Iraq has spent decades living under wars and sanctions, most recently defeating the terror group Daesh in 2017. While all eyes are on reconstruction and the return of the internally displaced to their homes, Iraq must not forget to treat its citizens who are in the throes of Serious Mental Illnesses (SMIs).
Conditions such as schizophrenia, bipolar diorder and psychosis are usually developed through a combination of physical, genetic, psychological and environmental factors. In some cases, war can trigger and deepen these psychiatric wounds but, scientists suggest the root cause is a perfect storm of a number of factors.
As we mark Mental Health Awareness Week, MEMO highlights a stigmatised section of Iraqi society turning to unconventional methods of treatment.
"Most of the psychotic patients go to the faith healers rather than the psychiatrist," says Dr Nesif Al-Hemiary, professor of psychiatry at the University of Baghdad.
"They tell them they are possessed by Jinns or bad spirits or that they are under the influence of sorcery or the evil eye."
"In reality, these are very ill people," he adds.
Al-Hemiary was part of the team to research Iraqi suicide rates in the first quarter of this year and has also conducted extensive psychiatric research on the Iraqi population and students at the University of Baghdad.
He says that of the 132 people who have committed suicide already this year, the majority had not sought help for a mental health condition before their death. This suggests that the systems in place to flag at risk individuals are not working.
The paper also detailed how women were just as likely to kill themselves as men – a shocking statistic considering that the World Health Organisation (WHO)'s 2016 global suicide report reported a rate of eight male suicides to every one female.
These illnesses create a greater risk of suicide in those who suffer from them.
WHO defines "traditional medicine" as "the sum total of knowledge, skills, and practices based on theories, beliefs, and experiences indigenous to different cultures." This is often in lieu of medical assistance to improve the treatment of physical and mental illnesses. "Faith healer" is a loose term for people using these traditional methods.
In Iraq, they often refer to themselves as "Sheikh", or "Imam". Al-Hemiary says that though their rituals have "Islamic colour," he doubts their religious credentials.
A study conducted in 2014 by students at the University of Erbil, in the northern Kurdish region, revealed the popularity of "traditional medicine" among those suffering from schizophrenia in the city of Najaf in south central Iraq.
Of the 70 patients surveyed at the outpatient facility at Al-Hakeem Teaching hospitals, 80 per cent had consulted a faith healer before their visit. It also found that, "being younger, less formally educated, married, and female was significantly associated with faith healer consultation."
The majority said they attended a ceremony where "healers" recited the Qur'an, prayed and made invocations. More worrying, however, was the use of methods such as hitting, starvation and puncturing thumbs to remove the Jinn (spirits).
"The healers don't even know what's wrong with the patient. They could have another health issue; a physical health issue which is put at risk. Some people have died because of that," Al-Hemiary tells MEMO from Baghdad.
"Or they are at risk of abuse, especially women. Some are even sexually abused by those faith healers."
Patients are paying a significant premium for these suspect practices which could cause significant damage to their psychological wellbeing. "Healers" advertise their services through satellite TV, earning them fame and esteem. However, the cures they are selling aren't cheap.
"For a visit to my practice, I charge $20," Al-Hemiary says. "The faith healers will charge anything up to $500."
Stereotypes about mental health are not unique to Iraq, nor the Middle East in general. Stigmas are reinforced stereotypes about a group of people and in the case of mental health, results in sufferers being labelled as "dangerous", "incompetent", or "weak of character". Once tarred with one of these adjectives, a person's quality of life can be severely impacted.
"Is it a big barrier [stigma]? Of course it's a big barrier. People think only the lunatics, or psychotic, go to the mental health services. So people avoid going, choosing other doctors or faith healers," he says.
When only the "lunatics" can access psychological services, warning signs of severe chronic conditions can be missed and symptoms misdiagnosed.
