Two years after the initial lockdowns of the COVID-19 pandemic, biomedical advancements like vaccinations and pharmaceutical treatments began to allow countries to relax strict social distancing guidelines, reopen schools and businesses, resume public events, and limit mask use in certain settings. On the surface, it may appear to be the “normalcy” that many had long been awaiting. Yet, multiple societal measures suggest that while scientists made stunning advancements to maintain and improve physical health symptoms of the disease, they have lagged on more hidden aspects of health that deteriorated in that same timeframe—specifically, mental well-being. Under the appearances of “normalcy” that many crave lie populations that are fragile, divided, and in some cases, experiencing mental health conditions and crises. Global responses to infectious health threats, like a pandemic, are typically robust and use significant resources. But for centuries, societies have largely ignored, overlooked, or even demonized and criminalized mental health ailments that can be just as debilitating.
It is estimated that about 792 million people—almost 11 percent of the global population—live with some form of mental health disorder, with the most common being depression or anxiety disorders. However, public surveys suggest that the percentage is much higher in many Arab countries, where nearly 30 percent reported suffering from depression (and even higher proportions among Iraqis, Tunisians, and Palestinians). Further, the significant youth population of the region today is aging and will have unprecedented needs for mental health care to manage dementia. Current estimates suggest a 400 percent increase in dementia in the Middle East and North Africa (MENA) region by 2050.
Even in the wealthiest countries with the most advanced health systems, mental health is neglected in terms of facilities, resources, and education.
Everywhere, even in the wealthiest countries with the most advanced health systems, mental health is neglected in terms of facilities, resources, and education. There are a few reasons for this, including stigma against mental illness, perceptions that mental health care is a luxury compared to physical health care, and outdated health delivery models that result in policies and practices that don’t serve today’s populations’ holistic health needs. Many of these structural challenges exist throughout the Arab region and are exacerbated by war, authoritarianism, economic hardship, and internalized stigmas against acknowledging and treating mental health issues. With such a young population in nations that play an outsized role in global politics and trade, it is vital to understand how societies in the Arab world function, including on issues of mental health that are unaddressed by current policies.
Drivers of Mental Health Challenges in the Arab Region
Establishing causation of mental disorders, which can include depression, bipolar disorders, schizophrenia and other psychoses, and dementia, is nearly impossible. Aside from the various individual characteristics of a person, like stress, traumatic experiences, genetics, nutrition, and exposure to certain infections or hazards at important developmental phases, there are many societal factors that determine one’s propensity to develop, identify, and/or treat mental ailments. In many countries, even for those who are able to access care, quality is often poor.
Like physical health, mental health is not just about illness, or lack thereof. A whole host of factors can exacerbate mental distress that impairs quality of life and health, like “discrimination, gender inequality, poverty, economic downturns, forced migration, and humanitarian emergencies.” Most of the countries in the Arab world unfortunately feature deficits in terms of both health system functioning and the societal support that provides the foundation for a secure and dignified life. It is not surprising that many of the countries of this region are reporting an increase in mental illness.
With few exceptions, studies of Syrians, Palestinians, Iraqis, and Yemenis show poor mental health outcomes, accompanied by an inability to receive mental health care.
Many of the world’s conflicts take place in countries within the MENA region. Syria is among the countries from where most of the world’s refugees come. It is well established that conflict-affected environments report a higher burden of mental health issues, as do populations that are forced to leave their homes. Indeed, many studies have looked at the mental health of the conflict-affected populations throughout MENA, including among Syrians, Palestinians, Iraqis, and Yemenis. With few exceptions, these studies show poor mental health outcomes among these populations, accompanied by an inability to receive mental health care. Other significant events, like the explosion at the Beirut Port in August 2020 or the massacre at Rabaa Square in Cairo in 2013, have also caused trauma at the population level. The massive humanitarian crises across the MENA region have for decades left generations of citizens, migrants, and refugees in various stages of mental shock and distress. At the same time, the lack of consistent and reliable mental health data from these countries prevents in-depth longitudinal analyses to determine the parameters of disease and its amelioration.
