Mental Health Solutions for Internally Displaced Persons: Studying the design, process and outcomes of a large-scale intervention in a camp in South Sudan

This thesis is rooted in the author’s professional experience as a public health officer in the Indian Army, with extensive exposure to disaster and emergency response. However, deployment to South Sudan in 2013 during the civil war revealed an unprecedented humanitarian crisis. Ethnic violence forced thousands of internally displaced persons (IDPs) into the UN Protection of Civilians (PoC) site in Malakal, resulting in extreme overcrowding, insecurity, starvation, and widespread psychological trauma. While emergency medical care was prioritized, mental health needs remained almost entirely unaddressed due to the absence of resources, protocols, and trained personnel. These conditions necessitated immediate innovation and led to the development of a community-based mental health intervention using displaced community members and the WHO Mental Health Gap Action Programme (mhGAP). This thesis documents the design, implementation, and evaluation of that intervention. Globally, forced displacement due to war, persecution, and disasters exposes populations to cumulative trauma before, during, and after displacement. IDPs commonly experience violence, loss of loved ones, chronic insecurity, poverty, and social disintegration, significantly increasing the risk of post-traumatic stress disorder (PTSD), depression, anxiety, substance misuse, somatization, and long-term disability. South Sudan represents one of the most severe examples of such crises, with profound mental health needs and minimal service capacity. Although global policy frameworks increasingly recognize mental health as a humanitarian priority, practical implementation—especially in sub-Saharan Africa—remains limited. This thesis argues that mental health must be addressed as a core public health concern rather than a secondary humanitarian issue. The theoretical framework acknowledges the complexity of trauma responses among displaced populations. Psychological distress often reflects understandable reactions to extreme adversity, making it essential to distinguish between situational suffering and clinical disorders within cultural and contextual realities. Humanitarian settings typically lack mental health specialists, infrastructure, and culturally appropriate care models, limiting scalability. To overcome these barriers, community-based and task-sharing approaches have gained prominence. Training Lay Mental Health Workers (LMHWs) from within affected communities leverages local knowledge, trust, and social cohesion, enhancing acceptability and sustainability. The WHO mhGAP Intervention Guide provides evidence-based tools for diagnosing and managing mental, neurological, and substance-use disorders by non-specialists. While widely implemented in low-resource settings, its application in which displaced persons themselves serve as mental health providers remains rare. This study represents an innovative extension of mhGAP in a conflict-driven displacement context. The research addressed three core questions: (1) the mental health status of IDPs in Malakal; (2) the feasibility and effectiveness of a community-based mhGAP intervention delivered by trained LMHWs; and (3) implications for policy and future humanitarian practice. A mixed-methods design was employed, including epidemiological screening of 2,100 adults using the SRQ-20, followed by in-depth assessments for PTSD, depression, anxiety, substance use, somatization, and disability. The intervention was evaluated through a randomized controlled trial, qualitative implementation analysis, and policy review. Program performance was assessed using the RE-AIM framework. Findings revealed an exceptionally high burden of mental health disorders, strongly associated with repeated war-related traumatic events. The LMHW-led intervention proved feasible, culturally acceptable, and well-integrated within camp structures. Participants receiving the intervention demonstrated meaningful reductions in PTSD and depressive symptoms compared to the delayed-intervention group. These results highlight the capacity of IDPs to function effectively as community mental health providers. In conclusion, the thesis demonstrates that early, community-based, mhGAP-informed mental health interventions are feasible, effective, and essential in humanitarian crisis settings. Mental health care is shown to be a foundational component of recovery and resilience for displaced populations, not an optional addition to humanitarian response.