|Year : 2019 | Volume
| Issue : 2 | Page : 217-224
Psychological and psychiatric care for Rohingya refugees in Bangladesh
Geraldine M Dyer1, Mukti Biswas2
1 MBBS, MPH, FRANZCP, Médecins Sans Frontières, Australia
2 Masters Clinical Psychology, Médecins Sans Frontières, Australia
|Date of Submission||22-May-2019|
|Date of Decision||21-Sep-2019|
|Date of Acceptance||30-Sep-2019|
|Date of Web Publication||29-Nov-2019|
Geraldine M Dyer
MPH, PO Box 696 North Cairns, Queensland, 4870
Source of Support: None, Conflict of Interest: None
This field report outlines a mental health and psychosocial programme provided by Médecins Sans Frontières for Rohingya refugees in Cox’s Bazar, Bangladesh. This specialised programme focuses on the identification, assessment and management of moderate to severe mental health disorders whereas the majority of mental health and psychosocial support programmes within this context are providing focused non-specialised care. The activities provided by the programme include counselling, psychological intervention and treatment with psychotropic medication. An outreach model utilising volunteers from the refugee community is critical for case identification and community sensitisation. There were challenges with recruitment of appropriate human resources and adequate space for consultations. The most common presentations are psychotic disorders − many of the patients have long histories of untreated illness. Discussion considers cultural factors relating to mental health in the Rohingya community and comparisons with mental health and psychosocial support programmes in a number of humanitarian contexts.
Keywords: Médecins Sans Frontières, moderate and severe mental disorders in refugees, psychiatric care in humanitarian contexts, Rohingya refugees
|How to cite this article:|
Dyer GM, Biswas M. Psychological and psychiatric care for Rohingya refugees in Bangladesh. Intervention 2019;17:217-24
| Introduction|| |
Complex humanitarian contexts
It is well established that mental health remains one of the most under-resourced sectors of health care when considering age-standardised years lived with disability (YLDs) (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018; Inter-agency Standing Committee (IASC), 2007). Hence, the expenditure on mental health in most countries during times of stability is not meeting the need − let alone when there are additional challenges arising from humanitarian crises (IASC, 2007). The usual twelve-month prevalence of severe mental health disorders is 1–2% of the population. However, following emergencies or crises, this figure can increase to 5.1% of the population (Charlson, van Ommeren, Flaxman, Cornett, Whiteford, & Saxena, 2019). This figure does not include other neuropsychiatric conditions such as epilepsy and dementia, which are often managed by mental health programmes in humanitarian contexts.
There has been progress in the last two decades towards routine integration of mental health responses into complex humanitarian contexts. It is only more recently however that such activities have begun to move from a focus on individualised trauma responses to a more inclusive approach providing comprehensive, culturally appropriate, psychosocial services for people with severe mental health disorders. There has also been a shift from vertical, standalone services to implementing, from the start of an emergency, a community-based mental health service response, which could then potentially support progress in national mental health policy (Jones, Asare, Mari, Mohanraj, Sherief, & van Ommeran, 2009).
Several projects in complex, emergency humanitarian settings including Aceh, Pakistan and Ethiopia have found that severe neuropsychiatric disorders − epilepsy and psychoses in particular − were common and outnumbered presentations with trauma-related conditions (Jones et al., 2009). A retrospective descriptive study of data from an Médecins Sans Frontières (MSF) project which provided mental health services in the Philippines in 2013 following a typhoon found that over a quarter of the mental health cases present were severe and the majority were pre-existing conditions (De Moraes Weintraub et al., 2016). These studies have consistently concluded that it is feasible to integrate care for severe mental health disorders into primary care settings in these contexts, that there is a demand for such services and that follow up care is a challenge. In addition, more sustainable programmes are supported by training teams of doctors, nurses and community workers (De Moraes Weintraub et al., 2016).
