Sources of stress in the practice of psychiatry: perspective from the Arab world

Abstract

The main challenges faced by psychiatrists in the Arab world are stigma, shortage of resources, role of the family and effects of conflicts and migration. Psychiatrists practising in this region have to adapt to these challenges and use creative methods to provide a good service to their patients.

A woman in her mid-20s presented to a private psychiatric out-patient clinic with a longstanding obsessive–compulsive disorder of contamination. She had fled her home country with her family because of an ongoing armed conflict. They were under temporary ‘visitor’ visas and the possibility of their stay not being renewed created immense anxiety. The patient was prone to bouts of anger on a regular basis, causing her to shout at her mother and brother. Her mother was concerned that the neighbours might complain, which might get the family into trouble with the police. The family were eager to know if the patient's condition was likely to improve with medication. They also asked if she could be admitted to an in-patient unit for treatment. Unfortunately, the psychiatric in-patient unit was not suitable for her needs and she could not go back to her home country because of safety concerns. The cost of treatment at a private clinic was expensive for the family. She was not eligible for state-funded healthcare.

The psychiatrist had to manage a complex situation created by stigma, effects of war and migration, lack of appropriate resources and the role of family. He maintained a trusting relationship with the patient and made sure no information was given to her family without her consent. Regular contact with the family was maintained to increase awareness about the nature of the patient's symptoms and to support the family in coping with the difficulties mentioned above.

This real life story illustrates some of the challenges involved in psychiatric practice in the Arab world. The following paragraphs contain personal reflections on the particular dilemmas psychiatrists may face in this region.

Background

In this article, the term ‘Arab world’ refers to the 22 member states of the League of Arab States (http://www.lasportal.org/ar/aboutlas/Pages/CountryData.aspx): Egypt, Iraq, Jordan, Lebanon, Saudi Arabia, Syrian Arab Republic (founding states), Yemen, Libya, Sudan, Morocco, Tunisia, Kuwait, Algeria, Bahrain, Qatar, Oman, United Arab Emirates, Mauritania, Somalia, State of Palestine, Djibouti and Comoros (this list is in order of date of joining the League). Arabic language is one of the official languages in all of these countries. The combined geographical area of this region is around 14 000 000 km² with an estimated total population of 300 000 000 people. These people share many cultural and historical attributes.

Stigma

Stigma of mental illness is a major obstacle for seeking psychiatric help. Although there has been some progress in raising awareness of mental health problems in recent years, the negative image of mental disorders continues to prevent many people from accessing psychiatric services. This has contributed to a large treatment gap that can be as high as 95% for depression and 80% for schizophrenia.

Stigma is not limited to the general public; it is seen among healthcare professionals. This has been attributed to the limited coverage of psychiatric disorders in undergraduate medical education. The lack of integration of psychiatric care with primary care is seen as a contributing factor to stigma and reluctance to accessing care (Yahia, 2012)

One of the negative views about mental illness is that it makes the affected person violent or dangerous towards other people. This view seems to be reinforced by the dramatic, stereotypical and negative portrayal of mental illness in the media (for a review see Zolezzi et al, 2018).

Many countries started various initiatives to reduce stigma of mental illness. The World Health Organization (WHO) has recommended more care in the community, which seems to have helped in decreasing stigma (WHO, 2006). Finally, many concerned psychiatrists have been doing advocacy roles by appearing in different media outlets to give a more balanced view of mental illness.

Resource gap

There is a significant difference between the level of need and the resources allocated to psychiatric services in most countries. There are a number of reasons behind this gap.

1. (a) Shortage of specialist mental health professionals is a well-known phenomenon in many countries in the region. This is partly due to the limited number of training programmes available. This leads to significant difficulty in recruiting appropriately qualified professionals to psychiatric services.

2. (b) Many healthcare policymakers are influenced by the negative views about mental illness that exist in society in general. Sometimes this leads to a lack of enthusiasm for investment in psychiatric services.

3. (c) New psychiatric drugs are not widely available in some countries, possibly for logistical reasons. For example, if the size of the market in a particular country is not big enough, new drugs become less available due to the relatively high financial risks associated with importing them.

4. (d) Mental health legislation in many countries is outdated and needs to be reviewed to reflect the needs of psychiatric patients.

Many countries have taken positive steps to address the gap in service provision. For example, the move from providing services in community settings rather than from large psychiatric institutions has helped in increasing access to services. New training programmes have been established in the region to address the issue of shortage of mental health professionals. Finally, mental health legislation is being updated in many countries.

Role of the family

Families have a bidirectional role in the care of psychiatric patients. On the one hand, the family constitutes the essential building block of society in the Arab world. There is an assumption and expectation that the family should look after their relatives if they fall ill, including looking after a mentally ill relative. This expectation leads to a protective approach from families that tend to ask to be involved in the care of the patient. Therefore, to help the patient receive the most appropriate care, psychiatrists have to protect the privacy of their patients while trying to maintain the relationship with the family. The psychiatrist's level of expertise is very important when it comes to navigating such tricky situations and achieving the best outcome for the patient. It is worth mentioning that most families do try to respect the privacy of the patient and support the psychiatrist in providing a good service.

On the other hand, families are affected by the illness of a relative. They deal with the social consequences of mental illness, especially the stigma attached to it. They are also responsible for providing long-term care for the patient due to the previously mentioned significant mismatch between high needs and limited resources (Fakhr El-Islam, 2008).

Conflicts and migration

There has been an increase in armed conflicts in the Arab world in recent years. This has exposed large sectors of societies to various traumas that would lead to increased psychiatric disorders. As a consequence, the region has witnessed mass migrations, both within countries of conflict and between neighbouring countries. One recent study found a 27.2% prevalence of post-traumatic stress disorder (PTSD) among a group of refugees. This figure was in the upper end of PTSD prevalence reported in international studies (Kazour et al, 2017).

The WHO has advocated for the development of programmes for disaster-affected populations and some of the countries in the region have established specific programmes for that purpose.