The mental health needs of immigrant workers in Gulf countries.

The oil-rich member states of the Gulf Cooperation Council (GCC) attract large numbers of migrant workers. The reported rates of psychiatric morbidity among these migrant workers are higher than among nationals, while the mental health services in the GCC countries remain inadequate in terms of both staff and service delivery. The multi-ethnic origin of migrants poses considerable challenges in this respect. The development of mental illness in migrants, especially when many of them remain untreated or inadequately treated, results in their premature repatriation, and the mentally ill migrant ends up facing the same economic hardships which led to migration in the first place. The availability of trained interpreters and transcultural psychiatrists, psychologists and social workers should make psychiatric diagnoses more accurate. Suitable rehabilitation services are also needed.

Migration and the international mobility of labour have made the Arabian Gulf a unique part of the world. The oil-rich member states of the Gulf Cooperation Council (GCC) – Saudi Arabia, Kuwait, Bahrain, United Arab Emirates (UAE), Oman and Qatar – attract the largest number of international migrants after the European Union and North America. This has given the GCC countries a unique demographic make-up, where local indigenous populations often constitute a minority of inhabitants. However, despite its overwhelming importance for economies and societies, the mental health of these migrants is underdocumented, underresearched and underreported.

Demographic characteristics of the GCC countries

Overall, migrants make up almost half (48%) of the population of the GCC countries (Fig. 1). However, this population parity is mainly accounted for by Saudi Arabia, the most populous of the GCC states, and, to a lesser extent, Oman, where nationals marginally outnumber the migrants. In the remaining four GCC countries, the proportion of migrants ranges from 54% (Bahrain) to 88% (UAE). Most migrants come from the Indian subcontinent and the Middle East. ‘Service workers’, including housemaids and non-skilled workers, constitute the largest subgroup, accounting for about a third of the workforce.

Fig. 1

Percentage of nationals and non-nationals in member states of the Gulf Cooperation Council (GCC). Figures for around 2010. Source: Most recent national data from the database of the Gulf Labour Markets and Migration (GLMM) programme (2013), European University Institute (EUI) and Gulf Research Center (GRC). Updated 8 November 2013

Mental health services in GCC countries

Mental health services in the GCC countries are provided free of charge for the local population while nominal charges are levied on expatriates. Although efforts to develop modern multidisciplinary mental health services are underway, the services remain inadequate in terms of both staff and service delivery (Table 1). The number of psychiatrists per 100 000 ranges from 0.3 (UAE) to 8.2 (Bahrain) and the number of beds per 100 000 ranges from 1.7 (UAE) to 33 (Kuwait). The shortage of allied mental health professionals, including psychologists and social workers, is even greater. The number of social workers per 100 000 ranges from 0.07 (Oman) to 2.9 (Saudi Arabia). The provision of mental health services is largely hospital based, with out-patient clinic facilities in some selected general hospitals. There have been recent moves towards decentralisation of services with stepwise expansion to the level of primary health clinics. The unique population demographics of the GCC countries pose considerable challenges for the already insufficient resources for provision of mental health services in the host countries.

Table 1

Psychiatric services (beds and professionals per 100 000 population) in Gulf countries

	Hospital beds	Psychiatrists	Psychologists	Social workers
Kuwait	32.78	2.62	2.29	0.66
Saudi Arabia	11.43	2.91	1.66	2.9
Oman	2.2	2.31	0.17	0.07
Qatar	3.98	1.66	1.26	0.46
Bahrain	28	8.18	0.5	0.87
United Arab Emirates	1.7	0.3	0.51	0.25

Data from World Health Organization (2011).

