-cost ratios for scaled-up depression treatment across country income groupings were in the range of 2.3 to 2.6. For anxiety disorders, the ratios were slightly higher, with a range 2.7–3.0.
We have to be clear that the provision of mental health and psychosocial support services at the community level cannot be seen only as a vertical or free-standing intervention offered in a health facility. Rather, it needs to be part of broad integrated platforms—population, community and health care—that provide basic services and security, promote community and family support through participatory approaches, and strengthen coping mechanisms not only to improve people’s daily functioning and wellbeing, and protect the most vulnerable (e.g., women and children, adolescents, elderly, and those with severe mental illness) from further adversity, but also to empower the affected people to take charge of their lives as valuable members of society.
If this is done, as Toluwalola Kasali observed, we will be helping the affected people regain “the ability to dream, desire and work for a future, one very different from their present circumstances.”
Related
Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC
WHO. Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013
WHO & UNHCR. Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings. Geneva: WHO, 2012
WHO & UNHCR. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015
WHO, UNICEF, UNFPA, UNHCR, & UN Action. MHPSS for conflict-related sexual violence: 10 myths. WHO: Geneva
Scaling-up treatment of depression and anxiety: a global return on investment analysis. The Lancet Psychiatry, Volume 3, No. 5, p415–424, May 2016
Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians
Partners in Health mental health site
WBG Mental Health website
Mental Health Innovations Network site
Grand Challenges Canada site
Disease Control Priorities. Vol. 3. Mental, Neurological, and Substance Use Disorders
Internally Displaced Persons (IDPs): An Integrated Approach to Rehabilitating IDPs with Dignity. Paper by: Toluwalola Kasali, 12 February, 2016
Thank you for the insightful piece. Do the cost-effectiveness estimates take into account the perhaps increased costs of implementing these interventions in conflict or post-conflict situations?
Providing mental health services to refugees should be an essential component of health and welfare programs. Furthermore research literatures in the US have shown it is cost-effective to provide mental health services to patients with mental health symptoms. There is a cos-offset to medical services ( especially inpatient services ) when mental health services are integrated into healthcare delivery system.
As noted on the blog, on the basis of needs assessments, one would need to adjust and adapt these estimates to emergency contexts. The study done by Chisholm et al (2016)included key categories of resource use: medication: 6 months continual antidepressant drug (generics)for moderate to severe cases; outpatient and primary care: regular visits for all cases, ranging from four per case per year for basic psychosocial treatment, up to 14–18 visits for moderate to severe cases receiving antidepressant drug and intensive psychosocial treatment (half of whom are assumed to receive this on an individual basis, the other half in groups). It was assumed that this care and follow-up would largely be undertaken in non-specialist health care settings by doctors, nurses and psychosocial care providers trained in the identification, assessment, and management of depression and anxiety disorders; and
inpatient care: few cases are expected to be admitted to hospital (2–3% of moderate to severe cases only, for an average length of stay of 14 days). Estimation also included expected level of program costs and shared health system resources needed to deliver interventions as part of integrated model of chronic disease management. These include program management and administration, training and supervision, drug safety monitoring, health promotion and awareness campaigns, and strengthened
logistics and information systems. The latter were estimated as on-cost to the estimated direct healthcare costs. The baseline value for on-cost was 10%
(and therefore grows in absolute terms during scale-up).
Hi,
Thank you for this interesting blog piece (which is very pertinent and timely). For me, some of the takeaways from this piece are: (i) mental health in fragile situations is an important issue and deserves attention (in part because such situations are (unfortunately) becoming more prevalent than not), (ii) mental health can be best addressed through an integrated approach (that goes beyond just a ‘health systems approach’ and involves various actors / sectors), (iii) solutions to deal with mental-health related illnesses need to be context-specific, and (iv) mental-health related investments are cost effective. As I thought through this, I had few thoughts in my mind. First, I think it would be quite important to distinguish between mental illnesses that result directly from the effect of conflict (e.g., PTSD?) and the mental illnesses that result from the conditions created by the conflict (e.g., the lack of shelter, food, water and sanitation, etc.). Second, there is no doubt that the role of community and family would be critical (as is the case even in non-fragile situations) but it would be especially interesting to understand how “stigma” plays out in such situations. Could we expect it to be more or less pronounced?
Thanks for putting the spotlight on a very important development issue. I don't think that we can use any metrics to even try to evaluate the cost effectiveness of these types of interventions since we do not have any meaningful baseline and an effective way of measuring the impact of treating mental disorders. The hidden statistics are likely to be very high. Through the Ebola Recovery and Reconstruction Trust Fund we provided a relatively small grant to support children who lost parents and/or siblings to the EVD through psycho-social interventions. This small intervention has done a lot of good to help ease the trauma suffered by children and we cannot underestimate the development impact of helping children get back to a more normal mental health level. As a development institution, we need to look at all aspects of development and not assume that others will pick up in areas where we normally don't operate. This is such an area that can have a transformational impact. I therefore welcome this article as a first step to discuss how we can increase our engagement with NGOs and other field based development partners that are operating in our fragile client countries and that are delivering interventions to improve mental health. Together we can do so much more. As mentioned, I think that the numbers in the article of people with psycho-social disorders caused by conflict and extreme poverty are likely to be significantly underestimated. We know from the UNHCR, that there are over 60 million displaced people by conflicts and natural disasters and some have been displaced for almost a lifetime. At some point a human will lose hope about the future and develop what could be irreparable mental disorders that puts a halt to development and more likely in reversal with a very negative long term impact on development.
Thanks Patricio for the post and Ivar for this reply. I agree that metrics are harder in this context but I think that we still need to do what we can in that regard; that there are some things we can do even now; and that by pushing the boundary we will be able to extend the boundary and measure impacts even better in the future. I suspect that many mental health interventions will come out quite well in terms of cost-effectiveness, exactly for the reasons that both of you highlight. In some ways the issue may even be larger, since similar types of psycho-social or 'soft skills' or 'noncognitive' interventions focused on hope and aspirations and agency may be quite effective also for individuals who are not suffering from any clinical mental illness but are still adversely affected by conflict and fragility.
While my work with Internally Displaced Persons has been very rewarding, it has also been very heart breaking to listen to their stories.
These are people just like you and me who have watched parents, children and siblings killed right before their very eyes; they have anxieties because of the horrors they have experienced, they find it difficult to have a good night’s sleep, they wake up with nightmares and fear for their lives. They have vivid memories of what has happened and the trauma is real.
The greatest injustice that can be done would be to reintegrate them into the society after their traumatic experiences without appropriate assessment and care; mentally, physically and socially. We must also take special care of the most vulnerable; the children, the women, the pregnant, and the elderly.
While this is the case, inside most stories, you find a glimmer of hope that all is not lost. They have been through terrifying experiences but remain unbroken; they are resilient and hopeful for the future that is ahead. That future however, is one we are all responsible for ensuring does not elude them.
I will share with you the story of Umar. He is displaced and orphaned however, Umar still has dreams that he holds very dearly; he wants to be the president of Nigeria someday.
His dreams are no less valid than my own dreams. Umar should have a chance of growing up to be whoever he wants to be. Professional counselling and mental health services will be essential in achieving this objective. Essentially, psychosocial support is important in helping to fill the gap between where Umar is today and where he can be tomorrow.
That reality also lies in our ability to get things right and the time to get it right is now. The best time to plan for the future is today.
We need to rehabilitate them mentally, physically, socially and economically. They need to be rehabilitated with dignity!!!
These are real lives and real people. It is also important that we get professional help; you cannot understand what you have never experienced or do not have the professional capacity to deal with.