Iraq's attempts to rebuild its mental health services, allowed to grow
moribund under the former regime, are complicated by low staffing levels, need
for more up-to-date training, and erratic funding, said psychiatrists and
others familiar with conditions in the country.
Mental health care and facilities had deteriorated since he left Iraq in
1979, said Najaf-born psychiatrist Sabah Sadik, M.D., who returned late in
2003 after more than 20 years in the United Kingdom. Largely cut off from the
rest of the world, psychiatric thinking had remained stagnant over that same
time. Care was generally provided either in private practice or as tertiary
care in the country's single, large mental hospital, said Sadik, now medical
director for the West Kent National Health service in the United Kingdom and
national advisor for mental health at the Iraqi Ministry of
Representatives from the Heartland Alliance, a Chicago-based nonprofit,
train community mental health workers in northern Iraq on treating victims of
torture who have posttraumatic stress disorder. The course required
interpreters for two different Kurdish dialects.
Photo courtesy of Heartland Alliance
There are an estimated 80 to 100 psychiatrists in Iraq, but some of them
may have left since the U.S. invasion. There are also few trained nonphysician
mental health workers, something that both the U.S. government and some
nonprofits are trying to change.
The ministry has declared mental health a priority and has looked at best
practices around the world as models for a new Iraqi mental health system,
said Sadik, speaking at a news briefing recently in Washington, D.C.
"We are trying to integrate mental health into primary care, build
mental health units into general hospitals, close the main mental hospital,
and introduce a mental health reform law," he said. "We are trying
to introduce the concept of community mental health services in primary care
and the use of the tertiary centers for consultation or brief
Many psychiatrists and mental health professionals had left the country
during the Saddam Hussein regime, which had neglected the health care system
and intimidated Iraqi professionals as a means of social control, added
Baghdad native Husam Alathari, M.D., a clinical instructor in psychiatry and
behavioral sciences at George Washington University in Washington, D.C. Since
2004, he has consulted with the Ministry of Health on substance abuse
treatment and training health professionals.
"The fall of the Hussein regime gives us an opportunity to look at
different models and systems of mental health care," said Alathari.
Stigma about chronic mental illness remains a problem, but people seem more
open to seeking help, said Alathari. The common practice of arranged marriages
means that people are wary of taking on the burden of a mentally ill relative,
although strong family bonds serve as a countervailing source of support,
explained Winnie Mitchell, international officer at the Substance Abuse and
Mental Health Services Administration (SAMHSA) in a separate interview.
Planning meetings have been held outside the country, most recently in
Amman, Jordan, last March, with assistance from the World Health Organization,
SAMHSA, Britain's Royal College of Psychiatrists, U.S. military physicians and
others. Security conditions remain too dangerous to hold such meetings within
Besides their ostensible purpose to plan a new mental health system, the
meetings have another value, said Mitchell. During the Saddam regime, merely
speaking up could be dangerous. The planning meetings allowed the Iraqi
participants to establish an unprecedented level of personal trust, aided by
role-playing in work groups. Sadik and SAMHSA Administrator Charles Curie,
M.A., jointly presented a talk on leadership and team building.
"In the old days, people just waited to be told what to do,"
said Mitchell. "Now, once they get over that, things just take
Much ground remains to be made up, even after several planning meetings
held outside Iraq, cautioned Karen Babich, Ph.D., director of global mental
health programs at the National Institute of Mental Health, in an interview.
Iraqis will need more exposure to current community care models and to
contemporary clinical practice, she said. For instance, the physician-centered
approach to care that formerly prevailed may be broadened to include nurses,
psychologists, social workers, or
Iraqi social workers in northern Iraq study jail monitoring techniques
and procedures under the auspices of the Heartland Alliance.
Photo courtesy of Heartland Alliance
To that end, professionals have left the country for brief training courses
in the United States, Britain, and elsewhere. Last year, 10 Iraqi
psychiatrists trained for three months at Sadik's West Kent site in Britain,
and 30 primary care physicians studied psychiatric concepts in a program in
the Persian Gulf state of Bahrain.
Another planning meeting is scheduled for March 25 to 30, in Cairo, at
which further integration of mental health with primary care and ways to deal
with substance abuse will be considered.
Prescription drugs looted at the time of Saddam's fall represent one source
of abusable drugs, especially anxiolytics. Alcohol abuse appears more common
than in most other Middle Eastern countries, said Sadik.
A drug-control law is before the Iraqi cabinet, said Alathari, who
expressed concern for potential abuse of illicit drugs. Iraq's geographic
position and the chaos of the insurgency may place the country on opium and
heroin trafficking routes and bring attendant problems. The prior regime
claimed there was no drug abuse in Iraq, so current treatment is limited to
detoxification and not rehabilitation or prevention, according to a SAMHSA
"There is a great need for training Iraqi doctors and for public
education about these questions," said Alathari. Heartland Alliance, a
Chicago-based nonprofit, has planned a training session in northern Iraq on
substance abuse in June.
Updating the system is further complicated by the distribution of health
professionals within Iraq. Psychiatrists are concentrated in the large cities,
while some rural provinces have none. Often, younger, less-experienced doctors
are assigned to the countryside, and little mental health infrastructure
exists in most of the country, according to Scott Portman, director of
international programs for Heartland Alliance. His organization now trains
mental health workers to treat victims of torture.
"Our funding is specifically for torture treatment," said
Portman in an e-mail interview from Suleimaniya in northern Iraq."
However, we are training the health care workers more broadly, as... it
is unethical to assist someone with PTSD but turn away someone with major
The students in this program are 200 medical assistants in rural hospitals
and clinics in northern and southern Iraq, areas relatively safer than the
center of the country.
In the Iraqi health model, medical assistants are considered better trained
than nurses and do preliminary triage and referral. They receive two years of
formal education at a medical technical institute, but there is no mental
health concentration in their program, unlike specialized training in
radiology, surgery, nursing, or pharmacology, said Portman.
The newly trained mental health workers are learning to provide
psychosocial services, medication management, and family and community
education and to help sensitize other health ministry staff to mental health,
mental illness, and psychological trauma, he said. Heartland Alliance's goal
is to place these workers in the 10 safest of Iraq's 18 provinces.
"The second phase of our program, if we are lucky enough to keep
getting funding, is to create a special mental health worker track in the
medical assistant technical colleges," he said.
The project also provides primary care physicians with a practical
psychiatric refresher opportunity to help them identify and treat PTSD and
major depression or other mood disorders and to recognize and refer severe
mental illness cases to psychiatrists in the cities.
"We train physicians to improve their ability to interact with
patients who are often traumatized and help the physicians supervise and
understand the role of mental health paraprofessionals," said Portman."
Physicians are highly educated and generally Western in
outlook—we try to train them to be more tolerant of traditional rural
Iraqi cultures and ideas regarding mental health and to reach out in their
communities to build alliances with religious leaders, schools, police, and
Elsewhere, a Swedish nongovernmental organization (NGO) is providing
therapy services in Northern Iraq, an Italian NGO offers psychosocial services
to children in Baghdad, and a Slovakian organization provides family support
programs in Baghdad.
However Portman fears that U.S. budget cuts may prevent Heartland Alliance
from continuing its work.
"A project like this requires a few years to be really
successful," he said. "The State Department's Bureau of Democracy,
Human Rights, and Labor funded it for the first year, but the administration
is cutting human rights funding for Iraq."
The current State department budget for these programs is $11.575 million
but the Department has not yet made funding decisions for the coming fiscal
year, said State Department spokesman Justin Higgins. "There's still
very much a need and we are working with NGOs and our coalition partners to
provide these services." ▪