In our final installment of articles exploring mental health in emerging markets, we take an in-depth look at the situation in the MENA region
The Middle East and North Africa (MENA) faces daunting challenges in managing a growing burden of mental illness, often in adverse conditions that can leave their imprint on generations to come. While the burden of mental-health conditions is above the global average in most MENA countries, the human resources, policies, funding and infrastructure to deal with these problems are sorely lacking.
According to a recent study led by the Institute for Health Metrics and Evaluation (IHME), mental disorders excluding substance abuse accounted for 4.7% of all disability-adjusted life years (DALYs) in the World Health Organization’s (WHO) Eastern Mediterranean region (EMR) in 2015, making them the ninth leading cause of disease burden.
That is below the average 9.3% of DALYs attributed to mental-health conditions in the Asia Pacific region. Moreover, WHO data indicate that neuropsychiatric disorders are responsible for 15.2% of all DALYs in Europe.
The much larger burden in Europe, nonetheless, in particular reflects not only better visibility and understanding of mental disorders but lower levels of stigmatisation and easier access to healthcare services where mental illness can be diagnosed, treated and recorded. The general lack of data on mental-health conditions in EMR countries, as well as the reluctance of many EMR citizens to present with such conditions for fear of social ostracism, mean estimates of prevalence and incidence across the region are likely to be substantially understated.
Burden of depression
In the EMR countries depressive disorders (42.1%), followed by anxiety disorders (21.5%), were by some distance the primary contributors to mental disorder DALYs. Seen as years lived with disability, mental disorders contributed 15.9% of the EMR total in 2015, ranking second only to musculoskeletal disorders. Depressive disorders and anxiety disorders were the third and ninth leading causes of YLDs, respectively.
Age-standardised DALY rates for mental disorders per 100,000 population remained almost constant between 1990 to 2015, as they did globally. However, EMR rates were consistently higher than global rates. Moreover, in their contribution to total EMR disease burden, DALY rates for all mental disorders moved up the rankings: for example, schizophrenia from 69th to 56th place and bipolar disorder from 77th to 65th.
As the IHME researchers point out, the already high burden of mental disorders is particularly worrying in a region where 16 out of 22 countries are classified as low and middle income (LMIC). Compared with the US$3–$4 per capita spent on mental health in the US, the average EMR outlay is US$0.15 per capita, with only 2% of regional governments’ health budgets allocated to mental health.
Not only is there a dearth of funds but of human resources to shoulder the burden. According to WHO’s 2014 Mental Health Atlas, the average mental-health workforce per 100,000 population in the EMR was 7.3 compared with 9 globally and 43.5 in the WHO European region.
Another study in 2012 found the highest psychiatrist-to-population ratios in Bahrain (5 per 100,000), Qatar (3.4) and Kuwait (3.1). EMR countries such as Iraq, Libya, Morocco, Sudan, Syria, and Yemen had fewer than 0.5 psychiatrists per 100,000 population. In Libya, Saudi Arabia and Sudan, the number of psychiatrists had fallen since a comparable survey was conducted in 1998. That leaves a very substantial volume of unmet needs. In 2010, WHO’s Assessment Instrument for Mental Health Systems estimated the median treated prevalence of mental disorders in the EMR at just 0.31%, with the unmet needs of children and adolescents surpassing those of adults.
War and demographics
War, terrorism, political instability, interpersonal violence and religious fundamentalism in several MENA countries have not only decimated the available infrastructure for mental healthcare but added significantly to the disease burden.
These are not the only factors at work, though. The IHME study found that the mental-disorder burden in politically and economically stable, high-income EMR countries was comparable to that in low- and middle-income countries (LMICs), some of which were in “complex emergency situations”. While these findings suggest a traditional pattern of economic development accompanied by the spread of ‘lifestyle’ diseases, including mental disorders, it also highlights the lack of available resources for people with mental-health problems in more crisis-ridden environments, as well as their focus on more immediately critical needs.
Individuals and families living under constant threat of sudden death, bombardment, oppression, displacement, homelessness or unemployment carry a heavy load of conditions such as post-traumatic stress disorder (PTSD), depression or anxiety.
A previous analysis of the WHO’s EMR Global Burden of Diseases (GBD) data for the period 1990-2013 found that Palestine had the highest burden of disease due to mental disorders, with 54.4% of boys and 46.5% of girls aged 6–12 years estimated to have emotional and behavioural disorders. An estimated 37.4% and 22.2% respectively of Iraqi and Afghani schoolchildren had mental disorders. Often this damage is barely recognised, let alone addressed, as families struggle just to stay alive. With many of those affected still very young, the MENA region is storing up problems for the future by neglecting mental health.
The median age across the EMR is around 23 years, while some 60% of the total population is between 15 and 59 years of age, and one third below 15. Although globally the Middle East is behind the curve in population ageing, the past two decades have seen marked improvements in key indicators such as life expectancy and child mortality. Longer lifespans will bring new challenges in the form of age-related neurological conditions such as dementia, Alzheimer’s and Parkinson’s disease. According to WHO estimates, by 2050 the number of Alzheimer’s disease cases in the MENA region will have increased by 125%.
In recent years some MENA countries have made efforts to address neglect of mental health through decentralisation of psychiatric units into general hospitals, training programmes for healthcare professionals or public-awareness campaigns.
Qatar, for example, launched a Mental Health Strategy for 2013–2018, aiming to increase availability and utilisation of mental-health services through comprehensive standards and guidelines. Pharmacological and/or psychosocial treatment packages are offered at low prices in some MENA LMICs, including Morocco and Iran.
