Dealing with mental illness in the Middle East

Psychiatric disorders are increasingly widespread in the Middle East. However, the model used to assess and treat patients in the region was developed by a primarily Anglo-Saxon population based in the United States and Western Europe.

Ziad Kronfol, a psychiatrist at Weill Cornell Medical College in Qatar (WCMC-Q) recently helped organize a conference to discuss how guidelines in the Middle East can be developed to better handle mental illnesses.

In an interview with Nature Middle East, Kronfol discusses the problem and suggests the short and long-term approaches for treating people with mental disorders in the region.

Is there a serious problem of mental illness in the Arab world?

Statistics indicate that the frequency of most mental disorders does not vary much from country to country around the world. Schizophrenia, for instance, affects 1% of the population worldwide. Anxiety and depression are much more common and affect at least 10% of the population. There is no reason to believe that Arab countries are any different. The few statistics coming out of certain Arab countries (e.g. Lebanon and Egypt) confirm this fact. The issue in the Arab world is more to do with stigma and ignorance than it is lack of mental health problems.

What are the differences between mental health issues in the West and the developing world? Why is there a need for a new model for treatment in this region?

Psychiatry, perhaps more than any other medical discipline, is very culturally dependent. Although diseases may be the same, the manifestations of any particular disorder vary with the culture in which it appears. In developed countries, mental illness is well characterized. For most psychiatric disorders, we know the manifestations, the risk factors and the complications based on data from that country. It is therefore easier to recognize and treat mental illness.

In developing countries, these data are essentially lacking. We do not know the exact frequency of such common disorders as anxiety or depression. We do not know how many people kill themselves and for what reasons. So the issues are mostly ignored. Even physicians may not be aware of the magnitude of the problem since these issues are often neglected in their medical school curriculum. We therefore decided in this meeting to start at the level of the (undergraduate) medical school curriculum because as long as the practicing physician is not aware of these problems, we will not be able to make much progress at the community level.

What are the cultural issues of the Middle East that can play a role in mental illnesses?

I already mentioned stigma and ignorance and their negative impact on mental health. However, factors such as family and religion could have a positive impact. Family ties are strong in the Middle East and this can play a positive role to the extent that they are used as social support rather than social pressure. Similarly, the impact of religion could be positive to the extent that it induces good deeds and protects the person from harm, including self-inflicted harm. In other words, religion can be a protective factor against suicide.

Furthermore, we cannot address cultural issues in the Middle East without mentioning the religious healer. Most mental health patients in this part of the world are first seen by the religious or spiritual healer whose task is often to free the patient from the "evil eye". Precious time is often wasted and suffering continues unnecessarily before scientific methods of treatment are finally used.

Are there any Arab states that have developed or are developing mental health education programmes that address the needs of the region?

War survivors need a special approach because their issues are much more complex.

There is certainly an increase in the awareness in most Arab countries of the importance of mental health problems as part of the total health care picture. This awareness however rarely translates into action on the ground. Most medical schools in the Arab world have a rudimentary psychiatry programme. It is mostly in the form of scattered lectures and short rotations in clinics or wards.

Little attention is given to teaching interviewing skills or changing attitudes toward mental illness. Little attention is given to the natural course of the illness and the effects of treatment by following the same patient over time. Little time is actually spent dealing with the patient and his/her mental issues. Clinical research is generally lacking. Clinical supervision is scarce.

While there are promising initiatives in Lebanon, Egypt, Morocco and some GCC states, this is unfortunately the state of affairs in most countries.

Are there groups that are specifically vulnerable to mental illnesses in the Arab world?

In the Middle East there is a large number of displaced people, mostly refugees and people who have endured military conflicts and wars. This population is especially at risk, particularly for posttraumatic stress disorder. Another large at-risk population in the Gulf region is the population of expatriates, mostly blue-collar workers and domestic maids who leave their countries of origin and come to work in GCC countries under sometimes less than optimal conditions.

Do these groups need special treatment regimens?

War survivors need a special approach because their issues are much more complex, as they may also be homeless, have lost one or more family member or loved one, and have themselves suffered physical and/or psychological injury. A team approach, whereby the nurse, the psychologist and the social worker play prominent roles seem to work best for these people.

The issue of blue-collar workers and domestic maids is slightly different as it is much more related to a specific person, group of people and/or agency. The best approach here could be preventive in the form of laws and/or guidelines that regulate the interactions between employer and employee.

How do you propose that education for medical students in this region of the world should be changed?

It is a myth that the treatment of these disorders is not affordable in poor developing countries.

