The Expert Commentary

Leading commentators offer their perspectives on the key findings of the ASDA'A Burson-Marsteller Arab Youth Survey 2018.

Attitudes to mental health have a high cost for Arab society

Osama Al-Sharif

Justin Thomas

Professor Justin Thomas is a Chartered Health Psychologist with the British Psychological Society and Professor of Psychology at Zayed University in Abu Dhabi, where he directs the Research Cluster for Culture, Cognition and Wellbeing. He earned his PhD in experimental psychology from the University of Manchester. Justin publishes extensively on topics related to culture and psychopathology. His most recent book is Psychological Wellbeing in the Gulf States: The New Arabia Felix. Justin also works to promote the public understanding of psychological science, writing extensively for the popular press, making regular media appearances and giving public lectures and workshops.

The ancient Romans, with a green tinge of envy in their eyes, referred to parts of the Arab world as Arabia Felix – happy Arabia. To what degree the people of ancient Arabia were happy is wide open to speculation, so too is the extent to which they experienced enduring sadness, anxiety and other types of emotional distress we consider symptomatic of mental health issues.

We do know, however, that the oldest existent manuscript devoted entirely to depressive illness comes from the Arab world: Maqaal ‘ala malaakhoolia (Treatise on Melancholy) was penned by Ishaaq ibn Imran, an Arab-Iraqi physician working in10th century Tunisia.

This marvellous work leaves us with no doubt that mental health issues – conditions that we might today call depression or bipolar disorder – were prevalent in the Arab world. Furthermore, it shows us that they were viewed, at least by some, as treatable psychological complaints rather than demonic possession, irreligiosity or weak-willed malingering.

This year’s Arab Youth Survey included a section devoted to exploring young people’s perceptions of mental health issues in the Arab world today. This focus is timely because, despite remaining widely underreported, mental health problems have reached epidemic proportions in many nations. The World Health Organisation estimated that 1.1 billion people around the world endured a mental health problem in 2016.

The cost associated with mental illness is presently the largest of any health issue, projected to reach $6 trillion per year by 2030.

The 2019 Arab Youth survey reports that almost one-third of respondents personally know somebody who is experiencing a mental health issue.

This finding resonates with the large global epidemiological studies, many of which have included sections of the Arab world. For example, the data from the 2010 Global Burden of Disease study identified the United Arab Emirates as having a burden of depressive illness above the global mean. The term “burden” comes from health economics and refers to the economic impact associated with a health complaint, for example, lost workforce productivity and treatment costs. Problems that have an early age of onset (affect youngsters) and a chronic course (last a long time) are particularly burdensome from an economic standpoint. In short, depression costs way more than diabetes.

Half of the Arab youth surveyed saw help-seeking for mental health issues as being viewed negatively within their respective countries. The stigmatisation of people experiencing mental health issues is very real and, in spite of the many brave celebrity self-disclosures, it persists and will undoubtedly continue to endure for generations to come.

Stigma towards people experiencing mental health issues has an ugly past. Consider that mental health patients in Nazi Germany were deemed as having “lives not worth living”.

Robert Proctor, Professor of History at Stanford University, suggests that gas chambers were first used in psychiatric hospitals. German psychiatrists are estimated to have been complicit in the murder of some 70,000 mental health patients. In the US too, many thousands of people with mental health issues were subject to compulsory sterilisation, in line with the so-called “prevention of idiocy act”.

While most nations no longer attempt to exterminate or sterilise people with mental health issues, we do continue to shun, stigmatise, demonise and discriminate. The UK mental health Charity, Mind, has scoured the globe for examples, which range from Lithuanian laws excluding people with mental health issues from home ownership, to swimming pools in South Korea that restrict access based on mental health status. Until July 2013, having a documented mental health issue in the UK would prevent you from becoming a company director, and exclude you from jury service.

These are examples of stigmatisation and discrimination at the institutional level, quickly fixed by changes to policy or law.

At the interpersonal level though, things can be far more painful and resistant to change. People will often exclude or ridicule individuals known to have experienced mental health issues. Some people might fear disgrace-by-association, even when the sufferer happens to be a member of their own family. In close knit collectivist societies, the stigma can extend from the individual to tarnish the whole family. In such a context, disclosing a mental health issue might cause social problems (e.g. reduced marriage prospects, employment opportunities) for other family members.

The culture of shame and stigma towards mental health problems radically reduces help-seeking behaviours. This is a real tragedy because, in many cases, getting help, early, can mean the difference between a quick and lasting recovery or a lifetime of languishing.

Of course, stigma is not the only reason people don’t seek medical help for mental health issues. There is little point seeking help if there is none readily available, or if it is perceived as substandard. This is the issue of accessibility, to which 55 per cent of Arab youth responded negatively, suggesting that access to quality mental health care was “difficult”.

The response to this question varied significantly by region, with 81 per cent of Levantine youth declaring access difficult.

With psychological therapies, which are often the most effective treatments for depression and anxiety, there is often a need to speak the language of the client and to have a proper appreciation of their cultural values. A broken leg is a broken leg in any language, but a broken heart is far more nuanced. Importing psychological therapists will not always be a viable option. There is a real need for home-grown therapists.

This means ensuring high-quality training and supervision for citizens and long-term residents interested in pursuing this career pathway. Improving access to high-quality care for mental health issues requires improving access to graduate-level training programs. This will ensure a steady supply of highly-skilled and culturally-competent mental health professionals capable of meeting national demand.