“Integrating Kuwait’s Mental Health System to end stigma: a call to action”

Abstract

Despite the global prevalence of mental illness and its negative effects on the economy in terms of healthcare spending, many affected individuals do not receive timely or adequate treatment due to stigmatization of such disorders in their communities. Being labeled as mentally ill can have detrimental consequences in several cultures. In Kuwait, the stigma associated with visiting the country’s main provider of mental health services, the Psychological Medicine Hospital, is an obstacle for many seeking professional help for mental health. Cultural acceptance of visiting the local primary care clinic, however, allows frequent contact with primary care physicians who often find themselves frustrated at their inability to provide psychiatric services because it is not part of their training. The refusal of the patient to be referred to a stigmatized institution further increases the challenges of treating such patients for these physicians. The integration of mental health care into general health services is a concept encouraged by the World Health Organization’s 2001 World Health Report and should be considered in order to overcome this dilemma. Such integrated care would serve as a cost-effective solution to facilitating the treatment of these individuals and reducing the stigma associated with mental disorders through education.

• Kuwait
• mental health
• health system
• psychiatry
• stigma

“I know that I need help, but if I go there people will say that I’m crazy,” Fatima mumbled with downcast eyes. Her primary care physician was helpless. Fatima was clearly depressed. She was a studious sophomore at Kuwait University and her grades had slipped recently. She was having difficulty attending class due to family problems and had sought help at the nearest place that was easily accessible as well as socially acceptable to visit: her local primary care clinic. However, her physician was stuck. After assessing her symptoms, it was clear that she would probably benefit from psychiatric evaluation and treatment, but this could only be found at the Kuwait Psychological Medicine Hospital (recently rebranded the Kuwait Center for Mental Health). “I would rather continue suffering than go there,” Fatima asserts. “Is there no trained doctor here in the family health clinic who can help me?”

Fatima’s story is not a unique nor surprising one in Kuwait. The regrettable answer to her question is that there is no one at her primary care center who can help her or the many others in Kuwait who continue to suffer like her. Help can only be found at a stigmatized facility that everyone avoids, leaving primary care physicians frustrated at the lack of service integration and their lack of training in providing such services. Fatima did not want to visit the Kuwait Psychological Medicine Hospital because of the effect this would have on her social reputation. She did not want a visit to the psychiatric hospital documented in her nationalized health record because she believes this would label her as mentally ill and that would be detrimental to many aspects of her life, including her chances of marriage and acceptance in social circles. To that stigmatized hospital she will not go, but she is willing to see any of the physicians who work within the comfortable walls of her primary care clinic. Unfortunately, in Kuwait, a family physician may be able to offer Fatima brief counseling and perhaps prescribe an antidepressant, but he is not trained to provide the basic behavioral interventions that would help her (Kuwait Institute for Medical Specialization, 2008). Furthermore, almost half of physicians working at primary care centers in some governorates are not board-certified family physicians, which means they lack even the most basic communication and clinical skills necessary for handling mental health issues (Abdulghafour et al., 2011). To Fatima, there is no other choice but to suffer in silence.

The World Health Organization has identified that mental disorders are among the 20 leading causes of disability globally (WHO, 2008). The human cost cannot be measured, but the economic costs are staggering. Economic estimates from Kuwait are lacking, but US data demonstrates that in 2001 the costs of mental health and substance abuse treatment were $104 billion, which represents 7.6% of total health care spending (Mark et al., 2005). The task of treating people with mental illnesses is made even more difficult by the widespread stigma against these individuals in many societies (Adewuya & Makanjuola, 2008; Lauber & Rössler, 2007; Lolich & Leiderman, 2008). Furthermore, this stigmatization has been shown to have a negative economic impact, which indicates that it must be addressed in order to find a solution (Sharac et al., 2010).

Although there are no studies showing the extent of this mental illness stigma in Kuwait, research done in Arab communities reveals that it may exist at an even higher level than in Western developed countries (Westbrook et al., 1993). Studies done in Qatar, a country with a similar cultural background and population demographic to Kuwait, showed that fear of people with mental illnesses is common and that mental disorders are believed to be a result of a punishment from God or possession by evil spirits (Berner & Ghuloum, 2011; Ghuloum et al., 2010). There is also a tendency for Arab families who care for a family member with a mental illness to experience fear, embarrassment, and disgrace of family reputations leading to feelings of secrecy and isolation (Dalky, 2012). Both public and self-stigma may negatively affect patients’ quality of life and influence treatment outcomes (Corrigan & Watson, 2002). Hence, reforms to mental health systems must take into account ways to overcome these forms of stigmas to alleviate the individual and societal burden of mental illness.

