Mental health services in Iraq: past, present and future

Abstract

Iraq is known to be the cradle of civilisation – a country with a rich history. Present-day Iraq occupies the greater part of the ancient land of Mesopotamia, the plain between the Euphrates and Tigris rivers. Some of the world’s greatest ancient civilisations arose in this area, and Iraq possesses a huge number of historical monuments and archaeological sites.

Modern Iraq has a geographical area of just under 440 000 km² and a population of just over 27 million. The main languages spoken in the country are Arabic, Kurdish and Turkman. The two main religions are Islam and Christianity. The country is in the lower middle-income group (according to World Bank criteria).

The proportion of the population under the age of 15 years is 41% and the proportion of those over 60 years is 5%. Life expectancy at birth is 59.1 years for males and 63.1 years for females. Healthy life expectancy at birth is 49 years for males and 52 years for females. The literacy rate for men is 54.9% and for women is 23.3%.

The healthcare system in Iraq is centralised and provided free of charge at the point of delivery. The Minister of Health is supported by three deputies and a number of directors and advisors, each having responsibility for a directorate. There is a plan for the new Iraq to look at devolution, with the governorates having some form of independence, as well as looking at private–public partnerships. Social services are provided by the Ministry of Labour and Social Affairs, and there is a close working relationship between the two ministries to provide social care alongside healthcare.

History of mental health services

Pioneers like Al-Razi (865–925) and Ibn-Sina (Avicenna, 980–1037) established the first mental hospitals and applied humane treatments. Indeed, the first mental hospital in the world was built in Baghdad in 705. The region then entered the dark ages and it was not until the middle of the 20th century that modern psychiatric services appeared in Iraq. In the early 1950s, Dr Jack Aboud and Dr Ali Kamal led in establishing Al-Rashid and Al-Rashad mental hospitals (the former was later replaced by Ibn Rushid State Hospital). The 1960s and 1970s saw the development of mental health centres and units in general hospitals, school mental health programmes and public awareness campaigns. Strategic short-term and long-term plans were established. However, from the mid-1980s onwards mental health services experienced a significant deterioration, with an exodus of psychiatrists, due to a poor (even intimidating) working environment, shortages of medication, lack of information systems and a lack of educational opportunities. This situation was compounded by three disastrous wars, 12 years of sanctions and the recent fall of the regime, followed by the continuing violence. In addition, there was widespread looting of medical facilities.

The country profiles section of International Psychiatry aims to inform readers of mental health experiences and experiments from around the world. We welcome potential contributors. Please contact Shekhar Saxena (email saxenas@who.int).

In the past, mental health planning was run within the Primary Care Directorate of the Ministry of Health by a physician, who was supported by an advisory committee of four psychiatrists, although they had very little influence. The group ran limited activities of public education, refresher courses for general practitioners and lectures for school teachers in an attempt to increase public awareness.

Recent developments: governance and accountability

In July 2003 the East Mediterranean Regional Office (EMRO) of the World Health Organization (WHO) held a meeting in Cairo as one of the WHO initiatives to support mental health in Iraq (see WHO, 2003). The new Iraqi government was appointed in September 2003. The Minister for Health declared that mental health was a priority, and appointed a National Advisor, who, with the support of colleagues, formed the National Mental Health Council (the first in the history of Iraq). The Council included representation from all relevant ministries and non-governmental organisations (NGOs) and there are plans to include service users. The Council had its inaugural meeting in March 2004. In June 2005 the Minister approved the structure for the National Advisor’s office shown in Fig. 1.

Fig. 1. The approved structure for the National Advisor’s office.

The National Advisor, with members of the National Council, has conducted field visits to oversee developments in mental health across Iraq as well as to lend support to colleagues.

National Strategy for Mental Health and Mental Health Act

The National Council engineered the return to work of psychiatrists, psychologists and social workers who had been unemployed or dismissed for political reasons, and those who had left their jobs in the past because of poor pay and working conditions.

The first priority the National Council set for itself was to draw up the National Strategy for Mental Health (a copy is available on request). Previous attempts by colleagues to do so over the past 20 years were blocked by the previous regime. Those attempts were revived and the National Council held a workshop to discuss and finalise the Strategy on 21 and 22 June 2004. The Mental Health Act was approved by the Cabinet in October 2004. A draft Code of Practice is out for consultation and is awaiting final approval.

Facilities

Iraq has two mental hospitals, both in Baghdad: Al-Rashad, with 1200 beds, and Ibn Rushid, with 70 beds. There are also four units in general hospitals in Baghdad and eight more units in other governorates. All facilities have limited resources. Multidisciplinary working is not practised.

The National Council has established ten outreach clinics and psychosocial support centres in Baghdad.

Workforce

In December 2005 the National Mental Health Council, in partnership with the WHO, completed the Assessment Instrument for Mental Health Systems (WHO, 2005). This showed that there were 1.6 professionals in mental health facilities, including private practice, per 100 000 population. Table 1 breaks this down further according to profession.

Table 1. Total numbers of workers in mental health facilities.

Discipline	Percentage of workforce	Number
Psychiatrists	33	91
Other medical doctors (i.e. non-psychiatrists)	2	7
Nurses	53	145
Psychologists	5	16
Social workers	9	25
Other mental health workers	47	128

The National Council engineered the return to work of psychiatrists, psychologists and social workers who had been unemployed or dismissed for political reasons, and those who had left their jobs in the past because of poor pay and working conditions.

