Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
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Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
Mental health of refugees and
displaced persons in Syria and
surrounding countries: a systematic
review
Constanze Quosh, Liyam Eloul & Rawan Ajlani
Over the past two years, Syria went from being the an ongoing refugee crisis that began in
third largest refugee hosting country in the world to 2006, as a consequence of the Iraqi war.
the largest refugee producing country. This article The war triggered complex emergencies in
provides the ¢ndings ofa systematic literature review countries throughout the region as a massive
on the mental health and psychosocial support in£ux of refugees spilled across its borders.
context, and the mental health pro¢le of refugees Prior to the eruption of the armed con£ict
(primarily Iraqi) and civilians in Syria. This in Syria, the government had implemented
review covers two periods: the complex refugee a generous policy towards the stay of
emergency that started in 2006 as a result of war refugees. However, the escalating arrival of
in Iraq, and the current internal displacement and Iraqi refugees in 2006 put an immense
acute complex emergency starting in 2011. The strain on the already under resourced
systematic review of the published and grey literature mental health sector (Quosh, 2011). With a
on the mental health pro¢les of Iraqi and Syrian population of fewer than 22 million (World
refugees and those Syrians who have been internally Factbook, 2010), according to government
displaced includes complementing analyses of the estimates in 2010, the Syrian Arab
needs and resources of di¡erent a¡ected populations, Republic hosted 750,000 Iraqi refugees,
using assessment results from Syria and surrounding nearly half a million Palestinians and several
refugee hosting countries. The problematic lack thousand refugees from Somalia, Sudan
of recent literature is noted, and the need for more and Afghanistan.
rigorous assessments, applied research and accessible Over a short period of time, Syria went from
grey literature identi¢ed. the third largest refugee hosting country,
primarily for Iraqi refugees (United
Keywords: internally displaced, Iraq, Nations High Commissioner for Refugees
Jordan, Lebanon, mental health and psycho- (UNHCR), 2012a), to the largest refugee
social support programming, refugee, Syria, producingcountry, with morethan1.9 million
systematic review,Turkey Syrians escaping its borders in less than
two years. It is further estimated that in 2013,
more than 4.25 million Syrians were inter-
Introduction nally displaced (O⁄ce for the Coordination
Syria is currently in the midst of a crisis level of Humanitarian A¡airs (OCHA), 2013d,
complex emergency, which started in 2011. Map 1 and 2). A United Nations (UN)
This situation is further compounded by and Government of Syria joint assessment
276
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
mission, in March 2012, highlighted mental Background
health and psychosocial support (MHPSS) Refugees in Syria: ¢rst crisis
as one of the most urgent concerns resulting Refugees in Syria have experienced
from the crisis. Foundations for MHPSS quickly diminishing resources and the
programming include understanding the deterioration of economic and living
mental health pro¢le of concerned popu- conditions.This is largely due to the fact that
lations, mental health systems and contexts. refugees do not have the right to work
This article describes the mental health legally in Syria, compounded by the recent
pro¢le of Iraqi refugees and Syrians during general breakdown of the economy and
both of the above mentioned periods, security. The overwhelming majority of the
within the context of a coordinated response recent refugees arriving in Syria (91%)
initiative for MHPSS programming in were from Iraq,62.2% of those sought refuge
Syria. It is complemented by an analysis in Syria six or more years ago, primarily in
of the shifting MHPSS resources and infra- urban settings. Most refugees expected to
structure available to a¡ected populations stay temporarily, but only 34,323 individuals
in Syria (Qoush, this issue), and inter-agency were resettled to a third country between
collaboration in Eloul et al. (this issue). 2007 and mid-2013 (UNHCR, 2013a).
There is general evidence that exposure This has led to a general lack of prospects
to continuous, distressing and potentially and loss of hope among those remaining,
traumatic events, depletion of resources, who are also increasingly at risk. Further-
forced displacement and lack of security more, 37.7% in 2012, and 43.1% in 2013,
can all negatively impact mental health have been identi¢ed as highly vulner-
and increase risk of maladaptation. There able with speci¢c needs1. Out of 95,000
is, however, a lack of research regarding registered refugees in 2012, 35.1% of the
the impact of prolonged uncertainty and families were female-headed households.
the instability of protracted displacement In addition, more than 20,000 individuals
settings, as well as of renewed violence were identi¢ed with a critical medical
and insecurity, on the mental health and condition; more than 9,000 are survivors of
resilience of refugees and internally dis- torture or extreme violence, and more than
placed persons (IDPs) in Syria. That said, 6,000 are women at risk (UNHCR, 2012a,
increasingly regular assessments, supple- 2013a).
