8, Issue 1, June 2017
Health Issues in the Middle East - An Overview
the wider view, treatment of, and attitude toward mental health
disorders in the Middle East is an ongoing journey as it has
been in the rest of the world.
of war and violence, displacement, refugees, occupations by
militia and terrorists, restrictions on women in traditional
societies, arranged and forced marriages, lack of tolerance
for gender dysmorphia, and domestic violence are causing mental
health problems such as PSTD, depression, anxiety and suicide
(i.e. affective disorders) and are contributing to the psychological
and socio-cultural causes of mental health disorders in the
region. In regard to organic mental illnesses (e.g. schizophrenia,
bipolar disorder) the stigma surrounding such mental health
conditions remains a problem along with lack of medical education
producing appropriately trained medical professionals, and
lack of psychiatric services and hospital beds. These are
all issues that have been faced and are still being faced
in various parts of the wider world.
This paper explores mental health and its treatment, training,
education and medical facilities in the Middle East and the
stigma that often surrounds these conditions as well as the
societal/psychological/environmental causes of mental health
problems and mental illness due to war and other societal
discord and cultural traditions.
Some forms of organic mental illness can be alleviated with
new or improved pharmaceutical and medical management (e.g.
while schizophrenia cannot be cured it can these days often
be well controlled through appropriate medication to the extent
that sufferers can lead a normal productive life) and/or psychiatric
treatment (e.g. cognitive behaviour therapy (CBT)) while other
issues causing despair, depression , anxiety and suicide in
some individuals may require social reform, government policy,
legal frameworks and indeed political peace and stability
In some of the more traditional Middle East countries societal
and cultural issues are still causing mental illness, and
appropriate treatment facilities and care providers, and political
recognition and human rights, freedom of women, recognition
of homosexuality and gender dysmorphia, could allow people
better freedom to make their own life choices and eliminate
some of the causes. These are issues that require social,
religious and political solutions that meet the real needs
of Middle East societies. The Arab Spring showed clearly that
there are a wide range of social attitudes within the region
and these have a bearing on society as a whole and countries
must work toward solutions that decrease the mental health
issues in their communities and allow people to make their
own choices within a religious, cultural and political framework.
It is also recognised that each country in the region has
its own approach, problems and successes. This paper looks
at the more general issues that affect the countries of the
region to a greater and lesser degree.
It must also be recognised that not all change is necessarily
good and the modernisation of societies also brings adverse
effects, and their own sources of mental health issues.
The first and most obvious social cause and source of mental
health problems is the seemingly endless plague of war in
The topic of man's propensity to war and willingness to wreak
terror and violence on his fellow man is a mental health issue
in its own right and one that requires far greater study.
This paper will look at the mental health effects of this
most barbarous tendency of humans.
War and conflict causes loss of loved ones and family under
cruel and extreme conditions, such as starvation, mass murder,
torture, rape, loss of home and a sense of belonging, deliberate
expulsion from homes and communities, loss of income and societal
and family structure, loss of societal norms, loss of social
identity, loss of faith and hope, prejudice and violence against
minorities, loss of dignity and self esteem.
Therefore war and conflict results in mental health issues
such as depression, PTSD, suicide, childhood behavioural problems,
despair and anxiety and often ending in suicide, or acts of
violence against others.
War and conflict currently debases and murders citizens of
Syria, Iraq, Yemen, South Sudan, Palestine, and Kashmir in
extraordinary numbers and touches the lives of all people
of the Middle East and has done so for millennia. It could
be argued that this inherited problem has caused ongoing mental
illness in some populations and has hindered progress and
social reform and personal ambition.
Those who flee countries under attack face new mental health
crises and issues in the countries that they either flee to
or in those countries that give them refuge.
