Mental health in the Syrian Arab Republic

Abstract

The following view was espoused in a 1903 Lancet editorial describing psychiatric services in the East: ‘The treatment of lunatics in the East has not yet fully emerged from the clouds of ignorance and barbarism which have surrounded it for ages.’ One of the first reformers was ‘Mr. Theophilus Waldmeier, a gentleman resident in Syria, who commenced in the spring of 1896 the work of helping and providing for the numerous sufferers from mental disease in Syria and Palestine.’ He attempted to introduce the methods of humanity and science in this field. In 1939 Bernstein described his visit to the Maristan Arghoum, a psychiatric hospital, in the city of Aleppo. He observed the complete lack of medical supervision, ‘bad’ patients being chained and the despotic rule of the ‘keeper’ of the hospital.

Demographics

The Syrian Arab Republic has a total area of 185 180 km², of which approximately 80 000 km² is cultivable land; the remainder is desert and rocky mountains. The country’s population in 2006 was estimated at 18.717 million. The population growth rate was 2.45%; 39.4% of the population were below 15 years of age and 3.3% above 65 years. In 2006, the crude death rate was estimated to be 4 per 1000 population per annum and the crude birth rate 30 per 1000 per annum. In the same year, life expectancy at birth was estimated at 72 years.

The socio-demographic correlates of psychiatric morbidity among low-income women in Aleppo, Syria, were studied by Maziak et al (2002), who concluded that the prevalence of ‘psychiatric distress’ was 55.6%, but there was no categorisation of these psychiatric disorders. The study used a special questionnaire based on items not relating to psychosis from the 20-item Self-Reporting Questionnaire (SRQ–20), as well as questions about background information considered relevant to the mental health of women in the population studied. (The SRQ–20 was developed primarily as a psychiatric screening tool to suit primary care settings in low- and middle-income countries.) ‘Psychiatric distress’ was related to a number of factors, including women’s illiteracy, polygamy and physical abuse, most of which are amenable to intervention. It is the authors’ opinion that women’s education is a very important factor for the mental health of this population. In 2006, mental illnesses contributed 0.2% of the total mortality, according to the Ministry of Health (no further details were given).

General health services

In 2005 the health expenditure per capita was US$58. This is very low in comparison with the UK (where the health expenditure per capita was US$2900 in 2005). The Ministry of Health budget was 1.4% of the government budget in 2005.

With respect to human resources, in 2006 there were 78 196 physicians, 27 636 dentists and 54 855 qualified nurses and midwives. The overall provision per 10 000 population of physicians, dentists and nursing and midwifery personnel was 14.8, 7.4 and 18.8, respectively.

The health system is based on primary care and is delivered at three levels: village, district and provincial.

Mental health services

Currently there are 65 psychiatrists and 40 psychiatric residents in the whole country.

Public sector

General adult psychiatry is the main specialty in Syria. Three different government ministries – Health, Defence and Higher Education (Damascus University) – provide this service.

The Ministry of Health runs the two main psychiatric hospitals:

• There are 800 beds at Ibn Sina Hospital, in Damascus, distributed over 18 wards, of which 600 are for male patients and 200 for female patients. Approximately 100 of these patients are under legal confinement.

• Ibn Khaldoun Hospital, in Aleppo, has 400 beds, 250 of which are for male patients and 150 for female patients.

In addition, there is a 30-bed addiction treatment centre in Damascus, with three psychiatrists, three psychotherapists and two social workers, who provide the service and supervise trainees. The Ministry of Health also runs community psychiatric out-patient clinics, which operate in nearly every big city in Syria; there are four such clinics in Damascus. They are run by trained psychiatrists and offer consultations and medical interventions but no psychological input.

The Ministry of Defence service includes two military general hospitals that have mental health departments. The biggest is Tishreen Hospital, with a 40-bed department.

The Ministry of Higher Education runs Damascus University Hospital (Al-Moassat Hospital), which has a psychiatric ward with 12 beds for the purpose of undergraduate and post-undergraduate and postgraduate training.