mented by research conducted in the The frequency and severity of protec-
region, have given indications of mental tion incidents a¡ecting refugees in Syria
health outcomes and directions for program- has risen sharply since 2012, including
ming. A systematic review of available harassment, kidnappings and killings
published and grey literature (see below for (UNHCR, 2013a). Although by 2012, the
full discussion) was conducted to provide number of refugees registered with the
an overview to inform MHPSS program- UN Refugee Agency (UNHCR) was also
ming and coordination in Syria, and declining, as many have £ed the rising
neighbouring, refugee hosting countries. con£ict. At the beginning of 2013, there
Both populations are of focus due to the shift were still more than 71,000 registered
of MHPSS programming in the region, from refugees in Syria (51% female, 49% male),
protracted humanitarian and development which has since declined to 50,000 by July
aid to complex emergency e¡orts. 2013 (Figure 1).
277
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
Iraqi population registered with UNHCR since end of 2007
250 000
225 000
200 000
175 000
150 000
125 000
100 000
75 000
50 000
25 000
0
End of 2007 End of 2008 End of 2009 End of 2010 End of 2011 End of 2012 End of May
2013
Figure 1: UNHCR Syria registered refugees (source: UNHCR, 2013b).
Internally displaced Syrians, Syrian refugees and infrastructure (especially health care infra-
a¡ected populations due to the current con£ict: structure, including the lack of essential
second crisis medications and supplies). Also, com-
By mid-2013, the UN estimated that nearly pounding this emergency, ‘the con£ict has
one in three Syrians required assistance. deepened social, political and sectarian fault
More than 4.25 million Syrians are inter- lines, a¡ecting the delicate fabric of Syrian
nally displaced. Delivering aid is di⁄cult society’ (OCHA, 2013b, 4). Importantly,
in some areas due to limited access, and OCHA has reported that ‘the a¡ected popu-
an underfunded humanitarian operation. lations have exhausted their resources and coping
Many thousands have been killed and mechanisms [. . .]. Traditional community sup-
injured since the ¢ghting erupted in March port mechanisms are failing due to displacement
2011. and distrust. This has had a signi¢cant impact
Di¡erent phases and varying displace- on the psychological wellbeing of the population
ment patterns can be observed associated and may lead to increased protection risks’
with intensity and locality of con£ict. (OCHA, 2013b, 13).
Many people were displaced several times Iraqi refugees from the ¢rst crisis settled
before deciding to leave the country. By mainly in urban settings and Syrians
July 2013, more than 1.9 million Syrians a¡ected by the current con£ict are over-
had crossed borders into neighbouring whelmingly displaced, and re-displaced,
countries. The situation is compounded into urban centres (such as Aleppo, Homs
by an economic crisis, rises in criminality and Damascus). As a result, both crises
and vulnerability, as well as limited access have an urban displacement population
to clean water, food and health care. pro¢le, which has implications for service
Additionally, there is a breakdown of basic delivery.
278
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
Map 1: Map of Syrian governorates with IDPs and people in need (source: OCHA,
2013a)
Map 2: Map of Syrian governorates and people in need, movements and refugees
(source: OCHA, 2013d)
279
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
Methodology the inclusion criteria, for the respective
Systematic literature review reviews are summarised in Appendixes 1
A systematic review of published and grey and 2 to this article, which may be found at
literature was undertaken by the UNHCR the website, http://links.lww.com/INT/A4.
MHPSS programme in Syria during its As the number of identi¢ed published
initiation phase and in preparation of the studies was very low for Iraqi refugees in
¢rst Consolidated Appeal Process for Syria, the scope was expanded to Iraqi
Iraqi refugees2, launched in December refugees in the region. The overall number
2008. Literature was reviewed for articles of published studies in the region was low
and reports annually, during the pre- as well; therefore the review also included
paration periods of inter-agency appeals grey literature. Grey literature comprises a
and regional response plans, between 2010 diversity of document types produced by
and 2012. agencies, academics, and governments,
With the changing situation, and the ‘where publishing is not the primary activity of the
Syrian Humanitarian Assistance Response producing body’ (Scho«pfel, 2010). Figures 2
Plan (SHARP) launched by the govern- and 3 detail the di¡erent stages and the
ment of Syria in collaboration with UN selection processes of the studies. Literature,
agencies in 2012, a recent systematic in both English and Arabic languages,
literature review was undertaken that also was included.
