FCV Health Knowledge Notes Mental Health and Psychosocial Support in Fragile, Conflict, and Violence (FCV) Situations Five key questions to be answered SUMMARY Mental health challenges in FCV situations are increasingly recognized by countries and international humanitarian and development agencies. This note highlights the best practices in designing, implementing, and evaluating a project involving a mental health and psychosocial sup- port (MHPSS) component Source: Amnesty International. disorders were US$2.5 trillion, among which two-thirds Q1 WHY invest were indirect costs due to productivity loss, a very high proportion in contrast to other common disease groups. In in mental health and an FCV context, the developmental impact of other psychosocial support development supports (such as education and employment supports) may be compromised without MHPSS. Inaction in FCV situations? with mental health problems may further increase vulnerability to and perpetration of violence. Two billion people live in countries that are affected by Investing in mental health has good economic returns, FCV. While mental and substance use disorders are the with the ratio of benefit to cost between 3.3 to 5.7. Many leading cause of years lived with disability (YLDs) interventions have been demonstrated to be very cost worldwide, the prevalence of mental health disorders effective (cost per disability-adjusted life year [DALY] can double in FCV situations. Between 15 percent and < 3 x GDP per capita) (cost per DALY < 1 x GDP per capita) 20 percent of crisis-affected populations develop mild-to- in low- and middle-income countries, respectfully. In moderate mental disorders such as depression, anxiety, scaling up mental health treatment and services, the and post-traumatic stress disorders (PTSD); some estimated total annual costs for all incident depressive estimates put that figure closer to 40 percent. An estimated episodes in receipt of treatment, including training and 3–4 percent develop severe mental disorders, such as other program- level costs, were as much as 2.50 psychosis or depression and anxiety. International Dollars per capita for low-income countries. Mental health problems not only harm an individual’s The World Bank has formulated country investment well-being and functioning but also limit educational cases for mental health (Ukraine, global) and strategies achievement, employment, and economic growth. It is to systematically incorporate MHPSS in operation projects estimated that in 2010 the global economic costs of mental (a toolkit, FCV MHPSS website). 1 Source: United Nations Population Fund (UNFPA), elist10.com, and jasontanner. Q2 WHO has mental problems but also leads to social stigmatization toward health needs in FCV victims, and victims may be unwilling to reveal information and seek help. situations? Children and adolescents are more susceptible to mental Various FCV contexts pose different mental health health issues than adults during conflicts. The PTSD challenges and require tailored solutions. Mental health prevalence among these groups may be as high as 50–90 also needs to be addressed in a country’s cultural and percent and major depression from 6–40 percent. social context. The perception, diagnosis, and services for mental health vary across cultures. Moreover, mental Wounded and disabled people have a higher risk of health problems often coexist with other physical developing psychosocial trauma symptoms in reaction to comorbidities, there- fore requiring an integrated approach. medical procedures, changes in their physical capacity and family and social role (for example, divorce and Victims of armed conflicts and violence experience high unemployment), and stigma or negative attitudes toward levels of insecurity, uncertainty, and loss, and disruption of them. Psychosocial supports may be needed to help daily life, and are more likely to develop extreme distress, patients cope at different life stages. depression, PTSD, somatization disorder, and alcohol abuse. Due to conflicts and violence, 65 million people (1 People affected by pandemics and emergencies (such percent of the world’s population) are forcibly displaced (24 as Ebola) experience extremely high levels of fear, anxiety, million refugees and 41 million internally displaced), face frustration, and mistrust in the affected communities, and numerous challenges during migration, and continue to social isolation. While community support and leadership experience stressors such as social isolation, poor access are necessary for effective case detection and tracking, the to education and employment, and financial hardship in the fear and mistrust make community engagement and resettlement process. community-based care extremely difficult. Survivors of sexual violence and gender-based Helpers and service providers (such as emergency violence (SGBV) include not only women and girls, but medical staff, community leaders, community health also men and boys. While gender-based violence (GBV) workers, and teachers) provide essential services and help affects 35 percent of women worldwide, it may be others. While helpers also experience the insecurity and exacerbated by conflicts and displacement, and affects as fear in their daily life, they may have additional distress from many as 50 percent of women. SGBV can take various work due to long hours, lack of resources, and secondary forms. Data on sexual