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A focus on local evidence gaps will improve care for people hit by war, say Mohamed Elshazly and Sarah Harrison.
The conflict in Syria is entering its sixth year. It is the largest humanitarian emergency both in terms of the needs of affected people and the funds requested to address them (US$3.18 billion) through the Syria Humanitarian Response Plan.  Yet despite the humanitarian efforts of organisations including UN agencies, the conflict is having a devastating impact on Syrians’ mental health and wellbeing.
Various programmes are already responding to their needs either inside Syria or in the region: general practitioners manage common mental health conditions, for example, psychosocial workers facilitate support groups, and community health workers promote mental health in urban community centres.
But these programmes need more support from scientific evidence — an agenda for research priorities — to ensure quality and feed into an overall mental health strategy for Syrians whether in or outside the country.
In 2011, a group of mental health experts used an innovative methodology to solicit inputs from a multidisciplinary group of 82 academics, policymakers and practitioners representing regions where humanitarian crises occur. They agreed a research agenda that advocated priorities over the next ten years. 
The past four years of our personal experience responding to Syrians’ mental health needs in the field have shown that we need to adapt or expand this agenda to fill local research gaps.
Community, stigma and culture
Community participation is a key element of mental health and psychosocial programmes, and this applies to all project phases. So researchers must pay special attention to how Syrian people affected by conflict perceive the idea of mental and psychosocial support, and whether the support being offered in their area is addressing the right issues.
How can this help practitioners in the field? Highlighting the role of stigma in relation to conditions such as epilepsy and psychotic disorders — and so working out how to reduce it — can improve the design of services and encourage local people to accept them. This is usually linked with better access to services, more social support and care from families or the wider community.
Better understanding of stigma through research can help practitioners in other ways, for example by informing the types of interventions offered, how they are delivered and how to evaluate a positive mental health outcome.Another stigma-related element to consider is to what extent interventions are culturally appropriate.  A common mistake is to blindly apply ‘Western-produced and tested’ interventions without considering the cultural diversity of Syrians. After all, beneath fresh divisions and factions created by the conflict, there is an ancient mosaic of different subcultures and ethnicities.
Close-knit communities and families can be an immense source of support to someone with a mental health problem. But they can also cause distress. At times, cultural practices can risk harm — through encouraging two people with mental disabilities to get married, for example, or by accepting conservative religious views offered by sheikhs and others that limit understanding of mental illness.
Integrated health systems
Beyond communities and cultures, there are systemic issues to consider. Not only is Syria’s public health infrastructure badly damaged by the current crisis, but the health systems in neighbouring countries are also overburdened as the needs of refugees add to those of host communities. This is a serious barrier to providing mental health services integrated within overall health systems.
Research can help here too, by questioning the different approaches to integrating services in a failing state. Such approaches might include training, supervision and mentoring, or offering support through other sectors such as education.
Among the Syrian refugees fleeing to neighbouring countries, the Gulf states or Europe are mental health professionals — and they leave behind a vacuum of resources against growing needs. There are only two psychiatric inpatient facilities in Syria, with varying levels of security and access, and too few staff remain to offer outpatient or inpatient services.Research should highlight what type of professionals are required to deliver services in such challenging circumstances, and point to sustainable capacity-building plans. For example, is it more important to train psychiatric nurses or to have professional accreditation for psychologists and social workers? Should policymakers in Syria and internationally advocate for more in-country medical students to specialise in psychiatry, or should they focus on creating a cadre of community health workers to conduct outreach and raise awareness?
Help for people on the move
More work should also be done on how to deliver services to a dispersed, mobile and highly insecure population by making the best use of available personnel such as social workers or school counsellors and community health workers.
Another area that needs attention is the referral mechanisms required during humanitarian emergencies to identify and link people to specialist services. Often there is no consensus on the content of referral forms or systems, and little evidence on how to provide referrals for people who are wary of data collection or about sharing personal data with other agencies.
Researchers must also consider the advantages and disadvantages of various referral systems — paper forms versus electronic systems, for example — while being mindful of the minimum requirements of informed consent, ethical considerations and reporting requirements.
These priorities are based on personal experience. To streamline them, we invite discussion with experts working in the field as well as affected communities.
Mohamed Elshazly is mental health and psychosocial support consultant currently working for the UN High Commissioner for Refugees in Iraq, and Sarah Harrison, based in Denmark, is the coordinator for the Inter-Agency Standing Committee’s Reference Group on Mental Health and Psychosocial Support (IASC RG MHPSS) in Emergency Settings. Elshazly can be contacted at [email protected] and Harrison at [email protected]
The opinions expressed here reflect the personal point of view of authors, and don’t represent their affiliated organisations in any way.
 Syrian Arab Republic — civil unrest 2016 (UN OCHA Financial Tracking Service, 2016)
 Wietse A. Tol and others Research priorities for mental health and psychosocial support in humanitarian settings (PLOS Medicine, 20 September 2011)
 Culture, context and the mental health and psychosocial wellbeing of Syrians (UNHCR, 2015)