included Syrian IDPs and refugees in the These searches identi¢ed a total number
region. of 5203 and 2112 articles for the Iraqi
The aim of a continued systematic review refugee and the Syrian refugee populations,
of literature was to ensure that UNHCR respectively. Without duplicates, this com-
and inter-agency programming, assessments prised a published literature of 4725 and
and coordination are evidence and good 1992 articles. The ¢rst author reviewed all
practice informed, particularly in terms of abstracts with regard to relevance; 30 articles
the mental health status and pro¢le of the on Iraqi refugees were identi¢ed for full
concerned population. text review, however, no article ful¢lled
The theoretical foundation for this review inclusion criteria for the Syrian populations.
is framed by the bio-psycho-social-spiritual The detailed full text review of these articles
approach and the psychosocial frame- led to 16 on Iraqis con¢rmed as meeting
work re£ected in the Inter-Agency Standing the inclusion criteria. Due to the lack of
Committee Guidelines on Mental Health and published studies on the mental health
Psychosocial Support in Emergencies (Inter- of Syrian IDPs and refugees, additional
Agency Standing Committee, 2007). studies were identi¢ed that provide infor-
For published literature, standard biblio- mation on the mental health status of
graphic sources were systematically the population before the crisis. Out of
searched, including PsycINFO, PubMed the 15 that were included from the database
and Medline, using di¡erent combinations search for full text review, seven were
of search terms synonymous to mental selected.
health, Iraqi and Syrian refugees and Grey literature was identi¢ed by contac-
geographic locations, such as Syria and ting humanitarian networks and MHPSS
neighbouring countries. The search termi- coordination groups in the region, and
nology used to identify studies, as well as through searching the internet platform
280
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
Iraqi refugees - systematic review
Indentification
5203 studies identified >100 documents identified through coordination
through database keyword search groups, NGOs, MHPSS platforms
Screening
478 duplicates 4725 studies selected for 67 documents selected for
excluded abstract review abstract review
Eligibility
4697 studies 30 studies selected for 39 documents 28 documents
excluded on basis of full text review on basis selected for full excluded on basis of
abstract review of abstract review text review abstract review
Studies and documents included on
Included
14 Studies excluded 19 documents
basis of full text review
on basis of full text excluded on basis of
4 studies 15 documents in Syria
review full text review
12 studies 5 documents regionally
Figure 2: Iraqi refugees: overview systematic review process ^ selected studies and papers.
Syrian IDPs and refugees - systematic review
Indentification
2112 studies identified >50 documents identified through coordination
through database key word search groups, NGOs, MHPSS platforms
Screening
120 duplicates 1992 studies selected for 40 documents selected for
excluded abstract review abstract review
Eligibility
0 studies selected
1992 studies 15 documents 29 documents
for full text review
excluded on basis selected for full excluded on basis of
on basis of
of abstract review text review abstract review
abstract review
15 studies included for
of full text review for
Documents included on 2 documents
Included
context Information
basis of full text review excluded on
7 studies 5 documents in Syria basis of full text
8 studies
additionally 8 documents regionally review
excluded
included
Figure 3: Syrian IDPs and refugees: overview systematic review process ^ selected studies and papers.
281
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
MHPSS.net. More than 100 documents Jordan (seven out of 16 published studies).
were identi¢ed and reviewed for Iraqi In contrast, among the 20 identi¢ed grey
studies, and more than 50 for Syrian studies, literature assessments, 15 were conducted in
according to the criteria. Syria and ¢ve in the region. Comparatively,
Twenty assessments on Iraqis and 13 on many health assessments were conducted,
Syrians were con¢rmed for inclusion in however, most did not include an assessment
the review. In addition to this, all PhD and of mental health, or if mental health was
master theses from the Faculty of Psycho- included, it was not appropriately de¢ned
logy and Education at the University of and measured.
