War, political and social instability play a part

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. When a country faces wars, political instability and unreliable access to food and water, it's not surprising that its citizens may grapple with mental illness. Dr. Hani Aiash is an associate professor at Upstate who serves as assistant dean of interprofessional research in the College of Health Professions. He's looked into Iraq's mental health crisis, and he's here to discuss what may lay ahead. Welcome back to "HealthLink on Air," Dr. Aiash.

[00:00:41] Hani Aiash, MD, PhD: How are you, Amber?

[00:00:42] Host Amber Smith: Good. Thanks. The Lancet recently published your correspondence, which looked at mental health in Iraq. I'd like for you to tell us what you found. But first, what is mental health and why is it important?

[00:00:55] Hani Aiash, MD, PhD: The mental health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others and make healthy choices. Mental health is important at every age of life, from childhood and through adulthood. People can experience different types of mental illnesses or disorders, and they can often occur at the same time. Mental illness can occur over the short period of time or be episodic. This means that the mental illness comes and goes with discrete beginning and end. Mental illness also can be ongoing or long lasting.

There is more than 200 types of mental illnesses. And around one in 10 people, approximately about 800 million people globally, have a mental health or substance use disorders, contributing to 10 percentage of the global burden of disease. In Iraq, the demand of mental health services remains one of the top priority areas requiring support.

Why it's important you told me. Because let's talk about the definition of health. As you know, the WHO (World Health Organization) definition states that health is a state of complete physical, mental, and social wellbeing, and not merely absence of disease or infirmity. Mental and physical health are equally important component of overall health. For example, depression increases risk of many type of physical health problems, particularly long-lasting condition like diabetes or disease and stroke. Similarly, presence of chronic conditions like diabetes and heart disease can also increase the risk of mental illness.

[00:02:57] Host Amber Smith: Did I understand you correctly? One in 10, globally, have mental illness or substance abuse, or both?

[00:03:05] Hani Aiash, MD, PhD: Yes.

[00:03:06] Host Amber Smith: What are the numbers like just in Iraq?

[00:03:09] Hani Aiash, MD, PhD: According to the recent studies, nearly 20 percentage of Iraqi population is currently afflicted with mental disorders. And the proportion of these affected people is still rising.

[00:03:23] Host Amber Smith: And is that because of war and political instability and lack of reliable access to food and water? Is that why, do you think?

[00:03:32] Hani Aiash, MD, PhD: Yes. There is multifactorial effect. At the current time, Iraqi's economic difficulties and security issues like internal conflicts and violence, bombing, shooting and kidnapping, and the lack of or the undeveloped medical facilities, and the availability of necessities such as food, as you said, water in some places, internal displacement over the recent three years, and also persistence of political instability.

Also, factors can contribute to increased mental illness as financial distraction, family problems, some physical injuries resulting from exclusions, psychological trauma and some other organic diseases, also. There is also the long-term effect of Covid on these people from loneliness, and panic attacks and anxiety can increase these numbers.

[00:04:27] Host Amber Smith: Well, I'm curious about the types of mental illness that you see and how those are traced to war. What impact war has specifically on what types of mental illnesses?

[00:04:41] Hani Aiash, MD, PhD: The most common sort of mental illnesses we can see in Iraq is post-traumatic stress disorders, depression and anxiety.

[00:04:51] Host Amber Smith: And what can be done for those?

[00:04:54] Hani Aiash, MD, PhD: First of all, all of this is iceberg, as mental health is iceberg. We must solve the problems. We must solve the issues causing this stuff. All of them need good mental status, a mental health program to be done in Iraq. That crisis resolution goal is to return the individual to the prior level of function as quickly as possible and to lessen any negative impact it can have on the future mental health, including anxiety, depression, as well as trauma or disorders such as post-traumatic stress disorders.

[00:05:29] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guest is Dr. Hani Aiash, whose correspondence was recently published in The Lancet.

How does the crisis in Iraq compare with the crisis in the US where we have a shortage, a severe shortage, of mental health providers and a growing number of people who need care? I wonder what the mental health services are like in Iraq.

[00:05:57] Hani Aiash, MD, PhD: In Iraq, seeking treatment (is) affected by stigma. There is a difference, culturally. Six of the psychiatric hospitals in Iraq exist, but don't even meet the bare minimum of the demand. There is a lot of infrastructure deficiencies and a shortage of doctors, shortage of healthcare providers there, due to a lot of cases, and a lot of stuff, mainly the inadequate funding for those people, number 1.

Number 2, they have a lot of problem in applying this concept or this program already planned with the WHO. And also there is a lot of stuff, the causes of these stresses, the causes of the mental health there. There is a lot of types of crisis and mental health problems. There, there is a lot war, and financial difficulties, post-Covid, a lot of stuff can be involved in Iraq. Our image here (in the US) is different. I can tell you exactly what's in (the) US.

In US here, mental illness are among the most common health condition in the United States. Millions of people are affected by mental illness each year, across the country. Twenty two point eight percentage of US adults experienced mental illness in 2021, about 57.8 million people. This represents one in five adults. More than one in five adults live with mental (illness), and one in five youth age from 13 to 18, either currently or at some point during their life, have had seriously depleting mental illness. About one in 25 US adults live with a serious mental illness such as schizophrenia, bipolar disorder, or major depression. Suicide is one of the leading causes of death in US. It was responsible for about 48,000 deaths in 2021. About 12.3 million also, estimated, adults seriously thought about suicide; 3.5 million made a plan: and 1.7 million attempted suicide.

