Editor’s note: Your mental health is important; do not ignore it. We urge you to seek help or talk to someone. If you are suffering from mental health issues or are having suicidal thoughts, please seek assistance immediately and reach out to the national suicide hotline in your country of residence. Know that you are not alone, no matter where you are in the world. Below are some of the numbers of such hotlines around the world:
- Lebanon, Embrace Lifeline, Ph: 1564
- The United Arab Emirates (UAE), National Committee for the Promotion of Mental Health, Ph: 920 033 360
- The United States of America, National Suicide Prevention Lifeline, Ph: 1 800 273 8255
- Canada, The Canada Suicide Prevention service, Ph: 1 833 456 4566
- Australia, Lifeline, Ph: 131 144
- France, Suicide Écoute, Ph: 01 45 39 40 00
Embrace is a non-for-profit organization established in 2013 to raise awareness about mental health in Lebanon and build a vocal and supportive community that ensures people with mental illness are respected, empowered, and able to access appropriate care without the constraints of lack of knowledge, shame or limited resources. Since 2013, Embrace has reached more than 20,000 people living all over Lebanon through awareness and outreach efforts. In 2017, the Embrace Lifeline (1564) was launched, Lebanon’s National Emotional Support and Suicide Prevention Helpline in collaboration with the Ministry of Public Health (MoPH). In 2020, Embrace launched the Embrace Mental Health Center which provides a range of free mental health services to everyone residing in Lebanon.
A fourteen-year-old girl sadly lost her life to suicide today in Lebanon. As this article rolls out, in March 2021 alone, we have lost more than fifteen people to suicide (reported to Embrace), with at least three cases being reported in the media weekly. As we are in the midst of a global pandemic, numbers are of great value. However, there are silent killers that we need to shed light on as well, and suicide is one of them.
The recent rise in suicides in Lebanon follows a decrease in the rates of suicide in 2020. Last year’s decrease may have been the result of several factors, including the COVID-19 pandemic and the Beirut blast, a catastrophe weighing 2,750 tons of ammonium nitrate, which shook the capital and the country to its core. Contrary to popular belief, disasters are not often accompanied by loss of life to suicide, as national solidarity tends to play a buffer. Yet, as Lebanon enters the second quarter of 2021, the economic and financial crises take a further toll on the population’s mental health, which has become increasingly compromised following a year of disasters. Cases of post-traumatic stress disorder (PTSD), depression, anxiety, and other mental health disorders have all been rising exponentially because of this.
Current Challenges to Mental Health Care and Access
Prior to looking at how to move forward, it’s imperative to understand the current state of mental health care in Lebanon and the barriers it is facing.
Cost of Services
Having previously been a service accessible to those with larger disposable incomes, the cost of mental health services in Lebanon today is an unthought-of luxury. While the demand has increased tremendously, so has the cost of services.
Mental health services in Lebanon are mostly provided by the private sector through private clinics and specialized hospitals. The price of a consultation in the outpatient unit averaged at 150,000 Lebanese Pounds (LBP) prior to the monetary crisis. These days, it can cost an average of 250,000 LBP in most private settings. While a psychiatric consultation may take place every three to six months on average, there is also the monthly cost of medication, which can range from 20,000 LBP to 500,000 LBP in today’s ailing economy. Moreover, weekly consultations with a therapist now cost double the national minimum wage, which is currently around 60 US Dollars (USD) per month. Due to these factors, patients either avoid the idea of therapy altogether or resort to non-governmental organizations (NGOs) that offer free services.
All things considered, the cost of mental health services is by no means the only barrier to adequate mental health care in Lebanon today.
Availability of Services
More than 25 percent of the Lebanese population suffer from mental illnesses or mental health issues such as depression, anxiety, PTSD, bipolar disorder, and/or schizophrenia, just to name a few. Where these patients go for therapy when they need it is another pertinent issue that needs to be addressed.
Given the financial crisis, most patients are seeking out NGOs that provide services at a minimal cost or free of charge such as International Medical Corps, IDRAAC (Institute for Development, Research, Advocacy and Applied Care), Restart, Skoun, the Makhzoumi Foundation, and the René Mouawad Foundation. While several of them have been doing this for many years in Lebanon, others have only recently added psycho-social support to their pre-existing services following the Beirut blast. Despite the fact that these services fill an important gap, NGOs continue to suffer from long waiting lists and overwhelmingly high demand, which is exacerbated by a supply that cannot keep up due to the overall lack of mental health amenities available in Lebanon.
The Emigration of Mental Health Professionals
In addition to the aforementioned problems, the supply and demand chain is also confronted with obstacles resulting from the emigration of mental health professionals. In the past eight months alone (particularly following the Beirut blast), a significant number of psychologists and psychiatrists have left the country. This mass emigration is creating a large void that cannot be filled by the NGO sector alone. They themselves are subject to fluctuations, being project-based and dependent on time-limited funding. This drainage in human resources comes only a few years after Lebanon had begun to build its much-needed network of mental health professionals.
Nonetheless, over the past couple of years, more funds have been invested into training programs to increase capacity among the current workforce. There have also been sizeable efforts to regulate legislation around the practice of psychotherapy in the country.
Ultimately, the emigration of the Lebanese mental health workforce will shift and have a profound impact on the way mental healthcare services will operate in Lebanon for the years to come.
