Impact of Multimorbidity on Mental Illness in the United Arab Emirates: A Review

Abstract

Multimorbidity, the co-existence of two or more non-communicable diseases, is increasing in prevalence globally. People with multimorbidity are at an increased risk of developing serious mental illnesses such as major depressive disorder, and anxiety disorders. UAE reports high rates of multimorbidity (metabolic syndrome, type II diabetes, hypertension, obesity). The prevalence of depression and anxiety disorders is significantly elevated in these patients, contributing to increased stress on the healthcare system. Barriers to effective mental healthcare delivery in these patients with multimorbidity include stigma, cultural and linguistic diversity, limited insurance coverage and shortage of mental healthcare professionals, particularly in rural areas. Clinically, depression and anxiety are often associated with somatic symptoms, complicating diagnosis in primary care. Evidence supports implementing measurement-based care using tools such as PHQ-9, GAD-7, and HADS for diagnosing and monitoring treatment in patients with depression and anxiety disorders. Collaborative care models, including primary care physicians, specialists, and clinical pharmacists, are essential for managing people with multimorbidity. UAE initiatives, such as the integrated mental health network SAKINA and the IFHAS population-based screening program, have reduced stigma, enhanced early identification, and increased access to mental health services. This narrative review explores the burden of depression due to multimorbidity in the UAE; corresponding challenges on healthcare delivery, especially in primary care; and national initiatives aimed at integrating mental health into primary care.

Introduction

Multimorbidity, defined by World Health Organization (WHO) as “the coexistence of two or more non-communicable diseases (NCD) within an individual”,¹ exhibits a notably high prevalence globally.² Projections suggest that this prevalence is anticipated to increase in the coming decades, presenting a significant health concern.² Multimorbidity significantly exacerbates the incident anxiety and depression, adversely impacting the individual’s well-being and daily functioning, underscoring the reciprocal relationship between these conditions.^3,4 Various factors, including disruption of biological processes, sleep disturbances, mobility limitations, stressful life events, psychosocial and socio-economic status, care-related factors, polypharmacy, and perceived psychosocial stress from multiple ailments, can influence the relationship between physical multimorbidity and incident depression.⁵

For instance, depression is two to three times as common in individuals diagnosed with T2DM than those without.^3,6 A relationship also exists between incident depression and an increased likelihood of cardiovascular disease (CVD) occurrences in those diagnosed with T2DM.⁷ Comorbid depression may also lead to increased appetite and lethargy, which can heighten the risk of hyperglycemia resulting from poor nutrition and decreased physical activity.⁸ These conditions share common pathophysiological changes initiated by complex bidirectional interactions involving autonomic and neurohormonal dysregulation, weight gain, inflammation, proinflammatory cytokines, abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis, and structural changes in the hippocampus.^6,7

Along similar lines, the heart-brain axis (HBA) represents a complex bidirectional interaction between the nervous and cardiovascular systems, where neurological conditions like stroke or epilepsy can trigger severe cardiac complications, and cardiac diseases such as heart failure can impair cognitive function. Stress—both acute and chronic—plays a critical role by activating the sympatho-adrenal system, leading to catecholamine surges, maladaptive cardiac remodeling (broken-heart syndrome which mimics heart attack), arrhythmias, and increased risk of heart attack and stroke, while also contributing to mental health issues like anxiety and depression that worsen cardiovascular outcomes. Overall, psychological distress significantly impacts recovery, quality of life, and disease progression in patients with cardiovascular conditions, underscoring the need for integrated mental and cardiac care.⁹

These sequelae may lead to Major Depressive Disorder (MDD), which according to WHO is characterized by persistent sadness, decreased interest in previously pleasurable activities (anhedonia), depressed mood, cognitive disturbances, and reduced energy, and is clinically an important, yet neglected condition.¹⁰ Individuals with multimorbidity are two to three times more likely to develop MDD than those without, highlighting the need for mental health assessment during routine medical visits and the implementation of a holistic approach to care.^5,11

Recent reports suggest that the prevalence of multimorbidity in UAE is high and that this enhances the risk of serious mental illness, highlighting the need for coordinated, collaborative and accessible mental healthcare. This narrative review explores the impact of multimorbidity in mental illness in UAE - prevalence, challenges they pose on the healthcare system, and the importance of primary care and national health policy in addressing them.

