The development of psychiatry in the Arab

world : the challenges and perspectives

WALID SARHANConsultant Psychiatrist

Amman-Jordan

Islamic Bimaristans in the Middle Ages

• the first proper Bimaristan built in Islam was in Damascus, by al-Waleed bin Abdel Malek and built in 86 Hijri (707 A.D.)

• They divided the Bimaristan into two sections, one for men and the other for women.

Section for psychiatry The halls of internal medicine which frequently included a section for the patients affected by fever and another one for patients having mania.

• Muslims realized the importance of the care for mentally affected patients. They frequently added to the big Bimaristans special places isolated by iron bars, specially for patients with mental diseases

• Muslim physicians knew that psychiatric and mental diseases required a special type of care and that the physician must be acquainted with the etiology of the disease from which the patient is suffering.

Mental Disease Bimaristan

Medical education The theoretical method in the medical

schools. A practical method for training and practice

where students gathered around the doctor in chief to see and examine the patients and the treatment he prescribed.

When the students finished the studying period they applied for an exam, took an oath and got their certificates.

Mohd Zakria Razi• While in Arabia & parts of Asia there was a revival of

scientific interest in Greco- Roman Medicine.

• 705 AD: Asylum 4 mentally ill….in Baghdad

• 900 AD: Rhazes ( Mohd Zakria Razi )• One of the Greatest name in Arabian Medicine• known as Persian Galen• Director & chief physician at Baghdad hospital• wrote more than 200 books

The first psychiatrist in history

• A Persian physician and philosopher, born near Bukhara.  

• He is regarded as a father of early modern medicine and clinical pharmacology, celebrated until today by nations of the East and West.

• History records that in Arabia & Asia mentally ill patients received a much more treatment than the patients in the dark ages of Europe.

• Muslim belief: insane were loved by God

1000 AD: Avicenna (Ibn Sina )

Al-Ghazali

• The great philosopher• The first psychologists• Al-Ghazali has sometimes been referred

to by historians as the single most influential Muslim after the Islamic prophet Muhammad(PBU)

Landmarks• Service • Rehabilitation• Psychiatry• Psychology• Sociology• Hospitals

Arab World

The Arab world• The Arab world is taken to mean the 22

members of the Arab League, accounting for 280 million people. The region has the largest proportion of young people in the world: 38% of Arabs are under 14. Life expectancy has increased by 15 years over the past three decades.

Arab World• The Arabic language forms the unifying feature of

the Arab World. • Though different areas use

local varieties of Arabic, all share in the use of the standardized classical language, which was constructed from Classical Arabic

Religion• The majority of people in the Arab World adhere

to Islam and the religion has official status in most countries.

• Overall, Arabs make up less than one quarter of the world's 1.4 billion Muslims

Individual Development in Arab Societies

Arab societies tend to be "father dominant" (patriarchal): The father is the head of the family and is considered a powerful and charismatic figure. He commands respect as the legitimate authority for all matters of the family (El-Islam, 1983).

The patriarchal structure extends throughout all levels of society.

Individual Development in Arab Societies-cont.

The father of the nuclear family is subordinate to his own father, who in turn defers to the authority of the head of the clan. All clan heads are subordinate to the head of the tribe or hamula.

The tribal or clan leader also serves as the spiritual and practical father of the whole group—he represents the collective to the outside world, oversees the rules for the clan or tribe, and guides their actions.

Is the Western nosology applicable also to members of the Arab/Muslim culture?

• Individuals are not individuated from the collective, the mind and body are not distinct entities, and the internal constructs of personality (emotions, thoughts, self, super-ego) are not distinct one from the other?

M.Dwairy

Heterogeneous Arab population

• The rapid changing Arab society has lead to heterogeneous groups in the society.

• Some Arabs are still very traditional while others have developed the western attitude to various degrees, in the same family and the same city or country.