Damascus were reviewed for the speci¢ed
time period. Out of 284 studies, one was Research design
related to Iraqi refugees in Syria (Al The majority of the published studies
Ammar, 2009/2010). Due to the lack of were based on quantitative research, while
grey literature on the mental health of the majority of the grey literature used
Syrian IDPs, additional grey literature was qualitative methods. Many refer to the
identi¢ed that provides information on di⁄culties in accessing communities in an
the mental health status of the population urban displacement setting. The quality
before the crisis. Out of 10, from the full and diversity of the research does not
text review, only one was selected (sum- warrant further quantitative analysis.
maries can be found in Table 2 of the
Appendix, published online, http://links. Results: mental health of Iraqi refugees
lww.com/INT/A4). The ¢ndings are summarised in relation to
Ultimately,16 articles (and seven additional what is of interest to MHPSS programming
articles) were identi¢ed through formal for the populations of concern. The full
bibliographic searches and 33 (and one summary of all studies can be found in
additional assessment) through grey litera- Table 1 of the Appendix, online, http://links.
ture identi¢cation, which provided a total lww.com/INT/A4.
of 49 (and 8 additional) articles and assess- Across di¡erent assessments, the majority
ments of published and grey literature of refugee and host communities were
included in this review. The lack of available indicated to be very resourceful, with
literature on Syrians can be attributed to comparatively high levels of education
the recent nature of the crisis, however and diverse professional backgrounds.
there is a lack of mental health studies in There was a willingness to support each
Syria, in general. other, but this was often contained
within the family environment as lack of
Findings: systematic review trust and a restrictive external environment
Iraqi refugees prevented social organisation.The majority
Geographic location and population of studies perceived religious beliefs and practices
The research on mental health and Iraqi (Jayawickrama & Gilbert, 2008), as well
refugees is very limited. Of the published as caring for younger family members,
articles identi¢ed, only four studied Iraqi to be their main sources of support and
refugees in Syria, and 12 in the region, meaning.
with the majority of the research with Very similar data were reported in studies
Iraqi refugees in the region undertaken in with Iraqi doctors in Jordan (Doocy, Malik
282
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
According to a survey based on WHO survey conducted in 2010 in Syria
the Harvard Trauma Questionnaire reported sadness (60%), desperation, loneli-
(HTQ) conducted in Syria in 2007 ness and anxiety (50%), sleeping di⁄culties
(Centers for Disease Control and Pre- (50%), a sense that everything requires
vention/UNHCR 2007): more e¡ort than usual (50%) (WHO, 2010).
While some studies did not identify gender
80% of Iraqi refugees participating nor age di¡erences, others reported that
said they had witnessed a shooting Iraqi women have higher rates of a¡ective
77% stated being a¡ected by air disorders than men (Community Develop-
bombardments and shelling, or ment Center/UNHCR, 2007; Doocy et al.,
rocket attacks 2013), while middle-aged and older men
75% reported that someone close trend towards higher rates of anxiety dis-
to them had been killed or murdered orders and posttraumatic stress disorder
72% reported being witnesses to a (PTSD). In addition, exacerbation of epi-
car bombing leptic and non-epileptic seizures, substance
68% reported interrogation or abuse, increased body pains and somatisa-
harassment (with threats to life) tion were reported.
22% said they had been beaten by Reports on Iraqi refugees in the region
armed groups con¢rmed a high sense of isolation, lack of
social support, loss of networks and safe
Other reports indicate a high incidence spaces, family con£icts, and lack of future
of kidnappingandgenderbasedviolence. opportunities, as well as their e¡ect on men-
tal health (Le Roch et al., 2010; El-Shaarawi,
2012; Community Development Centre /
& Burnham, 2010) and Iraqi refugees in UNHCR, 2007; Al Obaidi & Atallah,
Egypt (Al Obaida, 2009). 2009).
Di⁄culties in adjusting to the forced dis- Studies have also documented de-profession-
placement situation are often linked to alisation and the feeling of being ‘not useful
unmet basic needs, and the lack of livelihood in society’, particularly among men and
opportunities. Doocy et al. (2011) assessed adolescents (International Organization
food security and living conditions of for Migration (IOM), 2008). In some
Iraq refugees in Jordan and Syria, and extreme cases, desperation in adults led to
demonstrated dire ¢nancial needs and self-harm or harming others, notably in the
limited availability of assistance. form of suicide attempts, survival sex and
In quantitative surveys, symptoms of heigh- child abuse. Importantly, fundamental
tened anxiety and depressed mood were role shifts due to the inaccessibility of
often found, ranging from 42% among work and socio-economic di⁄culties often
samples of Iraqi refugees in Jordan to above resulted in domestic and sexual violence
80% in Syria (Center for Disease Control / (Jayawickrama & Gilbert, 2008; Le Roch,
UNHCR, 2007). In a secondary analysis of et al., 2010; CDC/UNHCR 2007; SARC/
two assessments in Syria and Jordan, 44% DRC, 2007; Refugee International, 2009;
of the adult respondents in Syria reported Chynoweth, 2008). Moreover, psychological
depressed mood, compared to 17% in stress and desperation intensi¢ed as the
Jordan (Cope, 2011). Respondents to a length of stay increased (Bader et al., 2009;
283
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
LeRoch et al., 2010). This oppressive and to already fragile social networks, mental
unstable climate often also made it imposs- health care services and other assistance.
