Mental Health Reforms in Lebanon During the Multifaceted Crisis –

Introduction

In 2020, Lebanon experienced total economic collapse, continued social unrest, and pressures stemming from the COVID-19 pandemic, which were all compounded by the Beirut explosion on 4 August in which over 200 were killed, 7,500 were injured and approximately 300,000 displaced. Indications of an impending economic down-turn had already begun in the summer of 2019 when the value of the Lebanese Lira began to decline. A proposed tax on WhatsApp calls in Lebanon on 17 October 2019 sparked a months-long revolutionary moment seeking to topple the corrupt political class. The Lebanese Lira, pegged to the US dollar at 1,500 since 1997 had plummeted to an average of 23,000 by August 2021, losing almost 90% of its value in 18 months. According to the Human Rights Watch, the number of those living below the poverty line has doubled, and tripled for those already living in extreme poverty in the past year. By August 2021, most Lebanese are experiencing severe power outages, with access to electricity for only a few hours a day. This development has been compounded by the Central Banks decision to lift subsidies on fuel, leaving many fuel distributors hoarding their stocks and selling at higher rates. Consequently, hospitals now find themselves in a dire state. The American University of Beirut Medical Center (AUBMC) issued a statement on 14 August 2021 that in two days it would no longer have enough fuel, potentially resulting in the death of 150 patients on respirators and dialysis machines.

Due to these multiple disasters, the Lebanese have experienced much stress which has been detrimental to the mental health of the population. The Lebanese have a long history with political turmoil yet discussing mental health is considered culturally taboo. This leads to a failure to address mental health issues which goes back several generations, as exemplified by the country-wide amnesia surrounding the civil war.

Responses to mental health in Lebanon and the region more broadly remain under-supported. In the months to come, challenges surrounding this health sector will be critical in Lebanons transition out of crisis. This paper therefore seeks to investigate the current state of the mental health system in Lebanon and provides policy recommendations to improve its adaptability in responding to this multifaceted crisis. By mental health system and infrastructure, we include public institutions pertaining to mental health, private hospitals, and various civil society actors (non-profit governmental organizations etc.) providing psycho-social support services. Addressing mental health in Lebanon will be essential to alleviate the suffering which is plaguing the population, but will also aid in realizing the goals of the October 2019 revolution for a break with the past and its legacies. A substantial political transition will require tools to manage mental health needs, which will, in turn, be reflected in how citizens are able to create, organize and reimagine state institutions and the overall political stability of the country.

Trauma may often distort a collective or individual memory. In the context of conflict-ridden societies, individuals suppress memories of their own communitys complicity in war crimes, attributing their own actions to self-defense. Moreover, dogma, established hierarchies, and identity-based fears derived from trauma can cause people to vote for or politically support entities that do not serve the interests of the individual or community in question. Turning to the United States, we can observe the case of the white working class, in which many citizens throughout forgotten America'' assign their allegiance to political actors due to anxieties over the perceived loss of their way of life or resources stemming from increased social mobility of minorities. In reality, the policies of the political actors they support do harm to such communities (by reducing access to healthcare and social welfare, lack of environmental protections, and the like). The perceived disruption of their imagined identity at the top of the social hierarchy in the American landscape has led some to identify with political forces at the cost of their health and livelihoods. For example, campaigns produced by the National Rifle Association claim the ownership of weapons will restore the white man's privilege and the balance of power, when in fact firearms have been proven to be one of the leading causes of white, male suicide. Leaders seeking to consolidate and maintain power will exploit these emotionally and historically charged grievances. This method is brutally effective, precisely because it links political participation to these grievances, and by consequence a narrative of imagined victimhood and desire for domination.

Similarly, in the Lebanese case, we can see a parallel in how various communities continue to politically support sectarian parties and individuals despite their proven track record of spreading misinformation, impunity for their criminal behavior, and corruption. According to emerging trends in the literature, particularly regarding the effects of clientelism, some scholars would argue that members of different communities, driven by fear-based identity politics, continue to either ignore or justify the acts of their sectarian leaders due to a belief that their survival is at stake and rests in the hands of these leaders. This dependency is only amplified by traumas of the past that fell along sectarian cleavages. Another common feature of communities affected by violent conflict is sequential traumatization. This occurs when a series of traumatic events through micro-aggressions to more overt aggressions are processed unconsciously, which can accumulate into a post-traumatic stress disorder. This accumulation of trauma in the population may impact its capacity to react to transgressions made on the part of the ruling political class. Consequently, adequately addressing the psychological implications of political unrest becomes that much more important and may contribute to political stability.

