Bahrain's Mental Health Hospitals have become Drug Stores
By Islam Al-Zeyni
Manama, Bahrain, (Al-Araby Al-Jadeed) – Um Fatima, 52, sat down to recount the details behind her history of depression. For two decades, Umm Fatima did not receive any therapy sessions to help her assimilate into the community and conduct her affairs as just another person. She claims that the hospital – only one of its kind in Bahrain specializing in mental health – is simply handing out medication.
“I need a human being to hear me and understand me, to understand that medicine is no substitute human interaction and kindness.”
Umm Fatima suffers from bipolar disorder, an abnormal mental condition characterized by alternating periods of depression and euphoria, according to the National Institute of Mental Health in the United States.
Ahmad Al-Garibi, a physician researching patterns of psychiatry in Bahrain, issued a study in October 2015 stating that depression was a primary concern in the country, occupying 33.4% of all medical cases.
This was confirmed in discussions by this reporter with five other physicians including psychiatrist Abdul Karim Mustafa, and clincal psychiatric advisor Bana Posbon. Both said that patients citing depression were the most common instance at their clinics.
Umm Fatima’s story is repeated among the 30 patients who were interviewed by this reporter. They confirmed that the hospital has a critical lack of doctors capable of taking in sudden influxes of patients and that this has left patients vulnerable to personal setbacks and regressed improvement due to a medicine-only focus that is at odds with international mainstream use of therapy.
A mother of another patient, who spoke on condition of anonymity, said that her son’s struggle with schizophrenia was only treated with drugs to keep them quiet and docile, but left him unable to reintegrate with society. She lamented this, saying only those better off were being forced to pay for expensive care in private clinics.
A doctor at the hospital who declined to be blamed explained that the lack of therapy sessions was due to a shortage in psychologists. As a result, he and his colleagues spend only a few minutes a day with as many as fifty patients per physician.
Behavioural Therapy Equipment
Sharifa Suwar; a behavioural and cognitive therapy specialist, confirmed that psychiatric patients needed between 12 and 14 sessions, focusing on rehabilitation and addressing patient concerns regarding their own perceptions of their life and person as well as their mental state.
The rise of psychiatric patients coincided with a budgetary increase from $14 million in 2010 to $28 million in 2016, out of a general budget of $1.254 billion set for Bahrain’s health sector.
According to Khaled Said, a regional advisor on mental health, the budget increase was attributed to greater spending for 80 different medicines as well as an expanded staff of 600 employees at the hospital. But this was not reflected in the number of psychologists hired, which only increased from 47 to 50 in five years and remains below the global standard set by the WHO of 20-30 doctors per 100,000 citizens. Currently, Bahrain only provides 3.6 doctors per 100,000 citizens.
In the daily care unit located in the Ibn Rushd Hospital, the head of the Behavioural Therapy Department says that there is only one doctor and occasionally two assistants patients, despite the increasing number who need rehabilitation.
“We have hundreds of patients waiting to meet a specialist just meant for them… May God help the specialist and the patients”.
When asked why there were not more specialists available, she said that “there was no desire for it in Bahrain, so students were inclined to choose other fields.”
She also showed this reporter an audio tape containing various techniques and methods for cognitive and behavioural therapy, claiming it helped calm down patients. Then she added that there was no specific methodology that was agreed upon by a majority of experts.
Outside her office, in a unit which had been founded in February 1992, patients sat waiting for their own sessions to begin.
Out of eighty visits to the unit between February 10 and March 22, 2016, this reporter found that of twenty patients residing in the hospital awaiting therapy sessions only four had received them. The remaining 16 had been left waiting due to the lack of a full-time specialist in the facility.
By these patients’ accounts the hospital does not take the initiative to offer these sessions, and when requested by parents or guardians usually results in a great deal of forms and paperwork to be filled out before culminating in “useless” sessions. These “useless” sessions are irregular in scheduling with months between them, an end result that has supervisors in the hospital speaking plainly that “patients who had money should not waste their time here.”