ible for many displaced Iraqis to address According to mental health professionals
and process traumatic experiences that in Syria, many refugees have presented
occurred prior to, during and after their renewed, multiple and complex vulner-
£ight, potentially exacerbating symptoms. abilities with increased existing high levels
Parents were concerned about education of anxiety, fear, hopelessness and depression,
for their children (some studies reported increased relapse among clients, and
high school drop-out rates, e.g. Centers regression to maladaptive coping mech-
for Disease Control / UNHCR, 2007), anisms (e.g., increased suicide attempts,
peer relationships and aggression among domestic violence). Many have considered
children, unstable family situations, stunted the di⁄cult option of returning to an
development, and child abuse. Parents also unstable and insecure Iraq. In a UNHCR
reported increased attachment, aggressive- study conducted in February 2012, an over-
ness (among boys), withdrawal (among girls), whelming 75% of respondents stated that
developmental problems, learning di⁄culties, the current deteriorating situation has had
and enuresis among children (Le Roch, a negative impact on their psychosocial
et al., 2010; Tsovili, Coutts & Quosh, 2010). and physical wellbeing (UNHCR, 2012b).
Refugees attributed their psychological Unfortunately, no further studies or assess-
problems to past (potentially traumatic) ments are available on Iraqi refugees in
experiences, as well as present distress and Syria since the beginning of the recent crisis,
adjustment di⁄culties (Salem-Pickartz, which prompted a shift of focus.
2009).‘Current perceived needs wasfound to mediate
the association between past traumatic exposure Findings: systematic review
and distress in Jordan’ (Jordans et al., 2012). Syrian IDPs and refugees
The current situation appeared to be exacer- Geographic location and population of studies
bating pre-existing mental health problems. Out of the 13 grey literature assessments
According to the preliminary analysis of a identi¢ed for Syrian IDPs and refugees, ¢ve
UNHCR assessment on psychosocial well- studied Syrian IDPs and eight studied
being, distress and functioning, the overall Syrian refugees in the region. A few additional
psychosocial wellbeing of the refugee popu- articles, as well as grey literature pre-2011,
lation has been consistently low, and the were included in the mental health pro¢le of
overall concept for psychosocial wellbeing Syrians in the Appendix online, in order to
is understood as a multi-faceted idea of provide additional contextual information,
fatigue (Quosh, 2013). http://links.lww.com/INT/A4.
Since mid-2011, the dynamics of the context
have changed signi¢cantly, which has had Research design
dramatic e¡ects on the wellbeing of refugees, Five of the assessments were based on
as well as the host community. Refugees have quantitative methods and eight on qualita-
been especially susceptible to the deteriorat- tive methods. Many refer to the di⁄culties
ing situation in Syria. Essential needs of conducting assessments inside Syria due
have become more acute. Many refugees to the prevailing insecurity. The quality
have been displaced from their Syrian and limited number of assessments do not
neighbourhoods, thus limiting their access warrant further quantitative analysis. There
284
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
has not been any comprehensive assessment fatigue, fear and loss of control, as well as
of the mental health of Syrian IDPs and family separation due to displacement and
a¡ected populations since the beginning shifts in gender roles. Across the di¡erent
of the crisis. Some small scale assessments assessments, heightened levels of distress,
provide snapshots of the current situation anxiety, fear, frustration, grief, fatigue, and
and indicate priority areas. depressed mood were found as well. The
review of available studies and assessments
Results: mental health of Syrian IDPs also highlighted isolation and lack of social
These ¢ndings are summarised in relation support. None of the assessments speci¢ed
to what is of interest to MHPSS program- or quanti¢ed ‘high levels’. An assessment in
ming for the populations of concern. The the northern governorates of Syria also
full summary of all studies can be found in reported that communal tensions were attri-
Table 2 of the Appendix online, http://links. buted to assistance being insu⁄cient to meet
lww.com/INT/A4. the needs of all those a¡ected (Assessment
Across the di¡erent assessments, it was Working Group for Northern Syria, 2013,70).
