Arab World: Mental Health, a Political Issue

Anxiety-Depressive Disorders: Tunisians at The End of Their Tether

A steep rise in the number of consultations and hospitalisations for anxiety-depressive disorders, skyrocketing sales of psychotropics. Tunisians are clearly in a bad way. And as far as health care is concerned, they are not all in the same boat.

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Since the beginning of 2024, the Razi psychiatric hospital in Tunis has taken in approximately 1,000 new patients. And the number of cases of anxiety-depressive disorders has risen significantly, Leila Chaibi tells Nawaat. She is a resident physician in psychiatry at the above-mentioned institution and is president of the Tunisian Association for Promotion and Prevention in Mental Health among Young People (ATPPSMJ). ‘The flood of patients is such that the waiting lists for an appointment are getting longer and longer,’ she says. The national production of certain molecules and their generics, prescribed for the treatment of pathologies linked to anxiety and depression is often unable to meet the demand. And the market shares of Tunisian laboratories have risen considerably, says Neila Ben Salah, psychiatrist and president of the Tunisian Association of private practice psychiatrists (ATPEP) in an interview given to Nawaat.

An observation confirmed by Naoufel Amira, president of the Tunisian Union of Dispensing Chemists, reached by Nawaat.

The widespread angst of Tunisians can also be deduced from the country’s ranking in the 2024 World Happiness Report published by the UN’s Sustainable Development Solutions Network. Out of 143 countries surveyed Tunisia is 115th. In 2023 it was placed 110th.

This ranking is based on several indicators including the feeling of being free, the absence of corrupt practices, income level and social support.

For lack of official statistics in Tunisia, health-care professionals refer to tangible data such as a number of patients, medical prescriptions, and a few scientific studies, some of them international, to evaluate the distress of ordinary Tunisians.

A worldwide tendency

The World Health Organization (WHO) defines depressive disorders as ‘mental disorders’ characterised by a state of ‘persistent melancholy or by the permanent loss of the capacity to experience interest in or derive pleasure from activities which were previously sources of both’.

The UN organisation insists on the necessity to distinguish between depression and ordinary mood changes and negative feelings due to the vicissitudes of life.

On a planetary scale, 8% of the population suffers from depression, 5% of all adults, (4% of men and 6% of women), and 5.7% of persons over 60.

The Covid crisis triggered a rise of 25% in the number of individuals affected by anxiety-depressive disorders, according to the WHO.

The pandemic shed light on the importance of mental health as a public health issue concerning the entire population, said Wafa Hajji, a clinical neuropsychologist for the ‘Health and psychology’ association in an interview for Nawaat. The crisis caused a considerable increase in the frequency of anxiety-depressive disorders.

‘Starting with the pandemic, we observed a brutal shift in the mental balance of an increasingly large fringe of the Tunisian population. Anxiety-depressive pathologies suddenly appeared. Other patients, who had been stabilised, experienced a relapse’ according to Neila Ben Salah.

Another disturbing, worldwide phenomenon: the harmful impact of the social networks on individuals. Happiness is no longer an object of philosophical enquiry, it has become an absolute necessity. The injunction to be happy in one’s married life or one’s work has never been so widespread.

‘Specialists’ of every persuasion give forth over the media with their ‘hints’ for leading a full and happy life. The web is flooded with this kind of content and reaps millions of ‘likes’ on the social networks. It promotes a distorted version of happiness, one essentially based on material factors: money, travel, etc. And the happiness industry has a pernicious effect on people’s mental health.

Its impact on young people is especially worrisome according to the authors of a national investigation published in 2023 and conducted by the Ministry of Health and The Group of Cooperation on the issue of the fight against the abuse and illicit trafficking of narcotics. The study establishes a connection between the use of screens, especially the social networks and video games, and potentially harmful effects of a psychosocial and cognitive order, associated with an even greater risk of anxiety and depression.

Young people increasingly affected

An assessment of mental health will differ from country to country and from one individual to another.

