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By Deborah Goodman
In 1979, Sabah Sadik, MBCHB, FRCPsych, DPM, a doctor
with 3 years of experience in general practice and 1
year in psychiatry, left his native country of Iraq.
Twenty-five years later, in December 2003, he returned
to visit relatives in Najaf, 100 miles south of Baghdad.
What he saw saddened him profoundly, and he resolved
to do all he could to assist in restoring mental health
and rebuilding the country's mental health service system.
Three months later, Dr. Sadik was appointed National
Advisor for Mental Health to the Iraqi Ministry of Health.
Members of the planning group
met in December at SAMHSA. (L to R) Jim Haveman, who
served as Senior Advisor to Iraq's Coalition Provisional
Authority; SAMHSA Administrator Charles Curie; Dr. Sabah
Sadik, National Mental Health Advisor, Iraq; and Jon
Wilkes, West Kent Trust, England.
This past December, Dr. Sadik attended a meeting of
the Planning Group on Iraq Mental Health, chaired by
SAMHSA as part of its commitment to help rebuild Iraq's
health care system for mental and addictive disorders.
In addition to SAMHSA staff,
Dr. Sadik, and other Iraqi officials, the ongoing planning
group includes representatives from the National Institute
of Mental Health at the National Institutes of Health,
the U.S. Department of Defense, and the U.S. Army.
Members of the planning group
met in December at SAMHSA. (L to R) Jim Haveman, who
served as Senior Advisor to Iraq's Coalition Provisional
Authority; SAMHSA Administrator Charles Curie; Dr. Sabah
Sadik, National Mental Health Advisor, Iraq; and Jon
Wilkes, West Kent Trust, England.
The meeting built on the process initiated when SAMHSA
Administrator Charles G. Curie, M.A., A.C.S.W., accompanied
the U.S. Secretary of Health and Human Services on a
visit to Iraq in February 2004 (See SAMHSA News,
May/June
2004). The purpose of the meeting was to plan for
an international conference in Amman, Jordan, on ways
to strengthen Iraq's mental health system. At the meeting,
Dr. Sadik discussed the work that he and colleagues from
Iraq, England, and throughout the world have undertaken.
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Challenges
Dr. Sadik described the deterioration of mental health
services in the country since the mid-1980s, when an
"exodus of psychiatrists" occurred "due
to poor and intimidating working environments, shortages
of medication, poor quality information systems, and
a lack of access to up-to-date knowledge and education."
An initial tally of mental health staff in Iraq—a
country with a population of roughly 25 million—produced
just 154 psychiatrists, 20 clinical psychologists (of
whom only 3 had appropriate training), 25 social workers
(none of whom were trained in mental health), and 45
nurses (also not properly trained in mental health).
The few existing mental health facilities had antiquated
ECT machines over 20 years old and very limited medication.
In addition to these meager resources and the instability
and shortages due to three disastrous wars, 12 years
of international sanctions, and ongoing violence, Dr.
Sadik noticed more insidious problems as well upon his
return.
"Iraqi society changed during the previous regime,"
he said, "primarily correlated to the way the individual
and communities have been oppressed. There is a noticeable
lack of confidence in one's self and one's abilities,
an indecisiveness, and a lack of initiative for fear
of mistakes and fear of reprisals." He likened the
phenomenon to that of refugees from concentration camps
after World War II, suddenly liberated but simultaneously
paralyzed by inaction.
Fortunately, Dr. Sadik said, he also found that "Iraqis
quickly embrace new ideas and remain enthusiastic and
willing to work on issues and services for the new country."
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Mental Health
Under Dr. Sadik's leadership, a National Council for
Mental Health was formed with representatives from other
government ministries as well as from mental health disciplines
outside the government.
The National Council's first priority was to draft
national plans for mental health. The plans are based
on several underlying principles. The first is the concept
of universal coverage of essential mental health care
for the population.