If untreated, one of the most dangerous mental illnesses that can develop is drug dependency disorders, according to Al-Hemiary. In the 2006/2007 Iraq Mental Health Survey (IMHS) there was a very low response to drug or alcohol abuse. By 2017, 16.7 per cent of respondents met the criteria for alcohol addiction with 7.02 per cent classed as being dependent on other substances.
Sherri Kraham Talabany is the director of the SEED Foundation, a mental health NGO working in Iraq's Kurdistan region. Kurdistan is a self-governed area in the north of Iraq and has been the destination of many people displaced from their homes during the most recent conflict with Daesh.
Kurdistan, like the rest of Iraq, is desperately lacking in psychiatric treatment facilities.
"We only have a few places where you can actually be checked into a mental health facility. A women's hospital and another more general facility here in Erbil," she tells MEMO while on a trip with some of the foundation's clients.
"We've had trouble getting people checked-in when they need 24 hour care if they're suicidal. We just can't support them with that," she explains.
"Sometimes it requires what we call a "caretaker" or a family member sitting with that person. Because there are such shortages of hospital staff."
With the country in ruins, developing social and community services is paramount to help patients begin to live normal lives. Al-Hemiary says that at one of the hospitals in Iraq, around 40 per cent of the patients are ready to be discharged but have nowhere to go.
"If they discharge them, they will end up in the street, and they will come back again," he says. "We need the support from the government so that those people can go out into society and can live like human beings."
In these cases, the responsibility largely falls on the family to take care of the psychotic or schizophrenic patient. Though family values are important in Iraq, the burden is difficult, and possibly inappropriate, for the family to take responsibility for.
"Of course the psychotic patient is a burden. Because the hospitals are inadequate, the government has tried to give some support for them by providing a monthly salary," he explains.
"For those who are working in a government position, they provide them with fully paid leave while they are sick. However, for someone who is unemployed, the amount is low, like $150."
With the family often taking the role of primary carer, one of the most important factors in stabilising a patient is proper medication. Without the pharmaceutical "safety net", patients are made to suffer more than necessary.
The conditions for home treatment are made even more difficult by the shortage of medications, which Al-Hemiary believes is due to corruption within the Ministry of Health itself.
In the private health sector, the ministry's inability to test medications has resulted in an influx of fake tablets hitting the market.
"A lot of companies that sell drugs in Iraq, aren't trusted companies. Many medications are fakes and therefore not effective in treatment," he says.
"They are imported from different places, from India, from China. For example, we have products that say they're manufactured in the UK and they're actually from India. They have no medical value."
The situation is similar in Kurdistan. A failure on the part of the Iraqi government to provide a budget to the region is resulting in pharmacies being unable to buy the necessary medication.
"We have no medication, especially psychotropic drugs that are needed for suicidality and major depression. Even if we have the money to pay," Talabany says, recalling attempts to get medications for her patients with more severe conditions.
"When I first moved here in 2016, poor people would go to public hospitals, they would get a prescription, and the government would dispense medication to them. Now, if you don't have the money, it's near impossible to get medication, even for chronic illnesses.
"I've heard cases recently about cancer. People have to buy their own chemo medication and bring it to the hospital. We're in desperate, desperate conditions," she says.
"The government is trying to find solutions, it just can't right now," says Al-Hemiary. "It's too big of a task and involves too many reforms to society to see any improvement soon."
Though there is a will to address these issues, it is unlikely that the country will be in the position to institute changes any time soon. With those in areas previously controlled by Daesh returning home, the Iraqi government has to expect an influx of refugees carrying their own psychological weights from the atrocities set on them.
However, just as at risk – possibly more so – are those people who have often lost connection with reality. When people have few other options through government ineffectuality, it makes sense that they will turn to one which promises a cure; be it drugs, alcohol, or faith healing. And these "cures" will wreak their own havoc on Iraq's recovery if left untreated.
The views expressed in this article belong to the author and do not necessarily reflect the editorial policy of Middle East Monitor.