In the present study, we report the prevalence of depression symptoms, which represent one of the most common and debilitating mental health disorders among Syrian refugees, and we explore their sociodemographic and clinical correlates. The main strength of this study is that to our knowledge, it is one of the very few regional, and the only national large-scale study addressing this issue among a representative sample of adult Syrian refugees in Lebanon.
As expected, the prevalence of depression symptoms among the study population was high, with an estimated one in four refugees meeting criteria for probable MDD. Positive PHQ-9 screening and consequently, probable MDD, was detected in 25% of the study population, which is considerably higher than depression rates (9.9%) previously reported among the general population in Lebanon (42). Our findings contrast a previous study that used the same depression measure on Syrian refugees in Germany, and in which only 14% of their sample screened positive for MDD (13). One of the main findings of that study was that post-migration conditions and future positive prospects in host countries may be protective against mental health disorders among these populations (13). Indeed, this could explain the discrepancy between their findings and ours, considering that post-migration factors in Lebanon are poor and may ultimately present important risk factors instead of being protective against mental health disorders (26).
In Lebanon, many post-migration variables present important obstacles towards adequate health and survival. For example, the high prevalence of depression symptoms could be attributed to numerous external factors beyond their exposure to traumatic events, such as the difficult conditions in which Syrian refugees live, the limited opportunities for development, and the many challenges associated with their social integration and acculturation (26). Additionally, the constant internal and regional socioeconomic and political conflicts promote little hope for refugees to settle in a stable context unless they travel to more developed countries, which is a solution Syrian refugees commonly request to overcome their documented adverse living conditions (26). The existing economic difficulties in Lebanon, which are now exponentially compounded by the fall of Lebanese pound (43), and by the colossal explosion that devastated the capital Beirut in August 2020 (44), may place Syrian refugees under further instability and vulnerability. With that said, the situation is currently expected to be worse in terms of mental health outcomes, considering the COVID-19 pandemic, which has restricted mobility, tremendously challenged the attainment of basic survival needs, induced added stress, and further limited opportunities for work and social interactions (45).
In response to the Syrian crisis, the MoPH in collaboration with the Ministry of Social Affairs and with local and international non-governmental organizations (NGOs) have been providing free-of-charge primary healthcare services, including mental health services, for UNHCR-registered Syrian refugees. Yet, due to limited financial capacities, these efforts have been reportedly unable to meet the increasing needs of these vulnerable populations (46,47). The situation is even worse for unregistered refugees who have restricted capacities to receive the appropriate healthcare support (47). Despite these efforts, symptoms of depression remain high, as indicated by our findings. Although mental health services and psychosocial interventions may induce relief of depression severity over the short-term, long-term improvements may require complementary macro-level changes in the living conditions of refugees, their legal status, and the need to foster positive future prospects.
It is also possible that mental health services are not reaching enough refugees. Notwithstanding the value of the provided services, Syrian refugees cite many barriers to seeking mental health services in Lebanon, including lack of trust in and limited knowledge of available services, limited mental health literacy and perceived need for treatment, lack of services especially in rural areas, associated difficulties in commuting, financial barriers and lack of mental health coverage, and social stigma which may impede refugees seeking healthcare fearing of shame and discrimination (46). Furthermore, due to pervasive cultural beliefs, Syrian refugees tend to seek religious healers as a first line of treatment for mental illness given their perceived cultural appropriateness and their reduced association with social stigma when compared to mental health professionals (48).
Despite high symptoms of depression in our sample, our findings are favourable in comparison to the last study that evaluated the prevalence of depression among adult Syrian refugees in Lebanon 5 years ago, in which a depression prevalence rate of 43.9% was reported (20). Although some important limitations may prohibit this comparison, such as their reliance on a clinical diagnosis as opposed to using a screening instrument, and their smaller sample size (n=310) (20), our findings may point towards an overall improvement. However, this could also be a result of the different sample characteristics, considering that Naja et al (2016)’s study represented refugees seeking social and healthcare services from two non-governmental organizations, whereas ours included a randomly selected representative sample of participants from the general population of Syrian refugees across Lebanon; under these different contexts, our sample would be expected to score lower on depression.