Context of Bangladesh
In low-income countries, such as Bangladesh, where mental health expenditure and mental health literacy are limited, available treatment for mental health disorders is not meeting the needs of the host community. There will therefore be even greater challenges in meeting those for an already vulnerable refugee population (WHO, 2016). Expenditure on mental health has previously been estimated to be 0.5% of the Government/Department of Health total budget for health in Bangladesh (WHO, 2017). Specialised mental health services and human resources tend to be limited and concentrated in larger urban settings which are primarily institution based (Islam & Biswas, 2015). This reflects the situation in many countries (IASC, 2007). There is little integration of mental health care into primary care settings. For Bangladesh, where there is a population of over 161 million people, there are 0.13 psychiatrists per 100,000 people and 0.12 psychologists (WHO, 2017).
Rohingya refugees remain in an extremely precarious and uncertain situation, fully reliant on humanitarian aid. Prior to displacement, access to health care in general, and psychiatric in particular, was limited or non-existent for the Rohingya population in Rakhine (IOM, 2018; UNHCR, 2019). Rohingya people have particular ways of explaining emotional suffering and severe mental conditions, usually through religious or somatic concepts (Tay et al., 2018). As reported anecdotally by Tay et al. (2018), the majority of cases have been managed in local pharmacies or by ‘medicine peddlers’ (untrained practitioners) often with long-acting depot injections and by religious and traditional healers. Other methods that very often involve serious human rights violations (violence, physical restraint, or neglect and abandonment) have been reported to and even witnessed by the MSF mental health and psychosocial (MHPS) team. These practices can constitute a significant barrier of access to care.
While studies into the mental health of Rohingya people have been limited, those that have been conducted indicate high levels of mental health concerns including PTSD, depression and somatic complaints (IOM, 2018, Tay et al., 2018). Many of these issues are compounded by daily stressors arising from living in refugee camps (Riley, Varner, Ventevogel, Hassan, & Welton-Mitchell, 2017). No epidemiological studies have explored the prevalence of other severe mental illnesses including psychoses, neuropsychiatric disorders such as epilepsy or pre-existing developmental disorders in the Rohingya people or indeed the validity of the available diagnostic constructs. Surveys conducted have indicated that up to 48% of Rohingya refugees are unaware of mental health services (IOM, 2018).
The MHPS programme therefore aims to alleviate the suffering of an extremely marginalised, vulnerable population with unmet needs. By providing this service in line with standard approaches as dictated by MSF’s mental health policy (2015), the aim is also to increase capacity of health workers and other key actors to identify, manage or refer patients as appropriate. More broadly, the programme aims to promote community awareness, reduce stigma and improve identification, assessment and treatment of people requiring mental health support.
| Description of the MSF MHPS programme|| |
An assessment was conducted in Bangladesh by an experienced MSF internationally trained psychiatrist in April 2018 to explore and develop a strategy for the mental health needs of Rohingya refugees. This assessment found that while there were multiple actors providing psychosocial support, the moderate, severe spectrum of mental health disorders was not being adequately addressed. A visit was conducted to the National Institute of Mental Health in the capital city Dhaka to gain an understanding of the training offered and human resources available.
A regular supply of psychotropic medication is also fundamental to meet the needs of patients with severe mental health disorders. MSF has an essential drug list guided by medications most commonly found in low- and middle-income countries, and in keeping with the mhGAP-IG (2016). Practically, it also endeavours to provide medications in line with those available in the particular country and which are easily available and affordable. Scoping needs, available HR resources and psychotropic medication availability were therefore all part of the assessment.
Design of the MHPS programme
The proposal was for two teams, each with a psychiatrist, psychologist, psychosocial counsellor (PSC), to provide a service in the two MSF outpatient departments (OPDs) and hospitals which were already operating and serving a catchment of approximately 170,000 people in seven camps. The facilities provided non-communicable (NCD) disease follow up, general consultations, sexual and reproductive health (SRH) including a maternity service, and medical management of sexual and gender-based violence (SGBV). As these facilities were already established, the teams had to fit into the existing structures. This was only feasible in one at the outset. Factors such as logistic constraints preventing building extensions during the monsoon season, uncertainty about the future of the project and the scarcity of appropriately skilled clinicians hindered the further development of the plan. Service implementation was introduced in a stepwise fashion to match level of activity with initial slow uptake.
