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The Silent Crisis in the Middle East

BAGHDAD, IRAQ - MAY 29:  Male patients sit and lie on the ground at the Al Rashad psychiatric hospital May 29, 2003, in Baghdad, Iraq. The hospital has been in complete disarray since being looted in the days following the end of the U.S.-led war.  Looters took crucial medicine and patient records were destroyed, leaving a team of six doctors the daunting task of getting the place in order and helping the patients, many whom have had their conditions deteriorate drastically.  It's estimated that around 800 patients escaped.  (Photo by Marco Di Lauro/Getty Images)
BAGHDAD, IRAQ – MAY 29: Male patients sit and lie on the ground at the Al Rashad psychiatric hospital May 29, 2003, in Baghdad, Iraq. The hospital has been in complete disarray since being looted in the days following the end of the U.S.-led war. Looters took crucial medicine and patient records were destroyed, leaving a team of six doctors the daunting task of getting the place in order and helping the patients, many whom have had their conditions deteriorate drastically. It’s estimated that around 800 patients escaped. (Photo by Marco Di Lauro/Getty Images)

by Yasmine El-Geressi

One in ten people worldwide suffer from mental disorders and as the Middle East is being gripped by conflict and war, it shouldn’t come as a surprise to hear that according to a study by researchers at Australia’s University of Queensland, the region suffers the world’s highest depression rates. Other researchers have also amassed evidence to suggest that psychiatric disorders are hectically expanding within Middle Eastern communities and it’s costing people in the region years off their lives.

Mental health is not a strong priority in the Middle East and this lack of prioritization means that the available resources are rarely translated into policy or planning for action at a population level by governments. Therefore, like with most medical conditions, many people living in Arab states are subject to insufficient support and assistance and while in the west mental health is becoming more socially accepted and better understood, stigma often prohibits discussion of depression and associated illnesses in the region. The lack of attention and care given to one’s mental health, within their communities and on a larger scale, within their countries means few people in the Middle East seek or receive help for their mental suffering.

The history of mental health treatment in the Middle East is in stark contrast to what is seen today in these countries. It is enlightening to learn about the region’s illustrious history in the field and it’s historic importance in the care and understanding of mentally ill individuals. The first psychiatric hospitals in the world were built in Baghdad in 705 CE, in Cairo in 800CE and in Damascus in 1270 CE. They were known to be safe and pleasing environments and were described to have pools, fountains, flowing water and flower gardens. Doctors experimented with treatments such as occupational and music therapy as healing methods, practices which were continued by physicians in the Ottoman civilization. What is also notable about such institutions in the Arabic empire, particularly when compared to the asylums in Europe that emerged over 500 years later, was that they were always in the centre of cities, making them easily accessible by those in need of help and minimising the social isolation of patients. The Arab region was also at the forefront of research into mental illnesses. Esteemed Muslim physician Ibn Sina’s (d. 1037) 14-volume tome ‘The Canon of Medicine’ was used in the west for more than 700 years.

Today, the human resources, services and attention given to mental health issues are grossly insufficient. In a region that has been destroyed by war and conflict, it inevitably carries a population that has been traumatised emotionally and psychologically. Consequently, the need for mental health services is overwhelming and supply is at the lowest possible level. Health services are below accepted standards and six out of twenty Arab countries do not have a mental health legislation and two do not have a mental health policy. Mental health expenditure as a percentage of total health expenditure also remains very low. For example, in the UK the NHS dedicates 13% of it’s budget to mental health, whereas in Egypt less than 1% of total health expenditure is dedicated, which is far below the range to promote mental health services. According to World Health Organisation (WHO), no Arab country has more than 0.5 psychiatrists per 10,000 people, whereas in America, there are 1.2 psychiatrists per 10,000 people. In countries exposed to conflicts and wars the figures are more disturbing. According to Doctors without Borders, there are currently only 4 psychiatrists for every 1 million residents in Iraq, and even fewer professionals are trained in related mental health professions such as psychological counseling.