Mental health of migrants in GCC countries

Migrants’ mental health in the GCC countries remains underinvestigated and few studies have addressed this important subject. A Scopus literature search, for instance, using the search terms ‘GCC countries AND mental health OR mental disorder’ and ‘refugees AND mental health OR mental disorder’ for the period 2010–13 revealed 8 and 291 citations, respectively. Zahid et al (2002, 2003, 2004), in a 2-year prospective study of hospitalised housemaids, reported that psychiatric morbidity was twice as common among them than in the local population. The researchers identified pre-immigration risk factors and precipitating factors, and described the nature of psychiatric disorders in this subgroup of immigrants. The pre-immigration risk factors included a history of psychiatric disorder, physical illness or hospitalisation. Almost half (48%) of the housemaids required interpreter assistance for assessment. Stress-related disorders were the commonest (49%) type of disorder; more than half of the housemaids had a breakdown within the first 3 months of their arrival; and the lack of contact with the family back home and harassment at work were identified as the commonest precipitating factors. Most (81%) of the housemaids were prematurely deported following their discharge from hospital (Zahid et al, 2002, 2003, 2004). Many housemaids, especially those with young children back home, and engaged in looking after employers’ young children, may experience guilt for having ‘abandoned’ their own (similar) children. Such a conflict may add to the distress of the already homesick housemaid. In another study, from the UAE, rates of depression and suicidal ideation were found to be higher in immigrant workers than in the native population (Al-Maskari et al, 2011). In view of the sample selection bias inherent in these studies and the dearth of methodologically sound studies, it is difficult to draw firm conclusions.

Given the psychosocial stresses surrounding the act of migration, coupled with the adjustment difficulties in the new environment, a considerable number of migrants develop mental illness. It is possible that many migrants with mild to moderate mental illness, especially in the absence of significant occupational impairment, simply pass unnoticed. The development of mental illness in migrants, especially when many of them remain untreated or inadequately treated, results in their premature repatriation. In addition to causing considerable inconvenience to the employer, mentally ill migrants end up facing the same economic hardships which led to their migration in the first place. The resultant migration failure perpetuates their difficulties as they have now to pay back the considerable sum of money, usually borrowed, paid to the immigration agent prior to the migration.

Mental health needs of migrants

The atypical presentation of some psychiatric disorders in migrants coupled with the reported mismatch between the various diagnostic criteria and phenomenology of the disorder, as described by migrants who are mentally ill, within the specific cultural context, present unique challenges for mental health service providers. Depressive illness in migrants, for example, has been reported to present with comorbid somatoform, anxiety and dissociative features (Saraga et al, 2013). The diagnostic process is further complicated by the cultural differences between the migrant and the therapist. All cultures develop processes that facilitate adjustment and conflict resolution, as well as pressures that foster conflict, deviation and maladjustment, defining thereby the spectrum of ‘normal behaviours’ as well as thresholds for tolerance of psychosocial stresses resulting in ‘abnormal behaviour’. Similarly, the culture-specific stresses and the beliefs and rituals used to cope with psychological tension underline the importance of diversifying the mental health staff resources in the GCC countries to include professionals familiar with, and sensitive to, the culture-specific spectrum of behavioural disturbances in subgroups of migrants with mental disorder. In a survey of European migrants, most thought that healthcare providers underestimated their language problems and that language difficulties made them more aggressive and paranoid towards the care provider (Watters, 2002). The availability of trained interpreters, transcultural psychiatrists, psychologists and social workers should make psychiatric diagnoses more accurate. Suitable rehabilitation services will help migrants receive mental healthcare and thereby gain either re-employment or settlement of deportation terms as stipulated in their contract of employment.

A rising demand for highly skilled people will increasingly expose the GCC states to what has become a global competition for talent. Nonetheless, low-skilled or unskilled manual workers will also be needed due to non-availability of local nationals to carry out such jobs. It is time now to regulate the flow of migrants, with stringent controls on recruitment procedures. Pre-immigration orientation programmes aimed at familiarising migrants with their prospective job responsibilities, and basic linguistic instruction, can help allay some of the anxieties related to working conditions in the new environment. Similarly, facilitation of regular contact with families back home, especially during the first few weeks after arrival, may help minimise psychiatric breakdown and migration ‘failure’. Lastly, given the limitations of the GCC countries in coping with the multicultural mental healthcare needs of migrants, collaboration with organisations such as the Red Cross and Red Crescent may help overcome some of these difficulties.