While using existing structures enabled the service to be integrated with the medical, NCD and SRH teams who also worked in these facilities from the outset, there were inherent problems with the capacity to provide confidential, private consultations. These issues became increasingly problematic as the number of patients increased, as happened over the ensuing months.
It was particularly difficult to recruit a psychiatrist in a setting where salaries are not competitive, programmes are temporary and long-term MOH positions will take precedence. A solution was developed to recruit, train and supervise mid-range practitioners such as medical assistants to provide support under the guidance of a psychiatrist. Implementation of this strategy was delayed, due to the need for clarification of legal restrictions related to prescribing of psychotropic medication. The programme was fortunate to employ a Bangladesh trained psychiatrist for nearly a year who worked alongside two MSF psychiatrists working as mental health activity managers, but the resignation of this specialist created a significant gap. A decision was made at this time to recruit a general doctor and provide mental health gap action programme (mhGAP) training and supervision in an effort towards greater sustainability.
The mental health activity manager role for the programme thus far has been filled by an international psychiatrist to provide ongoing supervision and training.
Community awareness of activities
The identification and recruitment of local people as volunteers to provide community support and cultural mediation are deemed to be a minimum requirement for establishing a mental health programme in an emergency context (IASC, 2007). It became rapidly apparent that outreach to the community by such volunteers was critical to the identification and follow up of patients, as well as raising awareness within the community.
Initially, the programme had four female volunteers, as there were concerns about the level of untreated sequelae from sexual assaults and gender-based violence. The demand for mental health treatment did not eventuate as anticipated however. The numbers of patients presenting or referred as a consequence of such trauma have remained small, despite increasing numbers presenting for medical care. This is felt to be due to cultural factors with the community attending health services often only as a last resort (Tay et al., 2018).
In order to increase the reach of the service to both men and women, 14 male and female Rohingya refugees were recruited as volunteers in each of the seven camps covered by the project. This led to an ongoing, increasing number of referrals. They have also been extremely valuable in the assertive outreach strategy, by calling defaulters, tracing patients whose adherence is a problem or identification of significant people for collateral information, as well as in communication of the needs and barriers to access to care faced by the population (especially culturally and geographically determined).
Mapping of other actors providing mental health and psychosocial services (MHPSS) and other NGOs in the catchment area was undertaken by the mental health activity manager, which provided an opportunity to network and provide information about the MSF MHPS programme.
A meeting was also conducted with religious and traditional healers to build relationships and facilitate referrals. Involvement of traditional healers is recommended by IASC (2007). Traditional healing plays an important role in Rohingya culture for the treatment of mental health disorders and hence has a role in the provision of culturally relevant treatment (Tay et al., 2019). Following this meeting there was a noted increase in referrals from traditional healers. Regular meetings are planned.
Training was conducted with the outpatient department staff and with the hospital staff, including maternity, to support appropriate referrals. Routine screening for anxiety and depression was initiated in the maternity unit using a shortened version of the generalised anxiety disorder (GAD) and patient health questionnaire 9 (PHQ9) (Staples et al., 2019). A consultation-liaison service model was provided to the hospital for patients admitted with comorbid psychiatric diagnoses, suspected overdoses or self-harm and psychosomatic presentations. A decision was made against actively admitting acute psychiatric presentations, due to the lack of experience of nursing and medical staff, as well as the lack of appropriate and safe space. These patients received more intensive outpatient follow-up.
The majority of referrals continue to be made by the volunteers with other sources, as per [Figure 1]. Only a small percentage is from the team providing medical intervention for SGBV, as discussed above. A small number is also received from other MSF projects which do not have psychiatric support.
Implementation of activities
To maintain dignity, reduce stigma and enable prompt access to the service, a symbol of a tuk-tuk was chosen to represent the service. A tuk-tuk is a three-wheeled motorised mode of transport used throughout Bangladesh. Patients are given a small, laminated card with this symbol and they can bypass the usual triage process. The symbol below is also used to identify the rooms used by the service.
