About a week ago, I met with a doctor at the Hamad Psychiatric Hospital in Doha, away from the main HMC hospitals in Medical City. The doctor I met with is Egyptian and has studied at the Weill Cornell Medicine school both here in Doha and in New York. She told me that the curriculum here exactly replicates the one in New York; the theory that is taught is the same, and the doctors learn how to apply that theory to their specific location (either New York or Doha) during their residency training with real local patients.
The government of Qatar has recognized mental health as an important issue via the National Mental Health Strategy for 2013-2018. The doctor I was talking to said that she’s observed the same distribution of mental health issues here as in the US. This is supported by the strategy, which states that “mental disorders in Qatar broadly reflect the WHO’s global estimates” (http://www.nhsq.info/app/media/1166. The most common mental health issues are anxiety, depression, and other psychiatric disorders like psychosis and bipolar disorder.
The doctor also suggested that overall, attitudes towards psychiatry and mental illness are the same across countries. In any medical setting, the psychiatry department will be seen as the one needing support the least even though it has the most challenging patients (many of whom are prescribed pills but lack the capacity to take them properly). Psychiatry will get the least amount of funding, respect, and support compared to other hospital departments due to a prevailing attitude that mental health isn’t as important as other medical fields. My interviewee said that even other doctors have a stigma against psychiatrists, despite expecting them to do a ton of work. She talked about how many non-psych doctors have a fear of the unknown, often sending medical patients with the slightest hint of mental issues to Psychiatry. So Psychiatry ends up with patients that have other physical issues and has to send them back to the appropriate medical department to be treated there first.
The doctor said that while the stigma against mental health is global, she has noticed it to be more prominent in Qatar than in New York. We agreed that might just be New York City, though, which is typically quite liberal and tolerant and not exactly representative of the rest of the country. “It’s a crazy city!” I said. “…Exactly,” said the psychiatrist, with a look. (Oops – I hadn’t meant that in terms of mental health, but more to say that the city is extremely diverse. I suppose I throw around the word ‘crazy’ too often, especially when telling people how New York City compares to Stockholm, Gothenburg, Malmö, or Doha.)
The doctor pointed out that a lot of the stigma towards mental health is evident in the use of euphemistic names. At the NewYork-Presbyterian hospital, the psychiatry department is called “Payne Whitney.” In Hamad Medical City, the primary provider for mental health services is the “Rumailah Hospital.” She gave another example: the HIV/AIDS department at Weill Cornell is mysteriously called the “Center for Special Studies,” which reveals continuing stigma against the disease.
We also talked about the importance of doctor-patient compliance with mental health patients and how challenging that is. The doctor said that encouraging compliance with psychiatry patients is twice as important than with other medical patients, as such patients usually live at home (with less oversight than patients in hospitals), have long term illnesses that are treated mainly with pills, and have mental issues that make it more difficult to adhere to a specific pill-taking regimen. It is much easier if the patient has a specific care provider, typically a family member. Sometimes mental health patients come to the hospital for check-ups alone, and it’s hard to tell if they’re telling the truth when they talk about their medicine. Others don’t seek help at all. Even if they are cared for a by a family member, negative attitudes towards mental health can still come into play. The doctor told me that she’s heard of some patients being kept at home by their family members, locked in rooms out of shame. When this happens, such patients only end up at hospitals after their family can no longer care for them and the situation has gotten out of control.
I asked the doctor what would make things easier in Qatar and what was currently lacking. She said that she would like to see more outreach programs and more residential services, meaning more space (more beds) for the patients and more funds for nurses to visit patients at home. Resources for residential services are usually allocated to geriatric and non-psychiatric departments; again due to stigma and a perception of psychiatry being least important.
The main focus, however, needs to be on reducing the stigma by normalizing mental health issues. The first step is getting rid of the euphemisms used to refer to psychiatric hospitals, services, and illnesses. The next step is awareness through advertisements and education. The doctor said that people in New York seemed more educated overall, which contributed to less of a stigma there. Also, when she was in the U.S., she noticed that ads for mental health treatments are everywhere. It’s true; you might watch an hour of television and see the same antidepressant ad twice. However, there are no such ads here. There’s less exposure to the idea of mental health issues and seeking treatment for them, meaning that it’s not as normalized. Overall, Qatar has to make more of an effort to educate its population about mental health through campaigns.
The doctor made a great point here about the health industry. She said that part of the reasons there are no ads here is because health isn’t an industry in Qatar – certainly not the way it is in the U.S. In Qatar, the government owns most of the hospitals and everyone is on the same insurance. There’s no view of medicine as a financial opportunity, so the hospitals don’t compete to be better. There’s no competition to offer a better experience for the patients or even for the doctors, who have no option for doing a residency outside of the Hamad Medical Corporation system. When there is a monopoly, there’s less of a drive to do better. (What’s interesting is that this could have happened in Sweden as well, where everyone gets healthcare for free and so the hospitals don’t have to compete for patients’ money. However, they all still work together to improve. One reason for this might be the tradition of user-centered design in Sweden). However, the downside to health being an industry as it is in the U.S. is, of course, the expense for patients. If you don’t have the money for hospitals or insurance companies, your health will suffer. Someone mentioned this in Sweden, too – that while the hospitals in the U.S. might compete to be better, it’s a competition driven by money rather than a want to provide the best patient experience. Conversely, Qatar is patient-centered in its recognition that everyone in the country deserves access to healthcare regardless of their ability to pay (also, there is a drive to improve patient experience, as reflected by the goals in the National Health Strategy).
“What about tech solutions for patients?” I asked. The doctor agreed with my observation that no one here uses health apps, which seems to be because people aren’t interested in preventative care or self-monitoring. She said that some patients would probably self-motivate to check blood pressure and glucose levels if given the option (probably diabetes patients). For any patient to use an app or other eHealth solution, however, it would have to be very simple. She suggested that it would only happen if doctors got involved and guided patients through downloading an app and using it, rather than patients finding such solutions on their own.
Finally, I asked about the effectiveness of following New York’s medical school curriculum in Doha. The doctor said that it works, because as I mentioned earlier, the theory is imported but application is localized. However, she told me about a class called “Cultural Competence,” which was about how to relate to patients with a different background from your own. “What if the class had been specifically about working in the Qatari cultural complex?” I asked. She said that the main topics of such a class would be the stigma against mental health in Qatar; the varying levels of medical literacy in the country; the history of tribal families; the need to expect and inquire about the use of traditional healing techniques; the role and education of the patient’s keeper (usually a maid or family member rather than a nurse); and the cultural idioms used in place of the official names for mental health issues.
However, Qatar is developing, and as I mentioned, the government has the fairly new National Mental Health Strategy. Development in the country will help develop everything, including attitudes towards mental health. There is also the larger-scope National Health Strategy, which outlines many goals for improving Qatar’s health overall (www.nhsq.info). Though another example of a euphemism, “naufar” is a brand new treatment for people with behavioral disorders and substance abuse issues (http://www.naufar.com/About-Us). It has residential and non-residential facilities as well as an awareness program. The country’s mental health plan also discusses the need to reduce the stigma. Hopefully, ads, television, education, and awareness campaigns will begin to normalize mental health issues in Qatar and eventually reduce the stigma, which could have a real positive medical outcome in the country’s mental health.
Sunday, 10/30/16: This post has been edited to replace “Westchester Program” with Penn-Whitney and to add nuance to the doctor’s observation of the pros and cons of health as an industry vs. government-monopolized health as a service for all.