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 May.

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 condition.FIG1

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 counselors.

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 officers.

"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 killed.

"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 health systems.

Despite the obstacles and the grim headlines, Afkhami and Everett see signs of hope.

"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."▪