‘It’s hard to generalise to offer a diagnosis of the psychic condition of a whole population. The phenomenon will vary from one individual to another, according to his or her personal situation,’ Wafa Hajji explains. However this specialist does observe certain similarities in the psychological problems she encounters. These are depressive anxiety disorders, conditions of post-traumatic stress and disorders linked to the use of narcotics. This situation does not date from the Covid crisis but goes back to the 2011 revolution.

Thus the number of patients admitted to Razi University Hospital for psychiatric disorders has risen from 4 to 5,000 annually before the revolution to double that figure in recent years. Even though there was a spike during the pandemic, the figure rose to nearly 9,400 in 2019, according to Kamel Ben Rahal, the general secretary of the first-level union at the Razi Hospital.

Since 2017, the requests for consultation concerning anxiety-depressive disorders have increased by 20%, the president of the ATPEP points out. This angst also affects young Tunisians. According to the 2018 Multiple Indicator Cluster Survey (MICS6), some 20% of young Tunisians between 15 and 17 suffer from anxiety and 5% from depression.

Besides which, the 2023 national study, referred to above, shows a change in narcotics usage since 2013. This consumption may now be considered a form of ‘self-medication’, explains the president of the Tunisian Association of Private Practice Psychiatrists. The study shows that non-prescription tranquillisers are among the substances most popular with young people between the ages of 15 and 17, according to this study. Their use ‘has significantly increased since 2017 and is higher than the average observed among European teenagers.’ And it’s the girls who consume the most. Women also consult more often for anxiety-depressive disorders, the representative of the ATPEP tells us. The mental overload due to the frictions between their professional activities and private lives plays a significant role here. This specialist also reports a growing number of young people among her patients.

A 2024 document setting forth the Health Ministry’s strategy for the promotion of mental health, given to Nawaat by the ministry itself, lists several vulnerable categories: children, women, the elderly, minorities and migrants.

Their strategy also targets certain environments such as prisons and workplaces. Among the causes of psychological distress in these environments, the authors of this strategy identify violets, discrimination, and difficulties accessing medical care.

Nor do the present political and social-economic crises improve matters. ‘There was a time when patients focused mostly on the problems connected with their private lives. Nowadays we almost sways hear the same things. They talk a lot about the stressful environment: instability, insecurity or the absence of any visible prospects’, says Neila Ben Salah.

Very sensitive as they are to the fate of the Palestinians, Tunisians have also been deeply moved by the war in Gaza, as is shown by a survey taken among patients in the mental health section of the Mongi Slim Hospital. It shows the negative or psychosocial repercussions generated by exposing Tunisians to the images of that war.

That survey was taken amongst 683 Tunisians having viewed on a daily basis the media programs covering that war; 80.5% of the persons questioned declared having experienced negative feelings, such as anger, despair or sadness. Some 12% spoke of a feeling of guilt.

Fear of the hospital has lessened but still lingers on

However, these data give only a partial picture of mental health in Tunisia. To take one example, the consumption of psychiatric drugs is ‘well below what it should be’ since many people fail to consult a doctor and are not given treatment,’ Doctor Wahid Melki, a psychiatrist, explains to Nawaat. He is a professor at the Medical University in Tunis and coordinator on the Technical Committee for the Promotion of Metal Health with the Health Ministry.

The same is true of the frequency of suicidal behaviour. Nor does their number express the actual dimensions of mental suffering. 121 cases of suicidal behaviour were recorded during 2023 according to a report published by the Tunisian Forum of Economic and Social Rights (FTDES). The forum lists the obstacles that make gathering these statistics difficult. They are essentially linked to the ‘taboo surrounding the phenomenon’, the report observes. Most suicide candidates are male. Among them, youths, children and migrants. But because of the religious ban on suicide, it is a rare occurrence in Tunisia.

