Mental health in Tunisia: Better or worse?
Mental health is a key part of a person’s wellbeing, in addition to protecting against physical illness, social inequalities, and unhealthy lifestyles. According to the Happy Planet Index 2016 results, Tunisia scores low in terms of wellbeing 1.
It has been demonstrated that the average happiness of a nation is highly correlated with better mental health care 2. Therefore, it is reasonable to focus on mental health services to promote wellbeing.
University hospitals are the main provider of specialised mental health care services. Over the years, an increasing proportion of Tunisian citizens have turned to the private sector. However, not every citizen can afford private health services. Acknowledging that mental health providers make a huge contribution in promoting the wellbeing of Tunisian citizens, other strategies to deliver mental health services could be considered given the increased demands for and the shortage professionals who deliver these services. (According to published statistics, on average, one psychiatrist serves 33,000 people, and one psychotherapist serves 23,000 people 3).
What has been done to promote mental health in Tunisia?
- At the primary care level
As mentioned above, Tunisia suffers from a deficiency in the number of mental health providers. The main users of mental health facilities are individuals with schizophrenia and mood disorders 4. Meanwhile, general practitioners (GPs) receive requests for about 30–40% various mental health consultations 5.
Public mental health services are organised by geographical area, which means that each area’s public service system is responsible for training primary care physicians, who serve the area, in mental health.6 Also, junior doctors and GPs keen to gain additional competencies are eligible to attend several courses organised by the four faculties of medicine. There are also multiple national and international congresses that provide talks focused on mental health topics to help their members keep up to date with the latest developments. Even though the majority of doctors benefit from regular, refresher training in the use of psychotropic drugs 4, previous studies revealed differences among Tunisian GPs in their competencies related to the provision of mental health services 4,7. Therefore, it is extremely important to increase their abilities to provide higher quality mental health care.
In 2008, the World Health Organization launched a new reform called mental health Gap Action Programme (mhGAP) to promote mental health in low-and middle-income countries (e.g. Tunisia). This programme’s aim is to reduce the gap in low-income countries’ mental health system capacity compared to high-income countries. The training programme, which is provided by mental health specialists, consists of in-depth training of non-specialists in mental health issues detection, treatment and management. The first training programme in the greater Tunis area was implemented in 2016, and its results were promising. Post training, most primary care physicians reported being more comfortable engaging with patients who have psychological difficulties and able to recognise and potentially treat psychological conditions 8. Subsequently, more training programmes were launched in several Tunisian governorates.
Additionally, since 2017, it should be noted that in the latest medical curriculum, residents in family medicine are required to attend additional mental health courses. They also must complete at least two months of practice in psychiatric departments, which was optional for previous GPs training. To evaluate and potentially refine the existing approach to training family medicine residents, more research is needed to assess their mental health knowledge and attitudes among newly graduated family physicians.
- At the virtual consultations level
A recent study revealed that the average delay in receiving adequate care for Tunisian citizens with severe mental illness (e.g. schizophrenia, bipolar disorder, and schizoaffective disorders) is 15 months 6. Early interventions can produce a significant, life-changing impact by reducing the progression of mental illness, and several countries have developed helpline services to provide immediate mental health care. Helplines offer several benefits, in particular, these calls appear to play an important role in supporting people at the early stages of developing common mental health problems 9.
Notably, the first Tunisian helpline dubbed Ahkili was launched this year, and it is available seven days a week from 12 p.m. to 12 a.m. This service could be a potential solution in improving early detection of mental illnesses, and it offers psychologists’ advice, support and referrals on a range of mental health difficulties including stress, depression, anxiety and life’s daily struggles. While it is not free, the helpline service appears cheaper than a typical face-to-face consultation.
Based on the evidence reviewed in the article, the current situation towards improving the quality of mental health care in Tunisia is not entirely without progress. For example, training to enhance GPs’ mental health knowledge and the establishment of a new helpline offer a glimmer of hope that the quality of mental health care will improve. Also, there are several other interventions being adopted to improve mental health among the Tunisian population.
Moreover, it appears younger Tunisian generations are more aware of mental health difficulties and ready to seek help from mental health services when needed3. It is an encouraging sign for continued innovation in mental health services delivery that perceptions are shifting away from stigma, and the future appears bright for further progress in the mental health of Tunisia.
- Touburg, G., Veenhoven, R. Mental Health Care and Average Happiness: Strong Effect in Developed Nations. Adm Policy Ment Health42, 394–404 (2015).
- Angermeyer, M. C., Carta, M. G., Ghachem, R., Matschinger, H., Millier, A., Refai, T., ... & Toumi, M. (2020). Cultural Variations in Public Beliefs about Mental Disorders: A Comparison between Tunisia and Germany. Clinical Practice & Epidemiology in Mental Health, 16(1).
- Spagnolo, J., Champagne, F., Leduc, N., Piat, M., Melki, W., Charfi, F., & Laporta, M. (2017). Building system capacity for the integration of mental health at the level of primary care in Tunisia: a study protocol in global mental health. BMC health services research, 17(1), 1-10.
- Khiari, H., Ouali, U., Zgueb, Y., Mrabet, A., & Nacef, F. (2019). Pathways to mental health care for patients with severe mental illness in Tunisia. The Pan African Medical Journal, 34.
- Spagnolo, J., Champagne, F., Leduc, N., Rivard, M., Piat, M., Laporta, M., ... & Charfi, F. (2018). Mental health knowledge, attitudes, and self-efficacy among primary care physicians working in the Greater Tunis area of Tunisia. International journal of mental health systems, 12(1), 63.
- Spagnolo, J., Champagne, F., Leduc, N., Melki, W., Piat, M., Laporta, M., ... & Charfi, F. (2018). “We find what we look for, and we look for what we know”: factors interacting with a mental health training program to influence its expected outcomes in Tunisia. BMC public health, 18(1), 1398.