In 2015 the UN Office for the Coordination of Humanitarian
Affairs estimated that 10.8 million people are affected by
the conflict in Syria, with 4 million refugees having fled
the country. In early 2015, UNHCR estimated 3 million people
in Iraq faced mental health problems. Millions of people have
experienced the trauma of political and religious conflict
and persecution in the Middle East, especially women, who
the Iraqi Ministry of Health have determined are disproportionately
affected by mental health illness due to recent conflicts
without Borders, (Medecins sans Frontieres) advises there
are currently only four psychiatrists for every 1 million
residents in Iraq, and even fewer professionals are trained
in related mental health professions such as psychological
counseling. Of the professionals working with Syrian refugees
in Iraq, there are only four who do on average 70-100 counseling
sessions per week with traumatized individuals. Similarly,
in Jordan, a country now hosting an estimated 659,828 refugees
(2) there are a total of 31 psychiatrists and 24 psychologists
for the entire population, including refugees from Palestine,
Syria, and Iraq. Lebanon and Turkey also have inordinate numbers
of Syrian refugees who have fled the barbarity in their own
country. Unfortunately, most psychiatric professionals are
strictly hospital-based and provide mainly biological care
leaving no mental health professionals to address Post Traumatic
Stress Disorder in populations. (1)
The International Medical Corps has identified a number of
challenges and recommendations including:
- Increase the availability of services.
- Make mental health care part of general health care.
- Train and license more mental health professionals.
- Address developmental disorders in children.
- Advocate for improved national mental health service provision
and policies. (4)
Mental health issues such as post-traumatic stress disorder
and depression are common in the Middle East. War compounds
these problems, making treatment harder to obtain. In Syria,
prior to the current conflict, mental health care was delivered
out of three hospitals in Damascus and Aleppo. One has been
destroyed and the other two are now inaccessible, according
to the World Health Organization (5).
In America there are 1.2 psychiatrists per 10,000 people;
no Arab country has more than 0.5, and most have far fewer.
The WHO reports that the number of sick is outpacing the number
of psychiatric beds, and the number of day-care facilities
is one-tenth of the global median. The result is that more
than three-quarters of people in the region who need mental
health care do not receive it. (5)
Stigmatisation of the mentally ill in any country does seem
an ancient animalistic response to the suffering of others
and it must surely be one of humanity's more primitive responses
based on 'de-identification with the herd' and the abandoning
and killing of the weaker members of the herd, or society,
in the case of humans. While this is a common streak in humans
and causes wars and conflict in its own right, much work has
been put into de-stigmatisation by medical professionals and
NGOs worldwide and the public are now educated on the truth
of organic mental illness - that is it is a medical defect
similar to physical medical defects and disorders and usually
can be treated pharmaceutically, surgically, or through psychiatry,
psychoanalysis or psychotherapy. At the least it should be
treated wisely and kindly.
Mental health stigma, defined as the "devaluing, disgracing,
and disfavoring by the general public of individuals with
mental illnesses", is a common barrier to care globally,
and is especially prevalent in the MENA region. (3, 6)
Additionally because of stigma, individuals suffering from
mental illness and families of the mentally ill rarely access
the help they need for fear of being judged and discriminated
against. Mental illness is often associated with social shame,
damaged reputation and diminished social status, leading many
individuals to avoid help. (6)
Culture provides a set of rules and standards that are shared
by members of a society. (7) These rules and standards shape
and determine the range of appropriate behaviour. These culturally
originating stigmas can and should be able to be avoided by
proper societal education and debunking of the myths that
surround mental illness.
Worldwide violence against, and subjugation of, women is at
epidemic levels and when including issues of domestic violence,
rape, murder, forced marriage, sexual slavery, violence against
women affects the majority of women in all countries of the
world. Again it is a mental health problem that requires an
encyclopaedic work in its own right. This paper will deal
therefore with the smaller scale and local societal issues.
higher number of female suicides in traditional societies
compared to societies where females have full human rights
and control over their own destiny is an important issue.
Some but not all Middle East countries have recognised these
concerns and now allow divorce due to marital breakdown, domestic
violence (physical, sexual and psychological) and women now
more often enter the workforce and earn their own living.
