Australian protesters demanding better treatment for refugees held in conditions that undermine mental health. Photograph: Anadolu Agency/Getty Images
When it comes to mental health, the global health community has failed.
Mental, neurological, and substance-use disorders are among the leading causes of the global burden of disease. By 2020, depression will be the second leading cause of disability. Suicide is a leading cause of death among adolescents. People with severe mental disorders die decades earlier than others in their community and face grievous forms of discrimination and abuse.
Our failure in the global health community is that we have left large proportions of those affected, up to 90% in some low-income countries, without access to even basic mental health care from which they can greatly benefit. Most governments spend less than 1% of their health budget on mental health, a figure also reflected in international development assistance for health. The consequences are grave, not only for the mental health of the individuals affected, but also for their physical health and the wellbeing of families and society at large.
This unmet need for mental health services is greatest among populations affected by conflict and displacement. Our world is currently in the midst of the worst humanitarian crisis since the second world war. But the violence does not end even when people flee the conflict zones. In refugee camps in Greece last month, we saw hundreds of Syrian children too afraid to leave their tents to play, frail elders on a hunger strike to protest abominable living conditions, and suicides that could have been prevented. Similar conditions can be found in refugee camps set up by the Australian government in small Pacific island nations. Millions who have faced some of the worst imaginable adversities and atrocities are exposed to further adversities, including denial of freedom and hope – conditions that undermine mental health among even the most resilient.
Facing an acute shortage of funding and resources, we must act creatively to ensure better mental health outcomes. The most important first step is ensuring that refugees are getting sufficient access to basics such as food. Actively working to normalise the appalling situations experienced by these populations – for example, by ensuring schooling for children and enabling work for adults – is a good strategy to promoting mental health.
But we can also look at some more creative approaches. Turning to community-based, non-professional providers to deliver psychosocial interventions can address the acute shortages of mental health professionals. This has been effective in low-resource settings such as Uganda, Pakistan, and India and recently proven more cost-effective than standard treatment.
Through short skills-focused trainings, simplifying complex treatments, peer supervision, and using models of illness which are consistent with the experiences of refugees, we can empower lay people in refugee communities to provide frontline psychosocial interventions. Those specialists who are available can design and oversee mental health programmes, as well as train, supervise, and support refugees in using evidence-based techniques to promote resilience and alleviate mental health distress in their own communities. This not only enables greater access to mental health services but, importantly, calls for the harnessing of personal and community resources, thereby giving refugees a sense of empowerment at a time of severe disempowerment.
Ultimately, however, there needs to be a structural revision in how those fleeing violence and conflict are welcomed and integrated in safe countries. The cost of doing nothing is immense. Untreated, the impact of conflict on mental health can endure for years, and over generations, at great cost to society. With more than 60 million people displaced by war, conflict, or persecution, now is the time for the global health community to wake up and realise what’s at stake if we keep ignoring mental health.
Laila Soudi is a researcher at Stanford University School of Medicine and director of mental health at the Syrian American Medical Society. Vikram Patel is Wellcome Trust principal research fellow at the London School of Hygiene and Tropical Medicine and co-founder of Sangath.