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
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
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
"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
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
"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
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. ▪