The Syrian crisis has been widely described as one of the largest refugee crises of recent times (Nadim Almoshmosh, Jefee Bahloul, Barkil-Oteo, Hassan, & Kirmayer, 2019; Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo, & Kirmayer, 2016). Close to 6 million Syrian refugees have fled to Syria’s neighbouring countries, namely Lebanon, Jordan, Turkey, Egypt, and Iraq (UNHCR, 2018). Lebanon currently hosts over 1.5 million Syrian refugees, a number equivalent to 25% of its population (Refaat & Mohanna, 2013), rendering it the country with the largest number of refugees per capita worldwide (Knudsen, 2016). The massive influx of Syrian refugees to Lebanon, coupled with their increased demand for healthcare services, has significantly strained the country’s already fragile healthcare system, and has hindered its ability to cater to their health needs (El Chammay & Ammar, 2014; E. Karam et al., 2016).
Having escaped from conflict settings, refugees often experience a multitude of stressors such as traumatic events, multiple forms of losses, discrimination, and acculturation difficulties among others during their journey of displacement (Hassan et al., 2016). They have therefore significantly higher odds of developing mental health disorders compared to the general population (Hassan et al., 2016). Many refugees are survivors of exploitation, torture, and sexual and gender-based violence, which further exacerbate their vulnerability to health conditions (Hassan et al., 2016). That said, they are less likely to receive mental health services because of social stigma, language and cultural barriers, imbalanced power dynamics with service providers, limited access to services, and low mental health literacy, including lack of perceived need (Abou-Saleh & Hughes, 2015; Hassan et al., 2016; Jefee-Bahloul, Moustafa, Shebl, & Barkil-Oteo, 2014; Weine, 2011). Recent evidence indicates that mental health is one of the most pressing health needs among Syrian refugees in Lebanon and neighbouring countries (El Arnaout et al., 2019).
Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), and other anxiety disorders have been reported as the most common mental health disorders among Syrian refugees (Acarturk et al., 2018; Georgiadou, Zbidat, Schmitt, & Erim, 2018), and they tend to be comorbid conditions. In the general population, MDD in particular, is the third leading cause of years lived with disability (YLDs) (IHME, 2020), and is considered a strong risk factor for suicide (May & Klonsky, 2016; Rogers, Ringer, & Joiner, 2018). Therefore, depression warrants special attention among this population due to its long-term implications that may impair social, individual, and vocational functioning, factors that are essential for survival, productivity, and resettlement (Poole, Hedt-Gauthier, Liao, Raymond, & Bärnighausen, 2018; Ventevogel, Van, Schilperoord, & Saxena, 2015). In one meta-analysis that included 24,051 refugees from multiple nationalities pooled from international studies, 44% were found to have symptoms of depression (Lindert, Ehrenstein, Priebe, Mielck, & Brähler, 2009). Despite certain limitations of that review, such as heterogeneity of the included samples, this finding mirrors others in the literature addressing Syrian refugees in Arab settings (Doocy, Sirois, Tileva, Storey, & Burnham, 2013; Jefee-Bahloul, Barkil-Oteo, Pless-Mulloli, & Fouad, 2015; Llosa et al., 2014; Naja, Aoun, El Khoury, Abdallah, & Haddad, 2016). Furthermore, previous reports from the literature assessing prevalence rates of depression among Syrian refugees in developed and developing countries have shown disparities in the findings. Depression prevalence rates were reportedly lower in developed countries compared to developing countries, which could be attributed to the limited capacities of the latter to cope with the needs of these vulnerable populations. In Germany, depression was detected in close to 14.5% of a Syrian refugee sample (Georgiadou et al., 2018), as opposed to 37.4% in Turkey (Acarturk et al., 2018), and 43% in Lebanon (Naja et al., 2016).
