BEIRUT (Thomson Reuters Foundation) - Syrian refugee Fatmeh fled to safety in Lebanon in 2011 after militants raided the family home, beat her up and tried to rape her. But her problems were far from over.
Two months after the attack Fatmeh - then aged about 12 - developed Post Traumatic Stress Disorder (PTSD). "Her mental illness became obvious when she started walking down the streets while screaming and beating herself," said Lebanese psychotherapist Charelle Ghazal.
"She had regular nightmares of someone trying to rape her. She put knives under her pillow to protect herself. She was awake all night and slept during the day when her family was awake."
More than a million Syrians have fled to Lebanon since the start of the conflict five years ago, placing a huge strain on health services in the small Mediterranean country.
Up to one fifth of refugees may be suffering from mental health disorders, but gaps in Lebanon's mostly private mental health services and a major shortage of mental health professionals mean many refugees' needs are not being met.
"The public health system in Lebanon is under tremendous pressure and the specialized services that are currently offered for Syrians in need of mental healthcare are not enough," said Rabih Chammay, head of Lebanon's mental health program at the Ministry of Public Health.
There is no data on the number of Syrian refugees with mental health problems, but the World Health Organization (WHO) estimates 15 to 20 percent of people in a humanitarian crisis suffer mild or moderate disorders, suggesting 200,000 Syrians in Lebanon could be affected.
Witnessing atrocities and losing one's loved ones, home, livelihood, friends, community and social standing can all create or worsen mental health problems.
The daily stresses of living as a refugee - lack of access to basic necessities and limited work and education opportunities - add to the pressure.
Common symptoms include anxiety, depression, withdrawal, insomnia, nightmares, tearfulness and despair.
Experts warned that a failure to address mental health problems would have social and economic repercussions for both Lebanon and Syria.
"If mental health conditions in children and adolescents are left untreated this will lead to a 'lost generation' which would have a longterm impact on Syria's future after the war," said Mohamed Elshazly, a regional mental health consultant.
The International Medical Corps (IMC), which provides psychosocial support for Syrian refugees in Lebanon, Jordan and Turkey, said people with untreated mental health issues could gradually lose their ability to function in society.
Children may drop out of school and fail to acquire skills needed to prosper in life. Adults may find it difficult to hold down a job, form healthy relationships or care for their children. This puts a strain on not only the individual but also the family.
If problems remain unaddressed, people's lives can spiral out of control, resulting in homelessness and increasing the risk of physical health problems, injury, violence and abuse, the IMC said.
FEAR OF STIGMA
Mental health services in Lebanon are mostly private so refugees rely heavily on NGOs for mental health care.
The government is now overhauling mental health care and integrating it into primary health care. Chammay said this would allow general medical doctors to offer mental health services and refer complex cases to specialists.
The Health Ministry, the WHO and the U.N. children's agency UNICEF have set up a taskforce of some 60 agencies which is training doctors, nurses and social workers to provide refugees with mental health services.
Psychotherapist Anne Marie Ghossain said one problem facing NGOs is that many refugees do not ask for help because they do not realize they need it. Others may be reluctant to do so when they have no money and are struggling to feed their families.
Ghossain cited the case of Mohamed, a seven-year-old Syrian who was having serious problems adjusting to life as a refugee, and was therefore failing at school. Therapy was helping, but his family stopped his treatment because they could not afford transport to the clinic.
Psychotherapists working with NGOs tend to treat refugees by focusing on changing troublesome behaviors, feelings and thoughts. But Ghossain said some refugees need longterm psychoanalytic therapy, which is difficult to provide given the shortage of specialists and the fact refugees often move around.
The stigma surrounding mental health is another hurdle. Many people are reluctant to attend mental health centers for fear of being seen as "mad". This is one reason why integrating such services into general health provision is important.
In Fatmeh's case, her parents initially took her to religious leaders to read Koranic verses for her. This is a common response in some communities where beliefs that mental illnesses have supernatural causes lead people to seek help from religious or traditional healers.
"When we offered our support, they resisted at first because they feared that their daughter would be seen by others as crazy if she takes pills," said psychotherapist Ghazal.
But Elshazly, the IMC's former regional mental health adviser, said the scale of suffering among Syrian refugees was reducing the stigma around mental health issues.
"Since so many people are affected, these problems have been voiced more and more. This is why there is a gradual change in attitudes," he added.
"For example, we are seeing people from rural areas of Syria who would not previously have admitted to mental health problems and who are now seeking help."
He said it was also widely recognized that humanitarian crises created an opportunity to push policy makers to focus resources and attention on improving mental health services.
Although Lebanon was already addressing gaps in its mental health services before the refugee influx, the crisis has accelerated reforms.
"Because disasters and conflicts lead to an increased incidence of mental health disorders, and because they expose the weak mental health systems in these countries, we get what we call a 'policy window'," Elshazly said.
"People tend to listen more when you talk about mental health during disasters and conflicts."
(Additional reporting by Emma Batha, editing by Ros Russell. Please credit the Thomson Reuters Foundation, the charitable arm of Thomson Reuters, which covers humanitarian news, women's rights, trafficking, corruption and climate change. Visit news.trust.org to see more stories.)