Methods

Literature searches and reviews were performed manually on PubMed and Google Scholar. The search terms included the cardinal subject related keywords used in the MeSH search of PubMed (such as multimorbidity, type II diabetes mellitus, hypertension, obesity, obese, morbid obesity, adiposity, high body-mass index, high BMI, psychological distress, major depressive disorder, anxiety, depression, low mood, unhappiness, UAE etc.) both separately and in combination. Only those articles that addressed the study objective and published in English language between January 1960 to December 2024 were considered.

Non-English publications, duplicate articles, conference abstracts, and animal or cell culture studies in the study area from the UAE were excluded. The articles of interest were selected, screened, and requisite information was extracted. In addition to peer-reviewed literature, data on epidemiology, care-gaps and national initiatives were also extracted from epidemiological reports. Documents from the UAE Ministry of Health and Prevention, available as news reports or gazettes, were retrieved from Google search. Titles and abstracts were manually screened, and full-text evaluations were subsequently conducted to ascertain key findings for this narrative review.

Results

Prevalence of Non-Communicable Diseases in UAE

The results of our literature search suggest that multiple NCDs constitute a critical public health concern in the United Arab Emirates (UAE), contributing significantly to mortality and morbidity rates.¹² NCDs, including CVD, cancer, diabetes, and chronic respiratory disease, significantly impact adults aged between 30 to 70 years, accounting for 77% of all fatalities and 17% of premature deaths in the region.¹³ Reports from the World Health Organization (WHO) also suggest that CVDs contributed to 40% of deaths.¹⁴ Additionally, the cardiometabolic risk factors (obesity, hypertension, dysglycemia, dyslipidemia, and central obesity) are also reported to be common in the young Emirati adults (Figure 1).¹⁵

Figure 1.

Association between multimorbidity and major depressive disorder in the United Arab Emirates.

Abbreviations: CKD, chronic kidney disease; CVD, cardiovascular disease; GAD, generalized anxiety disorder; PHQ, patient health questionnaire; PCP, primary care physician.

Challenges Posed by Multimorbidity on Health Services

Research conducted by Alkaabi et al on Emirati patients indicated a higher prevalence of depression in individuals with asthma and heart disease, and almost 40% of individuals diagnosed with heart disease suffered from depression.¹² With a documented prevalence of 22.7%, the occurrence of depression was high in individuals diagnosed with T2DM.¹² Also, women with CKD, CVD, and a longer duration of illness exhibited higher levels of depression.¹² The high rates of morbidity and mortality, along with the uncertainty surrounding the COVID-19 pandemic, contributed to significant mental health challenges in community-based settings (47.8–82.2%), affecting the psychological well-being and leading to various emotional consequences.^15,16 Other important observations are enlisted in Supplementary Table 1 and Figure 1.

One of the key challenges faced by the healthcare system in UAE is that the expatriates, who constitute a significant portion of the population, possess limited mental health coverage in their private insurance policies. Moreover, other factors such as fear of negative repercussions, financial constraints, lack of health awareness and resources, and geographical limitations may impede many of them from seeking timely mental health care. Also, individuals from diverse cultures or languages encounter significant challenges in accessing culturally appropriate mental health services.^17–21 On the other hand, individuals living in rural and underserved areas face significant challenges stemming from a shortage of mental health professionals and obstacles in accessing urban facilities. Challenges in identifying qualified physicians, overcoming barriers to treatment, and reliance on caregivers or limited family support for traveling to urban centers for medical care can cause patients to hesitate in seeking care.^18–21