reported that the majority of the displaced Parents reported that their children are
and a¡ected host communities were mobilis- fearful and show ‘signs of signi¢cant emotional
ing resources, such as community networks distress, such as nightmares, bed-wetting, or
and support. Many referred to religious becoming uncharacteristically aggressive or with-
beliefs and practices as a primary source of drawn; any loud noise reminds the children of the
support (UNHCR/SARC, 2013). violence they £ed from. Children with disabilities,
According to a stakeholder assessment chronic diseases or from single parent families are
in 2012 (MHPSS Working Group, 2012), particularly vulnerable and do not have equal access
60% of the respondents indicated a lack of to services. [. . .] Some children are exposed to
basic needs impacting mental health and maltreatment and neglect from parents who them-
wellbeing. This lack of basic needs was con- selves are showing high levels of distress and
¢rmed during a second stakeholder assess- are unable to cope with their own di⁄culties’
ment at the beginning of 2013 (UNHCR/ (Assessment Working Group for Northern
SARC, 2013), with increased severity. The Syria, 2013, 70).
lack of security, sudden forced displacement, Mothers were concerned about interrup-
destroyed homes and lack of shelter, or tions in education for their children and
overcrowding in collective shelters, lack of the e¡ects of not having basic needs met.
access to schools, health care and other High school dropout rates were reported
services, high unemployment and poverty (UNICEF, 2013; Assessment Working Group
were all reported to be priority concerns. for Northern Syria, 2013, 75). Serious child
Stakeholders covered the areas of protection concerns for tens of thousands
Damascus, rural Damascus, Homs and of children have been reported, including:
Aleppo, but could not provide information killing and maiming; sexual violence;
on other governorates. torture; arbitrary detention; recruitment
Similar to the ¢ndings among Iraqi and use of children by armed forces; and
refugees in Syria between 2008 and 2011, exposure to explosive remnants of war
focus groups in 2012 conducted by UNHCR (Assessment Working Group for Northern
with internally displaced Syrians in areas Syria, 2013, 68; UNICEF, 2013, 9). An
around Damascus, con¢rmed high levels of increased number of early marriages and
285
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
child labour was also reported (UNHCR/ camp in August 2012 (IMC/UNICEF, 2012)
SARC,2013). A remote assessment found that highlighted increased levels of fear, worry,
children’s exposure to extreme violence is grief, boredom and psychological distress
causing serious psychological distress and (45% felt intense fear all or most of the time).
impacting school performance (UNICEF, The most frequently cited coping methods
2013). were praying, smoking and socialising
It is di⁄cult to assess the scope of sexual with friends and family. Particularly, with
violence in Syria, but reports point to lack of durable solutions and livelihoods,
alarmingly high rates, including in combi- the level of frustration, anger and aggression
nation with physical violence and torture, is increasing (Rudoren, 2013).
and a signi¢cant portion of the reported WHO, in collaboration with the Jordanian
incidences involving men and boys as Ministry of Health, IMC and Eastern
targets. Although there remains a lack of Mediterranean Public Health Network
sexual and gender based violence (SGBV) (EMPHNET) is planning to conduct a
assessments, according to INGO reports mental health needs assessment in Amman,
stigmatisation of this subject, shame and Irbid, Ramtha, Mafraq and the Zaatari
distrust led to massive under reporting camp (Inter-Agency Standing Committee
(Assistance Coordination Unit (ACU), Mental Health And Psychosocial Support
2013; International Rescue Committee Reference Group (IASC MHPSS RG),
(IRC), 2012; Assessment Working Group for 2013). Results were not available at the time
Northern Syria, 2013). of this literature review.
Results: mental health of Syrian refugees regionally Lebanon
As there is not su⁄cient literature yet A similar assessment by IMC, at the
covering the mental health of IDPs in Syria, northern Syrian/Lebanese border showed
assessments that have been conducted comparable results to the one in Jordan
with Syrian refugees in the region are also (IMC, 2011). The participants reported
analysed in this paper. It is noted that the anxiety, feeling depressed, lethargy, eating
experience of displaced people who leave and sleeping problems, anger and fatigue.
their country of origin di¡ers from that of In particular anger, fear, anxiety, feeling
those who remain, and that the length of depressed and stress a¡ected relationships
time since displacement has an impact on within families, daily functioning and
adjustment and stressors. All of these factors health. Mothers described changes in the
will a¡ect results in data collection, how- behaviours of their children, and expressed
ever, the parallel needs are signi¢cant and, di⁄culties in handling them, as well as
given the lack of information on IDPs, an inability to show a¡ection. Positive
worth evaluating. coping mechanisms included going out,
exercising, and playing with one’s children.