In Kuwait, the cultural background plays a role in directing people’s preference to self-help or visiting a doctor when faced with symptoms of mental illness (El-Islam & Abu-Dagga, 1990). Kuwaitis are accustomed to a neighborhood structure that is highly cohesive and socialized where the subdivisions in each of Kuwait’s six governorates are centered around a major mosque, co-operative society, community hall, and publicly-funded primary care clinic. Residents often develop a close relationship with their district’s primary care physicians, a factor that may lead to improved patient-doctor relationships and better health care outcomes. In contradistinction, the mental health system in Kuwait is structured around a single psychiatric hospital that includes 48 psychiatrists, 17 psychologists, 8 social workers, and 294 psychiatric nurses. Psychiatric outpatient clinics also operate at the five regional hospitals and at other locations such as prisons and special schools (14 clinics) (WHO, 2001). However, there is no official collaboration between primary care and mental health providers in Kuwait. In the US, the presence of collaborative care between mental health services and primary care clinics has been shown to result in a faster and sustained improvement in patients’ mental health status (Hedrick et al., 2003). Moreover, satisfaction of older adult patients with mental health services has been reported to be higher when integrated in primary care settings (Chen et al., 2006). In Kuwait, where mental disorders such as depression are prevalent in patients attending primary care centers, family physicians recognize that primary care is a suitable place for managing these illnesses and are unsatisfied with the lack of mental health facilities at these centers (Al-Otaibi et al., 2007; Ben-nakhi et al., 2008). It becomes of great importance to consider whether changes in the structure and delivery of mental health services in Kuwait can be used to overcome this stigma by relocating them to more socially acceptable locations.

The World Health Organization’s 2001 World Health Report recommends shifting care away from large psychiatric hospitals and the integration of mental healthcare into general health services. This leads to less stigmatization of staff and patients, better screening, improved treatment of mental disorders associated with medical problems, and less costs due to the shared infrastructure (WHO, 2001). Collaborative care models in which mental health professionals are integrated within primary healthcare have also been shown to be preferred by primary care clinicians due to improved communication between mental health providers and primary care physicians, coordinated care of mental and physical health, and less stigma towards patients with mental disorders (Gallo et al., 2004). Although there is no single best practice model for all countries to follow, the World Health Organization states the integration should include training of primary care workers, the presence of a mental health service coordinator, the availability of specialist mental health facilities and professionals, and access to basic psychiatric medication in primary care (WHO/Wonca, 2008). An integrated community-based mental health service would then be able to decrease the treatment gap for mental disorders and generate good health outcomes in an affordable and cost-effective manner (Chisholm, 2005).

It is important to recognize the possible barriers to creating integrated mental health services in Kuwait’s primary care centers and the probable challenges that will arise with this change. The issue of stigma itself may make it difficult to accept the resulting proximity of individuals being treated for mental illnesses as it has been shown that people prefer that facilities for psychiatric care be located away from the community (Al-Adawi et al., 2002). Physicians must use this opportunity to educate community members about mental illnesses and encourage the utilization of mental health services. Another difficulty would be the need for additional training of primary care physicians to enable them to follow-up patients with mental disorders properly and the necessity of clear protocols to clarify their role in management. Other than psychiatrists, primary care centers might also require psychologists to treat mild mental illnesses using behavioral therapies. This, along with making psychiatric medication available at these centers, involves administrative decisions that may be slow to achieve considering the prevalent bureaucracy in Kuwait’s ministries. Once the integration of mental health services is achieved, there will be a need for a national campaign to spread awareness about these services to both physicians and the community. This may prove to be a challenge if the collaborative care model lacks support from either the primary care physicians or the healthcare authorities. Therefore, it is crucial for health policy makers to promote education in parallel to this integration and ensure the administrative and financial support of the Ministry of Health.

Kuwait’s healthcare system includes trained mental health professionals and primary care clinics that are readily frequented by people who suffer from mental illnesses. Until reforms are made to integrate these two services, the shame of visiting the Psychological Medicine Hospital will continue to prevent patients like Fatima from finding compassion and competent care. By providing mental health services at the primary healthcare level, many patients will be able to get the treatment they need with minimal stigma, and this would provide an excellent opportunity for health professionals to erase this stigma, once and for all, through education. Only then will the silence of suffering be broken across this invisible barrier of shame.

Since the original submission of this editorial a dynamic new leadership team at the Kuwait Center for Mental Health (formerly the Kuwait Psychological Medicine Hospital), has announced a plan to begin shared-care clinics between psychiatrists and family doctors in a pilot program at 5 of the countries community health centers. This a recent commendable step that the authors applaud and encourage. The road towards a fully integrated system as we describe in this writing remains long, but Kuwait is a few steps closer due to these recent efforts.

Declaration of interest

The authors report no conflict on interset.