Elsevier

The Lancet

Volume 374, Issue 9690, 22–28 August 2009, Pages 654-661
The Lancet

Health Policy
Severe mental disorders in complex emergencies

https://doi.org/10.1016/S0140-6736(09)61253-8Get rights and content

Summary

People with severe mental disorders are a neglected and vulnerable group in complex emergencies. Here, we describe field experiences in establishing mental health services in five humanitarian settings. We show data to quantify the issue, and suggest reasons for this neglect. We then outline the actions needed to establish services in these settings, including the provision of practical training, medication, psychosocial supports, and, when appropriate, work with traditional healers. We have identified some persisting problems locally, nationally, and internationally, and suggest some solutions. Protection and care of people with severe mental disorders in complex emergencies is a humanitarian responsibility.

Introduction

In the summer of 2004, Ahmed was half naked, incoherent, and chained to a tree on the outer edges of a camp for Darfur refugees in Chad, exposed to the blistering sun without shelter, and surrounded by a thorn fence to keep the cattle away (figure). Traditional healers had identified him when asked by a humanitarian agency if they knew people needing treatment for mental illness. Ahmed had first become ill 14 years before, in his early 20s, in Darfur. He had developed delusional ideas about his failure to get funding to continue his education and had become preoccupied with the belief that he had been tricked. He was often violent and sometimes mumbling and incoherent. The illness took a relapsing course and sometimes his aggression was such that he was restrained by his family. The family had sought assistance from a local traditional healer but it did not help. In 2003, he was calm but the conflict in Darfur disturbed him greatly, and he became aggressive and preoccupied again. When the family members fled from the militias, he refused to go with them, so they bound him to bring him with them.

At the camp, tents were allocated one for each family, not to individuals; therefore, the family had no solution but to chain him outside and provide food and water, which he often refused. Ahmed was diagnosed by the first author as having a paranoid psychosis and was treated with antipsychotic medication. The general practitioner from Chad, running the primary health-care service in the camp, the family, and one of the traditional healers received on-site teaching as part of a continuing mental health training programme to understand Ahmed's illness and how to treat him. Furthermore, one agency was persuaded to provide an appropriate individual shelter for him near his family. Within a week, Ahmed was calmer and able to communicate intelligibly with his family and health workers. Within a month, he was unchained and continued to be supported by the primary health-care team.

Ahmed's story illustrates the problems that families and patients with severe mental disorders face in humanitarian settings. They are often individuals with long-term, untreated illnesses exacerbated by conflict, flight, or disaster. Families, when being courageous and compassionate in bringing the sufferer with them as they flee, are then faced with inadequate shelter, absence of appropriate care, and are forced to restrain their ill relative by whatever means available, which results in further deterioration. Basic health-care facilities usually lack the appropriate medications and staff trained to use them, so those previously on medication are likely to relapse.1

Ahmed was lucky to have a family that wanted to care for him. Many ill people are abandoned by their relatives during flight. They are thus deprived of the networks of support and protection that could have enabled them to function. Verbally and physically abused, stoned, or beaten, people with mental disorders wander terrified, unfed, in rags, usually hobbled by some kind of chain, in all refugee camps. They are particularly vulnerable to the dangers of life in a conflict area or as refugees, failing to recognise orders from armed authorities (panel 1). To be displaced by war or disaster is to be dispossessed; to be displaced in such circumstances and suffer from a severe mental disorder is to be among the most dispossessed people in the world.

Section snippets

Complex emergencies and humanitarian settings

Complex emergencies are usually defined as situations in which there is extensive violence and loss of life; massive displacements of people; widespread damage to societies and economies; the need for large-scale, multi-faceted humanitarian assistance; and obstructions to such assistance by political and military constraints, including security risks for the relief workers themselves.2 The term humanitarian setting is increasingly used to include a wide range of conflict, post-conflict, and

The size of the problem

The extent of the problem is uncertain because little epidemiological work has been done in these settings. A recent study of 1043 hurricane survivors from Louisiana, Mississippi, and Alabama in the USA found that the number of people with serious mental illness doubled after the storm.15 A national epidemiological study done before the 2006 conflict in Lebanon—yet in the aftermath of more than 20 years of civil war—showed that 4·6% of people had a severe mental disorder (bipolar disorder,

Setting up services: actions needed

The framework of action in panel 2 is now the recommended set of minimum interventions for people with severe disorders in established international guidelines for mental health and psychosocial support in emergencies.1, 8

Addressing global mental health needs requires the appropriate training and supervision of health workers to integrate mental health into primary health care.26 The advantages of increased access, reduced stigma, and increased respect for human rights, a holistic approach to

Continuing problems

Persistent conflict, insecurity, and lack of physical access can on occasion make it difficult to initiate services or cause their suspension in the midst of a programme (panel 6). Health-care workers and facilities might, on occasion, be targeted, and patients might be unable to access care or understand the risks.

The increasingly participatory and rights-based focus of many psychosocial programmes and the fact that a high proportion of those accessing services are likely to have suffered

Crisis as an opportunity

Services created by non-governmental organisations in these contexts are a drop in the ocean compared with what is needed. In all areas mentioned, most people with severe mental disorders remain unrecognised, untreated, and unable to access services. Physical restraint is common because, in the absence of care, families see it as the most humane solution.43 Non-governmental agencies cannot be a substitute for effective government strategy and action. But they might sometimes be a stimulus.

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  • Cited by (0)

    Dr H Sherief died in July, 2009

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