BEIRUT: When Joe Jaber hired a young Ethiopian woman two years ago to help his elderly parents in Beirut, she seemed fine. But after a little more than a year, she began acting strangely.
Diana (a pseudonym to protect her privacy) would become unreasonably angry over small incidents, once hiding in a tree for hours after she was discovered to have lost the house key. She would abruptly change her mind for no apparent reason. For instance, she asked Jaber to take her photo to send to her parents, but while posing, she suddenly wanted to stop. He also noticed she would stay up late talking and laughing to herself.
In December, when he brought her the photo prints, she threw them on the floor. She packed up her belongings, barricading herself with them on the balcony, shouting and wailing hysterically.
Searching for help
Jaber drove her to the maid agency, enlisting relatives to sit on either side of her to stop her from escaping. A man there looking for a maid agreed to take her on a trial basis. But at dawn, he rang Jaber, saying Diana had threatened to kill herself. The agency refused to get involved, advising Jaber to buy her a plane ticket back to Ethiopia. But at the airport, Diana refused to board the plane.
Jaber took her back to the agent, who became abusive, yelling at Diana and even hitting her at one point. She eventually calmed down and chose to return home with Jaber. But in the middle of the night, she attempted to escape, and the next morning, she tried to jump off the balcony.
Jaber next turned to the police, who ignored him until a high-ranking army friend intervened. Diana was wailing and rolling around on the floor as the police arrived. They advised him to call the Red Cross, which said it would not be able to restrain her in the ambulance. Two general hospitals turned him away, though one recommended the Hopital Psychiatrique de la Croix in Jal al-Dib. They arrived at 8 p.m to no avail: The hospital refused to admit a foreigner at night. Finally, Jaber went to Hotel-Dieu de France, which accepted Diana into its psychiatric ward.
Calling Hopital Psychiatrique de la Croix the next morning, Jaber was told it would not admit patients from other hospitals. Finally, a friend intervened and secured a bed for Diana. Another helped restrain her in the car, as Jaber drove. Diana was diagnosed with schizophrenia and stayed in the hospital for about two weeks before being cleared to fly back to Ethiopia.
“I drove myself crazy to find the right place to go,” Jaber recalled, noting it would have been even more difficult if he had not had the money and connections.
A broken system
When it comes to foreign domestic workers (FDW) and mental health, “one of the major difficulties [they face] is accessing care,” said Dr. Rabih El Chammay, a psychiatrist and head of the fledgling National Mental Health Program established last May at the Ministry of Public Health (MOPH).
He noted that FDW are recognized in “Vulnerable Groups,” one of the five categories of the program’s new strategy announced on May 14. Two objectives relate directly to FDW: conducting a situation analysis of their access to mental health services, and mandating coverage of such services in their health insurance.
“There’s no mental health infrastructure for foreigners – and very little for the Lebanese,” echoed Dr. Brigitte Khoury, a clinical psychologist at AUBMC. She added that mental health problems were “immensely underreported and undertreated” in Lebanon. Approximately 85 percent of people who need care do not access it, Chammay said.
The only published national prevalence study of adults relies on data from 2003-04, led by psychiatrist Elie Karam. It found that 25.8 percent of adults have experienced at least one mental health disorder at some point. Just 10.9 percent received professional treatment, with delays of six to 28 years.
As for children and adolescents, an AUB study conducted in 2012 diagnosed 26.1 percent of the subjects with a psychiatric disorder and found 6 percent of them were receiving treatment.
From 2008 until 2014, there was an average of one suicide every three days, according to Dr. Ziad Nahas, the chair of AUBMC’s psychiatry department.
The MOPH does not have a specific budget for mental health. According to the WHO 2011 Mental Health Atlas, 4.8 percent of the MOPH’s budget was used for mental health of which 54.2 percent was allocated to inpatient care at psychiatric hospitals. The other 45.8 percent mostly covered psychotropic medications prescribed to outpatients, Chammay said.
The NSSF will cover 80-90 percent of drug fees, but offers just LL40,000 per day for inpatient psychiatrist fees, and LL15,000 for outpatient follow-ups with psychiatrists, according to Nahas. Neither the MOPH nor the NSSF cover psychologists or psychotherapists, though the combination of medication and psychotherapy is generally accepted as the most efficient treatment for mental illnesses.