The place of Arabs in science

Arabs comprise 5 percent of the world’s population, but publish just 1.1 percent of its books, according to the U.N.’s

Between 1980 and 2000, Korea granted 16,328 patents, while nine Arab countries, including Egypt, Saudi Arabia, and the U.A.E., granted a combined total of only 370, many of them registered by foreigners.

2003 Arab Human Development Report.

Education

• The region’s average mean years of schooling of six years is 1.3 years higher than those of South Asia and sub-Saharan Africa regions but 1.5 years below the World average and over four years below the average for Europe and Central Asia.

Violence • Wars• Terrorism• Occupation• Revolution• Demonstration

Scientific and technical journal articles 2007The world 758,137

20,980 Spain 4,980 Greece 413 Algeria 36 Sudan 18,194 India 3,264 Argentina79 Syria 4,366 Iran 17,831 Australia 757 Tunisia 6,623 Israel 41 Bahrain

8,637 Turkey 52,896 Japan 235 Bangladesh214 UAE 344 Jordan 7,071 Belgium

47,121 UK 242 Kuwait 27,799 Canada209,694 USA 238 Lebanon 56,806 China

18 Yemen 30 Libya 5,236 Denmark44,408 Germany 377 Morocco 1,934 Egypt 13,953 Russia 129 Oman 149 Ethiopia

589 Saudi Arabia 48 Qatar 30,740 France3,792 Singapore

EXPENDITURE ON HEALTH

According to the WHO World Health Report (2001) the health expenditure estimated as percentage of gross domestic product is highest in Lebanon (11.3%) followed by Jordan (8.8%), Tunisia (5.3%) and Bahrain (5%). None of the remaining Arab countries fulfilled the WHO recommendation of a minimum expenditure of 5% of GDP on health. In none of the sources could we find a reference to the specific expenditure on mental health services.

Mental health expenditure

• The mental health expenditure as a percentage of total health expenditure is not available in most Arab countries and not reported by the officials. Only three Arab countries have provided an estimate: Qatar (1%), Egypt (less than 1%) and Palestine (2.5%).

Adult literacy rate (both sexes) (% aged 15 and above)

GDP per capita (2008 PPP US$)

2010 2010Algeria 77.6 1 8,477 2

Bahrain 90.0 1 27,838 2

Egypt 66.4 3 4 5,840 2

Iraq 74.1 5 6 ..Ireland .. 38,768 2

Jordan 91.1 7 8 5,700 2

Kuwait 94.5 8 9 50,284 2

Lebanon 89.6 8 9 13,510 2

Libyan Arab Jamahiriya 88.3 1 16,999 2

Morocco 58.2 1 4,638 2

Occupied Palestinian Territories

93.8 8 9 ..

Oman 86.3 1 26,258 2

Qatar 93.1 8 9 77,178 2

Saudi Arabia 86.7 1 24,208 2

Sudan 60.9 5 6 2,300 2

Syrian Arab Republic 84.7 1 4,857 2

United Arab Emirates 90.0 7 8 56,485 2

Yemen 63.2 1 2,595 2

ARAB HUMAN DEVELOPMENT REPORT2010

In Egypt there are 3 journals published in English: Egyptian Journal of Psychiatry, since 1978 Current Psychiatry, since 1995 Journal of Neurology Psychiatry and Neurosurgery,

In Algeria the official journal of APA, in French.

In Jordan there is the Arab Journal of Psychiatry, since 1989

Eastern Mediterranean Health Journal, the official journal of

WHO/EMRO

Psychiatric journals in the Arab World

Prevalence of psychiatric disorders• The lifetime preva lence of any anxiety

disorder among adults was 16.7% in the Lebanese study and 13.8% in the Iraqi survey; that of any mood disorder was, respectively, 12.6% and 7.5%. The study carried out in Morocco reported a point prevalence of 9.3% for generalized anxiety disorder and 26.5% for ma jor depressive disorder, while the Egyptian study reported a point prevalence of 4.8% for anxiety disorders and 6.4% for mood disorders

Mental health legislation

• The Eastern Mediterranean Re gion (EMRO) office of the WHO, national psychiatric soci eties and national psychiatric leaders. Six out of 20 countries do not have a mental health legislation and two do not have a mental health policy. There is no information for Maurita nia and Comoros.