On the healthcare infrastructure front, reports published by United Arab Emirates Ministry of Health and Prevention in 2021 indicated that physician to population ratio was approximately 17.3 doctors for every 10,000 individuals and that this presented difficulties regarding the distribution of its workforce and imbalances in access to medical specialties.^20–22 Recent studies show the UAE has 0.3 psychiatrists and 14,000 beds per 100,000 people.²³ By 2030, UAE is predicted to have 11 million people, requiring 1,759 psychiatrists and 3,381 psychiatric beds to cater to their mental health needs.²³

Importance of Primary Care to Promote Awareness of MDD

Migrant workers from India, Pakistan, Bangladesh, and the Philippines constitute about 80% of UAE’s population, and studies indicate a high prevalence of depression and suicidal behaviors among this group.²⁴ Additionally, MetS, T2DM, and other chronic ailments were prevalent in immigrant population.^25–27 A significant correlation was found between T2DM prevalence, length of UAE residence, and nationality, suggesting lifestyle changes and western diets may have caused these health issues.²⁷ Considering this, improvements in the detection and treatment of minor mental disorders in people with multimorbidity by PCPs would minimize the strain on specialists, be easily accessible, and be inexpensive for the community.²⁸

Complexities Owing to Medical Comorbidities at Primary Care Level

On a practical note, the obstacles for PCPs in detecting depression encompass patient-related factors (challenges in diagnosis, patient reluctance to discuss depressive symptoms), GP-related issues (insufficient training, limited appointment time, multiple demands and other responsibilities) (Figure 2), and system-related challenges (barriers to accessing mental health services, insurance coverage issues).²⁹ However, studies have shown that training PCPs improves the management of depression,³⁰ affirming WHO’s thrust and focus. At times, PCPs may have to manage complex patients having multiple chronic diseases that need numerous medications which may cause drug-drug interactions and may exacerbate the illnesses.³¹ Care of such patients is very challenging and needs patient-centered care and collaboration with specialists to bring about desirable behavioral and health changes.

Figure 2.

Enhancing Mental Health Knowledge for Primary Care Physicians.

Abbreviation: CME, continuing medical education.

Patients Presenting with Exclusive Somatic Complaints

Many patients with depression or anxiety disorders may present exclusively with somatic symptoms, making it challenging for clinicians to arrive at an accurate diagnosis. Clinical practice guidelines recommend utilizing basic mental health screening measures in all patients who present to a medical facility irrespective of presenting symptoms. PCPs must be trained and equipped to screen patients for anxiety and depression using tools such as HADS, GAD-2, PHQ-2 or PHQ-9.^32,33

Measurement-Based Care in Primary Care Settings

Measurement-based care (MBC) involves monitoring disease progression by using validated scales and personalizing treatment based on patient response. While it is more common in other specialties, its adoption in real-world mental health settings is limited despite strong evidence suggesting MBC leads to favorable outcomes.^34,35 Main reasons for this being it is often regarded as time consuming and utility limited to clinical research. On the contrary, MBC leads to a better therapeutic alliance between the clinician and the patient. Certain easy to administer tools in the primary care setting are PHQ-9, GAD-7, WHO-5 and HADS. PCPs should be trained and encouraged to follow MBC. This may also help identify patients that require referral to specialist care.³⁶

Liaising with Mental Healthcare Specialists

Psychological factors significantly influence treatment-seeking behavior and adherence among individuals affected by systemic illness. Therefore, it is crucial for PCPs proficient in managing systemic illnesses to identify anxiety and depression and integrate a mental health component into the treatment plan.¹

Comprehensive mental health care can be integrated into primary care using consultation liaison technique or the collaborative care model. The collaborative care paradigm addresses behavioral health disorders in primary care with a coordinated, team-oriented approach and psychiatrists. Consultation-liaison psychiatry provides mental health services to patients in non-psychiatric inpatient settings.³⁷ Curth et al conducted two randomized controlled trials to assess the effectiveness of collaborative care versus consultation liaison for anxiety disorders and depression in Denmark, revealing that collaborative care exhibited superior efficacy.³⁸ However, the limitations of both methods include the continuous involvement of a mental health specialist, which can pose challenges in areas with a shortage of specialists, particularly in rural and underserved regions.³⁸

