Psychiatry in Iraq has been overcoming a number of hurdles since the fall
of Saddam Hussein's regime five years ago, besides the obvious burden of an
ongoing domestic war.
Mental health professionals from outside the country are contributing their
expertise to upgrade the knowledge of their Iraqi counterparts, according to
two presentations at APA's 2008 annual meeting in Washington, D.C., in
Iraq's mental health system was already stressed before the U.S. invasion
in 2003, said Amir Afkhami, M.D., Ph.D., an assistant professor in the
Department of Global Health at George Washington University Medical Center.
The health sector in general benefited from the explosion in oil revenues in
the 1970s, but health spending declined with the 1980-1988 Iraq-Iran war, the
1991 Gulf War, and the subsequent economic sanctions, he said.
Prior to 2003, there were 23 psychiatric hospitals and units, including 16
in Baghdad. The largest was Al-Rashad Hospital in the capital, with 1,300
beds. That included 250 for forensic patients, said Afkhami, who has developed
contacts with Iraqi psychiatrists since 1999.
Leading up to the U.S. invasion in March 2003, Saddam Hussein forcibly
evacuated all the patients in Al-Rashad as a part of a military strategy to
inject chaos into Baghdad at the time of the initial invasion, said Anita
Everett, M.D., section director of community and general psychiatry at the
Johns Hopkins School of Medicine, in an interview. Everett led a second panel
session on psychiatry in Iraq.
Al-Rashad Hospital and other mental health facilities in Baghdad were
heavily damaged by looters after U.S. forces reached the capital. Many
patients were dispersed, and women patients were kidnapped and raped, said
Afkhami. However, by July 2003 Al-Rashad was back in working order, although
patients who did come back were in terrible
The health sector in general suffered during this period, but mental health
services suffered even more, he said.
A political deal in 2006 gave control of Iraq's Ministry of Health (and the
nation's hospitals) to the party of Shiite leader Moqtada al-Sadr, he said.
Fearful of Sadrist militiamen, patients stayed away from hospitals, and
physicians refused to stay on-call in the evenings, according to Afkhami.
However, last fall a new minister of health, psychiatrist Salih Mahdi
Mutalib al-Hasnawi, M.D., took office, raising hopes that the ministry will
implement guidelines calling for rehabilitating the country's mental health
infrastructure, training psychiatrists and other mental health workers,
expanding treatment access, and reducing stigma, said Afkhami.
The system needs various kinds of help, said Everett. Statistically, there
is fewer than one psychiatrist, psychologist, psychiatric nurse, and social
worker each for every 100,000 Iraqis today, she said.
"And those are nominal numbers," she added. "Many haven't
practiced in years, although with some effort they could be mobilized into an
organized system of care."
Afkhami has visited Iraq several times since 2003, thanks to connections
established with Iraqi psychiatrists in the years prior to the current war. In
recent years, he has worked out of the relatively quiet Kurdish region in the
north, which serves as a launching pad for training and capacity building for
psychiatrists and mental health workers.
For instance, while lecturing at the Howler Medical University in the
summer of 2007, in Erbil in northern Iraq, he visited a hospital devoted to
war-wounded patients and noticed a large number of women in the burn unit.
They were, he discovered, not soldiers but survivors of suicide attempts by
immolation. They needed psychiatric care along with treatment for their burns,
but weren't getting it. So Afkhami worked with a local psychiatrist to begin
the first consultation-liaison program at the hospital.
Everett is a member of a network of psychiatrists and mental health
professionals from the United States and United Kingdom who have provided
medical education and community mental health planning assistance in Iraq
since 2005. This network is led by the International Medical Corps, a
California-based nongovernmental organization that provides relief assistance
and health care training. The coalition also includes members of APA,
Britain's Royal College of Psychiatrists (RCP), U.S. military physicians,
staffers from the Substance Abuse and Mental Health Services Administration
and the National Institute of Mental Health, and many others, she said.
Their professional activities since 2005 include three-month specialty
trainings in the United Kingdom and system-planning assistance and medical
education in neighboring countries such as Jordan in 2005 and Egypt in 2006.
Several Iraqi psychiatrists attended the recent APA annual meetings in
Atlanta, Toronto, and Washington, D.C.
More formal continuing medical education training began in 2007 as part of
the current Iraqi Kurdistan Project in Erbil because it is safer and more
politically stable than the rest of the country. Iraqi Kurdistan has had some
degree of autonomy since the first Gulf War.
Their first visit was spent providing continuing medical education,
identifying needs, and conducting proficiency examinations of medical
students. Asked how external psychiatrists could help, their Iraqi
counterparts requested direct clinical care, help with service planning and
development, and professional education, said Everett.
The Iraqis also wanted continuity, not one-shot appearances.
"Don't make this your last visit," they said at the time.
Everett visited the Kurdish region again in April 2008, as part of a team
that included Allen Dyer, M.D., Ph.D., a professor of psychiatry at East
Tennessee State University's Quillen College of Medicine, and Mohammed
al-Uzri, M.D., a psychiatrist born in Iraq who now practices in Britain and is
chair of the Iraqi subcommittee of the RCP.
This second annual CME meeting was sponsored by a number of agencies
including the Ministries of Higher Education and Health for Iraq and for
Kurdistan, the International Medical Corps, and the RCP.
Despite its recent agonies, Iraq still has important resources underlying
its present and future mental health system, said al-Uzri. There is a strong
medical model of care that can provide leadership, there are close family and
social structures to support patients, and there are a large number of
psychology and social work graduates who are now underutilized as
The demand for training was visible as 110 registrants showed up for the
April training session, despite the difficulties of traveling to Erbil from
all over Iraq. Most were early career psychiatrists and junior or senior house
"They were far from war, but the war was never far from their
thoughts," Dyer said. Many participants had their own stories of being
threatened with death, being forced from their homes, or having relatives
"I was impressed with their resilience, by their capacity to care,
but they often felt overwhelmed," he said. "They have what might
be called 'ongoing traumatic stress disorder'—anxiety, sleep problems,
headaches, and somatic concerns."
Another RCP delegation will return to Iraq in October to help train
nonpsychiatrists with a mental health "toolkit" to build
nonmedical capacity with social workers, psychologists, and other
professionals, said al-Uzri. The Iraqis also want to learn about a greater
variety of psychological therapies.
Internal psychiatric needs in Iraq are not the only concern. The mental
health consequences of war now extend beyond the country's borders too.
Perhaps 2 million Iraqis have fled their country and are refugees in Syria
and Jordan, said Peter Ventevogel, M.D., mental health advisor to HealthNet
TPO, a Dutch nonprofit, nongovernmental organization.
"Surveys show that the vast majority of these people are severely
distressed," said Ventevogel. "They need multilayered mental
health and psychosocial interventions."
At a minimum, many need food, shelter, and work to support themselves, said
Ventevogel. Community activities such as women's support groups, run by the
Iraqi refugees, can strengthen their fragile social fabric. Other non-Iraqi
nongovernmental organizations can help train primary care doctors in
psychiatric skills and can support opening up and modernizing existing mental
Despite the obstacles and the grim headlines, Afkhami and Everett see signs
"As American professionals, we have a responsibility in Iraq,"
said Afkhami. "We can help by going there to give lectures or by
inviting Iraqis to come here for study."
"I was very delighted to see the participation of residents and early
career psychiatrists at the meeting," said Everett. "There is a
dynamic group of young physicians with big hope for the future of Iraq."▪