After years of war, Iraqis try to heal scars to mental health

From The AP:

BAGHDAD — Jabar Abdul-Zahra's flashbacks are so vivid he can feel the asphalt against his cheek that night six years ago when he lay pinned to the ground between his two critically wounded brothers, the three of them caught in the crossfire as American troops and local militiamen fought in a Baghdad neighborhood.

The memory of waiting till dawn for the fighting to subside so he could ferry them to hospital has overshadowed the grief he felt when one brother later died from his wounds.

But the 43-year-old computer engineer didn't understand what was causing the flashbacks, or the palpitations and sheer terror that still overcome him whenever he sees people in uniform.

Until he happened to get a contract to hook up the computers at a new center being set up in the backyard of the Imam Ali Hospital. There he met psychiatrist Haitham Abdul-Razaq — and found out he was one of tens of thousands of Iraqis with symptoms of post-traumatic stress disorder, or PTSD.

The mental trauma center was the first of its kind in Baghdad, part of a new push by Iraq's Health Ministry to help Iraqis deal with the hidden stresses inflicted by the years of violence that followed the 2003 U.S. invasion. In the past year, nine more such centers have opened across Iraq.

"There is no doubt Iraqis have suffered some of the worst stress and trauma imaginable, but the hardest part is to get people to come here," Abdul-Razaq said. Since opening last fall, there have been only 200 patients at the center, in Baghdad's Shiite slum of Sadr City.

What deepens the problem in Iraq is the duration of the violence and how intertwined it has been with civilian life.

Countless numbers have witnessed car bombings, when all that is left is parts of human bodies strewn about, or have endured the killings or torture of their relatives by militants — and then similar attacks and violence occur repeatedly, even daily at some points in the 7-year-old conflict, providing triggers for the afflicted to relive their own trauma, said Mohammed al-Uzri, an Iraqi-born psychiatrist based at the University of Leicester, England.

The result goes beyond classical PTSD to something al-Uzri describes as "persistent traumatic stress disorder."

"One man described to me his experience after a car bombing, how the smell of burnt human flesh stayed with him and every time he tried to eat, he couldn't because he would smell that smell," said al-Uzri.

Al-Uzri, who left the country in the 1990s, has traveled repeatedly to Iraq as part of a program run by his Iraqi Mental Health Forum to work with Britain-based psychiatrists to build the capacities of their Iraqi colleagues.

For a population of 28 million, Iraq has only about 160 psychiatrists, whether fully qualified or in training, far less than Britain's standard of 10 psychiatrists per 100,000 people, said al-Uzri. Baghdad's only two psychiatric institutions — the Ibn Rushd clinic, which treats acute psychiatric disorders, and the Al-Rashaad hospital, which focuses on chronic psychosis such as schizophrenia — rarely handle disorders related to the stress of war.

The numbers of Iraqis with PTSD and similar stress-related disorders is little documented. The only Iraqi mental health survey so far, conducted in 2006-2007 by the World Health Organization and Iraq's Health Ministry, showed that more than 50 percent of the population had been exposed to some sort of psychological trauma, but only 3.5 developed full PTSD.

Some psychiatrists have questioned the accuracy of the figures in the study, carried out at the height of Iraq's sectarian bloodletting, suspecting stress-related disorders may be even higher.

At the new center at Imam Ali Hospital, the team of six psychiatrists, counselors and social workers was trained in Jordan last October by the Paris-based Doctors Without Borders in treating PTSD and related disorders, using cognitive therapy. The method aims to develop a patient's skills in identifying and changing dysfunctional thinking, behavior, and emotional responses.

It's often several sessions before a therapist can glimpse the traumatic event that is the root cause.

"The first day, they sit at the edge of the chair, without making eye contact," said Heba Mohsen, 25, one of the center's counselors. "We try to get them to open up, build confidence."

One patient, Ayad Hamdan Saad, 35, has been coming for a few weeks "just to talk." He gets nervous and has angry outbursts that have alienated his parents, nine siblings and most friends. He thinks it started after an explosion in Aalam neighborhood two years ago while he was on his way to English class.

"All I could see were these dead bodies around me," said Saad, a high-school teacher. "Now, every time I go near that place, I get afraid again."

But getting Iraqis to treatment is part of the difficulty. At the Ibn Rushd hospital, less than a fifth of the 74 beds are occupied, a sign of the stigma associated with mental illness in the society, says psychiatrist Shalan Joodah al-Abbudi.

At the Sarah mental trauma center in the southern city of Basra, psychiatrist Aqil al-Sabagh says primary care doctors need training to recognize stress disorders. The center opened in December, with 18 beds, four psychiatrists and two social workers, all trained in the U.S.

"Most patients here still go to quacks or clerics," said al-Sabagh. "They are given a piece of paper with some scribbled writing, told to put it in a glass of water and drink several times a day."

Ali Karim at least came to the right place.

Kidnapped by armed men in 2007 and released after his family paid the ransom, the 50-year-old father of five has been at Sarah since early March. He prays five times a day and refuses to speak to anyone, al-Sabagh says.

Only occasionally, when his mother or wife visit, Karim whispers to them: "They will come for me again. They are chasing me."