Specialist services

There are special foundations attached to the Ministry of Work and Social Affairs that provide treatment and rehabilitation for patients with intellectual disability. Child and adolescent psychiatric services are provided through non-governmental organisations and the above foundations. They deal with patients suffering from intellectual disability, autistic spectrum and other behavioural disorders. These foundations have clinical freedom and a lot of government support. They offer treatment and support to patients and their families under supervision of licensed psychiatrists and psychologists.

The private sector

While there is a private health system, there is currently limited private health insurance and so most patients who choose to be treated privately pay for their healthcare out of their own funds.

Private hospitals

There are only two private hospitals and both are in Damascus. They offer acute admission, as well as long-stay and out-patient clinics. Medical treatment and some psychotherapy are available. The larger is Al-Basheer Hospital, with 50 beds; the other is a recently established day hospital for adults, which also incorporates a special centre for autistic children.

A hot-line has been set up with the help of the private sector to offer free consultations and advice to people with mental health issues.

Private clinics

There are 65 private clinics in Syria; most (45 clinics) are in Damascus, and 10 are in Aleppo; the other 10 clinics are located in the other big cities, for instance Homs. The main specialty of these clinics is general adult psychiatry. There are only two child and adolescent psychiatrists in Syria.

Mental health policies and legislation

The rules governing mental health and psychiatric treatment in the Syrian Arab Republic are derived from the health legislation issued in 1981 by the Ministry of Health. Currently, a draft Mental Health Act is under discussion.

In 2001 the Ministry of Health established a Psychiatric Directorate to improve and develop services.

Admitting a patient to a psychiatric hospital is done either informally or under a court order.

A responsible psychiatrist or a family member can raise concern about a patient’s mental state. Following a referral, a committee of three psychiatrists will decide whether an informal admission is appropriate. After the patient has been in hospital for 1 week, another assessment by the same committee is done to validate the decision and the management plan.

If a patient refuses informal admission, she or he must be assessed by a psychiatrist in the community, who will then submit a report to a court. The judge may order an assessment by a general forensic doctor (there are no forensic psychiatrists in Syria). If the doctor decides to admit the patient, the committee of three psychiatrists decides the management plan.

If a patient commits an offence, a court may order an assessment by a special committee and if the patient is found to be mentally ill she or he will be detained in a high-security unit.

Professional bodies

Most of the 65 Syrian psychiatrists are members of the Syrian Psychiatric Association, which was established in 1996. Psychiatric residents can have honorary membership. The Association has an important role in medical education and training, by arranging conferences and lectures.

Training

Undergraduate training

Medical students have formal training in psychiatry as part of the syllabus for internal medicine. It includes lectures and clinical training during the fourth and fifth year (4 weeks each).

Psychiatrists

There are three different training schemes attached to the three ministries that provide the services (see above), with a total of 40 psychiatric residents.

Each scheme is a 4-year programme and at the end of it the doctor is granted either a masters degree in general adult psychiatry (Damascus University scheme) or a certificate to practise general adult psychiatry. The curriculum includes general adult psychiatry, addiction treatment and a compulsory 6 months in neurology.

There is a proposal for a temporary, instead of permanent, licence for psychiatrists, to be renewed every year, to ensure that high standards are maintained in clinical practice.

Psychiatric nurses

There are no psychiatric nurses in Syria, but instead general nurses with psychiatric experience. The Ministry of Health has acknowledged this problem and now psychiatric nursing is part of the nursing curriculum.

Psychology and psychotherapy

The Faculty of Education and Psychology in Damascus University is currently running 4-year courses to train students in social and psychological specialties. Students obtain a diploma in social counselling or a diploma in psychological counselling. Students can take a higher degree in clinical psychology and get a masters degree in cognitive–behavioural therapy.

Syria has very few psychodynamic psychotherapists; most of those there are have trained abroad. Other forms of psychotherapy (solution focus therapy, cognitive–behavioural therapy, behavioural therapy, art therapy, music therapy and so on) are not practised.

Research in psychiatry

Despite the existence of a few research projects, it is very rare for any of the results to be published. Every masters student in psychiatry is expected to conduct and produce a research thesis.

The future

The government is trying to develop modern psychiatric care by encouraging the establishment of more community-based services and smaller centres, and in addition involving the private sector more in the delivery of services. Syria is opening its market to some private insurance companies, and this may have a beneficial effect on service development.