United Arab Emirates (UAE).

This paper will focus on the current state of mental health services in the United Arab Emirates (UAE) and reflect on the various public health, socio-economic and psychosocial factors that have a major impact on the mental health needs of the population. It is to be borne in mind that the services described in this paper are in a state of rapid change, as the country is witnessing one of the fastest rates of development in the world.

Society and culture

Situated in the Arabian Gulf, the UAE has an approximate area of 84 000 km2 and a population of 4.1 million (UAE Census, 2005). Males constitute 67.6% of the population and females 32.4%; 20% are under the age of 15 years and only 1.8% are aged over 60 years (UAE Census, 2005). The literacy rate is 75.6% for men and 80.7% for women. Only 21.9% of the residents of the country are Emiratis (UAE citizens), while the remainder comprise expatriates from nearly 120 countries who have come to work in this oil-rich country. The largest ethnic group among the resident population is Asian, with the majority from the Indian subcontinent. The official language is Arabic and the official religion is Islam.

The UAE federation, formed in 1972, consists of seven emirates (Abu Dhabi, Dubai, Sharjah, Ajman, Um Al Qaiwan, Fujairah and Ras Al Khaima). The UAE is a high-income country, itself rich in oil reserves and also lying in a strategic location along the transit route of the world’s crude oil. The proportion of gross domestic product (GDP) spent on health is 3.5%. Life expectancy at birth is 71.3 years for males and 75.1 years for females (World Health Organization, 2004).

Sociocultural and traditional influences

In the UAE, tradition and religion are paramount. Mental health, reflected in good behaviour and conduct, is expected, as outlined by the Muslim religion. This also leads to the notion that supernatural forces can cause mental health problems. Consequently, self-blame and guilt resulting from the belief that mental health symptoms are a punishment for sins are not uncommon among people with mental disorders.

The usual first stop on the help-seeking route for mental illness is the traditional healer. In a study of the help-seeking preference for mental health problems in children, Eapen & Ghubash (2004) found that only 37% preferred to consult a mental health specialist. Alternative remedies are also much sought after, including Ayurvedic, homeopathic and herbal medicines.

The effects on mental health of social change associated with the rapid pace of development and Western influences have been the subject of several studies (e.g. Ghubash et al, 1994). While education, employment and social opportunities have started to improve perceptions of and attitudes to mental illness, the stigma associated with mental disorder is still a major factor that prevents individuals from seeking appropriate treatment.

Mental health policy and legislation

Since the formation of the country 36 years ago, significant progress has been made in the area of health, with most infectious diseases being eradicated. Vaccines as well as state-of-the-art treatments are available for most diseases. However, mental health is lagging behind in terms of policies, facilities and staff.

As yet there is no mental health policy at national level, although efforts have been initiated. A newly commissioned national committee is expected to develop proposals for a national mental health programme. A previous committee, established in 1991, made proposals for the universal provision of mental health and substance misuse services through primary healthcare, but this has not been satisfactorily implemented.

Federal Law 28, enacted in 1981, contains sections on the definition of ‘mental disorders’, ‘next of kin’ and ‘specialist’. There is also a section on the role of authorities and police in relation to psychosis and the detention of involuntary patients. The question of criminal responsibility is addressed by Sharia Islamic law and the courts rely on psychiatric reports for addressing the issue of insanity. Attempted suicide is a crime and homicide may result in the death penalty.

Mental health services

The psychiatric services, like physical health services, are primarily delivered through a public health system administered by the Ministry of Health. The recent formation of separate health authorities and the introduction of health insurance cover for all employees as stipulated by the government are rapidly changing this scenario, particularly in the emirate of Abu Dhabi and to some extent in Dubai. As a result, both private sector establishments and private–public partnerships are coming into existence. For example, in the emirate of Abu Dhabi, partnerships exist between the Health Authority of Abu Dhabi and leading international healthcare providers such as the Johns Hopkins International, the Cleveland Clinic, the Medical University of Vienna and Bumrungrad International Limited. The government of Dubai, in collaboration with Harvard Medical International, is developing the Dubai Healthcare City as the world’s first ‘healthcare free zone’; this is a self-regulated environment providing a platform for regional and international medical institutions to set up their own facilities in Dubai.

