As the humanitarian situation inside Syria continues to worsen, mental health needs among refugees fleeing to Iraq are steadily increasing, said Médecins Sans Frontières (MSF) ahead of World Mental Health Day on 10 October. In northern Iraq in Domeez refugee camp, MSF’s counsellors and psychologists are seeing growing numbers of patients presenting with far more acute symptoms than a year ago, when the mental health services began.

In 2012, around seven per cent 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 per cent. 

“The psychological situation in Domeez camp is an emergency in itself,” says Ana Maria Tijerino, mental health advisor for MSF. “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 among refugees to incorporate a mental health programme. Since July 2012, a team of trained psychologists and counsellors has been providing individual, family and group sessions. The mental health team works alongside the medical staff who help to detect the patients in need, and 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 2,620 consultations. 

“The need for mental healthcare 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, 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 wellbeing. It has become a desperate situation.”

Caring for patients with severe mental health disorders

With the increasing numbers of patients with severe mental disorders such as schizophrenia or depression, MSF has adapted its approach.  Some patients will seek care at the clinic, however in many cases, stigma around such disorders is a huge barrier to asking for psychological help. For these patients, MSF psychologists are conducting home visits, ensuring contact both with the individual and the family. 

Currently, MSF will refer these patients to a nearby hospital when necessary.  However, MSF is also working with the Department of Health to expand psychiatric care within the clinic itself.  This will reduce the need in future for referral outside of the camp, and ensure the patient is treated and more closely monitored nearer to their home and family.

Healing children’s wounds

The war and its aftermath have had far reaching consequences for the mental health of children. Currently in Domeez, children and adolescents comprise 50 per cent of all MSF’s new patients. Every week, between 15 and 20 children and adolescents aged 18 and under are admitted to the programme.

One of the most common symptoms seen in children of all ages is bedwetting, a reaction to anxiety and intense feelings of fear. Other symptoms children display include aggressive behaviour and isolating themselves from families and friends. To address these symptoms, the sessions 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.

Single men – another vulnerable group

In Domeez, a specific area in the camp has been allocated only for single men – those who arrive without family or wives. Living five or six to a tent and without the support of a family, their ability to cope has been greatly reduced. As the stigma associated among this group to seek mental health assistance at the clinic is higher, a male MSF counsellor goes directly to the tents and provides sessions there.

“Everyone here has a story,” says Nihad, 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. 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

Through its programme in Domeez, MSF is aiming to help refugees regain some sense of control over their psychological wellbeing. “We aim to help give them back some of their strength,” says 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.”

Interview with MSF psychologist in Iraq's Domeez camp

A patient's story - "It is difficult to have hope for the future"