The construction of the first dedicated psychiatric hospital in Dubai, and the priority this project has been accorded by the UAE government, could signal a new focus on mental health among policymakers in the Gulf region.
At an estimated cost of AED450m-500m ($122.5m-136.1m), the new Al-Amal psychiatric hospital development accounts for almost 5 per cent of the Public Works Ministry budget for 2013-21. The facility will be equipped to adopt a broad-based approach to mental health.
In addition to its treatment clinics and pharmacy, laboratory and radiology units, the hospital will have rehabilitation and therapeutic sections. Its architecture draws upon Emirati and Islamic styles, and seeks to create an environment to support programmes of psychological and physical rehabilitation, and help patients prepare for reintegration into society.
The treatment of mental illness and disability is not neglected in the GCC, but it is an area of health policy that rarely commands the public attention accorded to issues such as diabetes and cardiac disease.
So the decision to devote such focus and funding to a new, dedicated psychiatric hospital is an important move by the UAE authorities and a sign of the wider attention mental illness is beginning to attract in the Gulf. For example, recent research in Saudi Arabia has been exploring how medication regimes could be adjusted to provide more effective treatment for depression.
There is a growing recognition that mental ill health may pose more serious challenges for Gulf countries than was traditionally thought. According to the World Health Organisation (WHO), the share of neuropsychiatric disorders in the overall burdens of disease ranges from 14 per cent in Saudi Arabia to 20.8 per cent in Qatar.
Some professionals have suggested work-related mental health problems such as workplace stress are less common among Gulf citizens, whereas personal, family and wider social factors can be a significant influence.
Moreover, over the past five decades, Gulf societies have experienced huge social change. Of course, this is true of many other emerging economic regions; but it may be that the scale of change in GCC countries has been more extensive, in relative terms. This could be because it has embraced almost all citizens, rather than just part of the population.
Research suggests that rates of depression are actually quite high, by global standards. One estimate suggests depression costs Saudi society 201,000 years of potential productive life a year, measured in disability-adjusted life years, lost to early death or disability, while the UAE loses 39,000.
The 2012 annual report of Qatars Supreme Council of Health (SCH) warns that a lack of action in the past, combined with the general ageing of the population, is likely to exacerbate mental health problems. Its National Primary Healthcare Strategy 2013-18 says one in four of the population has a mental health problem, while research conducted at primary level suggests more than a tenth of the population suffers from depression or anxiety.
However, approaches to the provision of mental healthcare, and the attention given to training general medical personnel in the subject, vary considerably from country to country. A study recently published in the Journal of Clinical Psychiatry showed that many GCC residents who need treatment for mental illnesses are not currently receiving it.
There are striking differences in the range of facilities available for treating mental health problems, and the capacity of national systems measured relative to population. These seem to bear little relation to national wealth or state spending power and may be more easily explained by historical or cultural factors.
For example, Kuwait and Bahrain were regional leaders in developing a policy on mental health and they have by far the most substantial provision of beds in mental hospitals. Saudi Arabia also offers significant provision, but Oman, Qatar and the UAE lag far behind.
Yet, paradoxically, it is Qatar that has the best supply of community residential facilities for mental health patients.
Reserved treatment capacity for children and adolescents is not always available, according to the WHO. Only Bahrain has a dedicated residential unit at the main psychiatric hospital, dealing with a wide range of conditions and even social-related problems, such as the impact of bullying or abuse and teenage behavioural concerns. Some general trends do stand out, however.
In most respects, Bahrain and Kuwait are regional leaders in terms of provision, with Saudi Arabia also performing fairly well, in spite of its much larger population and geographically dispersed major cities and towns.
By contrast, the UAE has so far tended to have the weakest provision, according to the WHO, and the country has been substantially reliant on the reserved mental health beds provided within its general hospital system.
This may be partly a reflection of the federal system. There has long been a dedicated psychiatric hospital in Abu Dhabi. In Dubai, there has been specialist mental health provision within the general hospital system, also caring for patients from other emirates. So the development of a second specialist hospital the Al-Amal project in Dubai should radically transform the picture, hugely boosting the available dedicated treatment capacity.