violence against men and boys are trauma by witnessing the trauma of others. These often- less available. SGBV not only causes mental health 2 Q3 WHAT interventions • Capacity building for health staff and/or key community could be considered? actors to provide basic individual or group psychosocial supports; neglected individuals also need psychosocial support to • Providing MHPSS support to victims by mental health improve their well-being and improve the effectiveness in practitioners, health staff, or key community actors helping others (see ICRC guidelines for more details). through individual consultation, home visits, and group International guidelines recommend low-intensity and low- support; and • Advocacy, information provision, and sensitization. Some successful programs are Problem Management BOX 1 International Guidelines Plus (PM+) in Pakistan, and the step-by-step e-mental health program in Lebanon. on Providing MHPSS in FCV Situations Survivors of SGBV: IASC, ICRC, WHO, UNHCR, UNFPA, UNICEF, and the empirical literature have outlined good • WHO’s mhGAP for scaling up mental health practices in providing supports to victims of GBVs. In practice, a multi-sectorial integrated package of services services in low- and middle-income countries could be provided (see World Bank Project in DRC, Burundi, (mhGAP tools and training materials are widely and Rwanda) including medical, psychosocial, forensic, used to train providers) legal, and security supports. The delivery of GBV programs • IASC guideline for MHPSS in emergency could leverage phone-based interventions or synergize settings with the provision of reproductive and maternal health services, HIV services, or other basic health services to • WHO’s Building Back Better delineating reduce stigma associated with seeking GBV care and 10 country experiences in building back mental improve continuity of care. At the community level, good health systems interventions include advocacy and community sensitization programs to reduce stigma; offender • WHO and UNHCR’s toolkit for assessing MHPSS rehabilitation programs to prevent GBVs; and economic needs and resources empowerment and livelihood programs to help the vulnerable individuals achieve economic reintegration, boost self-esteem, and improve economic independence. cost MHPSS interventions in non-specialized health care and community settings complemented by referral of Children: UNICEF has extensive resources on MHPSS for severe cases to specialized health facilities. children. A systematic review of 11 randomized control Partners in Health’s mental health value chain (Table 1) and trials demonstrated the beneficial effect of focused psycho- a review of 61 MHPSS programs summarized the general social support interventions for children. In brief, MHPSS best practices for delivery of MHPSS services in FCV for children needs to be age appropriate, safe, and help contexts: children to learn and develop life skills and coping mechanisms. Other commonly implemented and evaluated • Deliver services at both the community level and the practices include Mercy Corp’s advancing adolescents facility level program in Jordan, Lebanon, Iraq, Syria, and Turkey; • Train community health workers and non-specialized comfort for kids (C4K) program (World Bank project in health professionals to deliver services Liberia); game- based interventions for Syrian refugees in • Work on the whole value chain: prevention, case Turkey; and a wide range of school and community-based finding, enrollment, treatment, follow-up, and interventions, and children friendly spaces worldwide. reintegration The wounded or disabled: Training and supervision of Specific best practices for various 1) hospital and/or physical rehabilitation staff, 2) local psychologists or counsellors, and 3) family members and vulnerable groups care- givers to provide MHPSS for preoperative patients, post- operative patients, and during the rehabilitation stage Victims of armed conflicts and violence: ICRC, IASC, can be considered. UNHCR, and WHO have summarized good practices in providing mental health programs targeting victims of People affected by pandemics and emergencies: IASC armed conflicts and violence, including internally displaced has developed guidelines for MHPSS in the acute persons (IDPs) and refugees. In brief, programs could emergency and post-emergency phases of pandemics. include: Besides managing mental health problems, restoration of the com- munity’s trust and resilience are also crucial goals 3 TABLE 1 Partners in Health’s Mental Health Value Chain for MHPSS (excerpt from Marquez (2016)) Training and Supervision: Clinical, Programmatic, Academic/Research Safety, Quality, Outcomes Measures (M&E), and Performance Improvement Prevention Case Finding Enrollment Treatment Follow-up Reintegration Health facility Health facility Health facility Health facility • Ongoing • Psychoeducation clinical care: • Choosing • Monitoring of • Diagnosis treatment plan symptoms and • Formulation • Medication functioning • Mental status • Screening management • Medication exam • Referral • Psychotherapy adherence • Medical exam • Community • Evaluation • Hospitalization support and laboratory/imag stigma • Crisis monitoring of ing • Staff and reduction management side effects • Triage severity community • School/ • Social • Social education religious-based interventions interventions • Social activities • Psychotherapy interventions • Staff and • Peer support community Community Community Community Community groups education • Intersectional • Parent and Ongoing: Referral to health collaborations family • Coordiation center by: education • Symptom • CHW • Home visits • Psychoeducation monitoring • Community • Assignment of • Psychotherapy • Medication member sick role • Social monitoring • Traditional • Case finding interventions • Adherence healer (passive and • Monitoring support • Family active (medication) • Psychosocial members support • Church • Psychotherapy • School • Observation Source: Marquez, Patricio V. 2016. Mental health among displaced people and refugees: making the case for action at the World Bank Group (English). Washington, D.C.: World Bank Group. 