Eastern Mediterranean Health Journal | Past issues | Volume 25, 2019 | Volume 25, issue 2 | Mental health services for youth in the Eastern Mediterranean Region: challenges and opportunities

Mental health services for youth in the Eastern Mediterranean Region: challenges and opportunities

Print PDF

PDF version


Atif Rahman,1 Hesham M. Hamoda,2 Afarin Rahimi-Movaghar,3 Murad Khan 4 and Khalid Saeed 5

1Professor of Child Psychiatry, University of Liverpool, Child Mental Health Unit Royal Liverpool Children’s Hospital, Liverpool, United Kingdom. 2Attending Psychiatrist, Boston Children’s Hospital Assistant Professor, Harvard Medical School, Boston, United States of America. 3Professor of Psychiatry, Director, Iranian Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Professor and Chairman, Department of Psychiatry, Aga Khan University, Karachi, Pakistan. 5Regional Advisor for Mental Health and Substance Use, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Citation: Rahman A; Hamoda HM; Rahimi-Movaghar A; Khan M; Saeed K. Mental health services for youth in the Eastern Mediterranean Region: challenges and opportunities. East Mediterr Health J. 2019;25(2):80–81. https://doi.org/10.26719/2019.25.2.80

Copyright © World Health Organization (WHO) 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

The Global Burden of Disease study (1) shows that the burden from mental and substance use disorders, measured in Disability Adjusted Life Years (DALYs), has steadily risen in the Eastern Mediterranean Region (EMR) over the last three decades and is higher than the global average for almost all EMR countries (2). Even more alarming is the finding that depression, self-harm, anxiety and conduct disorders constitute four of the top 10 causes of DALYs among girls and boys aged 15–19 years and suicide is a leading cause of adolescent mortality.

More than 70% of all mental disorders begin before the age of 25 years old. Risk factors for mental disorders include genetic pre-disposition, deficiencies in psychosocial or educational environments, alcohol and drug misuse, and family, peer or school problems (3). The Region has additional population level risks of high fertility rates, complex emergencies, instabilities, and rapid urbanization. But mental ‘health’ goes beyond mental disorders and encompasses an individual’s ability to cope with stress and to realise his or her own potential, despite adversity. This calls for integration of mental health into development work across sectors, and not just health services (4). Unfortunately, the EMR has a gross deficit of mental health resources for young people across all sectors, including specialised personnel, facilities and training schemes, and many EMR countries lack adequate mental health policies and laws (5). Unaddressed mental health problems will have serious social and economic costs, which are likely to persist into adulthood, and lead to inter-generational disadvantage.

Therefore, in order to reverse the trend it is imperative that drastic action is taken. There is a consensus among experts that early-life interventions are likely to be the most promising invest­ment in population mental health for the following reasons (4): First, early recognition of mental health problems or risk factors, such as parental mental illness, allows for remedial action. Second, early interventions contribute to tackling the damaging stigma associated with mental disorders as these become more symptomatic due to lack of treatment. Third, special attention to early interventions in high-risk groups, such as children affected by conflict and violence, abuse, maltreatment or poverty, can reduce disparities that are the inevitable consequence of poor mental health. Fourth, investing in child and youth mental health is not only a social and economic necessity, but also a moral obligation upon society.

Early life interventions when mapped on to developmental stages cover two critical periods: the first 1000 days; and school age. Given the brain’s plasticity, the first 1000 days, including the perinatal period (in utero to two years postnatal) and early childhood (two to eight years), are critical for healthy development and later mental health (5). The early home environment provides a key opportunity to implement interventions that can promote mental health and prevent mental illness. Several evidence-based interventions have demonstrable benefits for both infants and mothers, even in low-income settings (6). These include interventions focusing on parental skills training, maternal mental health, mother-infant bonding and interaction, play, responsiveness and stimulation. Integrated approaches incorporating psychosocial, nutritional and educational ‘common elements’ delivered seamlessly by health, education and social welfare services are necessary to maximise benefits from these interventions for mothers and babies (7). Population-level interventions, such as genetic counselling, screening of new-born babies (8) and reduction of maternal alcohol and substance use can prevent cognitive impairment and disability.

