Al-Sahira's world is falling apart. Two years ago, the 48-year-old lost three of her 14 children when their house in Aleppo was partially destroyed by shelling. The displaced family sought safety in Damascus, but then tragedy struck again last month when shrapnel took the life of her 13-year-old son Zakariya.
Sitting in a psychiatrist's office in a central Damascus hospital, Al-Sahira* struggles to stop her hands from shaking as she describes the mental anguish the bereavements have inflicted on her. "I don't know how I have coped. I spend a lot of time just sitting at home and looking at pictures of my dead children," she says. "I feel that I must speak to someone and tell them what I've been through."
Nahla, a 34-year-old psychiatrist from Qalamoun, 90 kilometres north of the capital, says Al-Sahira's suffering is part of a dramatic increase in psychological trauma affecting Syrians after five years of conflict.
"The crisis has had a deep psychological effect on people, but this is a perfectly normal reaction to an abnormal situation," says Nahla, who heads up the mental health and psychosocial support department of the UNHCR-funded Poly-Clinic, run by the Syrian Arab Red Crescent.
While there are no verifiable figures on the increase in mental health disorders among Syrians since the outbreak of the conflict, Nahla estimates that the number of people requiring treatment has roughly trebled. Of the 400-500 patients that her department treats each month, the most common conditions they encounter are depression (23 per cent), anxiety (18 per cent) and post-traumatic stress disorder (13 per cent).
Compounding the increase in suffering has been a corresponding drop in the number of practicing psychiatrists inside Syria. Figures from the Association of Psychiatrists in Syria show that there are currently just 70 qualified psychiatrists across the country – less than half the number before the crisis began. Several of Nahla's former colleagues have left the country, but it was the outbreak of conflict that convinced her to stay.
"Before the crisis I wanted to move abroad and specialize in child psychiatry, but I changed my mind and stayed to be with my family and help my country. Syria has given me a lot, and I had something to repay," she says. For those like Nahla that remained, that decision was not without cost. Like many of her colleagues, she has lost family members and been displaced from her home by the fighting.
The work also takes a psychological toll on the medical practitioners themselves. "No one is unaffected by what's happening in Syria. After five years, most of the staff members also suffer from psychological issues. We try to support each other and organize team-based interventions," she explains.
For patients such as Al-Sahira, while medication may be required to address specific conditions such as depression, equally important is the opportunity to share her experiences with a trained professional and begin the process of recovery.
"We can't take away the pain of people like Al-Sahira that have lost children, but we can listen without judgment and try to reconnect them with their families and social networks. Without this kind of help they would suffer far more and their conditions would worsen," Nahla says.
The only positive impact of the crisis that Nahla has witnessed is the removal of the stigma surrounding mental illness, with people that previously would never have come to her now seeking help.
She says the biggest challenge is ensuring that Syrians do not become inured to what is going on around them. "After five years of war, people are starting to get used to it. I'm constantly working to try to make sure they don't become accustomed to this situation. There is nothing normal about what is happening in conflict impacted communities in Syria."
By Charlie Dunmore