Muslim countries have the world’s highest rate of suicide and mental health issues according to research conducted by the University of Washington’s Institute for Health Metrics and Evaluation (IHME). Some 30,000 people committed suicide in 2015, up 100 per cent since 1990.
Mental health and in particular suicide, has long been one of the most controversial taboos across the Middle East. A lack of understanding, coupled with few psychiatric resources is fuelling an epidemic.
The region was once a pioneer in the development of psychiatry, in fact the world’s first psychiatric hospital was built in Baghdad in 705 CE with another later founded in Cairo in 800 CE and in Damascus in 1270 CE according to the Annals of General Psychiatry. Like other aspects of societal progress in the Middle East, stagnation supplanted innovation.
But now, Embrace, a mental health charity based in Lebanon, has reignited developments in psychiatric treatment by launching the region’s first suicide helpline.
“This is the first in the region to address suicide crises among individuals experiencing suicidal thoughts,” says Mia Atwi, co-founder at Embrace. “The hotline also targets individuals going through mental distress issues or are concerned about someone who might be suicidal or has mental health issues.”
The charity enlisted international experts to train its 30 volunteers who currently manage up to five cases a day – people calling in various states of desperation. Callers experiencing suicidal thoughts can be referred to Embrace’s network, which includes hospitals and emergency rooms where psychiatric help is available.
“The hotline is non-interventionist, unless there is an imminent crisis,” says Ms Atwi. “The caller provides us with the information needed which is sent to the Red Cross who visit the location to prevent suicide.”
Most of the calls range from half an hour to an hour, with the volunteers helping to provide hope to de-escalate suicidal risk. Embrace expects to receive some 2,000 calls a year.
According to World Health Organisation (WHO), the suicide rate in Lebanon is 3.1 per cent per 100,000 people. While this is lower than a place like the United States where the suicide rate is 13.5 per cent, it means that in Lebanon, one person commits suicide every three days.
“We’re a very small country, when a suicide happens, we know it affects a lot of people,” says Ms Atwi. “It has a much bigger impact than in other countries, it affects the family, friends, village, society and culture.”
When a person from a village commits suicide, it can inspire others in the vicinity to do the same, a trend that the team at Embrace has noted. “We say that 90 per cent of suicides happen because of treatable mental illness,” says Ms Atwi. “One in four will suffer from a mental health issue at some point in their lives.”
Data regarding the prevalence of mental health disorders across the region is limited. IHME’s most recent study determined the mental health burden of each country, calculated as the number of years of a healthy life lost due to a mental illness.
Palestine has the biggest burden of mental health disorders in the region. With the exception of Egypt, the countries of the Middle East all have a higher mental disorder burden than the global average. Depressive disorders are the most common mental health issue in the region, followed by anxiety disorders.
“From 1990 until 2015, females have consistently had a higher rate of burden compared to males in the region, this is similar to the global trend,” says Raghid Charara, a psychiatry resident at the American University of Beirut Medical Centre and a postgraduate fellow at IHME. “We believe the participation of women in the workforce could have been a contributing factor to that.”
That is not to say that women who work have a higher chance of suffering from a mental illness, rather the burden of employment, with lower pay than men, plus household chores that still fall into their realm of responsibility puts women under greater stress.
The stigma around mental health in the region has contributed to the lack of funding and discourages many doctors from pursuing a career in psychiatry.
Lebanon has one mental health professional per 45,000, the highest in the region according to WHO, while Yemen has the lowest with one per 200,000. Just $0.15 per person is spent on mental health in the region, whereas the US spends $3-4 per person according to Mr Charara.
The lack of funding and psychiatrists is problematic, which results in mental health issues going undetected or misdiagnosed.
That was the experience of Raja Sabra, a mental health campaigner.
“Many people think that physical ailments are the ones that we treat with medication and surgery,” he says. “Anything to do with the mind and feelings, because they’re not tangible, we tend to dismiss them.”
Mr Sabra was misdiagnosed with ADHD for which he was prescribed Ritalin.
“My thought process is so cluttered, I talk quickly, I cannot form thoughts, a few days after taking the medication I started getting worse and it amplified all the obsessions in my head,” says Mr Sabra.
It turned out that he was actually suffering from obsessive compulsive disorder (OCD) for which he was given anti-depressants. The medication began to work, but he also required therapy to tackle his anxiety.
“The fact that psychotherapy and counselling are not covered by [medical] insurance in many countries across the Middle East positions the field to be an option and not a necessity,” says Mai Elsayed, founder of Bitter Sweet, a UAE-based hypnotherapy clinic. “This gives an indirect message that only the niche community, those who can afford it, can pursue it.”
Perhaps the main barrier to effective treatment is the cost. Consultations are expensive and not usually covered by insurance. “There is clearly a problem, almost all the countries [in the Middle East] have a higher mental health burden than the rest of the world,” says Mr Charara. “There needs to be improvement in spending on mental health to create employment opportunities and a mental health workforce. Access to good healthcare serves the community.”
But attitudes towards mental health and psychological wellbeing are slowly improving across the region. “Over the past couple of years, there have been actions taken towards repositioning mental health and eliminating the stigma,” says Ms Elsayed.
When Mr Sabra began to blog about his journey battling anxiety and OCD, the response was very positive, leading him to work with Embrace to give talks about mental health in Lebanon. He also set up a support group on Facebook, which he says helped save one person from suicide. “People want to be informed, they want someone to talk about these things, but they don’t know who to speak to and they don’t know what to ask,” he says.
Initiatives like the appointment of a Minister of Happiness in the UAE and an attempt in some countries to incorporate mental health into primary healthcare centres are examples of such progress. Social media has also been a powerful tool in providing support to sufferers as well as helping raise awareness of mental health issues and to encourage people to see it as a medical problem rather than one associated with stigma and taboo.
In short, things are looking up…