Managing Pharmacotherapy in Multimorbidity

Reports indicate that patient-related factors such as forgetfulness, comorbidities, and misunderstandings regarding the disease and medication, in conjunction with medication-related issues like polypharmacy, adverse drug effects, pill burden, and cost, play a significant role in adherence to medication. The engagement of a pharmacist is instrumental in elucidating the significance of medication adherence, providing counseling, ensuring compliance, monitoring safe prescribing practices, and effectively identifying drug-drug interactions and ADRs. Enhancing interactions between physicians and patients, streamlining prescription processes, and clarifying patient misconceptions with scientific evidence may improve treatment adherence.³⁹ Efforts should also prioritize adherence to follow-up care visits and employ cost-effective strategies, such as sending reminders shortly before appointments, which have been shown to enhance attendance.⁴⁰ Considering this, it is essential to promote the monitoring of adverse drug reactions and medication interactions, with a caveat to promptly report any side effects. Collaboration between pharmacists and physicians is crucial for the safe prescribing and management of adverse drug reactions (Figure 3).

Figure 3.

Collaborative approach for better treatment and safe management of adverse drug reactions.

Abbreviations: AI, artificial intelligence; GAD, generalized anxiety disorder; PHQ, patient health questionnaire; PCP, primary care physician.

Discussion

Recent evidence indicates that the prevalence of obesity and diabetes is increasing in UAE owing to multiple factors such as sedentary lifestyle, sleep and dietary habits, tobacco consumption, and increased air pollution. These factors may also result in increased rates of multi-morbidity and mental health disorders. Multimorbidity impairs daily activities, diminishes quality of life, adversely affects future health outcomes, increases healthcare utilization, contributes to mental stress, and elevates mortality risk. This will subsequently lead to a substantial impact on patients, caregivers, professionals, and the entire healthcare system.

Mental illness continues to be stigmatized in the UAE, as individuals experience apprehension regarding judgment, discrimination, and possible harm to their family’s reputation. This fear of getting labeled can lead individuals to avoid seeking help, even when necessary, and can also hinder rehabilitation and integration into society. Considering this, it is crucial for public health officials to adopt measures that effectively tackle mental health stigma in a culturally and socially appropriate way, while also addressing the shortcomings in the existing healthcare delivery system.^18–21

The effective prevention and control of MDD requires a strong primary prevention strategy that includes a thorough examination of the social, familial, and environmental factors affecting mental health in individuals with chronic conditions. It is essential to critically analyze the socioeconomic factors, including poverty, education, and social inequality, as well as gender, familial, and hereditary influences on mental health outcomes. The analysis should focus on creating a method to prevent the onset of MDD through the provision of evidence-based mental health education that addresses and reduces triggering factors.^41–43 These findings suggest the need for native-language tools for effective mental health assessment. To avoid stigma, proper care should be accessible at the individual’s convenience while maintaining discretion. This is important because most of the underserved population works in the unorganized sector where job loss, financial instability, and stigmatization can be devastating.

Public health education must focus on reducing stigma related to mental illness through the systematic planning and organization of public awareness initiatives, educational programs, and personal narratives to create a more inclusive and supportive environment. Appropriate education should be integrated into school-based interventions to help adolescent students recognize signs of mental illness. The initiation of timely guidance and support is crucial, as it can enhance resilience and effectively manage mental health issues before they escalate to a crisis stage.^41–43

Enhancing constructive social interactions and strengthening public networks via NGOs, religious organizations, and other associations can effectively address challenges and promote resilience. For individuals in the economically productive age group, it is essential to emphasize the significance of a supportive workplace that promotes work-life balance, reduces stress, and provides access to mental health resources as necessary. Advocating for mental health policies that emphasize mental health education, enhance access to appropriate healthcare in underserved and rural areas, secure funding for public education and clinical research, and promote legislation addressing social determinants of health is crucial for achieving improved societal benefits.^41–43

The shortage of psychiatrists has been a global issue and considering this, the WHO has emphasized training primary care physicians (PCPs or family doctors), who play a crucial role in providing and achieving “health for all” in accordance with the “Declaration of Alma-Ata”, in the management of mental illness.²⁸ This would enable them to also care for mental illness in addition to a range of common ailments and NCDs. They develop trust and provide consistent care over time, which improves treatment adherence and community health and public well-being while cutting healthcare costs.^28,44,45 Importantly, this will also avoid the chances of patients being stigmatized, a possibility when seen visiting a psychiatrist for care, by relatives and colleagues.

