Mental health services in the Arab world.

• Author: Okasha, A.

INTRODUCTION

THE ARAB REGION HAS A POPULATION of 275 million with the highest population density being in Egypt. Despite several similarities that characterize our countries as a "homogenous" region with overlapping problems and challenges, yet mental health issues and services show several variations. Some Arab countries enjoy the highest income per capita, yet this is incompatible with the quality of mental health services available there. The per capita mental health services, the availability of a mental health act, the space allocated for mental health in medical curricula and the nature of the mental health challenges as identified by mental health professionals in the different Arab countries are but a few of the concerns that should be addressed in a review of the situation.

MENTAL HEALTH CHALLENGES

Large-scale community surveys are scarce in the Arab world. Despite the available resources that exist in the Arab countries collaborative multi-national cross-sectional and longitudinal studies have not been produced. However, there is lack of reliable epidemiological psychiatric base line data. This is partly related to the very concept of mental disorder itself, which may vary widely in divergent cultures (Ghubash and El-Rufaie, 1997), and to the methodological problems of assessment and evaluation. There is scarcity of valid, reliable and culture relevant Arabic psychiatric research instruments. There are doubts about the scales, which were originally designed for use in other cultures, due to problems relating to the linguistics and conceptual equivalence (El-Rufaie and Daradkeh, 1997).

In view of the above restrictions, Okasha & Karam 1998 conducted a mail survey to a number of colleagues in Arab countries investigating several aspects of mental health problems and resources. The outcome indicated that Arab countries seem to overlap in several of their concerns and expressions of mental health needs. Responses showed a consensus about the need for public mental health education, increasing the number of psychiatrists, upgrading the training and education of mental health professionals, the development of preventive and curative community mental health care services and the development of a mental health act.

As to mental health challenges, the development of rehabilitation services was a need expressed by the input from Bahrain, Jordan, Lebanon and Tunisia. Special education schooling children with learning disabilities and mental retardation was reported from Egypt, Jordan, Lebanon, Saudi Arabia, Tunisia and UAE.

Children in the Arab World constitute around 45 percent of the total population. The awareness about psychosocial development of children and adolescent is lacking among the majority of parents and teachers. A study done by Seif El Din et al. (1998) in Egypt portrayed the number of pre-school children having behavioral problems was nearly one fourth of the total sample (23.35%) and fifty percent of them reported having temper tantrums, followed by sleep problems, mainly difficulty in sleeping on their own and over activity. A school based study carried out in Saudi Arabia, reported that 13.4 percent of school boys suffered from behavioral and or emotional disorders, (6.9% were behaviorally disturbed, 5.5% were emotionally disturbed and 0.7% were mixed disorders (Abol Fotouh, 1996). In Alexandria, Egypt the prevalence of behavioral and emotional problems among pre-school children attending nurseries was estimated to be 22.5% (Abdel Latif et al., 1989). Available services are limited in comparison to the adult psychiatric services

In Egypt, Lebanon, UAE and Morocco there was a need for the development of drug abuse programs considering the rising prevalence of drug abuse, especially among the young (Table 1). Compared to developed countries, the types of drugs widely used in our part of the world are mainly either central nervous system depressants or hallucinogens. Both point to drug taking in our culture as means of an escape from rapid societal upheaval during a phase of national change and from stability and conservatism to an unknown contemporary modern society. Available models of developed societies are threatening and frightening for a nation that had a historical backlog of civilization. The nation is negotiating an identity crisis hand in hand with challenges of development (Akabawi, 2001).

Lebanon, UAE and Morocco expressed the need for child and geriatric services. Colleagues from Egypt, Jordan and Tunisia explicitly referred to a shortage in epidemiological research in mental health and disease. Community psychiatric surveys are an essential part of psychiatric epidemiology. They inform us about the need for services and whether these are changing; they allow us to examine disorders without the distortions of the referral process; they permit the identification of high-risk groups, and they enable us to examine the influence of important social and cultural factors (Ghubesh, 2001).

The clinical presentation of mental disorders in our region constitutes one challenge that requires special consideration, since it reflects on both the training needs and the facilities mostly commonly used by our patients. Seventy to 80% of psychiatric patients in developing countries tend to somatize their emotions and express their feelings in physical symptoms. Like the majority of developing countries, many mental patients in Arab countries tend to somatize their psychological symptoms. This tendency to somatization seems to protect the patient from the stigma of mental illness, but on the other hand it also leads him or her initially to consult with a traditional healer, general practitioner or an internist rather than a psychiatrist, i.e., this presentation of mental ill-health reflects on the pattern of consultation and should be taken into consideration in the design of mental health policies and programs.

According to Goldberg and Huxley (1992) patients tend to pass through different health care providing filters before they reach our clinics and hospitals. Out of every 1000 citizens 315 have psychiatric symptoms, 230 go to GP, 101 are identified and diagnosed, 17 are referred to the psychiatrist and only 6 are admitted to hospital, i.e., almost two-thirds of patients with psychiatric symptoms would first go to the general practitioner and of those only 50% would be recognized as having a psychiatric disorder.

The real challenge for mental health professionals is the first filter, i.e., patients realizing their mental health problems. This challenge, however, cannot be met without a reorganization of the health providing structures and the approach to medical education and training, and the latter cannot be systematically approached without the guidance of action oriented and policy oriented research.

A most challenging component at the level of the first filter is role played by traditional healers in our countries. Cultural beliefs of possessions and the impact of sorcery or the evil eye affect our patients' interpretation of mental symptoms. In this context the first resort for the families of mental patients is not necessarily even the GP, but the traditional healers who acquire a special importance because of their affiliation to the community and their claim of dealing with the "mystical," the "superstitious" and the" unknown," all of which are still powerful cognitive constructions in our region.

In all Arab countries traditional healers constitute a component of the informal and sometimes unofficial health...