(The identity of the correspondent has been withheld for security reasons)
DAMASCUS (Reuters) - It was cold and dark in the psychiatrist's office in downtown Damascus. The electricity had just gone out, a regular occurrence these days in the Syrian capital, and he wore a jacket and scarf for warmth.
Patients used the light from their mobile phones to climb a narrow staircase up five floors. The doctor, who asked that his name not be used, says his clients used to drive from all over the country. But Syria's civil war means many can no longer reach the capital across frontlines.
When pro-democracy protests started three years ago, Syrians had access to government-subsidized health care. But in the armed revolt that followed a government crackdown on the protesters, many hospitals have been destroyed, and psychiatric facilities have become almost non-existent.
Family networks have also collapsed under the pressure of war. Like other Arab countries, Syria had a long tradition of community involvement in the individual's wellbeing. But since the war began, communities have been uprooted and entire villages and towns have been destroyed, leaving society's most vulnerable people without a safety net.
The demand for psychiatric care has never been greater. Psychiatrists find themselves overwhelmed by cases of war-related trauma.
Today in Damascus, it is not unusual to see flyers with photos of patients who have disappeared after being displaced.
Even the more fortunate patients who live at home in relatively safe central Damascus, with access to the few remaining psychiatrists, find the stress of war can precipitate a crisis.
In the case of Sawsan, a 40-year-old woman living with schizophrenia, the sounds of war trigger her agitation and paranoia.
"On bad nights, when we can hear a lot of shelling and gunfire, she gets stressed," her mother said. "(Sometimes) she locks herself in her room for days, barely coming out to eat. It's been very difficult for us."
The family has to arrange for Sawsan's prescribed drug to be delivered from neighboring Lebanon as it is now almost impossible to get in Syria.
Ruba, a manic-depressive in her mid-fifties who has been prescribed Lithium for four decades, had a manic episode that her family thinks could have been prevented with a short hospital stay. But that is no longer an option because the main psychiatric hospital is located on the edge of Damascus in the midst of fighting and is no longer accessible.
So Ruba started disappearing for hours at a time, going on shopping sprees throughout Damascus, even during some of the worst mortar attacks on the city.
"It's one thing when we had to deal with this back before the war, and we'd go out and find her and bring her home, and no harm was done," said her brother. "But now? In the middle of a mortar attack she takes off to go shopping? If she doesn't answer her phone, we don't know if she's dead or alive or kidnapped? It's very scary."
International aid group Doctors Without Borders (MSF) said in October that 15 percent of Syrian refugees in an Iraqi refugee camp displayed symptoms of a severe mental disorder, double the number a year before.
"Our team is increasingly seeing more complex reactions and symptoms among the refugees. Disorders such as schizophrenia and severe depression are becoming more commonplace, and we are seeing many patients who have suicidal tendencies," said Ana Maria Tijerino, a mental health adviser for MSF.
In Syria, the Damascus-based psychiatrist says the magnitude and nature of the cases he comes across have forced him to rethink his entire approach to treatment.
"We're seeing a lot of cases of PTSD (Post-Traumatic Stress Disorder) ... Children who witness blood and gore. They can't shake the images from their mind. They see it every time they blink," he said.
Civilians living in rebel-held areas of Syria have to endure air raids, and the army prevents doctors and medicine from getting in. Doctors trying to cross government checkpoints have been detained, accused of aiding and abetting terrorists.
But Damascus-based doctors do provide medical care to civilians displaced from rebel areas and living in government shelters, which these days are usually school buildings.
One doctor working with the displaced told the story of a 12-year-old boy he met who was riding in the backseat of a car, holding his baby sister while the family escaped gunfire.
"The baby was hit by a bullet and she died in his arms. His parents say that he refused to let go of her for a long while after that, and had her blood all over him," the psychiatrist said, adding that the boy suffers from bed-wetting.
With help from international aid groups, local psychiatrists have been setting up therapeutic art classes for children throughout government-controlled areas, and training teachers in recognizing signs of psychological trauma.
Juliette Touma of UNICEF describes these programs as therapeutic, recreational activities like theatre, creative writing, music and sports. An estimated 4 million children in Syria are in need of such programs, she says, but many are beyond reach due to heavy fighting or military sieges.
For the tens of thousands who are reachable, Touma says the benefits are clear.
"At first they use strong colors like red and black and they draw tanks and soldiers and dead bodies. But after months ... we notice that they draw normal things like little houses and a little child going to school and a forest and flowers and things that children normally draw," she said.
(Editing by Janet McBride)