A Compounding Mental Health Crisis: Reflections From the Greek Experience With Syrian Refugees

“Amed” was a 14-year-old boy from Syria. He lived in Athens with his father and his 17-year-old brother. Amed was referred by the part-time psychologist at his junior high school to the psychiatry outpatient clinic of a pediatric hospital because of constant irritability. He complained, “I get mad when the kids laugh at me; I hate school.” The school psychologist asked that Amed be assessed after he had been suspended twice from school for fighting. The waiting time for diagnostic assessment was 3 months because of a staff shortage and increased demand for services.

According to his father’s report, it had been very difficult for Amed to handle his anger since they fled from Syria, and he had not been interested in academic or extracurricular activities ever since his mother and his little sister were killed. His father attributed his behavior to the influence of his older brother, who had also been in several fights with some native boys who were involved in serious delinquency and racist behaviors in their deprived neighborhood. The father admitted that he could not supervise his sons at home because he was working hard, doing odd jobs all day long.

Amed was 2 years behind his age group at school, and he believed that his classmates would think he was retarded or stupid. Native students often teased him because of his accent and his poor performance in Greek class. Even though he sometimes tried hard to concentrate, he could not pay attention in class, and he often thought about his mother and sister. When he was 9 years old and living in Syria, his mother and little sister were killed in a bombing on the street, whereas Amed, his brother and father, who worked as a teacher at that time, were at school and survived. Whenever Amed thought about that experience, he would become frightened and would try not to think about it, but then his mind would go blank and he would have a sense of losing time and getting confused.

After the mother and sister died, for fear that the rest of his family would be killed as well, the father decided that they would flee to Germany, where some of his relatives had migrated for employment several years earlier. During their difficult refugee flight to Europe, Amed lived in fear that someone would attack him, and he suffered from nightmares and felt very guilty that he had survived when his mother and sister had not. After 6 months, they reached Greece, but the father had to give up hope of settling in Germany. They ended up staying in Greece, where the family had no social support networks and a severe national economic crisis was reaching its peak. The father stated that for a long time he had been suffering from depressed thoughts because of the great difficulty he faced in making a living, adapting to a new setting, and helping his sons in school. He also worried that his children would forget their native culture.

During mental status examination, Amed made little eye contact and did not speak spontaneously; his responses to questions were logical, coherent, and rather abrupt. He seemed depressed and mildly irritable; no evidence of psychotic symptoms was displayed. In a second assessment session, he revealed that being at school often evoked intrusive thoughts of the morning his mother and sister were killed and that he occasionally experimented with cannabis with his friends, which helped distract him from these memories.

Diagnostic formulation ruled out major depressive disorder, oppositional defiant disorder, and conduct disorder, and a diagnosis of chronic posttraumatic stress disorder was made. At the same time, it was recognized that Amed was struggling with a number of psychosocial and environmental problems, including the death of family members, disruption of the family system, refugee flight, difficulties with acculturation, financial strain, inadequate parental monitoring, and discrimination by peers.