Jordan Negative coping mechanisms were primarily
A rapid MHPSS assessment with Syrians in smoking, watching TVand doing nothing.
Jordanian host communities in February An assessment in the Bekaa Valley (Pe¤rez-
2012 (International Medical Corps (IMC)/ Sales, 2013), showed similar overwhelming
Jordan Health Aid Society (JHAS), 2012) emotional responses for most respon-
and with Syrian refugees in Za’atari refugee dents, and reported that wellbeing is greatly
286
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
attributed to ful¢lling basic needs such and adaptation. Three out of four Syrian
as su⁄cient income, shelter and food. children have lost a loved one in the ¢ghting,
Similar priority concerns were reported more than 60% experienced events where
in di¡erent locations (Me¤decins Sans they felt their lives were in danger, and
Frontie'res (MSF), 2012). According to Pe¤rez- 50% had been exposed to six or more
Sales (2013), feelings of humiliation, linked traumatic events. However, 71% of the
to the frustration with dependency on girls and 61% of the boys also had strong
aid, were prevalent. While other studies close relationships to trusted persons for
indirectly present links between unmet help and support. At the same time, 30%
needs, dignity, humiliation and also sexual reported that they had been separated
violence (Doocy et al., 2011; Chynoweth, from their families. Also, around 60%
2008), the Pe¤rez-Sales assessment (2013) is of the children reported symptoms of
the only identi¢ed assessment that clearly depression (signi¢cantly higher among
links unmet basic needs with feelings of girls), 45% reported symptoms of PTSD,
humiliation and impacting dignity. 22% aggression and 65% psychosomatic
Negative emotions seemed to increase symptoms to a degree that seriously reduced
over time. Among the refugee community the children’s level of functioning (O«zer
a lack of unity, community organisation, et al., 2013, 36). Similar prevalence rates:
support, trust and con¢dence was reported, 61% PTSD; 53% anxiety; and 54% depres-
as well as increased frustration and anger. sion, were reported from a study with
SGBV, as well as experiencing torture, Syrian refugees in four camps at the
were reported among both men and women. southern Turkish border (Marwa, 2012,
Praying was described as the main coping 2013). The nongovernmental organisation
strategy (Pe¤rez-Sales, 2013). (NGO) Malteser International, planned
According to a study by Mobayad in camps to conduct a mental health assessment in
(referred to in Abou-Saleh & Mobayad, Turkey during the second half of 2013 (IASC
2013) prevalence rates of PTSD were MHPSS RG, 2013).
identi¢ed, from 36% to 62%, among adult
refugees. The main predictors for PTSD Limitations
among adults were exposure to ¢ghting Major weaknesses in the design and robust-
and hostility, as well as a history of trauma ness of studies constrain the analysis of the
before the con£ict. Prevalence rates of PTSD review. Some of the main weaknesses are:
were reported, from 41% to 76%, among
children. The main predictors for children Most research focuses on global
were the number of traumatic experiences categories of mental health problems,
related to the con£ict. An increasing disorder symptoms (particularly of
number of arranged early marriages and mood and anxiety disorders), and psy-
survival sex is reported in Jordan, as well as chosocial distress from a vulnerability
Lebanon (McLeod, 2013; IRC, 2012). perspective.
There is less attention to resources,
Turkey resilience and coping perspectives that
According to the Bahcesehir Study (2013), are an important part of understand-
Syrian children in Islahiye camp in southern ing the mental health pro¢le of the
Turkey display di¡erent levels of functioning community.
287
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review
Intervention 2013, Volume 11, Number 3, Page 276 - 294
There is very little culture-grounded The review likely identi¢ed most of the
research that focuses on positive factors literature relevant to the review aim.
of adaptation One constraint of the structured review
Only one study on resilience, as a process relates to the comprehensiveness of
protective factor against developing psy- the search process, the criteria, restricted
chopathology, was identi¢ed; however it time span and languages used to include
was conducted in a resettlement context articles and documents. Only the ¢rst author
(Arnetz et al., 2013), and indicates was engaged in the systematic review, which
a multi-dimensional and partially did not allow for a double blind selection
interrelated idea of vulnerability and of articles. E¡orts were made to identify
adaptation. Arabic (grey) literature and a number of
Culturally relevant conceptualisation resources were identi¢ed and translated.
of dignity and humiliation, as well as Only a few ful¢lled the inclusion criteria
their relation to unmet basic needs, are and it is possible that some resources were
rarely addressed. not identi¢ed.