The undergraduate psychiatry curriculum needs to be updated using modern teaching methods. The curriculum should emphasize both knowledge and skills. In addition to being equipped with up-to-date knowledge, the young doctor should be skilled in establishing "rapport" with his/her patient and have the necessary preparation to conduct a psychiatric interview. Those skills cannot be taught in large classroom lectures. They are acquired in small group sessions with a "hands on" approach.

Attitudes about mental illness need to change. Mental illnesses are currently viewed as disorders of the brain - disorders that can often be successfully treated with medications. We also need to make room for psychological approaches to treat mental illness. Recent research evidence has shown that psychological intervention can restore brain physiology the same way medications do.

A change in education curricula is a long term response. In the meantime, what can be done to address an urgent problem that is under-reported in the region?

Mental health professionals and public health workers need to educate the public about the importance of mental health. The World Health Organization (WHO) has predicted that by the year 2020 depression will be the second most frequent cause of disability worldwide, second only to ischemic heart disease. For people aged between 15 and 44 years, depression is the number one cause of disability, followed by alcohol consumption. This obviously calls for a public health policy that is geared to prevent and treat these disorders.

In poorer Arab states, there is a shortage of trained specialists. How can these countries be empowered to address mental health issues?

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. The best solution is to educate and train primary care physicians and family physicians to recognize and treat common psychiatric disorders. This is why we are advocating for curricular changes at the undergraduate level so that the primary care physicians of tomorrow will be trained to deal with the most prevalent mental conditions.

On the state level, is there a need to change mental health policies and plans?

Yes of course. First, we are asking that mental health be covered in the same way that other medical disorders are covered. Second, all countries should have a mental health "act" or " code" whereby the rights of the mentally ill for safety and quality care are balanced with their rights for freedom and confidentiality.

Take for example a suicidal patient who is refusing treatment. How do you balance his or her right to refuse treatment with the need to protect this patient from the consequences of their illness (i.e. suicide)? When can you force a patient to receive treatment to protect him or others from the consequences of his/her disease (namely suicide or homicide)?

The mental health professional dealing with the situation on hand or the police present at the scene need to have guidelines to help their decision making. There should be rules and regulations that govern different scenarios and applied in the forms of laws. Most developed countries have specific legislation dealing with these issues. This is not the case in most Arab states where the mentally ill can still suffer different forms of abuse or neglect.

There is a general understanding that treatment of mental illnesses is not affordable – especially in poorer developing countries. Is this true?

We in the Arab world have been for centuries advocating relaxation and rest as a cure for both physical and mental illness.

It is a myth that psychiatric disorders are prevalent only among rich or developed countries. It is also a myth that the treatment of these disorders is not affordable in poor developing countries. Most of these disorders can be treated with medications that are readily available in pharmacies worldwide.

The acute shortage of mental health specialists in developing countries can be mitigated by having primary care physicians deal with most common psychiatric disorders. In fact, treatment usually saves money because it reduces the huge losses associated with disability and unemployment that accompany mental illness.

The cost of the appropriate medication may be an issue in certain countries. Drug companies want to make a profit and insurance companies want to reduce cost. The mentally ill become an easy target, and the best medication, which is often quite expensive, is replaced by an older or less effective medication,, or medications may be denied altogether. This is where the problem lies. In Qatar we are very lucky because health care that includes medications and mental health is essentially universal and free. So in this regard, Qatar in a way is ahead of the curve.

You have focused on psychoneuroimmunology in your research in the past. Do you see a difference in this field between the West and the developing world?

Psychoneuroimmunology essentially means the study of the relation between the brain and the immune system. For clinicians it explores the relation between our mind (personality, emotions, level of stress, etc.) and our susceptibility to medical illnesses such as infection, heart disease and cancer.

The West, which has for centuries been influenced by Descartes' theory of separation of body and mind, is waking up to the notion that one can influence the other and vice-versa. In Asia and the Middle East, we have known this all along. Take for instance the practice of yoga or the whirling dervish dance advocated by the Sufis. The issue here is the control that the body and the mind can have on each other.

In the West, there is increased interest in the notion that negative emotions can have a deleterious effect on a person's general health. We in the Arab world have been for centuries advocating relaxation and rest as a cure for both physical and mental illness. Here again, we may be ahead of the curve.

Is there a need to address a general audience as well to change their attitudes?

This is of paramount importance. Unless there is a change in attitude at the grassroots level, things will not change much. The WHO, along with world, national and local psychiatric organizations each year promote a Mental Health Week to raise community awareness about mental health issues.

We at Weill Cornell Medical College in Qatar have joined forces with Qatar's Supreme Council of Health and Hamad Medical Corporation to organize such events. In addition, we have a monthly community education event called Medicine and U. My colleagues and I have participated by giving public lectures and organizing seminars to address those issues within our community.

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