4 of the psychosocial interventions. From a health policy perspective, the need for an emergency mental health Q4 WHAT has been done at plan with surge capacity for emergencies was an important lesson from the Ebola crisis. the World Bank? What are the challenges Helpers and service providers: Psychosocial support programs for helpers could incorporate structural support, and lessons learned? use workshops and meetings to train helpers to help them- selves, train helpers as peer support facilitators, train helpers to help others, and provide supervision to helpers. 38 World Bank projects with a MHPSS The employed: Comprehensive programs are available to component improve the mental health of the employed and entrepreneurs (World Bank Project in Pakistan) with the • 8 Health, Nutrition & Population (HNP) Global objective to improve economic productivity and business Practice operation projects (Appendix A) growth. • 30 Operation and knowledge management projects (2010–2015) in non-HNP Global WHO’s guidelines include a five-step process for Practices: Social, Urban, Rural, and Resilience (21), Social Protection and Jobs (4), Education BOX 2 Technologies to Support (4), Finance, Competitiveness and Innovation (1) Mental Health Programs • Ukraine, global and strategies to systematically incorporate MHPSS in operation projects • Globally, mobile technology has been applied to (a toolkit, FCV MHPSS website). improve mental health care. • People affected by conflicts, particularly displaced 7 World Bank reports and papers populations, have high ownership rates of on MHPSS handphones and smartphones. • Moving the needle: mental health stories from • In FCV contexts, SMS has been used to diagnose around the world (2018) depression among refugees. • Mental health in transition (Ukraine) (2017) • Technology has also been used to deliver • Mental health among displaced people and therapeutic interventions: A digital game refugees (2016) intervention for Syrian refugee children in Turkey • Mental health in Afghanistan: burden, challenges, effectively improved refugee children’s skills and and the way forward (2011) mental health; tele-psychiatry and psychological • Mental Health and Conflicts: Conceptual counseling have been used for service delivery for Framework and Approaches (2005) Syrian refugees in Lebanon and other countries; • Funding Mental Health in Post-Conflict Countries and an e-mental health intervention has been (2004) conducted in Lebanon. Smartphone-based mental • Integrating mental health and psychosocial health programs have been delivered to refugees interventions into World Bank lending for conflict- in Middle East and Europe with support from peer affected populations: a tool kit (2004) refugees and nonprofessional helpers. • In addition, there is growing interest in exploring 3 World Bank resource websites how social media can be used as a tool to provide on MHPSS social support. • Resources for Psychosocial Support in Fragile and Conflict-Affected Settings • World Bank mental health website • Violence against women and girls—resource guide 5 BOX 3 Financing Mental Health Care • There has been very limited financing for mental health in FCV countries. More funding from donors, country governments, and development agencies is needed to scale up mental health services in FCV contexts. • A World Bank report explored innovative funding mechanisms for mental health care, including the social impact bond, development impact bond, and other financial instruments. BOX 4 Voices from the Field Common Challenges Emerged from Task Key Lessons Learned Team Leader Interviews • Focus on community-level and primary care • Limited funding: Lack of mental health funding provision of psychosocial counseling and from donors and country budgets referral of severe cases • Demand side: Government, communities, and • Aim to improve well-being, functioning, and target populations may have low awareness of resilience at individual and community levels mental health problems and needs. Many cultures • Build local capacity (community health workers, also have stigmas toward mental health issues community leaders, and so on) and medicalize mental health issues. • Close collaboration and coordination with • Supply side: Some countries have low capacity partners and key stakeholders are critical to for mental health care (such as very low number of success qualified mental health professionals and lack of • Pre-launch period to allow system to adjust and specialized mental health facilities, medicines, and ensure language, cultural, and social health data) appropriateness of programs in local context • Sustainability: Large-scale mental health • MHPSS programs should be part of the cross- programs are expensive. There is uncertainty in sectoral efforts (including basic services, program scale-up by the national government education, livelihood, and other community without additional funding after completion of a resilient programs) to restore normality of life. World Bank project. • Use emergency MHPSS program as an opportunity for the country to develop or harmonize the national mental health strategy, and improve awareness and preparedness of country to future emergencies and related mental health issues (see Turkey example) 6 Q5 HOW should we evaluate mental health interventions? systematically evaluating mental health programs and policies, as well as an assessment instrument for evaluating mental health systems. A systematic review of empirical literature also highlighted several emerging trends in practices of evaluating mental health programs in FCV contexts. Study Design Six Dimensions to Measure Measurement Instruments • Mixed methods evaluation to • Program output indicators (such • A set of standardized instruments evaluate both the program rolling as the number of community health validated in FCV settings are out and outcomes (example 1) workers trained and supervised and available to measure various • Good designs (RCTs and quasi- the number of individuals or indicators, including: program experiment study designs) preferred households that received MHPSS output, anxiety, depression, and if context appropriate services) other mental health disorders, • Potentially harmful effects of • Recipients’ mental health quality of life, stress, insecurity, mental health interventions (article outcome indicators (such as stress traumatic stress, function and 1, 2) need to be considered and distress, depression, cognition, coping, resilience, hope, social • Differential impacts to subgroups and functioning) support, cognitive outcomes, (such as children, women, those • Resilience and coping indicators education performance, and who experienced GBV, more severe • Education and livelihood economic productivity. Moreover, cases) are important performance indicators customized instruments are also • Service referral indicators (such as available for targeted groups such number of people referred for as victims of wars, GBV, and youth. medical and other services) New technology such as biomarkers • Cost and cost-effectiveness and tablet-based cognitive tests and indicators surveys are increasingly used. The FCV Health Knowledge Notes Series highlight operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, The Netherlands, Norway, Sweden, Switzerland, The United Kingdom, as well as IBRD. . Author: Di Dong, Health Economist, Health, Nutrition and Population Global Practice, World Bank Group For more information on other HNP topics, go to www.worldbank.org/health 7 Health, Nutrition and Population Global Practice Operational Projects Project Challenges Size Year of TTL/Key Contact and Lessons Country Project (million $) Approval Person Mental Health and Psychosocial Interventions Learned Bosnia (P044424) War Victims 9.85 1996 Nedim Jaganjac Community-based psychosocial rehabilitation ICR report Rehabilitation Project (Technical Annex) Afghanistan (P129663) Afghanistan: 650 2013 Ghulam Sayed, Mental health services as part of Basic Package of System Enhancement Mohammad Health Services for Health Action in Hashemi (Project paper) Transition Project DRC, (P147489) Great Lakes 44.4 2014 Hadia Samaha, Integrated support for GBV survivors and violence ISR reports Burundi, Emergency Sexual and Patricia Fernandes, prevention at community and health facility level. Rwanda Gender Based Violence Verena Phipps- Integrated supports include medical, mental, & Women’s Health Ebeler, Miriam forensic, legal, social supports, and economic Project Schneidman empowerment. The project also promoted integration of GBV screening, support, and prevention with maternal and reproductive services and other basic health services (PAD) Liberia (TF0A0088) 0.8 2015 Rianna Comfort for Kids (C4D) Program GRM report Community-Based Mohammed- (blog article) Psychosocial Support Roberts, Preeti to the EVD Outbreak Kudesia Liberia (P146591) Supporting 2.75 2015 Preeti Kudesia, Psychosocial support and capacity building to ISR reports Psychosocial Health and Rianna improve long-term psychosocial health and resilience Resilience in Liberia Mohammed-Roberts at the individual and community level (PID) Guinea, (P152359) Ebola 390 2015 Preeti Kudesia, Counseling and other psychosocial support for Liberia, Emergency Response Ibrahim Magazi, patients and families in response to Ebola crisis Sierra Leone Project Shiyong Wang (PAD, PAD for additional financing) Yemen (P161809) Emergency 483 2017 Moustafa Abdalla Basic mental health services delivered by mobile Health and Nutrition teams in an integrated outreach model, and Project household level psychosocial support to women and children conducted by a network of community health volunteers and midwives. (PAD) Lebanon (P163476) Lebanon 150 2017 Nadwa Rafeh Provision of basic mental health package at primary Health Resilience health care clinics. Package includes (1) screening Project and case management of depression, psychosis, developmental disorder, and alcohol/substance abuse; (2) consultations with psychiatrists, psychologists, general practitioners, and social workers; lab tests and medication treatment (PAD)