All new referrals are initially assessed by a psychosocial counsellor, the presenting syndrome is identified and a subsequent referral is made to either the psychiatrist or psychologist. Specific activities are described in [Table 1] and [Table 2].
Training and supervision
Jones et al. (2009) have identified key components of training for primary health care workers to address mental health disorders in emergency settings. These include communication skills, basic problem-solving skills, psychological first aid (PFA), identification of common mental health presentations and appropriate prescription of psychotropic medication. The IASC Guidelines (2007) also have a dedicated action sheet for the minimum training required for health care workers.
The MSF MHPS programme has worked towards increasing the identification and appropriate referrals of moderate to severe mental disorders by other health care workers, in addition to training a dedicated team.
The programme has been fortunate in that it has mostly retained dedicated and committed staff throughout the duration of the project. They have gained considerable clinical experience. In addition, the need for appropriately trained translators was identified at the outset of the project and specific training undertaken. Examples of trainings are presented in Box 1.
WHO has undertaken mhGAP-IG training in Cox’s Bazaar as part of a collaboration with the Directorate General of Mental Health and the National institute of Mental Health. WHO describes this training as part of the vision of ‘building back better’ by contributing to a sustainable mental health care system for Bangladesh as well as playing a role in the emergency mental health psychosocial response to the Rohingya crisis. In 2019, several recently recruited members of the MSF MHPS team will attend this training. There are also plans for a doctor and medical assistant from the NCD team to attend the training to ensure that there is confidence throughout the project in assessing and managing moderate mental health disorders. The training will serve as a foundation for the prescribing clinicians in the MHPS programme to manage more severe presentations with further training and supervision by a psychiatrist. A peer supervision network and individual supervision will be implemented.
Daily meetings are held by the mental health activity manager or psychologist supervisor with the volunteers to provide supervision and support. Additional sessions on self-care are planned, as the challenges of both working and living within the refugee community are acknowledged.
| Findings|| |
Routinely collected data have indicated that over a quarter (26%) of patients had a previous history of a chronic physical or mental condition. Many patients have a history of previous treatment, both in Myanmar and the camps, with irregular injections of long-acting anti-psychotics usually prescribed at pharmacies. In total, 11% of patients self-reported as having sought treatment from traditional healers in the camp prior to presenting to the project. This is most likely an underestimation, as there are limitations to data collection currently, which allows for only one source of previous treatment to be recorded for each patient.
Since the commencement of the programme, 664 patients with moderate to severe disorders have been seen. MSF collects patient presentations by the syndrome group − aligned where possible with the mhGAP. The distribution of adult patients by syndrome is illustrated in [Figure 2] and [Figure 3]]. Over a third of adult patients presenting to the service have a psychotic syndrome. Some of these patients and families have reported a duration of untreated illness of between ten and twenty years. On occasion they are brought by family members in physical restraints and there have been instances where patients have reported being beaten or threatened. Over time, as these patients improve and with continued visibility of the volunteers, community awareness of the service and the availability and benefits of effective treatment is increasing, as has been reported to the volunteers and team.
|Figure 2: Proportion of adult syndromes MSF MHPS April 2018–April 2019. Note: 1) MUPS=Medically Unexplained Physical Symptoms. 2)|
Mania is included in psychosis syndromes
Click here to view
Children are underrepresented in the project, given that UNHCR has estimated that up to 40% of the population is under the age of 12 in the camps, as well as evidence from screening that a high proportion of children have emotional symptoms − potentially indicating more severe underlying problems (Kahn et al., 2019). Over a third of children who are referred have intellectual impairments or developmental delays. There are limited community options for supporting these children and their families, so particular efforts have been made to train the counsellors and psychologist in delivering a set number of sessions of psychosocial education to the carers.