The Lebanese population has long been exposed to conflict-related traumas and domestic instability, triggering a range of mental health disorders. Even preceding the current protracted crisis, around a quarter of adults in Lebanon suffered from one psychiatric disorder, demonstrating particularly high rates of post-traumatic stress disorder (approximately 25%). The last comprehensive study conducted on the prevalence of various disorders in Lebanon dates back to 2006. According to this study, the most common disorders amongst the Lebanese population were phobias, depression, and anxiety, often linked to war-related trauma. Depression was shown to be the most common individual disorder, with anxiety disorders found in 16.7% of the population and mood disorders in 12.6%. Approximately 4.3% of the population also experienced suicidal ideation. Individuals exposed to war-related trauma, possess a higher risk for developing one of these disorders, being three times more likely to develop a mood disorder and two times more likely to develop an anxiety disorder. This compounding risk is likely to have a pervasive impact in Lebanon, where approximately 70% of the population has been exposed to one or more instances of violent conflict.

In Lebanon, mental health needs are tackled by three main actors. Firstly, there are public institutions that consist of different branches within the Ministry of Health. Secondly, there are private hospitals and clinics that operate outside the public sphere. Thirdly, within civil society, there is a range of local, and international non-governmental organizations (NGOs) that fill the gap where state structures are insufficient. The following sections seek to explore the role each has played in the treatment of the mental health of the population.

Before 2013, the establishment of mental health infrastructure in Lebanon had been led primarily by the private sector, that is, private hospitals. Beyond private actors, local and INGOs would additionally work alongside these private intuitions. In 2014, the Ministry of Public Health launched the National Mental Health Program along with a five-year Mental Health and Substance Use Strategy to better adhere to the WHOs Global Action Plan for Mental Health 2013-2020. This strategy aimed to train primary care workers, introduce the dissemination of evidence-based treatments, and increase accessibility of services to Syrian refugees. Another pillar of this initiative has been to expand support for research in this sector. This research includes projects seeking to improve access to the WHOs Problem Management Plus program using technology, to enhance similar programs for children and adolescents, and to develop family-focused psychosocial support for at-risk youth. The Ministry of Public Health typically contracts out private hospitals to serve those requiring inpatient care. Only three mental hospitals and five psychiatric units placed within general hospitals operated in Lebanon prior to the Beirut explosion.

In terms of coverage, the Ministry of Public Health allocates only 1% of its budget for patients seeking treatment for mental health conditions. This percentage subsidizes the cases of hospitalization in three designated government hospitals, along with a small quota for private hospitalization. The Ministry also provides psychiatric medication. The National Social Security Fund covers hospitalization in one of the three designated hospitals, psychiatric medication, and a portion of private consultation fees. Members of the military and public employees also receive coverage for medication, a percentage of consultation fees, and hospitalization. Specifically, public servants possess public health insurance through the Cooperative of Civil Servants. The United Nations Refugee Agency (UNHCR) covers 85-90% of fees for Syrian refugees and PCR tests for COVID-19, the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) covers fees for Palestinian refugees in Lebanon, and various NGOs in civil society cover Lebanese who cannot afford coverage or insurance. With regards to vulnerable people, the Ministry has identified 13 vulnerable/marginalized communities in its strategy to improve mental health services in the country. Often, these are individuals who are not registered legally in the country and possess barriers to accessing services. Support for LGBTQI people also remains limited to services available within Beirut, with NGOs such as Mosaic, LebMASH, SIDC, and the International Medical Corps playing a large role in this community.

In 2013, the Lebanese Ministry of Public Health set up, in partnership with WHO and UNICEF, a Psychosocial Support Task Force (MHPSS TF). According to a former employee of the MHPSS TF, the unit coordinates with over 62 mental health and psychosocial non-governmental actors and seeks to implement various evidence-based interventions. These strategies include the integration of mental health into primary healthcare, developing community-based multidisciplinary mental health teams, training service providers on interpersonal psychotherapy, and piloting e-mental health services. Following the Beirut explosion, this initiative also established a comprehensive directory of mental health professionals for mental health support for those affected.

The former employee of the MHPSS TF highlighted how the general concerns surrounding trust in governance does not affect the work of the task force, as their expertise is sectoral, non-political, and transparent. One way in which the task force claims to operate is to map which actors are working on which issues, highlighting which services are available and which mental health disorders are prevalent on a platform administered by the ministry. Organizations and relevant actors sign MOUs with the task force agreeing to report their activities, and in return they can access information regarding needs in the general population mapped by the task force. Despite the alleged positive relations between the task force and these organizations, not all their activities are reported consistently to the task force due to the burden of their own work loads, obligations to external donors, and/or an absence of funding contingent on this reporting as incentive.

