Rayan Khatoun has been dreading 4 August. She has been constantly on edge as the anniversary of the port explosion in Beirut approached. The blast threw Khatoun into a wall as she came home from work and left her with a head injury, a fractured cheekbone and torn tendons. Since then, she has suffered from recurring nightmares, insomnia and anxiety attacks. “For months after, I was too scared to be anywhere near glass,” she says. “Sometimes, I experienced a sudden fear of open spaces as if I had nowhere to hide if something happened.” Khatoun’s children are in constant fear of something happening to her, after seeing how badly she was hurt. “We have lost our sense of safety completely,” she says. With the country in meltdown, failed by the political class, its people are in the grip of a mental health crisis without adequate resources to deal with it. Lifeline, Lebanon’s emotional support and suicide prevention helpline, says the number of calls it’s receiving each month has almost doubled since May 2021 to 1,050. The port explosion “ripped apart people’s homes, as they were in them”, says Dr Olivia Shabb, a clinical psychologist at the American University of Beirut. “It destroyed the ability for many people to have the most basic form of trust required to live with peace of mind.” Widespread power cuts caused by fuel shortages are also now lasting up to 22 hours a day. Without electricity at night to power air conditioning, many people are struggling to get enough sleep during the hot and humid Lebanese summer. “Sleep is an essential component of mental health,” says Dr Joseph el-Khoury, the incoming president of the Lebanese Psychiatric Society. “We are getting reports of babies not getting their essential sleep, with added stress on parents.” The power cuts have also forced businesses, already dealing with a volatile economy and currency fluctuations, to close early or for several hours each day, reducing much-needed income. “The situation is unbearable,” says Jean Antoun, who runs a coffee shop that was damaged in the explosion. “We have now no fuel, no electricity, and the prices of raw material and ingredients are changing by the hour.” Khatoun is torn about whether to attend the protests being held on Wednesday to mark the anniversary of the blast. She fears that being so close to the port could have an impact on her mental health. It’s common for symptoms to get worse around anniversaries, particularly if avoidance has been a coping mechanism, says Shabb. People can avoid discussing the blast or going near the port “but they can’t avoid the occurrence of a date and the sensations that will come with a muggy, sunny afternoon on 4 August”. Khoury adds that recirculating videos of the explosion itself are likely to distress those suffering from post-traumatic stress disorder (PTSD). “I do not think we can stop people from sharing, especially in the context of social media,” he says. “But I encourage those who feel the need to share, to share instead their personal story, or pictures that carry a symbolism for them. Even pictures of the damage and destruction are likely to trigger people significantly.” Mental health has been a low priority in the Lebanese health system, which is skewed towards high-cost interventions for the wealthy, rather than accessible care for the the general population. According to the Global Challenges Research Fund, two million Lebanese people could not realistically afford to go to a doctor in 2020. In the 12 months since the blast, demand for mental healthcare has increased, says Khoury. He has been prescribing psychotherapy, counselling and medication to treat survivors of the port explosion experiencing depression, anxiety and PTSD. There has, however, been an exodus of psychiatrists and psychologists from Lebanon, as the value of salaries dropped by about 90% due to the devaluation of the Lebanese currency. Khoury is now based mostly in Dubai. “Many who were comfortable financially for decades are now barely making ends meet,” he says. “Families are being broken, with one breadwinner having to move abroad.” While Lifeline currently has enough power to operate 21 hours a day, it has negotiated with the health ministry for solar panels to be installed to reduce its dependency on increasingly scarce fuel. This will enable it to provide a 24-hour service by the end of August, according to Hiba Dandachli, the communications director for Embrace Lebanon, the NGO which operates Lifeline. Callers to Lifeline are likely to continue to face power cuts and poor connectivity however, and these disruptions affect the ability of counsellors to establish a rapport with people in sensitive emotional states, says Dandachli. “The one positive aspect is that talking about mental health is no longer a taboo, especially for the younger generation,” says Khoury, “so this is leading to them seeking proper treatment.” However, even those who seek treatment may struggle to access medication. “A lot of critical medication is out of stock and agencies are not able to import new stock due to the devaluation of the Lebanese lira,” says Remi el-Haji, a clinical pharmacist at a hospital in Beirut. Khoury has seen patients reducing or stopping their treatment and using expired medication. There is concern about the impact this could have on those suffering from serious psychiatric illnesses and conditions such as Alzheimer’s. “Trauma treatment assumes a return to safety and that the danger has passed,” notes Shabb, “but there hasn’t really been a return to safety. People feel that there is no guarantee that if they heal here [in Lebanon], that they are not going to have to go through something similar next year or in a few years.” No one in authority has yet been held accountable for the port blast and politicians have shown little appetite for a robust investigation. Shabb believes that many of the mental conditions that people have developed over the past year are an understandable reaction to a “twisted context”. “We need to normalise the problem as a structural problem,” she says. “We can’t keep putting the responsibility on people to heal themselves when the conditions that govern them are so harmful.” In Lebanon, the Lifeline helpline can be reached on 1564. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, Mental Health America is available on 800-273-8255. Other international helplines can be found at www.befrienders.org