Follow-up has proven to be particularly challenging with the majority of patients only attending on average two appointments. Again, the outreach volunteer workers have been critical to addressing this problem and have been actively working to engage with patients who have commenced treatment. In total, 64% of 269 discharged patients were considered to have dropped out of follow up, as they had not attended for over eight weeks and were discharged after efforts to trace them by the volunteers.
| Discussion|| |
The MSF MHPS project has provided further evidence of the need and demand for a dedicated service to treat people with moderate to severe mental health disorders in a humanitarian context. These people are some of the most marginalised and vulnerable members of a community at any time, but arguably even more so in times of humanitarian crisis or upheaval. Consideration of the needs of people with severe mental health disorders in these contexts can, however, also be seen as an opportunity for longer term change and development in mental health care service delivery.
This field report shows that psychosis (35%), depression (22%) and anxiety (10%) were the most prominent disorders among the Rohingya community accessing the MSF MHPS service. Other research has suggested that the most common psychiatric disorders found among refugees are PTSD (19–36%), depression (5–44%) and anxiety (4–40%) (Turrini, Purgato, Ballette, Nose, Ostuzzi, & Barbui, 2017). The significant proportion of psychotic disorders is most likely due to the limited availability of treatment being provided by other actors. This finding has some similarity with those by Goodfriend et al. (2014) that 61% of a cohort in an emergency MSF project in North Kivu, Democratic Republic of Congo, were diagnosed with a psychotic disorder, but only 3% with a major depressive episode. Goodfriend et al. (2014), after consultation with local health staff, speculated that this could be due to families only bringing those patients causing more disruption to them and the community. This project, however, did not actively engage in case finding or community desensitisation, rather it was limited to acute presentations. Future research could explore whether there is an ongoing gap in recognition and acceptability of presenting and being treated for more common mental disorders and trauma, as has been suggested by the limited research already conducted (Tay et al., 2018). It is not clear if people with these presentations are seeking help elsewhere, not presenting at all or utilising other cultural idioms of distress such as somatic symptoms or chronic pain. It has been the experience of the team that most patients − even those with psychotic disorders − describe their symptoms in terms of somatic and bodily sensations.
Of the patients present with psychotic symptoms, it has become increasingly apparent that there are significant numbers of patients with chronic, untreated psychotic illnesses. This is most likely due to the lack of appropriate services in Myanmar, contributing to stigma and low mental health literacy. The duration of untreated psychotic disorders in some cases has been reported by patients and their families as between ten and twenty years. This finding would seem to suggest that severe mental health disorders in this population are not always linked to the emergency situation itself − an issue which other researchers have considered in relation to the demand for mental health care in these settings (De Moraes Weintraub et al., 2016). Instead, this finding would seem to support the hypothesis proposed by De Moraes Weintraub et al. (2016) that the demand is precipitated by external organisations identifying and addressing systemic and structural problems, thereby improving access to care. There are also similarities with the findings of Humayun, Azad, ul Haq, Khan, Ahmad & Farooq (2016) amongst internally displaced persons in Bannu, Pakistan, that 61% of the patients reported onset of symptoms prior to displacement. There were differences however in that 34% of their cohort had a primary diagnosis of depressive disorder with only 3% present with a psychotic episode. For many patients, accessing the MSF MHPS programme is the first opportunity for regular, consistent treatment and anecdotally in some cases it is no exaggeration that the reduction in suffering with symptom reduction and associated improvement in functioning have been life changing.
There have, however, been a number of challenges inherent in the delivery of the MSF MHPS in such a context, some of which have been identified in the literature previously. The scarcity of human resources has consistently been identified as a challenge. Hence there have been increasing moves to train primary health care or non-specialised staff in the identification and management of mental health disorders.
The challenges with recruitment of psychiatrists highlighted the need to train other health care workers in the assessment of mental health disorders and management including the appropriate prescription of psychotropic medication. Our experience is that sustainability is ensured by providing regular algorithm-base interventions (such as mhGAP-IG), crucially combined with consistent long-term clinical supervision of the trained staff. Sustainability frequently fails in the setting of even routine staff turnover without the addition of routine regular training opportunities and persistent quality supervision structures. In Bangladesh, medical assistants play a critical, clinical supportive role and are ideal for such training. Similar projects should explore available clinical resources (with a consideration of prescribing rights) and ensure this training is conducted from the outset of the programme.