The easy way to resolve this imbalance between the Middle
East and the rest of the world is the full emancipation and
human rights for women. This does not solve the problems of
woman's status generally in the world and certainly the issue
still needs to be properly addressed in all countries. It
cannot be seen as a gender issue as these problems do not
exist in the lives of other life forms on the planet where
females are generally prized - it is uniquely a human affliction
and arguably the cause of many of the wider problems affecting
The United Nations defines violence against women as "any
act of gender-based violence that results in, or is likely
to result in, physical, sexual or mental harm or suffering
to women, including threats of such acts, coercion or arbitrary
deprivation of liberty, whether occurring in public or in
A 2013 analysis conducted by WHO with the London School of
Hygiene and Tropical Medicine and the Medical Research Council,
based on existing data from over 80 countries, found that
worldwide, almost one third (30%) of all women who have been
in a relationship have experienced physical and/or sexual
violence by their intimate partner. The prevalence estimates
range from 23.2% in high-income countries and 24.6% in the
Western Pacific region to 37% in the WHO Eastern Mediterranean
region, and 37.7% in the South-East Asia region.
partner and sexual violence against women (World Health Organization)
Violence against women - particularly intimate partner
violence and sexual violence - are major public health problems
and violations of women's human rights.
Global estimates published by WHO indicate that about
1 in 3 (35%) women worldwide have
experienced either physical and/or sexual intimate partner
violence or non-partner sexual violence in their lifetime.
Most of this violence is intimate partner violence.
Worldwide, almost one third (30%) of women who have been in
a relationship report that they have experienced some form
of physical and/or sexual violence by their intimate partner
in their lifetime.
Globally, as many as 38% of murders of women are committed
by a male intimate partner.
Violence can negatively affect women's physical, mental,
sexual and reproductive health, and may increase vulnerability
Situations of conflict, post conflict and displacement
may exacerbate existing violence, such as by intimate partners,
and present additional forms of violence against women.
Updated November 2016
against women leads to mental health problems with suicide
as an outcome in women pre-disposed to depression and despair,
and those who see no way out of their desperate situation
due to lack of property, lack of rights and no assistance
or support from their original families. These are the key
societal factors that lead desperate women to higher suicide
rates in some countries of the Middle East.
statistics apply to all women in the world but in some cultures
women's choices are supported by family, government and legal
systems and women have freedom of movement, the right to choose
their own husband/partner, rights to own property, i.e. personal
human rights sometimes lacking in Middle East countries. Policies
to protect vulnerable women and their children need to be
implemented and backed up by legal and justice systems.
women have addressed these same issues in the same way over
the march of time and women in the Middle East are now also
facing them and are increasingly willing to face them and
find their true identity and demand dignity, autonomy and
In most countries the suicide rate is higher in males but
in some traditional ME societies it is women who suicide in
greater numbers, which confirms evidence that it is a religious,
social and cultural phenomenon. In countries where women and
children have full internationally accepted human rights such
suicide problems disappear as well as many other problems
major psychological factors found to be associated with suicidal
behaviour are depression, especially hopelessness, and psychological
disturbance, anxiety, or emotional instability. Psychiatric
disorder appears to increase the risk of suicide, with affective
disorders and alcohol and drug abuse leading causes. (8)
Investigations into the cause of significantly higher depression
rates in women as opposed to men in the Middle East and North
Africa (MENA) region have indicated a number of contributing
factors; many are psychosocial in origin, but most controversial
is the role of Islam.(9)
In an examination of the hypothesis that Islamic beliefs and
practices exacerbate stress and distress in women, evidence
from the MENA region, has shown that changing roles for women,
issues related to reproductive health factors as well as inherent
methodological problems of gauging subjective feelings like
depression, is considered. (9)
Some experts suggest that this new wind of change seen in
the Arab Spring is indirectly, becoming an increasing source
of stress for women. For example, Al-Lamky (10) has indicated
that the rapid modernisation, made possible by economic development,
has not been paralleled by an equally dramatic change in the
cultural values concerning the structure or roles of the family.
