Despite Lebanon’s turbulent history, a study carried out last year by the World Mental Health Initiative has shown the prevalence of mental health problems in the country is similar to that of the United States and the United Kingdom. Should the Lebanese rejoice at their iron-will? Are they simply more resilient? If so, what role does conflict play in forming this resilience? The results of this study produce as many questions as they do answers. Perhaps the most obvious among these questions is how a country like Lebanon, whose recent history has been so marred by violence and destruction, can have the same proportion of mental health problems as domestically secure nations who have faced no such political upheaval.
Reviews of the study by various science groups have posed a similar question. In an article titled “War and Mental Health in Lebanon,” the British blog layscience.net asks: “Are we really as stressed as the inhabitants of a war-torn nation? If the World Mental Health (WHO) Initiative surveys continue to show this trend, then some fundamental questions will have to be asked about why our secure, Western lifestyles don’t appear to be calming our minds, or reducing diagnoses.”
In an accompanying comment on the study, Ahmad Mohit of the WHO stated that the study “emphasizes the detrimental effect of war on mental health, but also indicates the resilience of the Lebanese population.”
The study was conducted in collaboration with various Lebanese universities; researchers interviewed a random selection of nearly 3,000 adults living in Lebanon using an Arabic version of the WHO’s “Composite International Diagnostic Interview” (CIDI 3.0). This interview tool generates diagnoses of mental disorders in the form of DSM-IV codes: the American Psychiatric Association’s standard codes for diagnosing mental disorders.
The study found that approximately one-quarter of the sample group had suffered from at least one type of mental disorder in their lifetime, major depression being the most common of these disorders. Almost identical results were produced by a similar study in the United States, published by the National Institute of Mental Health. “An estimated 26.2 percent of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year.”
The findings of the WHO study also show that “in Lebanon exposure to war-related events greatly increases the risk of developing for the first time several mental disorders,” adding that “further studies are needed to discover whether this finding” can be generalized to other countries.
These results pose the question: if war greatly increases the risk of developing mental illness, how can the Lebanese be as “mentally healthy” (for want of a better term), as the populations of the United States and the UK?
Dr Tima Al-Jamil, an assistant professor and clinical psychologist from the American University of Beirut, says that the supposed resilience of the Lebanese is based on identifiable phenomena.
“Psychological research has shown that there are many protective factors, including community/family support and religiosity, which are both highly prevalent in Lebanese society.”
This phenomenon – the “protective” factors in Lebanese society that can offset mental distress – goes some way to explaining why mental disorders may be less prevalent in Lebanon than in the US.
However, Al-Jamil also noted some problems with applying US measures to diagnose mental disorders.
“There are concerns of limitations regarding these general findings,” she says. “There are questions as to whether US-based measures and diagnostic categories can tap into the psychological distress in countries and societies outside the US, and thus may explain this downward shift in psychological distress.”
Given that the Lebanese have endured many years of war, involving their own countrymen as well as foreign powers, could this play a part in building resilience to mental disorders? According to the study, such actions (war and violence) should be expected to produce reactions (compensation).
“Ongoing conflict requires individuals and communities to develop coping strategies,” says Al-Jamil.
“Some of these coping strategies can be healthy, such as community work, the building of social and family ties, increased faith and ideology, increased determination, etc. However, other times, coping strategies can be unhealthy such as a sense of fatalism, passivity and dissociation,” she adds.
Both the WMHI and mental health experts within Lebanon agree that the Lebanese fair comparatively well in their mental health compared to the US and UK. However, there is also a consensus that war has a severely detrimental effect on people’s mental health. Al-Jamil was keen to stress the “extremely significant” role of war in causing mental disorders.
“War results in direct psychological effects such as terrifying intrusive thoughts and images known as flashbacks, a debilitating and uncontrollable avoidance of anything related to reminders of war, as well as general feelings of fear and mistrust.”
In addition to these direct causes, says Dr Al-Jamil, war also has indirect results associated with “the chaotic environment both outside and inside the home such as heightened supervision, increase use of drugs including alcohol, nicotine and sedatives, increased fear and anxiety of parents which gets transmitted to children.”
A similar study entitled “The Psychological Conditions of Children and Youth in Lebanon After the 2006 War” – conducted by a group of mental health and educational experts with the Lebanese Association for Educational Studies and the Kuwait Society for the Advancement of Arab Children – studied the effect of the 2006 Israeli invasion on the mental health of children in Lebanon. Somewhat predictably, the study supported the general conclusions of the WMHI study: it found a direct link between exposure to war and mental disorders, post traumatic stress disorder (PTSD) being the most prevalent in this case. Interestingly, the levels of PTSD among children in Lebanon were shown to be significantly lower than in other war torn countries; 26 percent of children in Lebanon showed symptoms of PTSD, compared to Gaza (2003) where 54 percent showed symptoms, and 42 percent in Afghanistan (2004). The difference in these results could be explained by the length and severity of each conflict.
The study also found that those with lower socio-economic status showed the highest clinical elevation, meaning that it is the poor who suffer most in war. Geographically, Nabatieh was the place with the highest exposure to war, and in turn the highest elevation of symptoms.
However, the study on 2006 noted that it was “remarkable” that the governorate of Beirut registered the highest clinical elevation of symptoms, even though the governorate of Nabatieh suffered the most exposure during the war. One explanation, the study continued, was that the impact on mental health in the south was less “because of ideological reasons, or what is referred to in psychology as resilience.”
This is a hint that areas like Beirut and North Lebanon, which haven’t been used to bearing the brunt of military action in recent years, could see their populations suffer relatively “worse” damage, because people lack the compensating factors that have built up over time in areas closer to the “front lines.”
Al-Jamil argues against complacency in light of the general findings on mental health in Lebanon, and says the local community should undertake a thorough self-examination, despite the indications that Lebanon is as mentally healthy as western European country.
“Compared to the US we are doing great, but we do have problems and we should focus on them. We should compare results among our own children and try to combat the rise in symptoms, regardless of how the US is doing.”