After more than six years of conflict, the Yemen crisis no longer makes top story headlines. But the war is not over, and the impact on this conflict on the wellbeing on those living in Yemen is extensive.
Antonella Pozzi, mental health activity manager for Médecins Sans Frontières (MSF), discussed the mental health crisis in Yemen and the ways MSF is working to promote mental wellbeing.
What kind of mental health issues do you see in Yemen?
Fortunately, in Hajjah governorate we see fewer casualties as a result of fighting compared to the early days of the conflict. What doesn’t usually receive attention, though, is the impact that this conflict has had on people’s wellbeing, and their mental health in particular.
In the city of Hajjah, about 120 kilometers northwest of Yemen’s capital, Sana’a, MSF supports Al-Gamhouri hospital to provide specialised mental health services. The range of conditions that we treat is very large; there are people suffering from anxiety and insomnia, and then we see patients presenting with severe pathologies such as psychosis, depression, bipolar disorder and post-traumatic stress disorder (PTSD).
In our service we regularly see patients following suicide attempts. A suicide attempt can be provoked by a variety of circumstances. Severe symptoms of psychosis can manifest as auditory hallucinations that tell the patient to hurt him or herself, or a patient might be suffering from severe depression. In the case of psychosis, it is important to understand the subjective experience of the individual, since hallucinations can seem very real and create a great deal of suffering.
"Living in a context of war means being exposed to constant stress for a long period of time."
Why are there so many patients suffering from mental health conditions?
Mental wellbeing is very much affected by external factors. The more intense someone’s circumstances are, the more their wellbeing will be impacted. Living in a context of war means being exposed to constant stress for a long period of time. Armed conflict in Yemen has not only affected people’s physical health: it has reduced their access to healthcare, education, and food, it restricts their freedom of movement and denies them the freedom to express themselves. This creates serious mental health disorders.
Patients with mental health issues in Yemen are no different to others experiencing conflict around the world. But 45 per cent of the patients we see in the MSF mental health clinic are severe cases. The number of severe cases is astonishingly high, especially taking into account that worldwide, and even in conflict settings, the number of patients presenting severe mental health conditions should not exceed 5.1 per cent of the total cases, as defined by the World Health Organization in 2019. The lack of services in the area of Hajjah city and for several kilometres around it means that all severe cases in the area are directed towards our services, which may explain the numbers.
How many people need medical support?
Authorities have identified more than 9,000 patients in the Hajjah area who are in need of mental health services. The actual number is probably even higher, since mental health needs tend to be underestimated. People often come to our clinic from distances of more than 100 kilometres to access our services, and it indicates the high needs across the country.
Because of the war, the population in Hajjah is accustomed to high levels of violence. People here are very resilient and their tolerance to adverse circumstances is very high. This means that they arrive at mental health consultations only if a mental health issue has become very obvious and disruptive to the patient and his loved ones. For instance, a family might only become alarmed and seek help when a patient is at the point of becoming agitated or paranoid and is threatening to hurt others.
The war and the lack of mental health services in the area has increased the prevalence of these sorts of conditions. In March, June, and July (for example) of this year, more than half of new patients seeking help at the MSF clinic presented with severe mental health disorders. The treatment of severe mental health conditions is very challenging here. In Yemen the first option for people with mental health symptoms is to seek spiritual treatment. The consequence of this is that sometimes, by the time that patients arrive at our clinic, they have been exposed to ineffective and sometimes harmful practices that exacerbate their symptoms. Seeking spiritual treatment instead of going to a health facility indicates the lack of mental health awareness among the population, another pertinent factor in this context.
What can be done to improve the situation in Hajjah?
It is essential to try to help the population to understand what mental health conditions are, and how to recognise them. This would give patients and their families at least some of the tools to handle severe conditions. In the case of psychotic patients presenting severe signs of agitation, the families often have to resort to chaining them, sometimes with fixed chains that patients wear for days or weeks, to deal with their crisis. When asked about these methods, the families clearly explain that they do not know how to handle the patients in moments of severe aggressiveness and agitation, when they pose a danger to those around them, so they apply these measures. Even If we empathise with the family’s need to control the symptoms, we have to take into account that these measures are extreme and in violation of basic human rights. This is one of the reasons why it is paramount to work on mental health awareness, so that when they face these types of symptoms families know where to turn to for professional help.
Lack of awareness and stigma are two sides of the same coin. Lack of awareness leads to stigma, discrimination, and segregation, and this leads to people hiding their conditions, increasing their suffering and isolation. This is particularly the case for women who are discouraged from sharing their feelings and from speaking up about their psychological struggles. In many cases this leads to severe states of depression.
What is the way forward?
In our daily work at the MSF clinic in Hajjah, we try to normalise mental health issues and help change the social understandings and associations that link mental health conditions with things like “craziness” and “danger”. These associations create stigma and suffering for mental health patients and their families. Norms do not change as fast as we would like, but it is our hope that if we keep committing to our work, the changes in our practices will have a direct impact on the way these notions are articulated within society, leading to a slow but hopefully sustainable change.
Even if the conflict were to end tomorrow, what it has done to people’s psychological health will be seen and felt for many years to come. Yemen needs a long-term comprehensive approach including more services to address the looming mental health crisis. If overlooked, mental health issues can turn into chronic problems on a larger scale, resulting in the isolation of those suffering from disorders. This can lead to further damage to the social fabric, which is already very weak. It is our hope that through our collaborative work we can contribute to improving the mental health conditions of a population that has already had to face and overcome adversity at profoundly deep and devastating levels.