Addiction• 6% of adult population.• Hashish-amphetamines-Heroin.• Inhalants in children and adolescents.• Smoking cigarettes and Hubble bubble.• Alcohol.??• The Arab world is undergoing an epidemic of

substance misuse with very poor services.• The treatment of substance misuse is part of

the poor mental health services.

Psychiatric hospital beds

• three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. A substantial reduction of psychiat ric beds occurred in Iraq, Jordan, Kuwait, Libya, Oman, Qatar and Palestine.

Country Mental health policy (year) Substance abuse policy (year) Algeria Yes (?) Yes (1990) Bahrain Yes (1993) Yes (1983) Djibouti No No Egypt Yes (1978) Yes (1986) Emirates Yes (?) Yes (?) Iraq Yes (1981) Yes (1965) Jordan Yes (1986) Yes (2000) Kuwait Yes (1957) Yes (1983) Lebanon No No Libya Yes (?) No Morocco Yes (1972) Yes (1972) Oman Yes (1992) Yes (1999) Palestine Yes (2004) Yes (2004) Qatar Yes (1980) Yes (1986) Saudi Arabia Yes (1989) Yes (2000) Somalia Yes (?) Yes (?) Sudan Yes (1998) Yes (1995) Syria Yes (2001) Yes (1993) Tunisia Yes (1986) Yes (1969) Yemen Yes (1986) No

Mental health policies in Arab countries

Country National mental health Mental health legislation

program (year) (year) Algeria Yes (2001) Yes (1998) Bahrain Yes (1989) Yes (1975) Djibouti No An old French legislation Egypt Yes (1986) Yes (2009) Emirates Yes (1991) Yes (1981) Iraq Yes (1987) Yes (1981) Jordan Yes (1994) Yes (2003) Kuwait Yes (1997) No Lebanon Yes (1987) No Libya Yes (1988) Yes (1975) Morocco Yes (1973) Yes (1998) Oman Yes (1990) Yes (1999) Palestine Yes (2004) Yes (2004) Qatar Yes (1990) No Saudi Arabia Yes (1989) No Somalia Yes (?) No Sudan Yes (1998) Yes (1998) Syria Yes (2001) Yes (1965) Tunisia Yes (1990) Yes (2003) Yemen Yes (1983) No

The Psychiatrists• The highest number of psychiatrists

is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists per 100,000 population.

Mental health workers• Psychiatric nurses per 100,000 population

range from 23 in Bahrain and 22.5 in Emirates to 0.09 in Yemen and 0.03 in Somalia.

• The same applies to psychologists and social workers, with the most substantial increase observed in Bahrain, Emirates, Jordan, Egypt, Ku wait, Libya, Saudi Arabia and Yemen

Big mental hospitals• Recent years have seen significant

changes in the field of mental health in the countries of the Arab Region. Psychi atric services, which were earlier totally confined to a few large mental hospitals, are now gradually being replaced by psychiatric units with both inpatient and outpatient facili ties in general hospitals.

Country Psychiatric beds per 100,000

Psychiatrists per 100,000

1998 2007 1998 2007 Algeria 14 25 1.1 2.2 Bahrain 33.8 33 3.7 5 Djibouti N.A. 7 0 0 Egypt 12.5 13 0.9 0.9

