Taking steps to deal with trauma

During quiet moments, Fadel Khadum Adel, a former soldier, often hears someone speaking his name into his right ear. The voice is a welcome one, usually that of his mother or father, but when he looks there is no one there.

Adel, 43, turned his head to reveal a gnarled stub of an ear - the rest was forcibly amputated, without anaesthesia, under Saddam Hussein, as punishment for his desertion from the army in 1987 during the Iran-Iraq war.

Adel has heard the voices, and worse, ever since.

“I’ve gone to doctors and they just say, ‘What’s your problem?’” he said, his features heavy and inexpressive. “I say, I’m depressed. They gave me medicines. But the medicines gave me hallucinations. So what I need is to talk.” Iraq’s mental health care system was once advanced for the region, but by 2006 fewer than 100 psychiatrists remained in a population of about 30 million, and almost no psychologists. Patients were isolated in understaffed institutions, apart from their families and communities.

But now the government has embarked on an ambitious programme to rebuild its ruined mental health care system in a country experiencing more than its share of traumas and stress. It will be built on a network of clinics that are team-oriented, with an emphasis on outpatient care and respect for patients’ rights - a radical departure from the existing system of institutional care focused on drugs and electroconvulsive therapy, often given without seeking a patient’s consent.

An unusual approach

On a recent afternoon, Adel sat with a community health doctor at the Sara Centre for Trauma, the nation’s first multidisciplinary clinic for post-traumatic stress disorder. The centre, which opened December 18, includes a psychiatrist, a community health doctor, a gynaecologist and a social worker, all working jointly.

“This is the first time we’ve had anything like this,” said Dr. Akeel al-Sabbagh, the centre’s consultant psychiatrist. “In Iraq, the psychiatrist is like a dictator. Even my colleagues now, they say, ‘Why would you talk to a nurse?’ In the U.S.A. we saw the nurse, psychiatrist, psychologist and social worker all talk together about the patient.” In 2008, six teams from Iraq spent a month at facilities in the United States, each concentrating on a different area of care. More teams are scheduled to make the same trip this year, with financing from Iraq’s Ministry of Health and the United States Substance Abuse and Mental Health Services Administration.

But rebuilding an effective mental health system will take years. In the meantime, primary care doctors are being trained to recognise and treat basic disorders.

Last year, 360 primary-care doctors took two-week crash courses in depression, anxiety, psychosis and other afflictions, using a curriculum developed in London for Nigeria. “This is a turning point in mental health services in Iraq, integrating treatment into primary care,” said Dr. Sabah Sadik, chairman of the Middle Eastern International Division of the Royal College of Psychiatrists, who is coordinating the programme.

A new beginning

For Adel, the change has meant a new start. As a soldier in the war against Iran, Adel ran away in 1987 after his brother was killed. He was quickly captured and punished with the amputation of his ear.

“I started crying and shouting,” Adel said of the pain. “We were put in a small room, hundreds of prisoners, with no space to sleep. We had to defecate and urinate in the same room. I started to hallucinate from fever.” When he got out of prison after a year and a half, he became depressed and lost his balance when he walked.

“I never wanted treatment,” he said, meaning antidepressant drugs. “I wanted to talk.” But until he discovered the Sara Centre last month, he never encountered professionals who offered therapy in addition to medication. Since then, he has been enrolled in a programme called cognitive processing therapy, which is devised to help trauma victims manage their haunting memories.

“To be honest, I’ve only seen this in movies,” he said. “I didn’t know what it was. They told me that whatever I said was a secret between us, and I could talk freely. I haven’t had this treatment in my life.”

© 2010 New York Times News Service