In areas of armed conflicts, efforts to provide mental health services for refugees
and internally displaced populations (IDPs) generally lack measures of effectiveness,
and the gap between research and practice is significant (1). The Syrian Crisis has
been described by the United Nations High Commissioner for Refugees (UNHCR) as “the
great tragedy of this century” (2). The UNHCR reports at least 24 agencies currently
providing mental health and psychological support to Syrian refugees (3). The actual
interventions provided vary considerably among the agencies, which complicates the
implementation of academic research and mental health services in humanitarian settings
(4). This is further challenged by the limited academic publications on the matters
of Syrian refugees’ mental health beyond basic needs assessment (3, 5–7). In an effort
to standardize mental health interventions in humanitarian settings, the Inter-Agency
Standing Committee (IASC) had published standardized guidelines for provision of mental
health services, but had not addressed the role of academic research (8). Creating
a research agenda for mental health in the less-resourceful settings has been emphasized
(9). However, there are barriers to establish academic research in emergency humanitarian
settings. Those barriers have been identified before (8), and we will mention few
examples here in relevance to the Syrian scenario.
The research conducted in conflict settings is often designed and executed by “foreign”
institutions outside the area of the conflict or disaster (8), and the Syrian Crisis
is no exception (5, 6, 10). This is likely to affect the efficacy and sustainability
of interventions. Incorporating local institutions and humanitarian workers in designing
and conducting the research would likely foster a sense of ownership in the locals
and ensure sustainability. For instance, thousands of educated Syrian youth have sought
refuge in the neighboring countries since the beginning of the conflict (11). Incorporating
this educated population as research assistants and cultural brokers in mental health
research projects would enhance ownership, sustainability, and efficacy of such projects.
Another obstacle for academic research is reaching the non-refugee; i.e., displaced
populations. The internally displaced living within the battlefields inside Syria,
is an example (10). Additionally, mental health research in refugee camps across the
borders requires availability of basic needs such as shelter, food, water, and basic
medical services which are not always secured, or stable (12), and can interrupt research
efforts. Hence, initiating needs assessment, intervention implementation, and effectiveness
studies in the relatively more stable areas such as Turkey (13) can allow for manageable
pilot research projects. In the future, those studies can be replicated and tested
in less stable areas.
In a recent study (currently in press and detailed elsewhere), one of us (Hussam Jefee-Bahloul)
and colleagues surveyed a sample of Syrian refugees in a busy refugee primary care
clinic in Kilis Turkey (6). The assessment used a standardized and validated tool
that can reflect psychological stress. In brief, a significant number of refugees
(41%) met the cut off criteria for needing further psychological assessment; however,
less than a half had a perceived need to see a mental health specialist, and less
so was open to mental health services provided via technology (telepsychiatry). The
example of telepsychiatry here is relevant to the topic of this article as it represents
an example of mental health innovative interventions that require testing in humanitarian
settings. Conducting a sufficient basic needs assessment in a very busy primary care
refugee clinic had mandated administration of a simple, time-efficient, and non-threatening
questionnaire rather than standard psychological stress test batteries. Recruitment
process was received with mixed reactions by the refugees; either desperation to seek
help or suspiciousness of the foreign workers (even though our data collection was
done by an Arabic speaking Arab-American medical student). Also, subjects of the study
were hesitant to cooperate given the stigma surrounding mental illness in the Syrian
culture. Nevertheless, this kind of needs assessment studies can be replicated and
used as cornerstones for interventions effectiveness studies in the unstable conflict
areas of Syria.
Here thereafter, a philosophical gap lies between the academic “perfectionistic” views
on research and the “practical” perspectives of humanitarian workers (e.g., the focus
of humanitarian workers on immediate short-term-outcomes rather than long-term-outcomes)
(8). This gap is justified by the emergency context of these situations. Refugees
fleeing conflict areas may exhibit acute symptoms of psychological stress that require
immediate attention by the humanitarian workers. The application of academic research
in these acute settings may not guarantee immediate effective remedies for people
under duress. Humanitarian workers may also have concerns that application of research
designs will interrupt the flow of humanitarian work. This can explain the hesitance
to incorporate research in conflict settings. On the other hand, the expansion of
this gap will prevent field-based humanitarian interventions from catching up with
evidence-based medicine. Hence, the need to bridge this gap and address these valid
concerns has never been more imperative. Incorporating thoughtfully designed interventions
and standardized outcome measurements into the routine humanitarian protocols and
training manuals may help solve this problem. It is worth mentioning that some academic
projects had successfully incorporated academic research into humanitarian settings
in the past (14–19) and more is hoped to be accomplished on mental health of those
affected by the Syrian Crisis.
Finally, the schism between the academic and the humanitarian platforms and audiences
adds to the observed gap. The academic literature and the humanitarian platforms rarely
merge. Some academic journals have designated certain issues to humanitarian causes
(4), however, this does not guarantee delivery of this information to the target audience,
i.e., humanitarian organizations, workers, and policy makers. Unifying the academic
and humanitarian platforms, can allow audiences from both fields to interact, share
experience, and collaborate on much needed mental health research in areas of conflict.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.