Hamid et al. (9) investigated the psychosocial aggregate of
depression in their sample in Jordan. Among many variables
associated with depression, the contribution of marital status
women, in contrast to widowed or separated women , scored
highest in the indices of depression. This implies that divorced
women did not fare worse compared to married or single women.
(9) This factor is true in all societies however, with married
women and unmarried men having the highest mental health prevalence
and unmarried women and married men having better mental health.
There is however an increasing prevalence of suicide and depression
in all global societies. It is predicted that depression will
become the leading cause of disability for all populations
by the year 2020. (9) This is likely mostly due to the general
state of humanity and with better communications making it
unavoidable for people to shield themselves from the facts
of life and our planetary vulnerability to destruction by
human and ecological means.
Homosexuality (LGBTI) and gender ambiguity/dysmorphia
The stigma or illegality of homosexuality has caused anxiety,
depression and suicide in those countries where it is still
outlawed, unrecognised and shunned. A main outcome of this
has been suicide, incorrect treatment, e.g. horrific surgical
solutions to homosexuality that do not address the real issues
and migration of homosexual refugees to countries where their
gender identity is more tolerated, in law and socially.
Several Middle Eastern countries have received strong international
criticism for persecuting homosexuality and transsexuals by
fines, imprisonment and death. However, some Middle Eastern
countries have developed more tolerant social attitudes and
taken some steps to protect LGBT people from discrimination
Israel has, since the 1960s, gradually developed more social
tolerance for LGBT people, and taken steps to recognize LGBT
rights. Jordan, Bahrain and Iraq are some of the few Arab
countries where homosexuality is not illegal. (13 ) (14)
In some other Middle Eastern nations, including Turkey and
Lebanon, changes in social attitudes and laws have slowly
come about as part of a larger campaign for greater tolerance,
pluralist democracy and respect for human rights. (13 ) (14)
Some Middle Eastern nations do not allow a LGBT community
or human rights movement to exist. Countries such as Saudi
Arabia, Kuwait, United Arab Emirates criminalize same-sex
sexuality, cross-dressing and any expressed support for LGBT
rights. (13 ) (14)
Some Middle Eastern nations have some tolerance and legal
protections for transsexual and transgender people, but not
for homosexual or bisexual persons. (13 ) (14)
Education and Practice
the Islamic community, mental illness is viewed by some as
a crisis of faith or a trial from God, and thus in some ways
a character defect. This and other stigmas around mental health
are also issues, and may underlie the significant lack of
mental healthcare professionals as well.
Despite the recent increase in mental health awareness at
a national level in the Middle East, most individuals dealing
with these problems have nowhere to go, no-one to talk to
and do not know how to access care. (15)
Regional prevention and awareness campaigns are minimal with
minor initiatives taking place in Jordan, the United Arab
Emirates, Lebanon, and several other Arab countries. (15)
Most Arab countries have started to recognize mental health
as an important part of their national health care plans and
curricula. Unfortunately, it rarely translates into policy
or planning for integrated action across the health sector,
let alone at the population level, and capacity building for
health professionals is limited.
Dr Ziad Kronfol, a well-renowned psychiatrist in the MENA
region, advises psychiatry rotations in most Arab medical
schools are basic, consisting of a few scattered lectures
and occasional visits to clinics and/or wards. Clinical research
and supervision are often non-existent. Even where services
are available, the resources needed to provide quality services
are often insufficient.(15)
A depression study conducted amongst focus groups in Jordan
by Drs Laeth Nasir and Raeda Al-Qutob reported that the most
prevalent theme among physicians was that they considered
depression a diagnosis that they had neither the experience
nor the time to treat. In addition, some physicians felt that
because patients did not understand their illness they would
not work towards the treatment. (15)
Besides the lack of availability of quality services, access
to the limited existing services is also a common problem
in many MENA countries. Obstacles can include personal financial
constraints, limited services for women, insufficient local
transportation and overly complicated referral processes.