We interviewed Dr. Georges Karam, to understand more about the role of civil society actors in the crisis.

Despite the claims made by the ministry of health, civil society actors painted a completely different picture concerning their work with the Ministry on the ground. The head of the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), an NGO, Dr. Georges Karam, asserts that the Ministry of Public Health has not performed its due diligence in providing adequate resources to civil society actors who function as part of the Task Force. He claimed that the ministry had not fulfilled its duty to address issues brought up by different NGOs, for instance the shortage of in-patient psychiatric facilities due to the pandemic. After a year and half of inaction, the ministry of health ultimately delegated responsibility to various NGOs to retrieve the necessary funds to build new facilities.

Of the NGOs involved in mental healthcare, International Medical Corps, ABAAD, Embrace, IDRAAC and Mdecins Sans Frontires remain the largest participants in the partnership with the Ministry of Public Health. Specifically, with regards to the COVID-19 pandemic, MHPSS identified its goals in working with such partners is to raise awareness on ways to cope with the stresses associated with the crisis, orient individuals to the available national lifeline and call centers, provide mental health support for those in quarantine, and support the mental health of healthcare workers and first responders.

IDRAAC gave some examples of the activities NGOs implement for mental health promotion. IDRAAC has played an active role in advancing academic work concerning the mental health sector, producing over 200 publications. Moreover, the institute has advocated for the reform of mental health legislation and led several public awareness campaigns. As a response to the Beirut port explosion, they have created a free walk-in clinic for psychological first aid and psychological assessments, as well as a 24/7 hotline.

Gaps exist in Lebanons mental health infrastructure. Beyond a general need for increased funding and expertise, one main challenge is the need to establish a solid referral system between all levels of care to guarantee access to outpatient- as well as in-patient services for persons with mental disorders. Lebanon has about 1.5 psychiatrists per 100,000 people, with most working in private practice or NGOs. In addition to a serious lack of resources, the majority of Lebanese with chronic mental health disorders do not seek help or treatment due to a lack of awareness regarding these disorders, along with various barriers (such as financial limitations and lack of resources) and social stigma. , , A study conducted in Lebanon showed that individuals with symptoms of anxiety may take 6-28 years to seek and receive the relevant treatment due to the societal barriers listed above. The failure to assess these cases can lead to a more rapid progression of these chronic disorders towards a state of debilitation. Mental health services receive minimal support from the state and qualify for little to no private insurance coverage. These services are concentrated in urban areas and remain underfunded. Geographical limitations are most pronounced in regions like Akkar, Marjeyoun, the areas near the Lebanese/Israeli border, and the Baalbek/Hermel area, which remain remote and demonstrate a lack of professionals in the mental health sector.

These mental health challenges have been exacerbated by the economic collapse of the country beginning in October 2019, only augmenting these barriers for those exhibiting chronic mental illness or new on-set disorders, particularly for especially vulnerable populations such as low-income groups and marginalized communities (e.g. refugees, migrant workers, etc.). Bouts of depression became more prevalent following the protests that erupted across the country in the same period and the subsequent economic crisis. Following the Beirut explosion in August 2020, many have reached levels of pathological depression. Moreover, individuals experiencing other mental health disorders have since relapsed. Lebanons National Emotional Support and Suicide Hotline, administered by the NGO Embrace, reports receiving triple the calls in 2020 than they did in 2019, due in part to the factors described above along with pressures derived from coronavirus-related lockdowns. This rise in needs has been paralleled by a massive blow to the countrys capacity to respond. In 2020, two in-patient psychiatric units were destroyed by the Beirut explosion and others were closed due to bed shortages in light of the COVID pandemic. Prior to the Beirut explosion, Lebanon was already experiencing a shortage of beds in such units. The head of IDRAAC urged for more in-patient psychiatric facilities due to the pandemic, which the ministry of health failed to coordinate. Dr. Karam added that medication shortages have become more common because patients have been rationing months-worth of psychiatric medications when they are restocked due to the economic crisis and the Central Bank's decision to no longer subsidize medications.