There are also wide variations in the supply of specialist mental health personnel. Once again, Bahrain is far ahead of its regional neighbours in the availability of psychiatrists, mental health nurses, specialist social workers, occupational therapists and other health professionals.
The WHO data shows provision in the UAE to be lagging well behind most other Gulf countries in most areas of specialist staffing. Perhaps this also reflects the administrative structure of the country: many emirates may lack the resources to establish significant local services and specialist staff teams for the treatment of mental health problems.
Delivery at primary level
One theme that has been attracting growing attention across the Gulf is the delivery of mental health diagnosis and initial care through the primary health system. In Bahrain, Kuwait and Saudi Arabia, most primary health doctors have been receiving in-service training in mental health issues, whereas other countries have been slower to develop this.
But last December, Muscat hosted the first GCC conference on integrating mental health into primary healthcare services, an event strongly endorsed by the WHO.
Besides the usual exchange of ideas and experience among specialists, this also produced agreement on the development of indicators to measure how primary health services perform in dealing with mental health issues. The WHO says integrating the treatment of mental health issues into the wider range of primary care provision reduces the social stigma that can sometimes face those with mental health concerns, and also make it easier to access care.
Applying this in practice will still pose challenges, because the provision of healthcare in the region is mainly not based around a national network of general practitioner doctors. So it is not always likely that a patient will raise initial concerns with such a generalist doctor, who may provide initial treatment, before referring a patient to a specialist if necessary.
This gap in health provision has been highlighted in research by US consultancy McKinsey & Company, which points out that GCC patients commonly go directly to a specialist clinician they believe to be appropriate for the condition they think they suffer from.
However, mental health is an area where it is sometimes hard for the patient or their family, as non-medical people, to identify that treatment might be needed, or even that there is a genuine health problem. They are, therefore, less likely to self-refer to a specialist.
That is why the new drive to incorporate the treatment of mental health into routine primary care marks such an important step forward for the Gulf medical sector.
By making the construction of the new hospital the centrepiece of his announcement of this years Public Works Ministry project programme, UAE Public Works Minister Abdullah Bel Haif al-Nuaimi sent a strong message about the importance the government now accords to this area. That could help to promote public acceptance and awareness of the need to treat mental health issues, including drug addiction.
Psychiatric care, so far, has not been a much-debated area of investment and there is a lack of information on the scale of the challenges Gulf countries face. Social and personnel factors further complicate the examination of what can be sensitive issues.
For example, Amr Mostafa, an Egyptian assistant professor of psychiatry who has worked in the Gulf, says data suggesting autism may be less prevalent among children in the GCC than in Western countries could reflect a shortage of expert knowledge. Paediatricians in Arab countries are less experienced in the diagnosis and management of psychiatric disorders than those in the West, he says.
Mostafa has also raised the question of whether genetic factors could come into play. He says marriages between cousins are a common feature of some elements of society and pointed to Saudi research suggesting a relatively high incidence of autism.
Ziad Kronfol, professor of psychiatry and psychiatry clerkship director at Weill Cornell Medical College in Qatar, has also pointed to the lack of information about the scale of mental health problems in the Middle East.
Kronfol does not believe there is information suggesting they are more prevalent than elsewhere in the world. Moreover, he says the strength of family relationships in the region may actually provide valuable help for those with psychiatric problems, while the strength of religious belief may also help to reduce the risk of suicide. However, he supports the case for better education both in the training of doctors in psychiatry and in increasing public understanding of mental health.
It is certainly an area that has been attracting increased attention from governments over recent years. In 2011 the psychiatry department of Qatars national health provider held nearly 20,000 outpatient appointments, about half for nationals and half for expatriates.
14 per cent: Share of neuropsychiatric disorders among overall diseases in Saudi Arabia
20.8 per cent: Share of neuropsychiatric disorders among overall diseases in Qatar