The significant gender disparities throughout the MENA region also serve as a potential backdrop for worse mental health outcomes. Women in the eastern Mediterranean region report a mental health burden higher than the global average, thought to be due, at least in part, to lack of female empowerment and the patriarchal norms common throughout the area. High rates of postpartum depression, brought on by higher-than-desired birthrates or lack of household support, also contribute to this disparity, especially as women are now newly expected to both manage their household roles and participate in the workplace. Other women-specific factors, like dynamics of polygamous marriages and prevalence of gender-based violence, place many women in situations where they are more vulnerable to mental distress.
Aside from such pivotal and obvious factors as humanitarian crises and gender imbalance, there is surprisingly little research on mental health in Arab states. Even in the wealthier Gulf states, which have among the most stable and accessible health systems in the region, research on mental health is scant. Most of the region’s ministries of health offer little in the direction of mental health, and regional professionals in counseling, social work, psychology, and psychiatry are lacking. Thus, we only have an imperfect picture of the mental health situation throughout MENA, which makes it difficult to assess risk factors on a more targeted basis or offer community-specific recommendations. Overlooking and shortchanging the clear mental health struggles of these populations, however, does not make these struggles disappear. On the contrary, it is likely to be creating the perfect conditions for even greater distress and continuing cycles of trauma for current and future generations.
Suicide
One devastating outcome from untreated mental health struggles is the incidence of self-harm or suicide, which results in more than 700,000 global deaths annually. Suicide is the fourth leading cause of death among 15–19-year-olds, and more than three-quarters of suicides (77 percent) occur in low- and middle-income countries. There are undoubtedly countless cases of attempted suicide that are not captured in these statistics.
Despite the historical and contemporary traumas that have taken place in the Middle East, suicide rates are comparatively lower than any other world region, and data suggests that overall rates have been decreasing.
Yet despite the historical and contemporary traumas that have taken place in the Middle East, suicide rates are comparatively lower than any other world region, and data suggests that overall rates have been decreasing. However, there do appear to be pockets where suicide is more common and even increasing. For example, poor social circumstances are thought to have led to an increase in suicide rates in Egypt as well as in the Gaza Strip more than a decade into a crippling Israeli blockade. Financial crises have also led to acute mental health crises in countries like Lebanon, where there has been a significant uptick in calls to the country’s sole suicide hotline.
In general, it is thought that in the Arab context, strong family bonds, a collectivist culture, low communal and religious acceptance of suicide, and lack of access to weapons and other objects of self-harm may serve as protective factors against suicide in this region. On the other hand, high levels of coercion and restriction, lack of reporting of suicidal ideation due to shame, lack of awareness of mental health support, and feelings of abandonment in one’s faith may be factors that make it more likely that an individual would seriously consider or attempt suicide. The role of religion and culture in moderating suicide in the Arab world is interesting; high levels of adherence to the Islamic faith have effected lower rates of suicide. Yet, the stigma against suicide and cultural beliefs about mental illness, like believing that such ailments are derived from the evil eye, may prevent an individual from seeking help or treatment, which may lead to a greater likelihood that a particular individual may attempt suicide. Stigma against suicide and wanting to avoid public shame may also cause a family to misreport the cause of death for an individual suspected of dying by suicide, which would skew available data.
Challenges of Tackling Mental Health
The Middle East has a robust history in the study of mental health. The first psychiatric hospitals in the world were built in the region: in Baghdad, Cairo, and Damascus. Early Muslim scholars wrote prolifically about mental health and mental illness, although cultural beliefs still centered around supernatural explanations like mental illness being a punishment from God, the result of possession by Jinn, or the effects of the evil eye. Yet many scholars disagreed with these supernatural explanations and conducted research and observation on mentally ill populations.
Today, very few countries in the Arab world even designate mental health expenditure as part of their overall health budget which, for many Arab states, is already insufficient.