Moreover, current structures and initiatives must also do more to acknowledge and adequately respond to the varying levels of vulnerability exhibited by different populations, particularly refugees, stateless people, and domestic workers. In light of the COVID-19 pandemic, these existing vulnerabilities have been exacerbated, triggering a range of mental health disorders. For many individuals in these communities, anxiety surrounding deportation, eviction, discrimination, and the potential loss of their livelihoods has led to immense psychosocial distress. In April 2020, more incidents of suicide were reported among refugees, along with a rise in cases of threats to self-harm and harm others, domestic violence, and divorce. Due to pressures surrounding housing and evictions, refugee women in particular are at risk of experiencing sexual and gender-based violence in this context. As a result of these factors, the refugee population is experiencing higher levels of mental health disorders, particularly anxiety, which may lead to longer-term and more severe iterations of these disorders. The prevalence of depression in the refugee population is estimated at 1 in every 4.

In addition to refugees and displaced people, similar social and economic pressures placed on domestic migrant workers in Lebanon have also been exacerbated by the multifaceted crisis. According to Mdecins Sans Frontires, the most severe forms of mental health symptoms were exhibited by female migrant workers who have approached them for psychosocial services, of whom 30% are suffering from depressive disorders and 27% demonstrate symptoms of psychotic disorders since the start of the pandemic.

According to the former member of the MPHSS Task Force, stigma and concern for confidentiality surrounding mental health disorders remain one of the largest challenges for treatment in Lebanon today. In a recent study, participants cited a lack of trust in the healthcare system, the quantity of services and the ability of specialists to adequately address needs and respect confidentiality. Moreover, many people are unaware of the proximity of organizations and their available services. As a result, these organizations often only target the same category or people in their campaigns, typically teenagers and those with access to social media. Various campaigns have been carried out on television through the Ministry of Health, though this approach has become more infrequent since the advent of the recent crises. Individuals from lower socio-economic status, the elderly, and those exhibiting extreme mental health conditions are the ones who are more likely to fall through the cracks of service provision. The former employee of the MPHSS Task Force also cited funding as a concern up until the Beirut explosion. Following the explosion, there has been an influx of funding and services, which in turn has allowed for enhanced awareness.

Improving approaches to treating mental health needs in Lebanon proves complex yet, in light of recent events, absolutely paramount. The range of related challenges calls for a variety of tools and solutions.

At the level of governance, the former MHPSS TF member urged for certain draft laws to be enacted which have been neglected by the parliament, for instance one which would make the MHPSS Task Force an official arm of the Ministry of Health with a substantial budget. This recognition would give the Mental Health department greater legitimacy and, as a result, normalize its role in public health more broadly. Greater allocation of funding to this department, particularly for better coverage of out-patient care as well as hospitalizations, would also allow for more coverage for individuals as only 1% of funds reach this department. Another example of a draft law submitted and neglected by the parliament is the law on the legalizing marijuana and those affected by substance abuse disorders, which would push for a larger focus on rehabilitation and reintegration rather than subjecting marijuana users to harsh prison sentences.

Beyond substance abuse, the only existing law pertaining to mental health in Lebanon is the Welfare Act and Protection and Treatment of Mentally Ill Patients (Legislative Decree no. 72-9/9/1993). It has been determined by lawyers Nizar Saghieh and Rana Saghieh to not be in conformity with international standards. In 2014, Legal Agenda reviewed and revised the statute with suggested amendments, which was endorsed by the Ministry of Health's National Mental Health Program. The draft law would define mental health based on international standards, stipulate clear procedures to promote treatment and the explicit responsibility of the state to realize these goals. Both through allocated funding for free out-patient care and the establishment of community-based mental health care centers for prevention, treatment and rehabilitation, the State would uphold its obligations. Moreover, this law would prioritize three objectives: first, to protect the rights of people with mental health disorders and their fundamental rights, particularly against discrimination and stigma. Second, the law would address concerns over equal access to services; and thirdly, it would regulate the involuntary admission of patients through judicial safeguards. However, this updated version remains a draft to date.

In terms of research, the last comprehensive study of mental health disorders and their prevalence in the Lebanese population is over 10 years old, underscoring the need for an updated, comprehensive study, particularly following the various instances of collective trauma of the past two years and the subsequent mental health needs. Overall, more research is needed to justify the redirection of legislation, policy, funding and services to alternative approaches that are cost-effective for those in need, and remains rooted in human-rights based and community-based models that are consistently monitored.