Government funding across the board is “heavily vested in reactive rather than preventative care,” Nahas said. An in-depth study on mental health funding co-authored by Nahas last year estimated that 78 percent of the money spent by the MOPH on mental health in 2011 was solely on inpatient admissions
Also, there are only three psychiatric hospitals in the country and most psychiatric wards at general hospitals do not accept government funding, Nahas said, citing a low reimbursement success rate and long reimbursement delays.
The NMHP is in talks with psychiatric wards at general hospitals, Chammay said, citing at least one interested in contracting with the MOPH to admit patients at lower rates. Under its new strategy, the NMHP will produce a report by 2016 recommending revised MOPH budget allocations.
Given the dearth of public funding, patients can pay out-of-pocket for private psychiatrists or psychologists, though sessions with a psychologist cost at least $100 per hour, according to Khoury. There are low-fee training clinics, affiliated to universities such as AUB, though these are mostly in Beirut.
The insurer’s role
The vast majority of mental health treatment is paid out-of-pocket, given limited government funding, the ineligibility of FDW and other foreigners for government-funded services, and a total lack of private insurance coverage of mental health services for both Lebanese and foreigners.
“It’s shameful that insurance companies can still manage these days to deny coverage for psychiatric disorders,” Nahas said. Chammay argued that insurers need to “understand that it costs less for them in the long-term to include mental disorders than to pay for the comorbidities or the [physical] complications of mental disorders.”
It would be an “easier battle” when it came to FDW, he suggested, as they were a small group and the Labor Ministry could simply mandate mental health coverage in FDW insurance plans.
Jaber had to pay out-of-pocket for Diana’s treatment, although he was able to secure heavily discounted rates at both hospitals through personal connections. Ultimately, he spent around $3,000 during the near one-month ordeal, including health care, plane tickets, lawyer fees, and other incidentals to support her.
The NGO gap
While there are NGOs that target FDW, mental health is typically not their focus. One of the most prominent, Caritas Migrant Lebanon Center, typically admits FDW who have fled an abusive employer or been abandoned by their employer at agencies or on the street, according to head of psychosocial services Maureen Mahfouz.
It has two psychotherapists to support FDW in its shelters who happen to have mental health issues, and if necessary, Caritas will take them to psychiatrists or mental hospitals. But Mahfouz emphasized, “We do not help migrant workers because they have a mental health crisis ... we’re not specialized to take [them].” She added that it was the employer’s responsibility to find and pay for their maid’s mental health treatment, as with other types of healthcare.
Mahfouz admitted that Jaber was a “rare” exception, and FDW like Diana were more likely to fall through the cracks.
Bolstering professional care
One of the MOPH’s key initiatives is integrating mental health into primary care. Chammay said it has trained approximately 50 ministry-network PHCs and 160 general doctors and nurses to assess and manage mental health patients. Its target is 100 PHCs in two years and 200 centers in five years, along with building a referral system between the centers and mental health specialists.
Bolstering primary care capabilities in Lebanon is crucial as, according to WHO 2011 statistics, per 100,000 people there are just 1.41 psychiatrists and 2.12 psychologists that tend to be concentrated in Beirut.
Both the Lebanese Psychiatric Association and the Lebanese Psychological Association have about 45 members each, though their numbers are not comprehensive as registration is voluntary. “There are never enough mental health professionals in low to middle-income countries,” Khoury noted.
Psychologists are not regulated in Lebanon, meaning “people without proper training are supposedly doing therapy and they call themselves anything,” Khoury noted. The Lebanese Psychological Association has submitted a draft law to license the profession which would make psychologists eligible to contract with the MOPH and NSSF
An ambitious vision
While there is much work to do to improve the mental health care system, Khoury said “things have improved tremendously” since she began practicing as a psychologist in Lebanon in 1997. And while “mentally ill people are [still] seen as crazy and a shame on the family,” the stigma is “much less than before.”
She said she was optimistic about the future, especially with the NMHP’s work.
The new NMHP strategy includes 77 objectives, tackling aspects of the mental health sector, such as legislation, funding and capacity building, with staggered annual deadlines until 2020.
“I must admit it’s a bit ambitious, but I think if we’re not, we wouldn’t really make a difference,” Chammay said. “We’re really counting on the participation of all actors,” he added. “They’ve been partners from Day 1 in the elaboration of this strategy so there’s a sense of ownership that’s really high.”
“We don’t have yet pledged money,” he said, “but we have a lot of interest from WHO, UNICEF, IMC and other international donors.”
“This is a national strategy ... so the main component is to have everyone working in the same direction. We don’t pretend the ministry will do all of this but we will be able to coordinate all that’s happening to achieve this.”