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Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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Lesley Pocock
medi+WORLD International
Macleay Island
Queensland
AUSTRALIA
Email
: lesleypocock@mediworld.com.au
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Volume 8, Issue 1, June 2017

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Mental Health Issues in the Middle East - An Overview


Lesley Pocock


Correspondence:
Lesley Pocock
Publisher
medi+WORLD International

Email: lesleypocock@mediworld.com.au

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Introduction

From 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.

Issues 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 society.
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.

Unique Challenges

War and conflict
The first and most obvious social cause and source of mental health problems is the seemingly endless plague of war in the region.

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 (1).

Doctors 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
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.

Status of women
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.

The 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 humanity.

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 private life".

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.

Intimate partner and sexual violence against women (World Health Organization)

Key facts:
• 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 to HIV
• Situations of conflict, post conflict and displacement may exacerbate existing violence, such as by intimate partners, and present additional forms of violence against women.

WHO Fact sheet
Updated November 2016
http://www.who.int/mediacentre/factsheets/fs239/en
/

Violence 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.

The 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.

Worldwide 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 respect.
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 in society.

The 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 is considered.

Married 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. (11, 12)

Depression
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 and harassment.

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)

Medical Education and Practice

Within 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.


Dealing with mental illness in the Middle East


Globally, 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 disorders.

Conclusion

Generally 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.

References

(1) http://data.unhcr.org/syrianrefugees/country.php?id=107)
(2) https://disqus.com/by/kristenlundquist/
( 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
quod.lib.umich.edu/j/jmmh/.../--mental-health-stigma-in-the-muslim-community?...
(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 Middle East
www.globalhealthmiddleeast.com/category/blog/ncds-blog/mental-health/
(11) http://www.apa.org/about/gr/issues/women/depression.aspx
(12) https://www.psychologytoday.com/blog/finding-true-love/201003/is-marriage-toxic-women-part-ii-massive-review-study-says-marriage
(13 ) http://www.albawaba.com/loop/despite-legality-jordans-lgbt-communities-are-still-facing-backlash-700656
(14) https://www.theguardian.com/world/2016/jun/21/gay-lgbt-muslim-countries-middle-east
(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.
http://www.natureasia.com/en/nmiddleeast/article/10.1038/nmiddleeast.2012.103
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

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