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The Royal College of Psychiatrists Improving the lives of people with mental illness

Network news from Kabul

Commentary from Yousuf Ali Rahimi, MD MRCPsych

Network news from Kabul - Yousuf Ali Rahimi, MD MRCPsych

Imagine London with only one poorly functioning, 60 bed mental health hospital with half a dozen senior psychiatrists and a dozen junior trainee psychiatrists. The patients would be not only from London, but referred from all over the UK.


Imagine yourself in a busy outpatient clinic, assessing a 12 year old child who has been caught just before blowing himself up in a crowded market and you are asked by the court whether he had mens rea. 


With only a medical school degree to your name, and no formal post-graduate psychiatric training (but maybe with a few years in the psychiatric hospital), no forensic nor child and adolescent psychiatry training, you are expected to asses him and provide a court report while a crowd of around sixty patients with their relatives are waiting outside to be seen. This all has to be done in a very short time, as the customary attitude to work in your country dictates a working day of only about three or four hours in the morning. On top of this you have a ward round to do. You are expected to meet the needs of all the inpatients, finish your jobs for the day by about noon, then go to your private clinic where you will see another fifty to sixty paying patients.


Would a British FY1 or FY2 or CT1-3 accept this job and the responsibility of it all? For a psychiatrist working in Kabul, this is to be expected as the pattern of normal clinical practice – and there is no alternative.

Facts and figures

Kabul, Afghanistan’s capital, with its rapidly growing population of around 5 million people, has witnessed four decades of unrest, mass migration and civil war, and as a result is now the fifteenth least developed country in the world, according to the Human Development Index. The average life expectancy is 43.8 years, and, according to UNICEF, it is the most dangerous place in the world for a child to be born.


Even before the arrival of Taliban in 1996, symptoms that met the criteria for major depression were prevalent amongst 97% of women who lived in Kabul and refugee camps in Pakistan. Post-traumatic stress disorder was recorded at 42%, and 86% of these women had significant anxiety symptoms (Rasekh Z, Bauer H, Manos M, Iacopino V, JAMA, 1998; 280(5):449-455).


During the Taliban era, major depression was reported 73-78% among women exposed to Taliban policies compared to 28% for women living in a non-Taliban controlled areas. (Amowitz LL, Heisler M, Iacopino V. Physicians for Human Rights, Boston, Massachusetts, J Women’s Health (Larchmt), Jul-Aug; 12(6):577-87; 2003).


Following the fall of Taliban, in a national multistage, cluster, population-based mental health survey of 799 adult household members (699 nondisabled and 100 disabled respondents) aged 15 years or older conducted from July to September 2002, Barbara Lopez Cardozo and colleagues reported: symptoms of depression 67.7% (95% CI 54.6%-80.7%) and 71.7% (95% CI, 65.0%-78.4%), symptoms of anxiety 72.2% (95% CI, 63.8%-80.7%) and 84.6% (95% CI, 74.1%-95.0%) for nondisabled and disabled respondents, respectively.


The prevalence of symptoms of PTSD was similar for both groups (nondisabled, 42.1%; 95% CI, 34.2%-50.1%; and disabled, 42.2%; 95% CI, 29.2%-55.2%). Women had significantly poorer mental health status than men did. (Lopez, et all, Mental Health, Social Functioning, and Disability in Postwar Afghanistan, JAMA. 2004; 292(5):575-584.


In another post-Taliban study in the Nangarhar province of Afghanistan, Scholte and colleagues reported:


  • 38.5% having symptoms of depression,
  • 51.8% with anxiety,
  • 20.4% with PTSD. 


Symptoms were more prevalent in women than in men (depression: OR, 7.3 [95% CI, 5.4-9.8]; anxiety: OR, 12.8 [95% CI, 9.0-18.1]; PTSD: OR, 5.8 [95% CI, 3.8-8.9]). Higher rates of symptoms were associated with higher numbers of traumas experienced. (Scholte W. et al, JAMA, Aug. 4, 2004, Vol. 292, No.5).


Two years ago it was estimated that more than 8% of the population between 15 and 64 years (approximately 940,000 people) in Afghanistan use illicit drugs, twice the global average (UN Office on Drugs and Crime (UNODC): Drug Use in Afghanistan: 2009 Survey, pp. 3-4). This figure might now be much higher, as the physical existence of a large population of addicts living under the bridges in Kabul currently is something that was unheard of few years ago. 


Network news from Kabul - Yousuf Ali Rahimi, MD MRCPsychMental Health services are provided by the Ministry of Health who run one psychiatric hospital in Kabul with only 60 beds allocated to people with mental disorders, and 40 beds for drug addicts.


This is not to suggest that there is a huge demand for beds, with overflowing wards: on the contrary, bed occupancy rates are usually low (less than 60% in the 2011). This is due to a combination of various factors, such as poor facilities and security, a stigma against mental health, staff attitudes and particularly  unhelpful policies (patients are not admitted unless a relative can stay with them at all times). The average duration of inpatient stay is 8.4 days, with a range from one to fifty one days (unpublished audit, Rahimi et al). Perhaps of interest to westerners is that all mental health clinicians have to wear white gowns in the hospital, and in the out patient clinics.


In 2011, the European Union funded a project implemented by International Medical Corps to improve mental health services in Kabul Mental Health Hospital. A college member, Dr Yousuf Ali Rahimi from Oxford, joined a small team in Kabul, including a mental health nurse from UK, to train clinicians in this hospital. The team designed a training programme which included:


  • core training in psychiatry,
  • experiential group psychotherapy,
  • group and individual clinical supervision, 
  • the use of a training portfolio.


Much time has been spent in designing the format of patient records, various assessment and referral forms, and offering technical help and support to the medical records office and the pharmacy. A crucial part of their time has been spent in the development of an outpatient and inpatient service culture, where patient confidentiality and good record keeping have been at the heart of their efforts. It has also involved developing a new of way working, so that patients seen are assessed in a private area. This is in the outpatient clinics and inpatient areas, and includes the multidisciplinary ward rounds, and in group and individual psychotherapy sessions.


Another College member, Dr Rex Haigh, also joined Dr Rahimi in Kabul to design a psychotherapy training programme for Afghanistan. He studied the current situation and practice in Afghanistan and what the needs are for the future of mental health in Afghanistan. Based on his experience in service development and designing training programmes, and after discussions with Afghan professionals, he developed a psychotherapy training curriculum and programme for Afghanistan that is “biopsychosocial, culturally congruent, and inexpensive”, being based on principles of group psychotherapy and an EU-defined ‘greencare’ philosophy. Details of this are in the following section.


Dr Haigh and Dr Rahimi met with our President, Professor Sue Bailey, and Chris Naughton, the College’s International Liaison Manager, on 21 December 2011 to discuss how the College can further support the development of the psychiatry profession, training programmes and mental health services in Afghanistan. You will hear more about this development in the next bulletin of our e-news.




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