Social and Economic Determinants
Mental illnesses result from an interplay of factors, including biological and genetic predispositions, individual psychological factors, as well as social and environmental contexts that shape the upbringing and life circumstances of a person. Today, the social and economic determinants of mental health cannot be overlooked. Without ensuring adequate living conditions (which include access to basic human rights, such as health care, education, shelter, and employment), an individual’s mental health naturally suffers and the risk of mental illness becomes higher.
The latest nationally representative data indicates that one in four people live with some form of mental illness in Lebanon. However, this data has not been updated in over ten years. While the prevalence of mental illness may not have increased significantly in that time, the latest data from the World Happiness Index (World Happiness Report 2021) reports that Lebanon ranks at 123 out of the 149 countries surveyed. It is also worth noting that more than 6,100 calls were made to the Embrace Lifeline, (the first National Emotional Support and Suicide Prevention Hotline in Lebanon) in 2020, which is more than triple the amount of calls received in 2019.
The Beirut blast has added a layer of complexity in the everyday lives of the Lebanese, who continue to be broken and at a loss. Getting justice will be crucial to restoring the Lebanese people’s wellbeing and to healing the traumatic residues of the explosion and the stress caused by the loss of people’s lifetime savings due to the economic crises. Without justice and the closure it might provide, these disasters could well and truly leave their mark on the people’s mental health for many years to come.
So, what comes next and how do we deal with the considerable challenges facing the mental health sector in Lebanon?
Tele-health and Online Therapy Options
Yes, the future is digital. Despite the unique challenges this poses to the field of mental health in particular, mental health services have dramatically shifted online. This is due to both the COVID-19 pandemic and the depleting human resources available in Lebanon.
However, like with other services that have made the shift from onsite to online, the most vulnerable populations without access to technology or digital literacy are among the most impacted by this change. Furthermore, it is impacting the rate at which people are seeking mental health services, which can be attributed to the controversy regarding the effectiveness of online psychotherapy compared to face-to-face therapy. To make matters worse, it is also causing many people who are in need of treatment to drop out of their respective therapy services.
While online therapy in Lebanon may be the way forward for a wide range of tech-savvy and younger citizens, it could compromise access to treatment and result in further disparities in care for the most vulnerable among the population.
Phone-based Mental Health Services
Amidst the challenges described above, the use of phone-based mental health services will likely ensue as an alternate source of assistance for people struggling with mental illness. In Lebanon, the Embrace Lifeline (1564) is a crucial service, the demand for which is high and will continue to climb. It is an anonymous and confidential service for those in emotional crises or contemplating suicide. The lifeline has saved the lives of countless people over the past three years and continues to be a highly utilized service.
Nevertheless, the Embrace Lifeline is no substitute for psychological therapy, as it is often accessed in order to request assistance with face-to-face psychological services within the community.
In 2015, the National Mental Health Program and the World Health Organization (WHO) launched the Step-by-Step (or “Khoutweh Khoutweh” in Arabic) self-help program, which is an electronic self-help intervention service via a mobile app for people with depression. This service provides users with a narrated story and interactive activities over the course of five weeks and is based on the principles of behavioral activation to alleviate symptoms of mild depression. Participants who enroll in the program also receive weekly brief follow-up calls by e-helpers to assist them with any technical or motivational issues.
The program was evaluated and demonstrated a significant impact on symptom reduction. Such programs are integral to the cycle of care for people struggling with mild symptoms of depression. They are free, easily accessible, and do not require advanced digital literacy. Step- by-Step will be relaunched by the National Mental Health Program in April 2021.
Primary Healthcare Centers
Primary healthcare centers (places where patients can receive free medical treatment for general physical health) remain a priority for optimal care in Lebanon. Not only do they provide care that is easily accessible, but they also play a key role in decreasing costs to the healthcare system, managing and preventing illness, improving health, and reducing the stigma associated with seeking mental health care. Since 2015, the National Mental Health Program at the MoPH has worked to improve the integration of mental health into primary healthcare facilities by training primary healthcare workers in Lebanon and equipping them with the skills and knowledge needed to identify and manage mental disorders.
It is of utmost importance to build the necessary awareness to encourage help-seeking behaviors in these centers. Several countries that have witnessed economic collapse, such as Cuba, relied heavily and successfully on their primary healthcare systems to deliver mental health care when secondary and tertiary systems suffered as a result of the economic crisis.
The COVID-19 pandemic has further shed a light on the importance of mental health like never before. Today’s public health sector cannot push any health agenda forward without including mental health at the top of its priorities. Ultimately, rebuilding the country and reviving its economy will require substantial effort and investment in mental health.
In health care and mental health alike, the goal is and should always be to ensure that no patient is left untreated because of financial issues, and that the quality of treatment remains uncompromised. All citizens must be able to access free and reliable mental health care services at all times.
Mia is a clinical psychologist, social entrepreneur, and co-founder and president of Embrace, a leading mental health non-governmental organization (NGO) in Lebanon. She has also recently been elected on the Political Council of Minteshreen, a youth-led progressive political party born from the October 17 revolution. Mia has worked in the field of mental health in Lebanon for the past 10 years and is a published researcher. Since 2013, she has been active in addressing stigma and awareness around mental health in Lebanon working in coordination with national stakeholders and multiple local and international organizations to lobby for equity of care in mental health, quality rights for people with mental illness, and implementing projects across sectors with the aim of improving mental well-being of individuals and communities.