As the Syrian conflict enters its ninth year, nearly 12 million people are in need of humanitarian assistance. Less visibly, many are also in need of mental health support. Globally, there is an extremely high burden of mental health disorders among conflict affected populations. A recent systematic review shows one in five people have a mental illness. 

In Syria, the population has been exposed to conflict and terrorism for almost a decade, and many have experienced multiple traumatic events. The protracted conflict has led to recurrent displacement, depleted socio-economic resources, destruction of infrastructure, and major gaps in the provision of health services. This is having a re-traumatising effect on those in northeast Syria and prevents psychological healing.

Recurrent displacement diminishes resilience and disrupts healing after trauma 

The Syrian conflict has resulted in the largest refugee displacement crisis of our time. The latest escalation in violence in northeast Syria forced an estimated 180,000 people to flee their homes. Before Médecins Sans Frontières/Doctors Without Borders (MSF) were forced to evacuate our international staff from the country, our team was working with people who had fled their homes and were living in overcrowded settlements in the town of Tal Tamer. MSF teams witnessed desperate, confused, fearful families, many of whom had lost relatives and had left everything behind—not for the first time. 

The psychological distress experienced by those in northeast Syria has been caused by severe trauma and exacerbated by recurrent mass displacement. Our MSF colleagues were also present in Ein Issa camp in northeast Syria, which has been home to displaced people since 2017. Between 2016 and 2017, more than 507,000 people fled besieged Deir Ez-Zor and Raqqa governorates, resulting in an influx of internally displaced people to Ein Issa camp. A study in the camp revealed high levels of exposure to violence and psychological distress. Atrocities, such as public floggings, executions, and public displays of dead bodies had been witnessed by 19% of those surveyed. Among men, 16% had been detained or kidnapped and 11% had been tortured, beaten, or attacked. Over a third of respondents were so distressed, disturbed, or upset that they had become almost or entirely inactive. A third of people showed obvious depressive symptoms and 14% felt so hopeless that they did not want to carry on living. 

In such settings, psychological recovery is hindered as people often lack the social and financial capital to improve their situations, arriving in fragile host communities that have little capacity to support newcomers. For many, this leaves them with limited access to food, water, sanitation, housing, adequate health services and education. Certain groups, such as older people, those with special needs, unaccompanied children and single mother headed households, are particularly at risk of mental distress. 

Another vulnerable group are patients living with chronic conditions. Thalassemia is prevalent in Syria and requires long-term medical care. MSF was treating nearly 300 thalassemia patients—mostly children—at the Tal Abyad national hospital until the recent escalation in violence forced MSF to suspend activities. For these patients, no longer being able to access treatment puts their lives in danger, causes physical complications, and severely affects their psychological wellbeing. Those with chronic medical conditions, like thalassemia, are at increased risk of depression, as a loss of control becomes a source of psychological stress for patients and their families, increasing the risk of psychological harm.

Mental health problems from recurrent trauma and displacement require a multifaceted response  

While the conflict in northeast Syria continues with no resolution in sight, many live in a state of “fight or flight”, expecting future adversity while the mechanisms required to process their trauma remain absent. 

Treatment for mental health problems from recurrent trauma and displacement require a multifaceted response. Clinical mental health interventions need to go hand in hand with efforts to mitigate difficult living conditions and to strengthen community based protection mechanisms. A focus on addressing their exposure to violence is not enough. The treatment of psychological problems must be prioritised alongside other needs, such as nutrition, treatment of chronic illnesses and personal safety.

Research shows that survivors of trauma view their mental health as a high priority and a prerequisite for self-efficacy; however, the latest military operations in northeast Syria have caused mass displacement and retraumatised an already vulnerable population. They have also forced MSF and others to suspend crucial medical services, including the provision of mental healthcare, to people in need. As a result, the hidden burden of mental health trauma continues to grow in northeast Syria. 

Olivera Novaković is clinical psychologist and REBT/CBT psychotherapist, working for MSF as Mental Health Activity Manager. 

Sally MacVinish is a public health specialty registrar in London, currently on placement at the Manson Unit, MSF UK.

Competing interests: None declared.