These practical obstacles to accessing mental health services
and treatment are further compounded by social barriers to
care (stigmatization) (15). Specific barriers included beliefs,
values, etiological perceptions and stigma. (16)
There are regions in the world where there is one psychiatrist
for one million people. The situation in some poor Arab states
is not much better. Primary care physicians need to be educated
appropriately to detect and treat mental illness in their
practice and know when to refer to psychiatric care. Curriculum
changes are required at the undergraduate level so that the
primary care physicians can be trained to deal with the most
prevalent mental conditions. (16)
Emphasis of education should be developed taking into account
the particular social, cultural and religious issues and needs
in the Middle East.
with mental illness in the Middle East
one in ten people are thought to suffer from a mental disorder
at any given time. The rate rises to one in six in areas affected
by war. In Syria, where mental-health care was delivered out
of three hospitals in Damascus and Aleppo before the war,
one has been destroyed and the other two are now inaccessible,
says the World Health Organization (5).
Recommendations for Specific Initiatives in Mental Health
Services and Training (17)
1. Upgrade the quality of mental health services
2. Encourage systematic efforts to upgrade the amount and
quality of mental health training for workers at all levels,
from medical students to graduate physicians, from nurses
to community health workers.
3. Promote efforts to improve state gender policies, toward
interdicting violence against women, and toward empowering
women economically, and to make women central in policy planning
and implementation of mental health services. Research should
evaluate the mental health consequences of these programs
for women, for children, and for men.
4. Encourage initiatives to attend to the causes and consequences
of collective and interpersonal violence.
5. Direct efforts specific to primary prevention of mental
disorders, and behavioural, psychosocial and neurological
the Middle East along with many other countries is slowly
responding to the issues of mental health in the general community
and starting to address it on a country by country basis.
The Middle East no doubt, has similar levels of organic/psychiatric
illness as does the rest of the world.
It does however also have a greater proportion of mental health
caused by social factors of violence and war, terrorism, occupation,
and crimes against women and girls.
These are part of the need for greater social reforms and
governments are to be encouraged to start implementing better
medical education strategies, social planning, policies and
education to provide a qualified workforce to treat these
conditions, better public education to reduce stigmatisation
born of medical ignorance and a legal and justice system that
supports human rights for all.
( 3) Ayse Ciftci. Nev Jones and Patrick W. Corrigan Mental
Health Stigma in the Muslim Community Journal of Muslim Mental
Health, Volume 7, Issue 1: Stigma, 2012
(4) International Medical Corps 2015 Report, "Addressing
Regional Mental Health Needs and Gaps in the Context of the
Syria Crisis," http://internationalmedicalcorps.org/document.doc?id=526.
(5) World Health Organisation
(6) Shamaila Usmani. Access to mental health care in the Middle
East-what are the barriers? Apr 22, 2014 Blog. www.globalhealthmiddleeast.com/access-to-mental-health-care-in-the-middle-east/
(7) Ciftci (1999) Mental Health Stigma in the Muslim Community
- University of Michigan
(8) Societal and Cultural Suicide Rates. Sultan Qaboos Univ
Med J. 2009 Apr; 9(1): 5-15.
Published online 2009 Mar 16.
(9) Liyam Eloul,1 Aamal Ambusaidi,2 and Samir Al-Adawi*,1
Silent Epidemic of Depression in Women in the Middle East
and North Africa Region
Emerging tribulation or fallacy? Sultan Qaboos Univ Med J.
2009 Apr; 9(1): 5-15.
(10) Sara Al Lamki, Mental Health Archives - Global Health
(13 ) http://www.albawaba.com/loop/despite-legality-jordans-lgbt-communities-are-still-facing-backlash-700656
(15) Shamaila Usmani . Access to mental health care in the
Middle East-what are the barriers?
(16) Mohammed Yahia. Physicians in the Middle East should
develop bespoke methods to treat psychiatric illness which
address the region's cultural, ethical and genetic peculiarities.
17 EK Proctor, J Landsverk, G Aarons. Implementation research
in mental health services: an emerging science with conceptual,
methodological, and training challenges. Mental Health Services,
2009 - Springer