While this early period is critical, later childhood and adolescence – especially school age – present further opportunities for ameliorating the effects of early disadvantage, and thus building resilience and reducing the harmful consequences of conditions that have an onset during this period (9). Good schools provide a natural, non-stigmatizing, culturally acceptable, accessible and potentially sustainable platform to build social and emotional competencies. In relation to the prevention of mental illness and substance abuse, systematic reviews show that universal socio-emotional learning (SEL) interventions in primary and post-primary schools promote children’s social and emotional functioning and academic performance in the long term (10). The most effective interventions employ a whole-school approach where mental health activities are supported by a school culture involving staff, students, parents, school environment and local community. The School health Implementation Research Network in the Eastern Mediterranean Region (SHINE) project promotes mental health through a manualized school-based intervention in EMR countries of the region (11). For mental disorders in youth, treatment strategies including ‘talking therapies’ like cognitive behavioural therapy and medication for selected conditions, are included in the WHO Mental Health Gap Action Programme Intervention Guide (12), aimed at non-specialist health care providers, especially in low- and middle-income countries.

The Regional Framework to Scale Up Action on Mental Health in the Eastern Mediterranean Region (13) was adopted by Member States at the 62nd Session of the WHO Regional Committee for the Eastern Mediterranean held in Kuwait, 5–8 October 2015, and identified high impact, cost-effective, affordable and feasible strategic actions supported by a set of indicators to monitor the implementation of the plan (14). Countries in the Region need to focus on implementation of this framework to help achieve targets set out in the sustainable development agenda and WHO’s ambitious vision as expressed by the aspirational “triple billion” targets (15). The overwhelming evidence suggests that the best place to start is with early life interventions.


  1. IHME. Global Burden of Disease 2018 (http://www.healthdata.org/gbd).
  2. Charara R, Forouzanfar M, Naghavi M, Moradi-Lakeh M, Afshin A, Vos T, et al. The burden of mental disorders in the Eastern Mediterranean Region, 1990–2013. PLoS ONE. 2017;12(1):e0169575.
  3. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, et al. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011 Oct 22;378(9801):1515-25. https://doi.org/10.1016/S0140-6736(11)60827-1
  4. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolron P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018 Oct 27;392(10157):1553-1598. https://doi.org/10.1016/S0140-6736(18)31612-X
  5. Rahman A. Mental disorders in the Eastern Mediterranean Region. Int J Public Health. 2018 May;63(Suppl 1):9-10. https://doi.org/10.1007/s00038-017-0986-1
  6. Newman L, Judd F, Olsson CA, Castle D, Bousman C, Sheedan P, et al. Early origins of mental disorder – risk factors in the perinatal and infant period. BMC Psychiatry. 2016; 16:270. PMID: 27473074
  7. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. Lancet 2017; 389(10064): 91-102. https://doi.org/10.1016/S0140-6736(16)31390-3
  8. Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE. Grand challenges: integrating maternal mental health into maternal and child health programmes. PLoS Med. 2013;10(5):e1001442. https://doi.org/10.1371/journal.pmed.1001442
  9. World Health Organization. Community genetics services: Report of a WHO Consultation on community genetics in low- and middle-income countries. Geneva: World Health Organization; 2011 (https://apps.who.int/iris/bitstream/handle/10665/44532/9789241501149_eng.pdf;jsessionid=AD2EF4BA721A536EFC340D5034162ECC?sequence=1).
  10. Fazel M, Patel V, Thomas S, Tol W. Mental health interventions in schools in low-income and middle-income countries. Lancet Psychiatry. 2014 Oct;1(5):388-98. https://doi.org/10.1016/S2215-0366(14)70357-8.
  11. Tennant R, Goens C, Barlow J, Day C, Stewart-Brown S. A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people. J Public Ment Health. 2007;6(1):25-32.
  12. National Institute of Mental Health. School Health Implementation Network: Eastern Mediterranean Region (SHINE) (https://bit.ly/2EI04QI).
  13. World Health Organization. Mental Health Gap Action Programme (mhGAP) Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings – Version 2.0. Geneva: World Health Organization; 2016.
  14. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Regional Framework to Scale Up Action on Mental Health in the Eastern Mediterranean Region. Cairo: WHO/EMRO; 2016 (http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_18700.pdf?ua=1).
  15. Alwan A, Saeed K. A new agenda for mental health in the Eastern Mediterranean Region. East Mediterr Health J. 2017;20(7):459–460 https://doi.org/10.26719/2017.24.3.459.