Psychiatric services are delivered primarily through out-patient clinics in general hospitals and polyclinics, as psychotropic medication requires prescription by a specialist. Primary care facilities play a limited role, while community psychiatric services are nonexistent. In-patient facilities are available in the emirates of Abu Dhabi (Abu Dhabi Psychiatric Hospital, with 163 beds, and Al Ain Hospital, with 30 beds), Dubai (Al Amal Hospital, with 80 beds at present and a plan for considerable expansion; as well as a small unit at Rashid Hospital) and Ras Al Khaima (which has a hospital with 10 beds). Individuals needing in-patient treatment in other emirates are referred to one of the nearest general hospitals with psychiatric staff (e.g. Sharjah). The purpose-built Abu Dhabi Psychiatric Hospital also has a dedicated unit for child psychiatry, a day care facility, a secure forensic psychiatry facility (30 beds) and a unit for addiction disorders. Police and prison services are integral to the substance misuse programmes, although treatment is offered on a voluntary basis for those who comply with the regulations of the treatment unit.

The delivery of psychiatric services through primary care is best developed in the city of Al Ain, which hosts the only academic psychiatry department in the country. This initiative was launched in 1991, and is accompanied by ongoing efforts to train primary care physicians and carry out psychiatric research (El-Rufaie & Absood, 1993). A similar initiative was started in 1995 for mental health problems in children at the primary care level through the school health services. This was followed by the launch of a school mental health screening programme (Eapen, 1999).

Psychiatric training

The Academic Department of Psychiatry at the Faculty of Medicine and Health Sciences, UAE University, was started in 1990 with the primary mission to contribute to the undergraduate educational programme in psychiatry and behavioural sciences, which is oriented to the needs of the UAE community. The psychiatry clerkship is an 8-week programme, and every effort is made to meet the highest international standards of quality in training, to enable its graduates to compete for advanced training at top centres around the world.

The graduate training programme currently offered is a structured multi-centre 4-year residency programme. The clinical training is complemented by an academic component organised by the university department, Al Ain, and the residents take the Arab Board Examination in Psychiatry.

Psychiatric sub-specialties and allied professions

The Academic Department of Psychiatry in Al Ain was instrumental in establishing child psychiatry services in the Al Ain Medical District. The Department is solely responsible for providing these services, which include out-patient, inpatient and consultation–liaison services at the two teaching hospitals in Al Ain, and receives referrals from other emirates. In the absence of the sub-specialty for intellectual disability, provision of services in the area of developmental psychiatry is also undertaken. At the community level, the Department has pioneered the introduction of a comprehensive school mental health screening programme initially in Al Ain, and then at national level, utilising the structure and resources of the school health services.

Main areas of research

The Academic Department of Psychiatry in Al Ain is the centre for psychiatric research. The main areas of activity are:

epidemiological studies (e.g. Abou-Saleh et al, 2001; Eapen et al, 2003)

diagnosis and classification of disorders (e.g. Hamdi et al, 1997)

translation, development and validation of psychiatric instruments (e.g. Daradkeh et al, 2005)

personality and psychosocial aspects of physical illness (e.g. Eapen et al, 2006)

transcultural psychiatry (e.g. Salem, 2006)

biological and genetic research (e.g. Bayoumi et al, 2006)

mental health and special populations (e.g. Swadi & Eapen, 2000).

Workforce issues and resources

In general, psychiatric services are limited, with an estimated 1.4 psychiatric beds per 10 000 population. The services are considerably understaffed when compared with other high-income countries, with only 2 psychiatrists, 1 psychologist, 1.2 social workers and 11 psychiatric nurses per 100 000 population. Proficiency in Arabic is considered desirable, which poses a considerable challenge to recruitment.

Outlook

Since the formation of UAE as a federation of seven emirates 36 years ago, the country has made phenomenal progress in all areas, including health, but mental health has not received the attention it deserves. In this regard, development of a national mental health policy and a comprehensive review and implementation of legislation should take priority.

Programmes are needed for special populations, such as children and the elderly. Currently, psychiatric services are primarily hospital based, but there should be a broader vision in service delivery, with initiation of community outreach services, strengthening of clinical services, and integration of mental health with primary care services. The staff shortage is significant and urgent attention should be given to improving training opportunities. Significant research data exist regarding the nature and occurrence of mental disorder, as well as on some of the culture-specific risk factors and unique clinical presentations. These data could form the basis for the planning and development of a comprehensive mental health service in the country.