Psychiatric Patients Awaiting their Sessions
Psychiatrist Sharifa Suwar confirmed that patients like Umm Fatima suffering from manic-depressive disorders do not need such lengthy hospital stays, and agreed that sit-down sessions could better address anxieties and help with social integration.
However, Umm Fatima has received none of these treatments according to her medical records, though the head of the hospital Doctor Adel Al-Awafi declined to comment, citing “doctor-patient confidentiality”.
Imbalance and Disruption
Dr. Awafi said that there were instances where it was affordable to seek care abroad, but insisted that therapy, in all its forms was available in Bahrain. He also said that drug therapy in the country was successful and had improved the conditions of 70% of patients, while the rest had been impacted by social conditions.
Doctor Michael Craig Miller, an assistant professor of psychiatry at Harvard Medical School, disagreed with this analysis. “Therapy is as important as anti-depressant, because it is based on the fact that our thoughts make us suffer as much as external factors. It can work to change our way of thinking unhealthy and give us a sense of comfort” he said.
The Root of the Problem
Dr. Tarek El-Madawy, owner of a private psychiatric clinic, says the problem in Bahrain is the critical lack of government-employed psychiatrists, which has driven citizens to private clinics. However in reviewing these private clinics, many seemed to make use of the situation by lacking scientific proof of their techniques or promoting religious-based therapy.
This has meant that only 143 patients had received treatment according to official figures from 2014, with no numbers available for 2015 or 2016.
When interviewed, Khalid Saaed, the World Health Organization’s Regional Adviser for Mental Health and Addiction, said that Bahrain suffers from a lack of statistics on psychiatry. He added that the country needed to adopt a mental health bill, be it the one suggested by the Ministry of Health or the one already in parliament since 2013.
Resorting to Private Care
Although the psychiatric hospital provides free treatment to citizens, many are choosing to receive psychiatric treatment in private clinics, believing that therapy would help them overcome their problems. Of those, however, some who are unable to pay the costs and appeal to charities. Others resort to borrowing.
Out of 50 patients interviewed in two private clinics, 18 said that their relatives had been treated first at public hospitals before moving to private clinics due to ineffectiveness. They asserted that the public health service detained patients and pacified them rather than helped them address their problems as happens in private care.
Dr. Awfi said that “the hospital is working to the capacity available,” and added that those leaving the hospital for private care are perhaps looking for “more privacy”.
However in five separate comparisons of different types of depressions, this reporter determined that those who received private-sector treatment improved and found it easier to integrate into society or to return to their studies or work.
Table: A comparison of five different depression types, being treated in both private and public healthcare.
The average cost of treatment in the Bahraini private sector ranges between $ 110 and $ 265 per hour per session. A patient might need as many as two hour a week at a cost $372 a week. This is more than a quarter of the salary in a country where the average income is $1358.
In addition, Dr. Awafi revealed that there are no provisions by Bahraini insurance companies for mental healthcare, a fact confirmed by this reporter. As a result, the patient is left to endure the public hospital’s drug regimen, or pay out of pocket for treatment in private clinics.
Medicine Is Free But It Is Not Enough
Bahrain’s psychiatric departments have dedicated wings for children and the elderly, and the government itself provides any medicine necessary free of charge despite the high expense, sparing patients thousands of dollars for drugs such as antipsychotics and neuroleptics.
This has cost the government hospitals around $ 2.6 million, according to information obtained from the Ministry of Health.
But parents of patients interviewed believe that the drugs are not enough, insisting that therapy sessions are needed. To that, Dr. Awafi replies that the psychiatrists must determine it necessary in order for any patient to receive the sessions, so as to then uniquely prepare for each case.. After that, permission must be granted from both the patient and his family or guardians.
Mental Health in Limbo
Aggravating the problem is the absence of a Mental Health Act to determine the process of treating patients or the right type of treatment. In 2013, members of the Bahraini House of Representatives submitted a bill “for the promotion of mental health services and patients’ rights”, but the proposal has yet to pass.
This investigation was completed with support from Arab Reporters for Investigative Journalism (ARIJ) and coached by Ghassan El Shihaby. Nicolas Awad translated the investigation into English.