Suicide is connected to other forms of injuries and violence. For example, people who have experienced violence -- including child abuse, bullying, sexual violence -- have higher suicide risk. Being connected to a family and community support, having access to healthcare also decrease with other social behavior.

Also mental health crisis is particularly acute for older people, and the youngest adult is compounded, because people lack health insurance or access to healthcare provider depending on where they live. Possible reason by mental health also is getting worse, including factors like social media use and isolation or loneliness. However, other factors like family history and experience with other health conditions can play a role. So what mental health conditions are on the rise? We have an anxiety disorder, depressive disorder -- the cause may be different from Iraq, but the risk factors here, we have a lot of risk factor can be joined together, and some of the risk factors are like social media use. You know, Amber, that about 72 percentage of Americans use social media.

While social network platform have allowed many people to stay in touch with family and friends, research has shown that some downside to social media, especially regarding mental health, unhealthy behavior associated with the social media includes comparing oneself excessively to others, cyber bullying, experiencing fear of missing out. Many studies have linked social media used to poor mental health outcome, especially among younger people.

There is a recent systematic review found that excessive time spent using social media was associated with anxiety, depression, negative body image and psychological distress. And the research (has) also shown that reducing social media use have the opposite effect. There is one study (that) found that the college students who limited social media use for three weeks showed significant reduced (amounts of) loneliness and depression compared to those with unlimited use.

So there is some form of social media -- particularly Facebook, Snapchat or YouTube -- were linked with higher levels of self-reported depressive symptoms, according to the study, that surveys about 5,000 individuals. We cannot ignore Covid-19 because the pandemic brought a rising number of people with mental health concerns. Before the Covid-19 pandemic research suggested the rate of serious psychological stress among US adults consistently ran between three and four percentage. And anxiety and depression increased by 25 during the first year of the pandemic. In US alone, one in five adults reported that the pandemic significantly negatively impacted their mental health. And among them, one of the top factors was the social isolation people endured during the pandemic.

So being unable to work, lack of support from loved one, engaging socially less often was linked to social isolation, and death of the loved one. At the end, we have a lot of data about what's happening during Covid and also post-Covid. And now we say that access, the cost of access of mental health provider also, as you said, is widely seen as a problem. The cost of mental care, 80 percentage of people said that some barriers can make them not going to the healthcare provider, like 80 percentage of the people in one study said that the cost of mental health care is high. Health insurance company not covering mental health service like they do physical health. Not enough mental health care providers such as therapists, counselors who take insurance. Stigma, or shame associated with mental health, a problem especially in Iraq, this one can apply very well in Iraq. Not enough mental healthcare providers such as therapists and counselors. And lack of diversity among mental health care providers.

And by the way, President Biden outlined a multi pronged approach to address the country mental health crisis, including goals to integrate mental health into primary care, investing in the workforce and new approaches to programs that provide care. What he said is, let's get all Americans the mental health services they need, more people they can turn to for help and full parity between physical and mental health care, he said in his address in March (2023.)

So we have a lot of issues here and there, but in the end, suicide was top nine leading cause of death in people ranged from 10 to 64. Suicide with the second leading cause in death, here, for people from age 10 to 14. So this is big problem. And as I told you we have problems here and problem there. We have a lot to do in everywhere, all over the globe, to minimize this mental illness.

[00:13:28] Host Amber Smith: Yeah, it sounds like we have some similarities with Iraq, even though the causes may be different and our cultures are different, but we both have depression and anxiety rates that are elevated, and we both have severe shortages of practitioners.

Do you have some ideas you'd like to share for solving the mental health crisis in Iraq?

Number 1, expansion of the number of hospitals, mental health professionals and the specialized psychiatric facilities in each region.

[00:13:58] Hani Aiash, MD, PhD: Number 2, to keep the progress achieved.

Number 3, financial contribution by government or NGOs (Non-governmental organizations.) Implementation of comprehensive and culturally relevant mental health policy in Iraq. Community-based mental health initiative would enable local health care providers and community leaders to detect (and) address mental health issues.

Telehealth and e-mental health service would expand access to mental health care, while culturally sensitive therapy would integrate traditional healing technique and involve religious leaders there because they consider mental health as a shame.

And education and awareness efforts would minimize stigma. Workplace mental health initiative would encourage employee wellbeing, and resilience-building programs would emphasize coping skills. Peer support networks and stakeholder cooperation would ensure coordinated service delivery. Evaluation, and monitoring -- these tactics regularly would be essential for determining their efficacy. And implementing any necessary modification for continual improvement. Education and outreach program, very important to increase public awareness about psychological problems in order to encourage people to seek assistance and to reduce the stigma associated with mental health. Also, using the social media to help in the changing the improper knowledge about mental health.

Remote researches -- this is very important, to know the statistics of the prevalence of mental illness in these countries, it's type, risk factors, complications, to diagnose before we treat, because mental health, as I told you, is the iceberg. We must diagnose what the size of this problem inside these countries and what the factor affecting and how can we prevent.

[00:15:46] Host Amber Smith: And the most important is to encourage the governments to relieve stressors and conflicts and promote the quality of life in a peaceful environment for all the population because war will not solve the problems. Life is win-win. Nobody must lose. And all the people lose when the people have conflicts. I appreciate you making time to talk about this, Dr. Aiash.

[00:16:15] Hani Aiash, MD, PhD: Thank you very much.

[00:16:16] Host Amber Smith: My guest has been Dr. Hani Aiash. He's an associate professor at Upstate who serves as assistant dean of interprofessional research in the College of Health Professions. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.