Access to mental health care in the Middle East-what are the barriers?

Access to mental health care in the Middle East-what are the barriers?

 

Shamaila Usmani

With 1 in 4 people in the world affected by mental health problems, it is quite likely that you will know someone – a friend, family member, or neighbor – that suffers from mental illness.

If this is the case, do you think this person would know where to turn to for help?

Would they actually seek help from a trained mental health professional?

Or would they even know that they were suffering from a mental health condition?

Despite the recent increase in mental health awareness at a national level in the Middle East, chances are quite slim that individuals dealing with these problems will know where to go, who to talk to and how to access care.

Regional prevention and awareness campaigns are minimal with minor initiatives taking place in Jordan, the United Arab Emirates, Lebanon, and several other Arab countries. Plus, with high levels of skepticism towards mental health problems,1 awareness rarely translates into action on the ground,2 and numerous barriers to care exist.

Quality of Services and Access to Care

Most Arab countries have started to recognize mental health as an important part of their national health care plans. Though recognition is a key step forward, it very 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.

According to Dr Ziad Kronfol, a well-renowned psychiatrist in the MENA region, psychiatry rotations in most Arab medical schools are basic, consisting of a few scattered lectures and occasional visits to clinics and/or wards.2 Clinical research and supervision are lacking and very little attention is given to engaging with the patient and his/her illness. Even where services are available, the resources needed to provide quality services are often insufficient.

To further comprehend the lack of mental health awareness in the medical field, consider the results of a depression study conducted amongst focus groups in Jordan by Drs Laeth Nasir and Raeda Al-Qutob, which found astounding but sadly unsurprising results.

The study 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 the illness, s/he would not willingly work towards the treatment. Very few healthcare providers actually expressed the need for ongoing care for depression in particular.3

Aside from the availability of quality services, physical 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.

Barriers to Care – Culture and Stigma

These practical obstacles to accessing mental health services and treatment are further compounded by social barriers to care.

In a systematic review of mental health services in the Middle East, a reported 42 out of 78 (54%) of barriers to treatment and service implementation were due a lack of acceptability within the cultural context.

Specific barriers included beliefs, values, etiological perceptions and stigma: 4

Beliefs and Etiological Perception

The most common barrier identified was a lack of awareness, attributed to national level mental health recognition and policies not translating into ground level initiatives.

Another barrier is the preference of traditional healing over Westernized, scientific methods of treatment. Methods such as religious healers or amulets against the evil eye are usually perceived as less stigmatizing and familiar as they have been used to treat these conditions for generations.

Moreover, individuals who attribute the cause and symptoms of their problems to be rooted in external and supernatural realms such as religion (divine punishment) or evil spirits are also more likely to seek treatment from traditional and spiritual healers over professional mental health providers.4

Values

Referring to the community values that prioritize close and interdependent relationships between the individual, family and the larger community, Drs Nasir and Al-Qutob highlight that mental illness is viewed as a flaw in the individual’s character or upbringing and, in turn, the collective ethos of the community.

This explains why many Arabs turn to the family and community for help with their issues – mental health included – before pursuing professional allopathic services, a point at which stigma increases drastically.4

Stigma

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 especially prevalent in the MENA region. 5

Due to stigma, individuals suffering from mental illness rarely access the help they need for fear of being judged and discriminated against.

In the Arab world, mental illness is often associated with social shame, damaged reputation and/or diminished social status, leading many individuals to avoid or drastically delay seeking help given the risk of these consequences.

And of course, given the close relationships between individuals and their community, it is often impossible to seek help without everyone finding out about it.

Focus group participants from the Jordanian study stated that mental health problems like depression can even affect women’s prospects for marriage as these illnesses are considered shameful and embarrassing.1

It is thus no surprise that individuals would prefer to avoid accessing professional care for the fear of being stigmatized by those that they hold so dear.

The Way Forward

Globally, as in the MENA region, we repeatedly hear about the numerous barriers to accessing mental health care, with stigma at the forefront.

Though there may be many starting points from which to initiate change, overcoming ignorance and misguided beliefs about mental health through raising awareness is key. The evidence above also suggests that any effort to develop effective campaigns and interventions should incorporate faith and patients’ understanding of their condition, and capitalize on the close familial and community relationships within the Arab region.

In my next few mental health blog posts, I hope to highlight the few promising initiatives taking place in the MENA region, starting with IDRAAC, a non-profit non-governmental organization dedicated to mental health in Lebanon and the Arab World through the promotion of research and awareness.

 

1. Jumaian A, Alhmoud N, Al-Shunnaq S, Al-Radwan S. Comparing views of medical employees and lay people towards stigma in mental health issues. Jordan Medical Journal. 38: 80-3. 2004

2. http://www.nature.com/nmiddleeast/2012/120724/full/nmiddleeast.2012.103.html

3. Nasir L and Al-Qutob R. Barriers to the diagnosis and treatment of depression in Jordan. A nationwide qualitative study. Journal of American Board Family Medicine. 18: 125-131. 2005

4. Gearing RE, Schalbe CS, MacKenzie MJ, Brewer KB, Ibrahim RW, Olimat HS, et al. Adaptation and translation of mental health interventions in the Middle Eastern Arab countries: A systematic review of barriers to and strategies for effective treatment implementation. International Journal Social Psychiatry. 59:671. 2013

5. Abdullah, T., Brown, T.L. Mental illness stigma and ethnocultural beliefs, values and norms: an integrative review. Clinical Psychology Review, 31: 934-948. 2011

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