Compounded by the coronavirus pandemic, Lebanon’s nine-month long economic crisis has taken a heavy toll on the mental health of the Lebanese, say experts, who warned of an upcoming “mental health pandemic.”
“It has been a very long confinement that started with the revolution and continued with the virus,” said Pascale Tannoury, a clinical psychologist at a private hospital and psychotherapist.
"That's why now I fear a mental health pandemic. I feel it around me. People can't function normally. They can't pay for sessions either. Therapy is expensive and not paid for either by insurance companies or by social security," she told The National.
Last October, Lebanon’s worst-ever economic crisis reached boiling point, pushing hundreds of thousands into the street and forcing the country to grind to a halt. Shops, schools and universities barely had time to re-open for a few months early in 2020 before they had to close again due to Covid-19.
The consequences of both crises have been dire. Around 60 per cent of the Lebanese could be living in poverty by the end of the year, according to local officials. The Lebanese pound has lost 70 per cent of its value in nine months, while inflation has soared.
“People lack incentive, lose their appetite, have trouble sleeping and difficulty in starting again the activities that they used to do before confinement,” said Ms Tannoury. “These are usually symptoms of depression.”
Because of Lebanon’s extreme financial instability, NGOs have observed that many patients with mental health conditions feel overwhelmed by the pandemic.
“If I get infected, the Lord will help me. I can’t let myself obsess over the coronavirus or I’ll end up in a psychiatric hospital,” said Abir, from the northern region of Akkar.
Trapped in an abusive marriage until her husband’s death three years go, Abir has suffered from depression and suicidal thoughts. Unable to pay for a private psychologist, she has received free mental health support from Doctors Without Borders (MSF) since last summer.
Before confinement measures were imposed in mid-March, Abir, who stays at home to look after her three sons, used to receive financial help from friends, but that stopped when they lost their jobs.
"The economic crisis is very bad. If I'm sick or anything – regardless of psychological problems – there will be no doctor and no medicine," she told The National, highlighting her financial distress.
The World Health Organisation said last month that mental health will become a significant post-pandemic issue.
But few Lebanese can afford a visit to a private psychologist. A session typically costs between US$40 and $200 at Lebanon's official – but barely used - official exchange rate of 1505.7 Lebanese pounds to the dollar, said Ms Tannoury.
Additionally, some psychologists have adjusted their prices in the national currency closer to the black market rate, which currently hovers around 5000 Lebanese Pounds to the dollar. The price hikes have caused anger on social media, with some complaining that it would only fuel further anxiety.
Lebanon’s National Social Security Fund partially reimburses inpatient care and psychiatry sessions but not visits to a psychologist.
This should hopefully change in the coming year when professionals establish their own order, paving the way to partial coverage by state insurance, said Rabih El Chammay, head of the national mental health programme at Lebanon’s health ministry.
But today, certain Lebanese hospitals are reluctant to treat mental health patients if they are covered by one of Lebanon’s six publicly managed funds because the cash-strapped government can take years to pay them back.
"Some hospitals are more cooperative than others, but I think on the ground people are still struggling to get access to in-patient care," Mr El Chammay told The National.
The ministry issued a memo reminding hospitals that they cannot refuse anyone in need of urgent psychiatric care if they are at risk of suicide or suffering from an acute psychotic episode.
“I think the need [for mental health support] will definitely increase because of the compounded crises…What we know from international studies is that there is a risk of increase of two to threefold for suicide, depression and anxiety, during a crisis,” said Mr El Chammay.
Calls to Lebanon’s national suicide hotline, Embrace, have surged since last December.
“Some days we had more than 300 calls when our average per month used to be 300 or 400,” said Embrace’s executive director, Lea Zeinoun. But because of social stigma, the evolution of deaths by suicide is difficult to assess as they are not all reported as such, she added.
As the number of deaths due to Covid-19 has remained relatively low, initial fears caused by the pandemic have been supplanted by worries over Lebanon’s economy.
"The coronavirus feels pretty distant to people now in Lebanon," Ms Zeinoun told The National. "People are now concerned about not being able to pay rent or buy food."
Additionally, new crises can trigger and awaken past traumas, said Nivine Geagea, resilience program coordinator at local NGO Himaya, which works in the child protection sector.
This is particularly relevant in Lebanon, which suffered from a 15-year long civil war that ended in 1990 and a series of security crises in the past decades, including a wave of targeted assassinations against politicians followed by a spill-over of the Syrian war.
“People may be reliving the feeling of insecurity, difficulty to project in the future and to find a meaning and order amid chaos,” said Ms Geagea.
The additional stress in households that are already under pressure can also lead to an increase in domestic violence.
“There is a rise in stress and irritability in people; with the confinement coping becomes harder and harder. We see violence in households,” said Anaelle Saade, mental health supervisor for MSF in northern Lebanon.
However, quantifying this kind of violence is nearly impossible, said Ms Saade. NGOs have reduced their work in the field, meaning that referrals about domestic violence also decreased.
Women's rights NGOs previously told The National that they noticed an increase in complaints of gender-based violence after the pandemic hit Lebanon, with a surge in requests for shelters for life-threatening situations.
Police data reveals a 74 per cent increase in murder cases during the first five months of 2020 compared to the five previous months.
“The majority were committed by people with mental disorders in the context of domestic violence and not for economic reasons” a source from the Internal Security Forces said.
The source attributed the surge in murders to confinement measures imposed by the government to curb the spread of the coronavirus pandemic.
However, Mr El Chammay cautioned against equating mental health issues and crime.
“Occurrences of acts of violence is not higher in persons with mental disorders than in the general population,” he said, observing that the former were more often victims of violence than perpetrators.
"Lebanon is doing a bit better than surrounding countries when it comes to mental health, but the gap is still huge between what is needed and what there is," he told The National.
Though several professionals pointed out that a number of campaigns in the past decade have increased public awareness of mental health issues in Lebanon, the topic can still be difficult to broach within families.
"My mother thought that if I went once or twice to see the psychologist, I would be fine, like I had the flu or something," Tania Elmir, one of Ms Tannoury's patients, told The National.
Unlike her parents, Ms Elmir, 32, barely remembers the trauma of Lebanon’s civil war. “But we went through the 2006 war, the explosions and the bombings,” she said. “We have no time to process the first trauma then we get another.”