The National Council, with the support of the Japan International Cooperation Agency and the WHO, ran training programmes for Iraqi nurses, held in Egypt (two 6-week courses in September and November 2004 for 40 senior nurses). Another 2-month course started in Bahrain in April 2006.

Academic activities

The National Council has organised a number of multidisciplinary educational activities for mental health workers. Dr Sadik has been appointed Visiting Professor in Psychiatry at Baghdad University and has become a member of the Iraqi Scientific Council for Postgraduate Studies and the Arab Board in Psychiatry.

Research and publications

Fifteen pilot studies have now been completed and a full research programme was expected to be concluded in April 2006, when reports on individual projects were to be submitted for publication.

A special issue on Iraq of the Muslim Mental Health Journal was planned for October 2006.

Drug misuse

A National Council for Drug Misuse was re-established in 2004 but in February 2006 it joined the National Council for Mental Health to become the National Council for Mental Health and Substance Misuse. It is chaired by the Minister of Health and has representatives from the Ministry of the Interior, the Ministry of Social Welfare and other committees within the Ministry of Health.

A programme to address drug misuse has been agreed in collaboration with the regional WHO team (a copy is available on request) and a drug control law has been submitted to the Cabinet for approval.

Iraq is now a member of the United Nations Office on Drugs and Crime.

Child mental health

The National Council supported the formation of a multidisciplinary Child Mental Health Association. Registered with the Arab Psychiatric Association (APA) and the World Child Mental Health Association, the Iraqi Child Mental Health Association has been asked to lead on educational activities as well as to draw up a strategy for child mental health.

Non-governmental organisations

The National Council has supported various activities headed by NGOs, including:

• the Heartland Alliance’s Integrated Torture Treatment project

• a psychosocial support project for children in Baghdad, run by MOVIMONDO of Italy

• a psychosocial support project for children and families in Babylon, run by the organisation ‘Together’ from Slovenia – this has now been extended to Baghdad

• a psychotherapy service with a focus on children, provided by Diaconia, a Swedish organisation that operates offices in Dahouk, Erbil and Suleymania (the Heartland Alliance has collaborated with staff from Diaconia to deliver Heartland Alliance training in Dahouk)

• the rehabilitation of Ibn Rushid Hospital, supported by the Japanese government

• the rehabilitation of Al-Rashad Hospital, funded by the Red Cross.

World Health Organization

The EMRO of the WHO has supported the planning and training activities of the National Council. This included finalising the National Strategy. More recently, the National Mental Health Council in partnership with the WHO completed the Assessment Instrument for Mental Health Systems mentioned above. Further work has now started on a national screening programme for mental health.

In collaboration with the WHO, the following activities have been approved for funding, to start in the near future:

• a needs assessment workshop (as part of a national mental health survey, which was due to start in June 2006)

• rebuilding of mental health facilities (work on 12 units has already been completed)

• building of new mental health units in general hospitals (six in total: two have been completed, work has begun on two and work is yet to start on the remaining two; in addition, approval for another six units has recently been given)

• a national epidemiological survey with the Composite International Diagnostic Interview (CIDI) (this has just started).

Partnerships

The National Council has established a working partnership with the US Substance Abuse and Mental Health Services Administration (SAMHSA), through regular teleconferencing as well as participation in stakeholder events. A planning group formed of international experts connecting with SAMHSA’s support has been invaluable in securing training curricula and opportunities, service development and planning and drawing in international expertise.

With the support of the SAMHSA, the WHO, the UK Department of Health and the World Bank, the First Action Planning Iraq Mental Health Conference was held in Amman, Jordan, in March 2005 (a copy of the proceedings is available on request). A second conference was held in March 2006 in Cairo, Egypt.

The WHO has been instrumental in supporting all of the above activities and developments.

The Royal College of Psychiatrists has supported:

• the Iraqi Mental Health Forum (IMHF) in the UK

• representation of Iraqi mental health professionals at its annual and regional meetings

• the formation of a subcommittee of the Board of International Affairs to address and support Iraqi mental health services and training needs.

The UK Department of Health has provided financial support to address service development and training needs.

The distribution of medicines and equipment, the movement of staff and the organising of training events remain high-risk activities.

In a recent meeting of Iraqi psychiatrists a committee was elected to prepare for and oversee fair and free elections for the Iraqi Psychiatric Association. Close liaison continues with:

• the American Psychiatric Association

• the International Institute for Mental Health

• the Kent and Medway NHS and Social Care Partnership Trust

• the United Nations Office on Drugs and Crime.

Challenges

The potential to achieve a high standard of comprehensive community-based mental health services in Iraq is a reality. However, the ongoing violence and poor security, coupled with bureaucracy and political instability, have hindered progress. Progress has been very slow on developing an efficient and effective information system, in establishing performance management and in applying healthcare standards. The distribution of medicines and equipment, the movement of staff and the organising of training events remain high-risk activities. Recent improvements in the pay and conditions for staff working in higher education have led many health service professionals to switch to teaching. Furthermore, physical threats to doctors have forced many to leave the country.

In spite of these difficulties, the achievements of the National Council for Mental Health and Substance Abuse in such a short period and its continuing activities have been a landmark in Iraq’s recent health services history.