The plans also emphasize primary care at the community
level and integration of mental health care with general
primary care services. This includes the establishment
of mental health services in the 150 primary health centers
to be built or renovated throughout the country. Dr.
Sadik noted that currently, Iraq does not distinguish
between primary and secondary health care, and yet primary
health care providers are seeing many people with somatization,
overt depression, and anxiety.
The plans address the following areas: primary care
services (mental health services provided in the primary
care setting); secondary care (traditional mental health
services for persons with mental illnesses); mental health
training and education/human resource development; building
scientific programs and research capacity; and policies
and support for mental health programs.
To decrease stigma and meet service needs, the plans
include education efforts for members of the public and
health care personnel. Community initiatives are encouraged
by offering support to families and organizations. The
plans urge more research on mental health problems in
Iraq, as well as appropriate legislation and administrative
structure to support the program.
Several efforts have already been launched. For example,
for the last 20 years Iraq has lacked proper mental health
legislation that would establish such things as a code
of practice and relevant training standards. In October
2004, the Iraqi cabinet approved such a plan drafted
by the National Council for Mental Health together with
the Iraqi Ministry of Justice.
The National Council also has supported activities
by Nongovernmental Organizations (NGOs) from several
different countries. For example, an NGO from Italy,
Movimondo, sponsored a project for children in Baghdad.
The organization "Together," from Slovenia,
sponsored a psychosocial support effort for children
and families in Babylon. Diakonia of Sweden offered psychotherapy
and services for children in Duhook, Erbil, and Suleymania.
Japan also ran a training course for 40 senior Iraqi
nurses in Egypt in September and November 2004.
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Substance Abuse
Dr. Sadik said that there are indications of an emerging
drug abuse problem in Iraq, although the exact extent
is unclear due to the limited resources for monitoring
the situation. He suggested several contributing factors,
including the instability and lack of law enforcement
coupled with a rapidly changing social and economic situation.
Unemployment is prevalent, he said, especially among
youth. The geographic location of Iraq, the lack of border
controls, and the proximity to countries that traffic
in opium and heroin, have also increased the availability
of drugs, he added. Finally, he noted that thousands
of criminals imprisoned during the previous period had
been released.
"The previous regime claimed that there was no
substance abuse problem in Iraq," said Dr. Sadik,
"so people providing treatment had to work in secrecy."
Because of this, there is an urgent need to build expertise
and establish programs. Currently, substance abuse treatment
in Iraq is limited mostly to detoxification and not rehabilitation.
A plan to address the issue of drug misuse was recently
finalized in collaboration with the regional World Health
Organization team. Five broad strategies guide the development
of drug abuse services in Iraq:
Understand the dimension of the problem through
surveys and rapid assessment studies. Organize services and integrate them with general
health care and community
care services. Develop human resources and provide needed training. Launch prevention programs, especially in schools. Provide administrative support.
Noting the similarities in strategies and principles,
Dr. Sadik said, "Planning for both mental health
and substance abuse services is proceeding hand in hand."
Looking to the future, he added, "I remain optimistic
in spite of all the difficulties. The idea of returning
to Iraq came out of love for the country and for the
Iraqi people. The Iraqi population has been very resilient.
I think a great asset to them has been the achievements
of the past, and that it is possible to rebuild once
there is stability, clear lines of accountability, and
funding. Added to that, there is a great asset in the
Iraqi professionals outside the country and what they
can offer in terms of the process of cross-fertilization."
Speaking about his visit to the United States, Dr.
Sadik added, "Seeing colleagues from various parts
of the world who are committed to supporting Iraq and
have worked so hard in putting ideas and proposals together
has enhanced my hope. It says a lot about the goodwill
that exists." 
Key Elements
of Iraq's Plans for Mental Health
Mental Health Services: primary, secondary,
specialty care Mental Health Training and Education Scientific Programs and Research Policies and Support for Mental Health Programs.
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