Few studies used mixed-method The time span covered a longer period than
approaches, sampling strategies often the actual crisis periods in order to identify
relied on convenience samples (not ran- general studies on mental health of the
domly selected) and sample sizes tended population of concern for the purpose of
to be small and not representative. better understanding context and baseline.
Many studies did not provide su⁄cient
information on methodology, the meas- Discussion
urement instruments used and the This systematic review provides an overview
validity of those measures for the context, of existing literature and a foundation to
consent procedures and stigma, as well inform MHPSS programming. It indicates
as ethical considerations or approval by a clear need for more comprehensive
ethics committees. and integrated mental health assessments
Many health and disability assessments with robust mixed-method research designs
only provided results in the overall and urban assessment methodologies.
categories of physical and mental dis- The analysis further suggests that health
abilities. assessments should integrate mental health
Particularly assessments identi¢ed aspects more consistently and rigorously.
through the grey literature search have During the systematic review, only a few
methodological shortcomings. studies could be identi¢ed for Iraqi refugees
Most studies pay limited attention to and displaced Syrians. The low number
cultural concepts, as well as terminologies can be attributed to several di¡erent con-
without validation in the native language straints; primarily limited physical access
of study participants. Measurements to the most a¡ected areas (particularly due
for psychosocial problems and mental to the humanitarian and urban displace-
disorders carrydi¡erentdegrees of stigma- ment context), and limited capacity and
tisation, which may impact reporting. competing priorities severely impacting
There is also limited attention accorded support and service provision. Given that
to potential cultural tendencies to express this review covers mental health data for
distress through somatic complaints. the two major displacement crises of this
288
Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.Quosh et al.
decade, there is very little known about The ability to address basic needs and
the mental health and resilience of the daily stressors, as well as past (potentially
displaced populations. traumatic) experiences, is important
Based on the identi¢ed studies, the majority in explaining mental health outcomes.
of the assessed populations were able to However, few studies looked at the complex
adjust to extremely di⁄cult situations. How- interrelationship between past and current
ever, much of the research focused on global stressors, as well as the link between di¡erent
categories of mental health problems and aspects of wellbeing and mental health,
mental disorder symptoms. Respective ¢nd- including what contributes to resiliency and
ings are consistent with the high prevalence adaptation. It is important to understand
rates documented in the refugee and forced this complex relationship, including aspects
migration literature, particularly of depres- such as dignity, humiliation and coping,
sion and PTSD among adults and children, as well as cultural concepts of mental
as well as signi¢cant variations in those health. Fatigue (taaban) was identi¢ed as an
rates. While it was reported that mental overarching concept to express psychosocial
health problems co-occur with health pro- distress among Iraqi refugees, but there is
blems, there was no systematic assessment neither research on idioms of distress and
of psychosomatic conditions, pre-existing wellbeing, or on help-seeking behaviour in
chronic or severe, and comorbid mental either forced displacement context.
disorders, as well as cumulative exposure Humanitarian aid delivery must include
to potentially traumatic events. The focus considerations that do not exacerbate
on sets of symptoms fails to present the mental health problems and psychosocial
diversity of responses at di¡erent levels distress, nor negatively impact wellbeing.
(including at the community level) and In order to close the research/practice gap,
provides limited information for a com- research needs to be oriented towards
prehensive, context sensitive and integrated what is relevant to inform humanitarian
response. aid delivery.
No coherent patterns for age, gender, Given the importance of grey literature
education, background, or for factors that and assessments in informing MHPSS
would indicate higher risk or protection, programming and coordination in these
were identi¢ed. However, decreased socio- situations, the relatively low quality of their
economic status, loss of meaningful social designs and result presentations is prob-
roles and support were indicated to result in lematic. It is vital to increase investment
worse mental health outcomes. Religious in technical guidance, capacity building,
and spiritual coping, as well as social support, and ¢eld/academic collaboration, as well as
was identi¢ed as protective factors. It was applied ¢eld relevant research.
shownthat inadditiontotheriskofdeveloping Desk reviews of humanitarian assessments
mental health problems, there is a high often rely on accessible grey literature
risk for developing social problems in both (mostly in English). Due to limitations
crises. Parents in both settings were very in accessing academic search databases,
concerned about interrupted education available studies are often not included
for their children. There is a need to invest in desk reviews, lowering the quality of
more in assessments of children’s psycho- the assessment. Facilitation of access to
social wellbeing. academic journals for humanitarian aid
289
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Intervention 2013, Volume 11, Number 3, Page 276 - 294
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