Within the healthcare system itself, there must be campaigns that are accessible to those who are not active on social media or from a low socio-economic status. Such campaigns may include appearances on local news channels with viewers of varied demographics as televisions are more widely available then social media. According to the former ministry of health worker, news appearances for mental health campaigns were common prior to the Beirut explosion, but seem to have decreased in frequency since then. Specifically, such campaigns must aggressively address the prevailing obstacle that is stigma and confidentiality in Lebanon in seeking mental health support. The state structures must also include in their educational campaigns education surrounding coping strategies and prevention that also prioritizes and normalizes informal care before individuals arrive at mental health disorders that require hospitalization. An effective referral system must be established here that expands upon the linkages established by the task force and civil society actors to ensure individuals receive continuous care. According to the founder of IDRAAC, studies conducted by the association demonstrate that individuals do not seek mental health care primarily due to a lack of information regarding available services, rather than a lack of financial resources. This further highlights the need for enhanced awareness surrounding mental health disorders as well as resources available.

Finally, due to increased demand for mental health services at a distance due to the COVID-19 pandemic, tele-mental health initiatives may offer a viable route for vulnerable groups in Lebanon, particularly where services are stretched thin, and this could prove cost-effective and flexible to changing contexts. Despite concerns over security of sensitive information, data protection and privacy for vulnerable populations, and infrastructure barriers (electricity and internet access), such an approach could help alleviate the burden of a system overloaded by a dramatic increase in mental health needs.

As for disaster trauma-specific policies, government policies are generally required to set the aims and objectives for psychosocial and mental healthcare responses in disasters. They should use evidence-based strategies to lay out the basic architecture of care. In addition, proper clinical policies should be set in place for healthcare staff on proper screening.

Models of disaster psychology are shifting towards preventive psychological measures for better preparedness prior to disasters. , It is critical that Lebanon have prospective plans for providing psychosocial and mental healthcare in the event of a disaster, taking into consideration the immediate, and more long-term phases after disasters. The lack of these kinds of policies greatly delays proper psychological care.

In preemptive planning, it is important in shaping policies to keep in mind that every phase after a disaster has a specific set of necessary targets. During the immediate phase, preliminary assessment of psychological needs, determining of populations most at risk, and psychological first aid (PFA) are recommended. PFA involves evidence-informed measures to comfort victims of disasters and reduce future development of mental health disorders. This can be through seeking out individuals at risk, providing safety and comfort, stabilizing overwhelmed patients, providing information on coping, and linking them to appropriate services should the need arise. This service can be administered by non-trained professionals such as first responders or emergency rooms. This process must also provide support to health care practitioners affected and under immense duress.

Ahead of time, the mapping of existing services, and the establishment of networks for efficient collaboration between different actors, remains essential. At this stage, it is crucial to have identified which groups are most vulnerable to poor mental health reactions to trauma. These have been identified in the literature as women, children, the elderly, the physically disabled, ethnic minorities, and displaced populations, as well as first responders and individuals from low socio-economic status, or suffering from substance-use like smoking, loss of economic livelihood, poor social support, and weak family support This ensures that marginalized communities such as migrant workers and refugees are given appropriate care via outreach to their respective community centers. In the medium phases of recovery, proper policies should be in place for primary care services to be educated on appropriate screening and treatment of post-traumatic health disorders and reactions. In the long term, a minority of individuals will develop long-term mental health disorders such as post-traumatic stress disorder (PTSD) and other mood disorders such as anxiety and depression. It is essential not to remove funding or prematurely terminate trauma policies. Chronic psychiatric disorders require appropriate maintenance for years after trauma. As made evident by the Beirut port explosion, Lebanon is no longer operating in the preemptive planning stage. Instead, the country must simultaneously plan for the future by installing effective psychological disaster preparedness tools as discussed above, and focus on diagnosis and treatment of long-term, trauma-induced mental health conditions to pull itself out of the current crisis. True and substantive reform can only be realized through this double-pronged approach.

More research and accounts should be made available on what psychosocial strategies have worked and which have failed in Lebanon to better inform this decision. What is available in the literature should be tailored to what would be culturally sensitive to Lebanon.

With the advent of the 2019 revolution, several dimensions of the Lebanese system (i.e. political, economic, etc.). have been challenged in unprecedented ways. However, the essential role that mental health plays in leading to social and political change cannot be ignored. Reforming mental health infrastructure eases suffering and allows communities to thrive by equipping them to make economic, political, and social choices that prioritize their own welfare. In the Lebanese context, ensuring a healthy, collective mental health is and will remain essential in furthering the goals of the revolution to every facet of life and establishing a functioning and just State.

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The views represented in this paper are those of the author(s) and do not necessarily reflect the views of the Arab Reform Initiative, its staff, or its board.

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Mental Health Reforms in Lebanon During the Multifaceted Crisis -