Unfortunately, conflict and the colonial legacy in the region in the past century, along with some persisting cultural beliefs, preempted some of the development in medicine and science that was proliferating in other parts of the world, including in public health investment. Today, very few countries in the region even designate mental health expenditure as part of their overall health budget (which, for many Arab states, is already insufficient), and the proportion of mental health personnel to population is exceedingly low. Communities are rarely educated about warning signs for mental illness, or the physiological and environmental factors that can contribute to it. Even primary care physicians, the type of doctor most accessible to those with access to health care in Arab countries, are not often well educated about mental health and may give inadequate advice or overlook signs and symptoms.
Further, there is a pervasive stigma against recognizing and treating mental illness in many Arab states. Stigma can come either from public perceptions of mental illness, in terms of discrimination, prejudice, and even fear and avoidance, and self-stigma, which can cause a mentally ill person to have a negative attitude about their own status. This can cause them to ignore or privately deal with symptoms like hallucinations, delusions, and anxiety. Mentally ill people may even reject treatment if offered, for fear of being labeled and potentially alienated from friends and activities. This stigma is so pervasive within cultures that it appears to persist even among those who leave the region; a recent study found that American Muslims are twice as likely to attempt suicide as some other religious groups. The authors of the study suggest that aside from community stigma against mental health diagnosis and treatment, American Muslims are more likely to experience religious discrimination that can increase rates of depression and anxiety.
Overcoming the Mental Health Challenges Facing Arab Populations
Until there is a global reset in our approach to mental health care, people with mental illness, regardless of home country, face significant barriers to diagnosis, treatment, and social support. However, identifying the specific challenges of the Arab region presents multiple options to get closer to the kind of care people with mental illness need and deserve.
The main structural challenges of the region that have been addressed in so many other contexts—war, displacement, authoritarianism, gender inequality, insufficient economic development—are among the largest barriers to meeting the mental health needs of Arab populations. These factors are not necessarily causal; many people live in contexts of war or inequality without fitting clinical criteria for a mental health diagnosis or experiencing symptoms. Many others living in relatively stable, more egalitarian countries with sufficient economic means still experience minor or severe mental health issues which, indeed, are universal. Yet unquestionably, removing stressors about surviving, sustaining basic life necessities, and maintaining some ability to plan a future would remove unnecessary trauma from the lives of millions, especially among the most vulnerable, like women, people with disabilities, and minorities of all kinds.
Many countries in the Arab world, experiencing large population growth and rapid urbanization that threaten to stress already insufficient health systems, are shifting to more holistic health practices.
Many countries in the Arab world, experiencing large population growth and rapid urbanization that threaten to stress already insufficient health systems, are shifting to more holistic health practices. This means a greater emphasis on prevention, more campaigns about health risks like smoking and high-sugar foods, and targeted attempts to hire and retain health professionals, especially specialists. However, this long overdue transition has not yet included enough initiatives related to mental health, whether it is increasing education of mental health in medical schools or working with community or religious groups to reduce stigmas of having or seeking treatment for mental ailments.
Studies show that mental health literacy in Arab states, even among health care professionals, is limited. Poor working conditions for mental health professionals lead many in the region to leave, and the need to hire them is high; in Lebanon, there were fewer than 100 registered psychiatrists left in 2021. These countries and the humanitarian agencies operating within must make mental health as great a priority as physical health and increase funding for both. The Arab region, facing pressure from an aging youth bulge, decades of war, decreasing food and water security, and the unknown effects of impending climate change, cannot afford to lose the full vitality and creativity that will be needed in its population to begin to address these challenges. Some countries are investing in initiatives at schools, and many humanitarian agencies in the region offer some type of mental health programming. Yet there is simply not enough supply to meet the overwhelming demand, and individuals who need mental health care cannot wait for initiatives that will improve access in years or decades. Urgency on the part of all involved stakeholders should be the order of the day.