Patients with depression and anxiety often exclusively present with somatic complaints such as pain, fatigue, issues with the digestive system, and sleep disturbances. These patients pose a significant challenge in primary care as mental health issues are not considered unless they also show symptoms suggestive of emotional distress. They continue to be treated for their somatic symptoms with minimal impact on quality of life. In these scenarios, in addition to providing training to PCPs, collaborative multi-specialty efforts including PCPs, specialists and allied health staff like nutritionists, pharmacists, social workers, psychologists, and physiotherapists may be required for optimal personalized and holistic care.^46,47

Another key area where primary care practitioners play an important role is ensuring adherence to medication, especially in patients with multimorbidity and polypharmacy. Adherence to medication is crucial for effective illness management, minimizing relapse risk, and improving quality of life. Clinicians must have a comprehensive understanding of common drug-drug interactions (DDIs) and choose the most suitable medication, dosage, and frequency when treating multimorbid patients to prevent adverse drug reactions. It is crucial to educate both the patient and family caregivers regarding the importance of maintaining a schedule and the need for adherence throughout the treatment process.

Overview of National Initiatives for Psychiatric Care in UAE

In recent years, the government of UAE has embarked on numerous initiatives aimed at enhancing public health. These efforts include enhanced accessibility to healthcare services; institutional telemedicine facilities and introducing mobile healthcare units. Strong emphasis is being placed on preventive care by focusing on increasing awareness of mental health disorders among patients with chronic medical illness and implementing mandatory screening for depression and anxiety in primary care services in high-risk disciplines. Focus is also on improving the healthcare workforce, emergency response systems, public-private partnerships and healthcare finance. When compared to the past, the implementation of these programs has significantly enhanced access to healthcare for all citizens and residents, with the advantages becoming increasingly evident. However, the lack of insurance continues to remain a challenge for some residents in terms of access to care.⁴⁷

The focus on health technology is evident in the implementation of electronic medical records, telemedicine services, and mobile health applications aimed at improving healthcare delivery and outcomes. This has enabled healthcare providers to deliver care that is more tailored and effective for patients. The flagship initiative by Pure Health built on Department of Health, Abu Dhabi’s Mental Health model of care, SAKINA (meaning “tranquility” in Arabic) was launched in May 2024.⁴⁷

SAKINA is an integrated network of Mental Health services across the Emirate of Abu Dhabi, providing easy and early access to Mental health through satellites in Primary Healthcare Centers (PHCs) and interdisciplinary integrated clinics at tertiary hospitals.⁴⁸ SAKINA was established on three pillars: Awareness and Prevention, Excellence in Clinical Care and Rehabilitation and Reintegration, thereby fulfilling all the gaps across the journey of mental health. It is currently the largest Integrated Mental health network in the region. SAKINA services are also integrated into PURA, a digital platform using technology to offer evidence-based guidance and access to virtual mental health services. The network integrates and facilitates end-to-end mental care facilities through a range of nodal points that are easily accessible, like at home and in community settings.^48,49

SAKINA adopts a preventative approach to mental illnesses from initial screening in primary healthcare centers for common conditions such as Depression, Anxiety, Postpartum Depression and Dementia using standardized screening tools such as PHQ-9, GAD-7, EPDS and MoCA, followed by prompt referrals to psychiatrists based within the SAKINA satellite clinics located in PHCs. SAKINA has also established interdisciplinary integrated clinics across tertiary hospitals in areas of high risk for psychiatric comorbidities including but not limited to Oncology, Chronic Disease Clinics, Post Stroke, Neurological services, Women’s health, Geriatric Services and a vast network of SAKINA for Children services dedicated to patients under the age of 18 years across Pediatric subspecialities with an emphasis on neurodiversity. The network is methodically designed to incorporate comprehensive and holistic mental health services in an accessible and stigma-free environment.^48–50

