The global epidemic of physical noncommunicable diseases (NCDs) is occurring at a time when more people are affected by humanitarian crisis than ever before. The Médecins sans Frontières (MSF) NCD programme in Irbid (north Jordan) has served Syrian refugees and the host Jordanian population since 2014. One of the principle themes to emerge from a recent evaluation of the programme was the enormous impact of war and the refugee experience on NCD care delivery and patients’ self-management.

“Treating their NCD is not just medical; they have to have hope...”

“Treating their NCD is not just medical; they have to have hope,” explained a doctor treating Syrian refugees in the programme. The MSF team’s experience confirmed the axiom that “there is no health without mental health”: their patients’ psychological issues were inextricably linked to their physical NCDs. You couldn’t treat one without the other. 

An elderly Syrian man described the trauma his community had endured: “The suffering which our people went through wasn’t witnessed by any other people in the earth.” 

Addressing stressors associated with forced displacement 

In any population, chronic physical conditions and mental illness or distress often co-exist. There are many links between these conditions: chronic physical disease is a risk factor for developing depression and anxiety, while having a mental disorder is associated with reduced help-seeking, poorer treatment adherence, and poorer prognosis for chronic physical conditions. 

There is clear evidence that distress and mental disorder increase following trauma, and a growing belief that the chronic stressors associated with forced displacement intensify these risks ². Stressors may include social isolation and loss of social supports; discrimination; poverty; poor access to basic services; increased risk of exploitation and violence (including domestic violence); and worry about family members left behind ². Moreover, among Syrian refugees, the elderly and those with chronic conditions report especially high levels of stress ³. As a coping mechanism, people may turn to behaviours that exacerbate NCDs, such as smoking and drinking alcohol ⁴. 

Inclusion of mental health and psychosocial support 

When MSF initially set up the Irbid programme targeting the NCDs responsible for the greatest morbidity and mortality in pre-war Syria – namely hypertension, cardiovascular disease, diabetes and chronic respiratory diseases – there was little clinical or programmatic evidence to guide them ⁵. To deal with the mental ill health evident among their patients, the team added a mental health and psychosocial support (MHPSS) component to the service, initially focussed on supporting medication adherence. 

However, the burden and breadth of patients’ psychosocial morbidity soon became apparent. Patients were affected not only by sadness, bereavement and loss, but also by overt post-traumatic stress disorder, psychosis, self-harm, suicidality, and experiences of torture and sexual and gender-based violence. One MSF counsellor reported:

“NCD patient cases were some of the hardest cases I ever dealt with… these patients not only suffer from hypertension, diabetes, etc., they are refugees who lost almost everything.”

The service thus evolved to encompass group and individual psychosocial counselling, humanitarian support and, later, clinician-delivered, primary-level mental health care. 

Overcoming challenges in implementing MHPSS

The MSF team encountered a number of challenges in delivering MHPSS services. When interviewed in 2017, they felt the service was not reaching everyone with mental health needs. This was thought to be partly because of patients’ limited awareness of the service and their reluctance to attend, but also due to low referral rates and a lack of “buy-in” from medical staff, in addition to a lack of formal screening. 

Some of these issues may have been tied to the sociocultural context and approach to mental health. Patients clearly linked the physical, psychological and social dimensions of their illnesses and many ascribed the onset or worsening of their NCD to their traumatic war and refugee experiences. As one Syrian patient explained:

“I had hypertension because of a psychological reason … (because of) inner sadness and all the incidents that occurred in front of us, such as killing and destruction.”

Yet, many patients didn’t perceive the MSF programme as a source of support for their psychological problems. This seemed to be because their coping strategies were rooted in family or community structures or because patients felt they couldn’t influence the forces responsible for their suffering. 

The MSF team came up with several solutions to these issues. These included the introduction of ad-hoc psycho-education sessions to engage patients in waiting rooms, delivery of MHPSS training sessions to the wider clinical team and implementation of depression screening using the validated PHQ-2 tool, which assesses the frequency of low mood and anhedonia during the previous two weeks (recommended by the mhGAP guide for humanitarian intervention) ⁶. 

The need to better integrate physical and mental NCD care through evidence

So what are the implications of this experience? The lessons learned from the MSF NCD programme in Irbid around the need to include mental health care alongside care for physical NCDs in humanitarian settings are more relevant than ever before. Ideally, physical and mental NCD care should be: 

- patient-centred and culturally appropriate; 

- integrated at primary level; and 

- situated within a tiered set of services, linked by robust referral pathways ^2,7. 

We also need further implementation research to help strengthen the evidence base on effective MHPSS care and tools for use in humanitarian contexts.

About the author

Éimhin Ansbro (@EimhinA) is a Research Fellow in NCDs in Humanitarian Settings at the London School of Hygiene and Tropical Medicine. Her fellowship is funded by MSF to evaluate their NCD programmes in various settings. She is a specialist in Family Medicine with an interest in public health and chronic disease. She has worked in the field and as an NCD consultant with MSF, co-authoring the MSF NCD guidelines and supporting NCD programmes. She is interested in helping design streamlined models of care for NCDs in humanitarian settings and in the role that fixed dose combination drugs may play in this area. 

The Centre for Global Chronic Conditions

Health in Humanitarian Crisis Centre

References

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6.        mhGAP Humanitarian Intervention Guide (mhGAP-HIG) | Mental Health Innovation Network. http://www.mhinnovation.net/resources/mhgap-humanitarian-intervention-gu.... Accessed June 7, 2018.

7.        UNHCR - UNHCR’s Mental Health and Psychosocial Support for Persons of Concern. http://www.unhcr.org/uk/research/evalreports/51bec3359/unhcrs-mental-hea.... Accessed May 4, 2018.