Meeting the challenge of substance misuse and deliberate self-harm
Key challenges identified from the literature and the workshop include structural barriers to accessing mental health care include cultural and religious norms, transportation to specialised services, as well as lack of familial support. Such barriers to need to be addressed at a local level through engaging with communities and families to reduce stigma and promote mental health and psychosocial interventions and to facilitate access to mental health care. [2,5] The shortage of mental health professionals across Syria (which existed before the start of the conflict with fewer than 100 psychiatrists per a population of 22 million) were noted barriers to access care. [9] Scaling up and training mental health professionals of all cadres is urgently required given the significant increase in mental health needs among the population, particularly complex needs. Furthermore, a lack of insurance and/or health coverage of psychiatric or mental health services more broadly can exacerbate barriers to care and must be urgently addressed. [25]
During the workshop, examples of good practice and innovations to meet the needs of patients in Syria were explored:
- The use of telepsychiatry and telepsychology interventions
Researchers have established the utility and acceptance of in addressing the mental health needs of Syrians remotely, which can reduce access barriers as well as human resource shortages inside the country. [13, 14] Some limitations to these interventions, however, include lack of or limited technological literacy, poor internet connection, as well as lack of financial resources to sustain these programs.
2. Adoption and adaption of WHO mHGAP (Mental Health Gap Action Programme) interventions
Severe lack of mental health infrastructure to meet growing needs of Syrians should be mitigated by the integration of mental health services in primary care or community-based care settings. [12] Initiatives like these have been spearheaded by WHO in their rollout of mhGAP inside Syria, which has led to at least 30 participants, including psychologists, psychiatrists, and social workers, with training in mhGAP. [41] Within mhGAP, there are comprehensive sessions regarding recognizing and treating symptoms of substance abuse and/or self-harm. Thus, ongoing mhGAP training is recommended. [42]
Workshop discussants concluded that there have been some interventions used internationally with good results, such as mhGAP, that have been and should be utilised more broadly in Syria to address a range of mental health issues including self- harm and suicide. By utilising this programme to train a broader range of healthcare professionals as well as other professionals working in other sectors such as education, it would be possible to screen for and assess the risk of suicide and substance abuse amongst young people at school age who may benefit from treatment the most. Furthermore, there have been some interventions, such as CASP (Contact and Safety Planning) and STARC (Skills-Training of Affect Regulation – A Culture-sensitive Approach) trailed with refugee populations that may also be applicable for patients inside Syria. [43] The WHO has also developed some self-help guides on managing basic mental health conditions available in many languages, including Arabic, that could be provided to patients to support them in their own recovery. However, many of these manuals focus mainly on managing distress than more serious issues such as substance abuse or suicide, including among healthcare workers.[44, 45]
- Multi-year investment and prioritisation of MHPSS programs
Provision of mental health services in Syria is inconsistent and constantly changing; projects are usually short term and donor driven with limited evaluation of impact and cost-effectiveness. In terms of substance abuse, most of the support is focused on acute management of withdrawal, with some larger hospitals providing detoxification services. There are currently no trained health professionals able to provide long term support for people with addictions. The coordination of service delivery and research exploring MHPSS issues over time is limited and requires prioritization and investment from funders.
- Prevention through family skills training
During the roundtable, examples of good practice and innovations to meet the mental health and psychosocial needs of Syrians were noted. For example, the key role that parents or primary caregivers play in protecting children from the stresses of conflict was highlighted. Primary caregivers experiencing high levels of stress are less likely to provide children with the various positive interactions that promote healthy psychosocial and physical development. [46,47] Instead, children are more likely to experience harsh parenting, which increases children’s risk of a variety of enduring emotional and behavioural problems. This global trend of compromised caregiving through conflict has been highlighted too with research on conflict affected families in Syria, as well as contexts hosting Syrian refugees and in countries such as Ukraine.[46-48] Family skills resources and interventions aimed at caregivers in conflict contexts have been found to be effective in encouraging safe and nurturing relationships between parents (or primary caregivers) and children in their early years and, as such, preventing many problem behaviours and mental health challenges, including violence and substance misuse. [46, 48] Such resources have been trialed successfully with Syrian families affected by the current conflict, indicating significant improvements in child and caregiver wellbeing.[48] The development of the United Nations Office on Drugs and Crime (UNODC) multi-level family skills pyramid of open access resources, that includes a range of resources from light touch psychoeducational materials to more specialized forms of trauma-informed interventions, was presented as a means of both screening and provision of appropriate levels of assistance. [47] Furthermore, open-access family skills resources available at every level of this model were shared in English and Arabic. [49]
It is important that all interventions are context specific and culturally adapted and so it may be useful to engage with local community leaders and local religious leaders when implementing psychiatric interventions, especially considering the impact that social stigmatization may have on this specific cohort of patients. These individuals can support in increasing awareness, highlighting issues and signposting to available services or ongoing interventions where appropriate. However, it is also important to consider the limitations in working with religious and community leaders that may have opposing opinions to those being taught and so it is necessary to take a balanced and considerate approach when trying to engage with these individuals. To address the issues of substance abuse and suicide effectively, a systems-based approach that tackles the social determinants of these conditions as well as the management of the cases themselves is essential. [50]
You can add here a reference to the work I did with colleagues:
Almoshmosh N, Jefee-Bahloul H, Abdallah W, Barkil-Oteo A (2020) Use of store-and-forward tele-mental health for displaced Syrians. Intervention Volume 18, Number 1,Page: 66-70