PHOTO: IMC An Indonesian man receives counseling from IMC after losing his entire family and his home in the South Asia tsunami. IMC has integrated mental health into community health services by training national health professionals to diagnose and manage mental illness.

DEPRESSION

Many refugees suffer from depression. Mental illness due to depression can be very serious and may lead to suicide. The symptoms of depression may also be disabling and prevent the refugee from studying, working and enjoying any activity.

The most common causes of depression are loss of a family member or friend, and the sickness or death of a child. Other common causes are the loss of valuable property and extreme poverty. Another cause of depression may be a shameful or embarrassing event within the community such as an unwanted pregnancy, the break-up of a marriage or being fired from a job. Hurtful and terrifying experiences such as rape, or being attacked and robbed by bandits, can also cause depression.

In some depressed people, you will not be able to find a cause. Some depressions seem to happen for no identifiable reason.

Almost all refugees at times feel sad and hopeless about their situation. But even with these feelings, most do not suffer from the mental illness called depression. Depressed people feel very sad and hopeless for months. Nothing gives them pleasure. They believe that nothing and nobody can help them in their suffering. They do not seek help because they believe their situation cannot be improved.

Symptoms

The most common symptoms of depression are:

• overwhelming sadness and deep sorrow;
• hopelessness;-thinking about harming oneself;
• crying easily;
• worrying constantly;
• anxiety, tension;
• lack of joy in life;
• lack of energy, easily becoming tired;-physical complaints such as headaches that do not go away;
• poor sleep;
• weight loss;-lack of interest in sex;-difficulty in paying attention or remembering;-feeling "bad", worthless or less respected than other people.
• Depressed people often complain of physical symptoms. Take care not to be distracted from the main underlying psychological disorder.
  

ACUTE PSYCHOSIS

A person may be brought to you who is "out of control" or "confused".

An "out of control" refugee has lost the ability to listen to anyone. People who are out of control may shout loudly and threaten to hurt themselves and others. Or they may sit quietly in a room and refuse to answer your questions or respond to your instructions.

A "confused" refugee will not be able to tell you where he or she is, or what time of day or day of the week it is. Confused people will not be able to tell you what they are doing or why. They may not even be able to tell you who they are. A confused person may become out of control.

The difference between acute and chronic psychosis

Some people are psychotic (unfortunately people often call them "crazy" or "mad") for a short while. This "acute psychosis" can last for days or weeks. It may occur once or several times in a person's life.

Some other people are psychotic for longer periods. They may seem quite well and behave quite normally some of the time, but at other times they behave in strange ways which do not fit the "normal" behaviour of their community. At the beginning of a period like this, they may seem to have an acute psychosis but this is a long-term problem that needs long-term treatment. These people suffer from "chronic psychosis".

CHRONIC OR LONG-TERM PSYCHOSIS

In any refugee community there may be people with chronic psychosis. When they first come to your attention, they may seem to have acute psychosis. If left untreated, these people can have many more acute psychotic episodes. Over time, their family life, work or school performance may suffer because of their illness. You need to identify refugees who suffer from chronic psychotic illness. You can then manage their illness so that they can stay with their families, continue to work, and spend as little time as possible in hospital.

Even when these people are no longer acutely psychotic, they may continue to act in strange ways. They often seem out of touch with reality. They have strange beliefs that are not true. For example, they may believe they are God or a king. Sometimes they have strong feelings that people are trying to hurt them. Often they hear voices and see or smell things that do not exist. For instance, they may say they are able to hear the voice of a dead ancestor talking to them or about them outside their head. Sometimes they may join in with the talking and seem to be talking to themselves.

In most cultures, people with this illness are unkindly called "mad" or "crazy". Sometimes others will avoid them because they are considered to be possessed, or it is thought they will bring bad luck or are dangerous. However, these people are suffering from a disease of the brain. The cause of this disease is still unknown but treatment can often help them. Refugees who have this illness are not bad people. People with this illness are more likely to be hurt or cheated by others than they are to hurt or cheat others.

The major symptoms of chronic psychosis are:

• false beliefs;
• hearing voices or seeing or smelling things that do not exist;
• speaking very quickly or very slowly;
• talking to oneself or making strange comments to others;
• becoming withdrawn or overly excited;
• bizarre behaviour such as waving hands, shouting, collecting useless things and religious behaviour that is abnormal in one's culture;
• difficulty in sleeping or disturbed sleep;
• becoming easily upset or frightened by intimate relationships and personal responsibilities.
  

People with this illness often suffer from it throughout their lives.

MENTAL DISORDERS CAUSED BY HURTFUL AND FRIGHTENING EVENTS

Emotional symptoms may be associated with very hurtful events and terrifying life-threatening situations. These events may be caused by other people, as in the case of torture or imprisonment. They may also be caused by natural disasters such as a severe earthquake with great loss of life. Fortunately, most refugees who have suffered shocking or terrible personal events in their lives do not become mentally ill.