SAKINA is also involved in creating and promoting mental health awareness and mitigating stigma in the community through intensive community and school-based educational endeavors, corporate wellness programs, crisis help lines, and campaigns by partnering with public and private organizations transforming mental health care in the UAE.^49,50 SAKINA is also integrally aligned with “IFHAS”, Abu Dhabi Public Health Centre’s (ADPHC) screening program for actively screening for mental health issues in the general population attending primary care clinics for a range of socially important chronic ailments like dental issues, T2DM, hypertension, cardiac ailments, some cancers. This proactive integrated health screening program helps in early detection of both mental and important non-communicable health issues and devises timely medical intervention to mitigate the illness and its complications. The dementia screening and memory clinics established across the network have also helped identify individuals with mild cognitive impairment, and initiate mitigation measures by focusing on the modifiable risk factors (smoking, sedentary lifestyle, hyperglycemic index, hyperlipidemia etc). This preventive healthcare initiative has paved the way to reduce/delay/mitigate the onset of irreversible forms of dementia.^49,50 These initiatives by the government in partnership with healthcare providers have led to changes in the narrative surrounding mental health across the country, reducing the stigma and misconceptions towards seeking care. The distinctive solutions have played a pivotal role in enhancing the health and wellbeing of the population in the UAE.^49,50

There are some limitations that need to be considered. This work is limited by the unavailability of some papers, non-English publications were not considered, likely publishing bias, and the inherent limitations of the published studies. However, concerted and dedicated attempts were undertaken to collate, evaluate, and integrate a range of articles on varied aspects being addressed in the study area, especially over the last 25 years. In our opinion, this narrative review provides insights that can pave the way for future research, may support adoption of innovative clinical and community-based approaches, and may aid policymakers in UAE and beyond.

Conclusion

The high prevalence of multimorbidity in UAE enhances the risk of serious mental illness, highlighting the need for coordinated, collaborative and accessible mental healthcare. This narrative review examines the prevalence of multimorbidity and mental health care access in the UAE. The national psychiatric care programs designed for primordial prevention, promoting awareness, primary care, collaborative care, and psychiatrist coordination are steps taken in the right direction. Efforts should be made to ensure all segments of society are adequately benefited, and help is available where required. Consequently, integrating mental health into primary care requires focusing on skill enhancement, collaborative care models, and implementation of digital technologies. Investigating the patient’s journey throughout the illness trajectory is essential, necessitating mixed-method studies that employ validated questionnaires and qualitative interviews. The data will identify deficiencies that will assist in addressing the gaps in the system and help plan methods to reach the underserved and the needy.

Funding Statement

Medical writing support was funded by Viatris.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

SM has received speaker honoraria from Lundbeck, Janssen, Pfizer, Newbridge, Servier, Lily, Genpharma, Abbvie, Spimako, Exeltis, MSD, Hikma, Viatris, Labatec, Takeda, and Biogen. He has received travel grants from Janssen, Lundbeck, Viatris, Pfizer, and Newbridge. He has been part of the fiduciary role in committees or advocacy groups at Lundbeck, Janssen, Newbridge, AMD, Pfizer, and Boehringer Ingelheim. US and PP are currently employed by Viatris and hold stock in the company. AC is an employee of Viatris. OH reports Honoraria for lecture, outside the submitted work. NNA reports Support for the manuscript from Viatris, during the conduct of the study; Honoraria from Johnson & Johnson; Meeting/travel support from Abdi Ibrahim and Boeringher Ingelheim; Leadership or fiduciary roles from Board member of Lived Experience People Forum, outside the submitted work. The authors report no other conflicts of interest in this work.