It is also hard to measure the extent of the psychological malaise among Tunisians with regard to what is left unsaid. Men, contrary to women, for cultural reasons have difficulty putting their sufferings into words or getting help. This verbalisation is seen as a sign of weakness, as opposed to the requirement of virility laid down by their education.

This reluctance to seek professional help for a case of mental suffering distorts the data on the mental health of Tunisians. ‘There is a tendency to normalise these sufferings’, asserts the president of the Tunisian Association for the promotion and prevention of Mental Health among youths.

Thus taboos and denials still surround the issues of mental health. ‘People still tend to consult gurus, marabouts and clerics rather than going to a doctor,’ Leila Chaibi deplores. And she exclaims: ‘Mentally ill people are still stigmatised. The words psychiatric hospital alone scare people.’ This stigmatisation sometimes comes from health specialists themselves; Neila Ben Salah is sorry to say.

This reluctance to get professional help is shown by the lag between the first sign of mental distress and the date of first consultation. This lag amounts to fifteen months on the average can be as long as ten years, Chaibi warns. In the meantime, the diagnosis will change and worsen. Which is not without consequences for the person in question, she regrets.

However, this psychiatrist has observed progress. Some Tunisians now find the courage to consult a specialist. ‘Mood disorders, especially those involving anxiety and depression, are less stigmatised.’

More generally, issues of mental health are increasingly raised by the media; as witness the popularity of the podcast ‘Deep Confession’ followed by many on the social networks. Life-coaching, including in professional circles, has become fashionable. And the phenomenon has acquired such proportions that it is beginning to worry health-care specialists.

‘Today consulting a life coach has a better press,’ Leila Chaibi observes. The craze for this kind of treatment offers ‘certain risks’. ‘Some coaches imagine they are psychotherapists able to treat relatively serious pathologies,’ she warns.

Stigmatisation but also a lack of resources make it increasingly difficult to seek qualified medical assistance. All Tunisians do not have equal access to medical care.

Incomplete coverage

The government’s austerity policy hinders the hiring of psychologists and psychiatrists in the public sector, as the coordinator of the technical committee for the promotion of mental health with the Health Ministry readily admits. The average density of psychiatrists in 2019 was 1.26 for 10,000 inhabitants. By 2021, it had dropped to 1.25.

As a result, the number of health professionals in public establishments no longer suffices to meet the growing demand for consultations, Leila Chaibi points out. Regional inequalities are especially striking.

Graphics 1 &2 Result: Some Tunisians turn to private sector psychiatrists, where a consultation costs 80 dinars. A sum which is not within everyone’s reach. And even the private sector is no bed of roses.

‘Not all patients benefit from social security coverage so that their medical costs are refunded,’ as the president of the association of Tunisian private practice psychiatrists points out. Besides which, she regrets that the National Health Insurance fund does not cover the cost of all medication. And the availability of medicaments is sporadic. ‘For months now, certain substances have been out of stock,’ she deplores.

All of these failings have been noted by the Health Ministry’s technical committee for the promotion of mental health. The committee has listed other malfunctions in the dispensing of care for patients.

Among these is a lack of motivation, commitment and material among front line practitioners in dealing with mental illness. They also warn against a lack of outreach, a lack of epidemiological data and the fact that treatments are concentrated in Razi Hospital.

This situation is likely to get worse with more and more psychiatrists and family doctors leaving the country, as the authors of the strategy of the technical committee for the promotion of mental health at the Health Ministry point out in their report.

And those are not the only ones who choose to leave the country. Today, everybody is out for themselves. The President of the Tunisian association for the promotion and prevention in the matter of mental health in young people sees there a symptom and a consequence of psychological distress.

These sufferings have a cost: human, societal, medical and economic. People with severe mental disorders die on the average ten to twenty years younger than the population at large. ‘Globally speaking, the economic consequences of mental health problems are enormous: the losses of productivity and other indirect costs for the society are often far greater than the cost of mescal care proper’ the WHO warns us.

  • © Nawaat.