There have been some positive initiatives in the field of mental health in the Arab Region in recent years according to WHO. Some Arab countries have started to recognize mental health as an important part of their national health care plans. Psychiatric services, which were earlier confined to a few large mental hospitals, are becoming decentralized and are now gradually being replaced by psychiatric units with both inpatient and outpatient facilities in general hospitals. Training programmes in mental health for general practitioners, non-physicians and health personnel working at primary health care level have started in a large number of countries as a part of in-service skills enhancement programmes. For example, Qatar has acknowledged that depression is a prevalent problem in the community and has been working to improve its mental health services. A new law was introduced that for the first time gave residents with mental health conditions specific rights regarding their treatment and authorities have also invested significant funds in opening up new treatment centres.

Another important aspect of mental health in the Middle East is the conflict between ancient teachings and the modern day approach to the issues of mental disorders. Many sufferers rely on traditional healers and precious time and money is often misspent meaning suffering continues unnecessarily before scientific methods of treatments are finally used, if used at all. In the United Arab Emirates, approximately half of patients suffering from psychiatric disorders sought non-professional care before attending specialized services. This pattern of health seeking behavior is influenced by cultural beliefs regarding the supernatural in provoking symptoms of mental illness. Sufferers will visit traditional or religious healers with the hope of being cured of their illness by getting spirits expelled or being freed from the “evil eye”.

In most Middle Eastern countries there is no interaction between medical professionals and traditional or Islamic healers. An integrative approach may bridge the gap between traditional healing and Western-based therapies. A UK study published in the British Journal of Psychiatry that looked at jinn possessions and mental illnesses suggested that an open discourse should be encouraged between religious authorities and mental health professionals. Mental health professionals can teach religious healers to recognize mental illness and religious professionals can in turn educate health professionals about the importance of religious factors in mental illness. Cooperation between the two healing methods could help to better address the treatment preferences of people from the region. Medical therapies are based on western theories of mental illness, carried out by western researches and whose evidence consists predominantly on western samples but although diseases may be the same, the manifestations of any particular disorder vary with the culture in which it appears.

ALEPPO, SYRIA - SEPTEMBER 11: Mentally ill people are seen at the garden of a psychiatric hospital at Azez town of Aleppo, Syria on September 11, 2016. Approximately 400 mentally ill people, who come from different region of Syria and several countries, receive treatment at the hospital. (Photo by Arif Hudaverdi Yaman/Anadolu Agency/Getty Images)
ALEPPO, SYRIA – SEPTEMBER 11: Mentally ill people are seen at the garden of a psychiatric hospital at Azez town of Aleppo, Syria on September 11, 2016. Approximately 400 mentally ill people, who come from different region of Syria and several countries, receive treatment at the hospital. (Photo by Arif Hudaverdi Yaman/Anadolu Agency/Getty Images)

People with mental illness experience the compounded disadvantages of the acute shortage of mental health specialists, stigma and in many cases, having their illness ignored and dismissed. Keep going, walk it off, tough it out, are messages people are used to hearing in Arab culture where invisible illnesses are often trivialized and not only is there a lack of awareness and ambivalence on the issue, but an overwhelming majority of people avoid discussing and dealing with the matter altogether.

Epidemiological research suggests that more than half of the people who might benefit from mental health services refuse to access them so as to avoid being labeled as “mentally ill.” Unlike other illnesses, mental illness is often associated with social shame, damaged reputation and weakness in the Arab world and studies have shown that Arabs living in the United States and the United Kingdom share similar fears of stigmatization. Also, those who do seek treatment are often concerned about how people will view them if knowledge of their condition is made public and fear becoming disqualified from full social acceptance.

Family and community ties are strong in the Middle East and this can play a positive role to the extent that they can be used as social support rather than social pressure. Therefore, there is strong potential for the breaking down of social barriers but for this to happen there must be a change in attitude at a grassroots level. Arab countries should do more to raise awareness about mental issues by educating the community on the nature of mental heath, its signs and treatment routes.

Moving forward with issues that are surrounded by stigma is not always simple or fast and although there are plans to address the deficiencies in Mental Health care and awareness in the Middle East, they are rarely implemented fully. There must be much greater prioritization of the vital mental health needs of the people in the region. Progress will require techniques that integrate health, awareness and culturally sensitive practice. By matching these techniques with the required resources, the lives of thousands of people will be improved.

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