Iraq to Give Primary Care Lead in MH Treatment

Two nations embroiled in separate conflicts are using different strategies to cope with the mental health outcomes of war on their populations.

In Iraq, security has improved somewhat in the last two years, but it is hardly a country without danger, said two Iraqi psychiatrists at APA's 2009 annual meeting last month in San Francisco. Nevertheless, the Iraqi Ministry of Health is steadily pursuing a plan to move from an institutionally focused mental health system to one based in the country's primary health clinics.

The ministry recently announced results of a national mental health survey begun two years ago. Psychiatric morbidity in the country is about 18 percent, mostly manifested as anxiety and depression and affecting women more than men, said Emad Abdulrazaq, M.D., the ministry's national mental health advisor. He was accompanied by Mahfoodh Alsaydan, M.D., a lecturer in psychiatry at Mosul University Medical College.

Abdulrazaq is also concerned about drug abuse, although not the kind involving hard street drugs. “Mostly psychotropics are abused,” he said. “Many prescription drugs are available over the counter, and people can walk into a pharmacy and buy them without a prescription.”

The ministry, headed now by a psychiatrist, has ambitious plans for revamping the mental health system, said Abdulrazaq.

“The mental health system under Saddam Hussein was dominated by psychiatrists and based in hospitals,” said Abdulrazaq. “The ministry, with the help of other government agencies and outside nongovernmental organizations [NGOs], is planning a decentralized system that will involve integrating primary care and mental health centers. Psychiatrists will manage counseling and referral, and education for staff, as well as educating the community and schools about mental health issues.”

Implementation progress is slow, however, he said.

Eventually, one doctor and one nurse from every primary care clinic will receive training as a team in mental health, said Abdulrazaq. They will then be able to prescribe psychotropics to treat anxiety and depression and to train the rest of the clinic staff. Additionally, they will train local teachers how to recognize and communicate with children with psychological problems.

The transformation of the Iraqi mental health system is still in process, said Anita Everett, M.D., section director of community and general psychiatry at the Johns Hopkins School of Medicine's Bayview Campus. Everett has taught in several training courses for Iraqi mental health personnel.

“The distribution of actual services is very variable by governate (defined as an administrative division of a country) and local region, but the important political policy principle is that the Iraqis are prioritizing a primary care system and not spending great sums on secondary and tertiary care,” said Everett in an interview. “Primary care physicians and staff have received training in recognizing and treating common mental health symptoms, [although] what has actually translated into practice is less clear.”

Further decentralization will come once inpatient mental health units and properly stocked pharmacies are established in at least one hospital in each governate, said Alsaydan. At present, such units are under construction in Anbar province and in the city of Mosul. Three trauma centers to treat women victims of trauma are under development, two in Baghdad and one in Falluja. The Iraqis are also building or rehabilitating several psychiatric hospitals in several larger cities.

The government has increased physician salaries, and a few have returned from exile, but the country needs more psychiatrists, psychologists, and social workers, as well as more training for all of them, said Abdulrazaq. Several teams of Iraqi mental health professionals have trained at hospitals and medical schools in the United States over the last year, and the Substance Abuse and Mental Health Services Administration has helped train staff for a geriatric unit at Ibn Rashid Hospital. Continuing medical education courses in psychiatry have been offered in Irbil, Baghdad, and Basra by a consortium led by Britain's Royal College of Psychiatrists, with some American participation. A German NGO is providing two weeks of training every six months in child psychiatry to Iraqi psychiatrists.

Meanwhile, a couple of borders to the east, the conflict between NATO forces and the Taliban in Afghanistan has spilled over into Pakistan and intensified there in recent months. An estimated 3 million people have been internally displaced in the northwest of the country due to fighting between Pakistan's army and the Taliban and their allies. Many people were poor to begin with and are now housed in camps in hot tents.

“The most striking thing is to see the younger children who are stunned by their experience, often depressed, and don't eat,” said Khalid Mufti, M.D., chief executive and medical director of Ibadat Hospital in Peshawar. These problems are compounded by generally “scanty” mental health resources in the region—there are only 20 psychiatrists in the Northwest Frontier Province—and a lack of expertise in child mental health.

“The Pakistani Psychiatric Society has been teaching GPs [general practitioners] principles of psychiatry,” said Mufti. “It was a long-term program, but now it is a crash program.”

Mufti is also chair of an NGO called Horizon that is sending representatives to train local people. They have involved local religious leaders who in turn have given sermons in the mosques encouraging people to go to clinics for mental health treatment.

“We must fight the mental health battle on many levels,” said Mufti. “For that reason, we need international expertise, moral support, and media attention.”

“We want psychiatrists to spend time with the internally displaced persons to reassure them that they are not forgotten and to give them hope,” said Haroon Rashid Chaudhry, M.D., head of the Department of Psychiatry at Fatimah Jinnah Medical College and Sir Ganga Ram Hospital in Lahore and president of the Pakistan Psychiatric Society. “It is especially important to send educated female volunteers to talk to the women.”

S. Arshad Husain, M.D., a professor of psychiatry at the University of Missouri-Columbia, director of the International Center for Psychosocial Trauma, and former chair of APA's Committee on the Psychiatric Dimensions of Disaster, has discussed with Pakistani authorities ways to help train local mental health professionals to better recognize and intervene in cases of depression, posttraumatic stress disorder, and other psychological sequelae based on his experience following the earthquake in Pakistan in 2005.

Former APA President Pedro Ruiz, M.D., told Psychiatric News that he presented a report on the situation in Pakistan in mid-June at the executive committee meeting of the World Psychiatric Association in Madrid and recommended some assistance in this regard. ▪