With millions exposed to daily violence, kidnappings, deaths of loved ones and displacement, Syria is now in the midst of a mental health crisis. Though exact numbers are difficult to pinpoint, psychologists and medical experts say hundreds of thousands could be afflicted with illnesses ranging from from acute depression and paranoia to Post-Traumatic Stress Disorder (PTSD) and harder-to-treat psychiatric disorders like schizophrenia.

Beirut-based psychologist Aya Mhanna has been working with Syrian refugees in Lebanon and Turkey for the past two years, including hundreds of media activists, political refugees and journalists – people who still go in and out of the country. She works regularly with international NGOs and aid groups like UNICEF and WorldVision.

Here, she discusses the scope of Syria’s mental health crisis – and what must be done to fix it.

Syria Deeply: How big is the mental health problem among Syrian refugees today?

Aya Mhanna: It’s a huge problem. People cannot even imagine how dangerous Syria is, and how risky it is to go in and out, and how much there’s a need for [mental health] support. There’s a lot of work being done by foreign and local NGOs, especially in Lebanon, but the need is so huge that there aren’t enough social workers and mental health doctors.

Syria Deeply: What illnesses are you seeing today?

Mhanna: It depends on who you’re working with. There’s a range of people suffering from a range of illnesses. For example, there’s a lot of gender-based violence [that stems from mental illness]. There are problems with women who are being sexually abused or forced to get married to a foreigner or a stranger so the family will have money. We have a huge problem with the psychiatric response to trauma and the fact that these people are [traumatized] from having left their country. They fled elsewhere, they left their daily activities.

We start by looking at mental health issues related to depression, anxiety and PTSD. Not everyone is suffering from [generalized] PTSD. Yes, there’s a traumatic effect to this conflict, and everyone [right away] says “it’s PTSD, it’s PTSD.” But we tend to forget that these people are really resilient, and they might have [the normal reaction to trauma], or they might have something else that isn’t PTSD.

We have anxiety, depression and, yes, PTSD. We have the psychological effects of the daily stressors of the refugee situation – sometimes it’s acute stress, due to the lack of water, nutrition, education, or even the fact that some of the refugees live in such close proximity to others and don’t have their own space.

Then there are issues related to child abuse. It’s still a taboo, but there’s a lot of sexual abuse, which leads children to start wetting the bed, or to start crying for no apparent reason. They tend to be very isolated. There’s lots of violence and aggressiveness among these children. Among adult women being abused, the most common problems we see are depression, suicide and the rejection of their children.

We have a lot of problems related to refugees who were kidnapped, abducted or tortured before leaving Syria. We see that some of them have psychotic episodes, where they start to hallucinate. It’s like they aren’t living in reality anymore. They become isolated and paranoid, and they think everyone wants to kill or hurt them. And that really affects their families.

You see a lot of psychiatric disorders going untreated, from severe acute depression all the way to schizophrenia. It’s been interesting to see the evolution of the disease. We use the Beck Depression Inventory [a widely used 21-question diagnostic questionnaire] to give us an idea of the severity of depression in people, and every time I go [to the border], it gets worse and worse. It shows that Syrians are clinically depressed. The first thing we worry about with this is suicide. Since October 2013, I have seen 172 media activists. And seven of them have already committed suicide.

Syria Deeply: What is the solution?

Mhanna: We need to get host communities, including those in Jordan and Lebanon, to understand that there is a humanitarian crisis, not just a political crisis. We start by trying to raise awareness. We then need to try and expand the scope of work of international NGOs like UNHCR and let them work with local NGOs. Then we need to implement psycho-social empowerment groups. We need to work on the children’s education, because we can’t build a healthy society for the future without it. Without education, mental health in the community will get worse and worse. The psycho-social fabric will worsen.

We also need to provide activities and safe places for children. We need to provide places where women can develop their skills, things like sewing and cooking and teaching classes – to empower them to be able to live their daily life far from home. This kind of development is a “must” in order to tackle depression and other mental illnesses. We have to raise their self-esteem. We need to make them feel safe and emotionally supported, and allow them to talk about their problems, their feelings, their concerns. We need group support groups where they get peer support – where they feel if they are really depressed, they will be heard by social workers and psychologists.