Low uptake of services at the beginning of a project should not be seen as a hindrance to recruitment and development of teams. As Jones et al. (2009) highlight, the longer services continue, the greater the number presenting, as awareness of the availability of effective treatment begins to grow. The initial slow uptake may be attributed to limited mental health literacy. As Tay et al. (2018) describe, most Rohingya people believe that mental illness is shameful, a sign of weakness or in some cases a consequence of malevolent spirits (jinn) or a punishment from Allah. Traditional healers or religious leaders are more likely to be consulted in the first instance and health services only if these interventions are not successful. It is important to be respectful of such beliefs, as one treatment does not preclude the involvement of the other. As many Rohingya people will only seek medical help if they believe the origin of a problem is physical, it is an imperative to provide training for medical or primary health care workers in understanding these idioms of distress (Tay et al., 2018). Training provided by the MSF MHPS team has led to a consistent flow of referral from the medical teams. Presentation of patients with epilepsy to mental health services has been documented in other contexts and was a finding in the current setting. This is most likely due to a range of factors including limited supply of anti-convulsants or because people with epilepsy are seen as having mental health problems and are therefore stigmatised. Many will also have co-morbidities such as hypoxic brain injury, developmental problems or behavioural disturbances (Jones et al., 2009). For these patients a referral pathway was established with the NCD team. There have, however, been ongoing concerns about the diagnosis of epilepsy and commencement of anti-convulsant treatment for non-epileptic seizures, as was also raised by Tay et al. (2018). Referrals are therefore also encouraged from the NCD team to allow a more thorough analysis of the case and support to the families to manage through support from the MHPS team. Further training is also planned for identification of epileptic versus non-epileptic seizures.
Practical considerations in implementing such projects in humanitarian contexts include a careful consideration of space. While there are benefits in being integrated in an OPD or primary care setting, privacy and confidentiality need to be ensured. This is challenging in a busy clinic when demand is high and people do not share an understanding about private consultations. Larger rooms to create child-friendly spaces and for group or parenting activities are suggested − particularly in view of the under-representation of children found in this and other similar projects. There are current plans in progress to build a new space for the MSF MHPS team taking into account these factors. Consideration should be given to the use of a non-stigmatising symbol for the service, particularly if literacy levels are low and understanding about terms such as mental health is also limited.
The outreach model supported by Rohingya volunteers was critical to community sensitisation, case identification and follow up, as evidenced by the number of referrals from them. The dedication of these volunteers in view of the challenges of both living and working in a refugee community is acknowledged. Care must be taken to provide opportunities for supervision and support.
Whilst psychosocial services are increasingly available in emergency contexts, patients with severe mental health disorders typically remain beyond the scope of these activities, although they constitute a significant health need amongst the population. The future challenge for the MSF MHPS project is how to integrate with and help build sustainable mental health services within Bangladesh, working with the Ministry of Health. By training, supporting and supervising staff to provide an accessible, effective service, the need for such services continues to be highlighted, in addition to addressing the persistent stigma and discrimination faced by those with severe mental health disorders.
The authors would like to acknowledge the work of Dr Elisabeth Hoffmann, Dr Miguel Palma, Dr Samshun Alam, Muhammad Humayan Kabir Shohag, Mamonor Rahaman, Rubel Dhar and Kawser Mahmud for their previous and ongoing work in establishing the project and activities. Technical support was provided by Dr Tonia Marquardt (Deputy Cell Manager, MSF), Dr Greg Keane (Mental Health Referent, MSF) and Myriam Karimet (Data Project Officer, MSF). The authors were responsible for the conception, research, writing and interpretation of data presented in the field report. Dr Dyer is the guarantor. In kind support only for time to write the report and analyse data was received from Médecins Sans Frontières. The manuscript has been read and approved by both authors.
Financial support and sponsorship
Conflicts of interest
The authors have no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]