Building a mental health system in Iraq


As readers of this space are aware, I do not hold back on my critiques of our so-called “system” for dealing with offenders with mental illness. Mental health staff in correctional settings, in particular, are always being asked – whether by state funders, or by contracted health care vendors, or simply because of their ever-growing caseloads – to do more with less.

But I am taking a hiatus from my soapbox to share a different view of some of the amazing things that are happening here in the US, looking through the lens of a country with services that were decimated by 30 years of dictatorial rule.

In September and October, under the auspices of SAMHSA (the Substance Abuse and Mental Health Administration, a division of the US Department of Health and Human Services), six teams from Iraq, each including psychiatrists, nurses, and social workers, will be visiting the US to engage with experts in the areas of substance abuse, trauma, women's issues, child mental health, and forensic mental health. I am privileged to be one of the organizers for the forensics team, who will spend four weeks engaging in a series of experiences within Maryland's forensic services. They will be observing and interacting with specialized police interventions for people with mental illness, with mental health courts, with jails and prisons, and with forensic hospitals. We anticipate a very active learning process – both for the Iraqi visitors and for their hosts here in the US.

We take so much for granted here. We have an amazing participatory government, one in which too few of us take part. Our Constitution is a living, growing document that still is meaningful and serviceable after 220 years. We value rights more than perhaps any other nation in history.

Of course, there is much that is lacking here. Our country and the various jurisdictions therein – my state of Maryland included – seem to be engaged in an orgy of incarceration. Rather than treat, or rehabilitate – we punish. Instead of working to make participating citizens, we throw away people even before their brains have finished maturing.

Other cultures do things differently. Whereas we focus on liberty and autonomy, other countries focus on the value of the family as a unit. I have learned that Iraq is one such culture. Are we right? Are they right? What can we learn from one another, and from the way different cultures have chosen to do things?

Iraq has an estimated 100 psychiatrists for its estimated 31 million people – that is one psychiatrist per 100,000 people. If 10% of people suffer with mental illness (a very conservative estimate given all of the trauma that Iraqis have experienced), then each Iraqi psychiatrist alone is responsible for the needs of 10,000 people. Quite a caseload. By contrast, there are about 38,000 members of the American Psychiatric Association – and perhaps two thirds of American psychiatrists – including many who work in correctional settings – are not members of this organization. The US therefore has at least one psychiatrist per 8000 population, and possibly as many as one per 3000. Things are even worse in terms of other mental health professionals: Saddam needed psychiatrists to medicate people, but he had little use for psychologists or social workers.

So, let's all take a break from our critiques – they are valid, but they are built on a foundation that permits us to want things to be better, and a system that allows us to be change agents from within. Things can always be better, but let's not forget that for most of the world, they are a much, much worse.

In my next blog, I will tell you what we have shared with our Iraqi visitors, and what we have learned from them about doing more with less – a whole lot less.

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at

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