Emirates N.A. 14 0.9 2 Iraq 7 6.3 0.1 0.7

Jordan 20 15.7 1.1 1 Kuwait 47 34 2.6 3.1

Lebanon 47 75 1.2 2 Libya 56 10 0.3 0.2

Morocco 7.6 7.8 N.A. 0.4

Mental health resources in Arab countries

Oman 5.5 4.9 0.2 1.4

Palestine 14.2 8.8 0.8 0.9

Qatar 37.9 9.7 0.8 3.4 Saudi

Arabia 6.5 11.8 2.4 1.1

Somalia N.A. 4 0.5 0.06

Sudan 0.1 2 0.2 0.09

Syria 7.8 8 N.A. 0.5

Tunisia 9.6 11.3 0.8 1.6

Yemen N.A. 18.5 0.1 0.5

Psychiatric nurses per 100,000

Psychologists per 100,000

Social workers per 100,000

1998 2007 1998 2007 1998 2007 Algeria 1.1 4.2 0.8 0.2 0 0.4 Bahrain 13.3 23 0.5 0.8 1 1.5 Djibouti 0 0.2 0 0 0 0 Egypt 2 2 0.3 0.4 0.09 0.1

Emirates N.A. 11 0.9 1 0.6 1.2 Iraq 0.1 0.1 N.A. 0.05 0.05 0.2

Jordan 0 2 0.2 0.6 0.5 2 Kuwait 16.2 22.5 0.9 1.4 0.4 0.4

Lebanon 0.9 5.03 1.9 0.6 0.6 1.5 Libya N.A. 0.05 0.3 5 0.2 1.5

Morocco N.A. 2.02 N.A. 0.03 N.A. 0.007 Oman 0.2 5 0 0.2 0.1 0.5

Palestine 3.2 3.4 1.7 1 0.7 1.1 Qatar 7.4 10 1.4 1.2 1.7 10 Saudi

Arabia 6.3 6.4 0.5 1 0.9 2.4 Somalia 0.03 0.03 0 0 0 0.2 Sudan N.A. 0.2 0.01 0.2 0.01 0.1 Syria N.A. 0.5 N.A. 0 N.A. 0

Tunisia 3.3 0.2 0.1 0.6 0 N.A. Yemen N.A. 0.09 3.2 1.2 0.01 0.04

Traditional healers

• Cultural beliefs of possessions and the impact of Jinn or the evil eye affect interpretation of mental symptoms.

• the first resort for the families of mental patients is not the general practitioner, but the traditional heal ers, who acquire a special importance because of their claim of religious background.

The Challenges• The public awareness is poor.• The governmental services are poor.• Private services are scattered with

various standards.• The patients and their families face the

stigma, finding the service, and paying for it.

• Lack of mental health professionals.• Poor research

The Challenges • In the Arab world, health and education

budget assignment is below the recom mended requirements far better quality of life.

• The budget al lowed for mental health as a percentage from the total health but it is far below the range to promote mental health services. The mental health human resources and the inefficient data.

Recommendations • Public and governmental awareness .• Research, training, and cooperation .• Mental health policies and legislations

should be updated.• Drug addiction need to have priority on

the national agenda.• Special care should be given to the

causalities of wars, terrorism and violence.

Recommendations• Mental health professionals to

work as a team.• Liaison psychiatry could help

in getting the support of the medical profession.

• Child and adolescence psychiatry should be given good attention.

• Cooperation with international centers .

References :

1. Ibn Abi Usaibi'ah, Uyun al Anba, P. 45. 2. Isa, A., The History of Bimaristans in Islam,

Damascus, 1939, P. 9. 3. Noshrawy, A.R., The Islamic Bimaristans in the

Middle Ages, Arabic Translation by M. Kh. Badra, The Arab Legacy Bul. No. 21, P 202.

4. Ibn Al-Atheer, Al-Kamel Fi al-Tareikh, The perfect in History, Cairo, 1290 H. V. 4P. 219.

5. Ibn Joubir, Rehlat Ibn Jouber, The Journey of Ibn Jouber, Cairo, 1358 H.

References

"Mental health services in the Arab world“. A. OKasha -Arab Studies Quarterly (ASQ). 2003

THANK YOUwsarhan34@gmail.com