Previous research suggests that despite the harsh conditions that Syrian refugees often experience, some key post-displacement variables may act as protective factors, may buffer the severity and incidence of mental health conditions, and may contribute to posttraumatic growth (Georgiadou et al., 2018; Taher & Allan, 2020). For instance, obtaining a visa or residence permission, residing in acceptable living conditions, receiving financial support, and having access to social and healthcare services, among others, have contributed to better mental health outcomes (Georgiadou et al., 2018). Rightfully so, findings have confirmed that besides the existing acute and chronic stressors, the mental health of refugees largely depends on the social, economic, and cultural environments associated with their pre and post-displacement experiences (Porter & Haslam, 2005). However, the status of Syrian refugees in Lebanon is far from being ideal, with potential protective factors being compromised and minimally available (Kerbage et al., 2020). As an example, Syrian refugees have restricted rights in Lebanon, which limit their access to proper healthcare, education, and employment opportunities, due to the lack of a clearly defined legal and administrative framework under which they can operate (Blanchet, Fouad, & Pherali, 2016; Kerbage et al., 2020). Such systemic precariousness excludes potential opportunities for long-term integration, and places Syrian refugees in Lebanon at increased risk of developing mental health problems (Jayawickreme et al., 2017; Killikelly, Bauer, & Maercker, 2018). In addition to that, Syrian refugees lack basic needs such as food, water, and shelter. Their acculturation is also compromised, as they tend to experience discrimination resulting from the strained Lebanese-Syrian relations due to host community fatigue with their protracted presence, largely due to job competition and exhaustion of resources and services (UNHCR, 2019). This discrimination is also manifested as part of the larger socio-political climate in which continuous pressures are being exerted on Syrian refugees that threaten their physical, financial, and social security (Kerbage et al., 2020; Mourtada, Schlecht, & Dejong, 2017; Sim, Bowes, & Gardner, 2019).
Finally, the lack of sustained funding for mental health services, the fragmented mental healthcare system, and the scarcity of research make it extremely difficult to understand and respond to the psychosocial needs of refugees. Syrian refugees, being a high-risk group, have unique psychosocial needs that should be clearly addressed by mental health workers, based on evidence-driven and culturally-sensitive findings. That said, concerted efforts have been made by the National Mental Health Program (NMHP) at the Ministry of Public Health (MoPH) in Lebanon in collaboration with other healthcare and humanitarian actors to address this problem (Chammay, Kheir, & Alaouie, 2013; El Chammay & Ammar, 2014; El Chammay, Karam, & Ammar, 2016; E. Karam et al., 2016). Since the inception of the Mental Health and Substance Use Strategy for Lebanon 2015–2020, the MoPH has worked on integrating mental health services into the primary healthcare centres (PHCs) by training healthcare workers on the Mental Health Gap Action Program (mhGAP) to enhance access to mental health care (MoPH, 2015). In addition, the MoPH established the Mental Health and Psychosocial Support Task Force (MHPSS-TF) in collaboration with the World Health Organization (WHO) and the UNICEF to coordinate the work of over 62 actors on the mental health and psychosocial support within the Syrian crisis response in Lebanon (E. Karam et al., 2016). This has increased the efficiency and effectiveness of efforts targeting this problem.
In this context and despite the established initiatives, to our knowledge, there are limited large-scale studies on the prevalence of depression and its correlates among adult Syrian refugees in the Middle East. In fact, despite the urgency of the crisis, according to a recent systematic review, only six studies emanating from a conflict-affected low-to middle-income country were conducted in the Middle East to assess the prevalence rates of mental health disorders among refugees (Morina, Akhtar, Barth, & Schnyder, 2018). Clearly, there is an immense need for further research on the mental health of Syrian refugees in this region to better understand the associated risk factors, and to support the development and implementation of global mental health policies addressing this population (Morina et al., 2018).
The present study aims to examine the prevalence rates of depression symptoms and their sociodemographic and clinical correlates among Syrian refugees in Lebanon. This study also aims to provide researchers, policy makers, and practitioners with a comprehensive understanding of depression among migrating populations, which would constitute a foundational base for future interventions and related programs and policies.