The following are the most common symptoms associated with hurtful, violent and terrifying refugee experiences:

• Flashbacks. The person relives the shocking and hurtful event as if it is happening all over again. For example, people who witnessed the murder of their parents may feel they are witnessing it again just as it actually occurred several months or years before. They hear the sounds, smell the smells and feel the sensations originally associated with the murder. They re-experience this terrifying and hurtful event while awake.
• Continuously remembering the hurtful and terrifying event and not being able to stop thinking about it.
• Nightmares (terrifying dreams).
• Very disturbed sleep.
• Easily getting upset (being shocked by loud noises and sudden sounds such as a door banging or a barrel falling off a truck).
• Feelings of sadness and hopelessness.
• Fear of being left alone or of leaving the house.
• Fear that someone or something is going to hurt one again.

PHOTO: IMC A drawing by an 11-year-old girl from Darfur, depicting the graphic violence he had witnessed. Art therapy in refugee camps like this one in Chad, is a crucial component of IMC’s psychosocial programs worldwide.

Refugees with these symptoms will usually be exhausted. They will be physically worn out by their daily memories, flashbacks and nightmares. The nightmares wake them up at night and they are so frightened that they cannot go back to sleep. When they get up in the morning, they are tired from lack of sleep and then start having flashbacks and upsetting memories. The cycle is repeated day after day.

Refugees who have this disorder worry a lot and are easily frightened. They fear ordinary things such as the dark, meeting people, or travelling in a car or bus. They often refuse to be left alone. Almost all refugees with this disorder feel hopeless and depressed.

MENTAL DISORDERS CAUSED BY BEATINGS OR OTHER INJURIES TO THE HEAD

Some refugees may have suffered injury to the head. Some may have experienced beatings to the head while being tortured. Others may have had plastic bags placed over their heads or have survived attempts to drown them. Head injury can also occur from shelling or rocket attacks, being thrown from a truck, falling from a height, or sliding down a steep slope.

The brain can easily be damaged by a fall or a beating that might not seem severe to the refugee. After damage on the outside of the head has healed, the refugee may have disabling or unpleasant mental problems.

The following are the most common symptoms of mental disorders caused by beatings or other injuries to the head:

• headaches;
• dizziness;-tiredness and lack of energy;-disturbed sleep or loss of sleep;-arguing or fighting for no reason;-crying or laughing easily;
• forgetting things easily;-not being able to pay attention;-not being able to think clearly;
• worrying in case the mind is "broken";-no longer being able to work or help with family tasks.
  

How to identify people with mental disorders caused by beatings or other injuries to the head

Refugees with this problem, or their families, may not be able to recognize a mental illness caused by head injury, especially if the head injury occurred many years ago.

EMOTIONAL DISTURBANCES ASSOCIATED WITH INTENSE FEAR AND WORRY

Refugees have many worries and fears. They have to cope with many problems they did not have before becoming refugees. These problems may include lack of proper food and shelter, unemployment, and danger from bandits or warfare. Most refugees also think a lot about what they have lost and worry about the future, especially for their children.

Sometimes these worries and fears will overwhelm refugees. An event may occur that is finally too much for them to cope with. They may then develop severe emotional and physical complaints. Neither family nor friends can help relieve these complaints.

A mild depressive illness is often associated with intense fear and worry. The work or school activities of people with such an illness are not seriously disturbed. They will ask for your help only after traditional healers or other medical practitioners have failed to ease their symptoms. They may also have tried drugs and alcohol and found that they have little effect.

The most common mental symptoms of this illness are:

• overwhelming fears and worries;
• muscle aches, soreness, twitching, feeling shaky;
• restlessness, getting easily tired;-feeling keyed-up or on edge;
• easily being frightened by loud noises or sudden sounds;
• difficulty falling asleep or staying asleep;
• getting angry easily and complaining a lot;
• not being able to keep one's mind on work or play.

The physical symptoms of this illness are:

• rapid and irregular heartbeat;
• shortness of breath;
• sweating or cold clammy hands;
• dry mouth and a lump in the throat;
• dizziness and lightheadedness;
• nausea;
• diarrhoea;-hot flushes or chills;
• headaches;
• frequent urination;-impotence or premature ejaculation.

Some people also have special problems such as:

• Fits of fear (or panic), lasting from a few seconds to several minutes. They may include sweating, extreme nervousness, a choking sensation and a feeling that one is going to die or be harmed or go mad.
• A terrible fear of a common object or situation, such as knives, enclosed spaces, open spaces, cats, chickens or other things.
• A terrible fear of leaving home or being in public places.
  

EMOTIONAL DISTURBANCES RELATED TO POOR SLEEP

Almost all refugees have had problems with their sleep. Sleep problems are common to all the mental illnesses you will deal with in your community. Poor sleep can be caused by physical illnesses, especially if there is pain or discomfort. Refugees who abuse drugs or alcohol will also have trouble sleeping.

The most common sleep problems you see will not be caused by illness but by changes in camp conditions. These may include extreme weather conditions such as storms or drought, or worries about new rules related to resettlement, refugee status, food distribution or military activity.

Serious poverty and difficult and unexpected personal situations can also result in poor sleep. For example, a refugee's sleep may suddenly become disturbed on receiving bad news about a member of the family.

Dramatic changes in camp conditions or in a refugee's personal or socialsituation can turn an occasional sleep problem into a more serious one. The refugee will now sleep badly every night rather than just two or three times a week. The person may also relive the past in bad dreams or worry about the current situation. Lack of sleep and sleep interrupted by bad dreams cause people to feel tired the next day. Eventually a person becomes exhausted by this daily cycle of poor sleep and tiredness.