Egypt passed a law in 2009 to accelerate provision of mental healthcare, protect patients’ rights and giving them more say in treatment, although new indications of neglect have emerged since then. Iraq rebuilt its mental-health system following the 2003 invasion to accommodate more care outside hospitals.
Kuwait, Lebanon and even Syria have made efforts to decentralise treatment and integrate mental health into primary care. Donor funding enabled Jordan to build three local mental-health centres in 2008-9, leading to more comprehensive reforms. In 2015, Israel introduced reforms that transferred responsibility for mental health from the state to statutory health maintenance organisations, although not without some resistance.
Much remains to be done, at the level of policy, funding, infrastructure, human resources and cultural change. Reform processes in countries such as Iraq, Syria and Jordan are stymied by war, lack of funds or influxes of refugees.
Even in the richer Gulf states, investment in mental healthcare remains low-priority. According to the WHO, for example, Saudi Arabia has stand-alone mental-health legislation and policies, yet only around 3.9% of government expenditure on health goes to mental disorders (in Egypt the proportion is around 2%, in Algeria 7%, and in France 13%).
Culture, gender and social change
Cultural factors are of particular importance across the MENA region. Mental illness is heavily stigmatised, rarely discussed, associated with personal failure and family shame, and attributed to external, non-psychological influences such as lack of religious faith or demonic possession. Faith healers and religious authorities tend to be consulted before even general practitioners, let alone psychiatrists.
Sadness may be regarded as intrinsic and instructive to human experience, while the traditions of individualism and self-disclosure underlining Western psychology sit uneasily with the emphasis in MENA societies on collectivism, modesty, humility and honour.
By presenting differently – for example, depression expressed obliquely as pain in the heart – mental-health conditions will stay below the radar while indigenous data and research are scarce. This complicates management strategies based on definitions and diagnoses originating in the US or Europe.
Pressure for societal change also has an impact on mental health. This relates particularly to the role and status of women, who are disproportionately affected by mental-health issues in MENA countries. Between 1990 and 2015, EMR DALY rates in women were consistently higher than in their male counterparts, as well as in the EMR compared with global rates.
Rigid gender roles, social and political marginalization or sexual violence have contributed to this burden. Now, the growing education and empowerment of MENA women, their increased participation in the workforce and diminished appetite for early marriage, are putting new strains on the traditional family unit and mainsprings of identity.
How much reformist agendas can resolve these tensions remains to be seen. Despite the more liberal climate in Saudi Arabia under Crown Prince Mohammed bin Salman, for example, women remain subject to male guardianship that can limit their access to any healthcare, let only mental-health services.
That said, the general trend towards modernization and away from Islamic conservativism in Saudi Arabia could help to loosen the grip of religion on perceptions of mental health, as well as attitudes to diagnosis and treatment.
From the bottom up
Pharmaceutical companies active in mental health must approach the MENA region from the bottom up, and with acute sensitivity to cultural difference.
Leaving spiritual healers or religious authorities out of the equation, for example, will be less productive than building bridges between religious or spiritual support and western modes of intervention. Religious authorities can be educated to recognise mental-health symptoms and make appropriate referrals to health systems.
Culturally-specific campaigns, aimed both at the public and healthcare professionals, to raise awareness of mental-health disorders as diagnosable and treatable conditions will pave the way for modern therapeutic interventions, including pharmaceuticals. The UAE Ministry of Health and Prevention, for example, recently signed a memorandum of understanding with Lundbeck to raise community awareness of mental-health disorders.
Sanofi has run a National Mental Health Anti-Stigma Awareness Campaign in Egypt, reaching an estimated 22 million listeners through radio slots. In Morocco it signed a five-year collaborative agreement with the Ministry of Health to improve care provision for people with mental-health problems and epilepsy. This involved training 40 psychiatrists, 40 neurologists, 160 general practitioners and 160 nurses, as well as raising awareness about mental disorders among the Moroccan public.
Campaigns such as these must also stress the importance of holistic approaches to managing mental-health conditions, preferably with multidisciplinary input and drawing on the strong family ties characteristic of the MENA region. They must also tackle stigmatisation, where to date there has been little effort at organised intervention: an evidence-based stigma reduction programme in Turkey was one notable exception.
Shortages of qualified mental-health specialists may alternatively hamper prescribing or encourage over-reliance on medication. In the long run, neither will flatter pharmaceutical companies as responsible partners in enlightened mental-health strategies.
Funding and support for education and training of mental-health specialists, from college-level upwards, will help create an environment in which mental-health conditions are more widely recognised, and appropriate medical interventions both understood and encouraged.
Digital capabilities, allied to other forms of therapeutic intervention, have potential to reach patients in the community where mental-health services are thin on the ground or underused. Egyptian digital start-up Shezlong is expanding access to MENA mental-health services by enabling patients to connect privately with a psychiatrist online.
Position for reform
There is an urgent need to improve mental-health management in the MENA region. Current levels of awareness, understanding, funding and provision barely scratch the surface of the problem.
The mental-health map across the region is diverse and complex, ranging from stress-related conditions linked to busy lifestyles in oil-rich nations such as Saudi Arabia or Qatar, to PTSD, depression and anxiety in war-torn countries where mental illness is buried under the rubble of everyday survival.
By positioning themselves at the forefront of tentative reforms in MENA countries, pharmaceutical companies can reap the commercial benefits of extensive unmet need while helping to bring mental health above the surface and into the mainstream of healthcare provision.