In terms of its correlates, our findings show that age, gender, and marital status are strongly associated with an increased risk for depression. We found that older age is associated with higher risk of depression, which contrasts previous findings showing an inverse relationship (13), or no correlation (17,20) between these variables. In specific, individuals over 45 years of age are at highest risk of developing depression, and this may be a result of several contributing factors. From a social perspective, older individuals in the Arab region are regarded as pillars of their families, and they tend to hold leadership roles in their communities (49,50). Previous research suggests that as a result of the war, this community role may be disrupted, impacting familial connectedness and social ties, and bringing along feelings of isolation and inadequacy (49). From a clinical perspective, older individuals often have pre-existing and chronic conditions which may warrant further medical attention. In this regard, unmet healthcare needs due to the limited resources in these communities may further aggravate their mental health conditions and general well-being. Finally, comorbidities between cognitive disorders and depression may be more pronounced and severe among this age group, which may impact their well-being and overall functionality (51).
In terms of gender differences, previous research consistently reported higher prevalence rates of depression among women compared to men across studies among the general population, and this is also true of research among Syrian refugees (13,17) congruent with our findings. Although some of the same justifications that have been previously cited in the literature may still be used to explain these gender-based variations, other explanations that are specific to Syrian refugees in Lebanon should be considered. For example, women in refugee settings tend to be subjected to early and forced marriage and bear family responsibilities at an early age, in addition to being exposed to sexual harassment and violence in the household and community at large (46), all of which are potential stressors that increase the risk of developing MDD. Also, these women allude to child rearing and associated responsibilities as important sources of stress and anxiety, especially when considering their worries about the discrimination and bullying their children may face in schools in Lebanon (46).
The association between marital status and depression has been previously examined among Syrian refugees, whereby being married was found to be protective against depression in one study, potentially due to its association with social support (17), and where no relationship was found in others (12,13,20). In our study, being widowed increased the odds of having depression, but this was not the case for being single or divorced. The experience of going through a death of a spouse in this community could place individuals at higher risk of developing depression than if they were single or divorced.
On the other hand, several variables were found not to be related to depression, most importantly the location of the informal tented settlement and the period of stay in Lebanon. It is possible that the properties of the four examined informal tented settlements for refugees in Lebanon entail similar living conditions that are below the appropriate standards and share similarity in terms of the availability of support and healthcare services, which translate into poor mental health among their residents. As for the period of stay in Lebanon, although previous studies suggested that a longer period of stay is associated with higher risk of depression (17), in our study we did not find any such association. This suggests that the period of stay in Lebanon is not correlated with the risk of developing depression, given that the mental health of Syrian refugees may be equally compromised among newcomers and long-term residents. That said, arriving in Lebanon before and after the breakout of the Syrian war in 2011 was accounted for in the study analysis, and no significant differences in depression scores were observed.
In terms of the clinical characteristics, we found that reporting a neurological condition or a history of mental illness increased the risk of depression, presumably because mental illness is directly related to depression symptoms, and neurological conditions are frequently comorbid with depression (52). On the other hand, diabetes, CVDs and coronary artery diseases were not found to be risk factors for depression, although these have been associated with depression in previous studies (53,54). Similarly, although reporting hypertension and the use of psychiatric medication have shown a statistically significant association with depression at the bivariate level of analysis, this was not replicated at the multivariable level. This means that unlike neurological conditions, non-communicable diseases may not be significant risk factors for developing depression among Syrian refugees in Lebanon. Possibly, these associations might be clouded by the overall high symptoms of depression in the study population.
In order to gain a clearer understanding of mental health disorders in this population, we recommend for future research to explore a wider range of disorders in this population such as anxiety disorders, PTSD, and substance use disorders for example to better understand their prevalence and correlates. Also, large-scale studies are needed to examine the relationship between pre and post migration factors such as legal status, living conditions, and available aids and services on the mental health of this population in this area.