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Psychiatric treatment should always include multiple fronts Addiction assumes prominence in Kuwait

“IN general it’s been shown that most doctors that go into psychiatry have other interests outside of medicine in the humanities, in philosophy, in poetry, in art, and psychiatry, which means understanding the human psyche- that’s where the word comes from, which means to understand the soul in Greek.”
Dr Mohammad Alsuwaidan is an assistant professor of psychiatry at Kuwait University and at the University of Toronto. In Toronto he is affiliated with two divisions; Brain therapeutics and Philosophy, Humanity and Educational Scholarship. He is also the Founding Head of Mood & Anxiety Disorders and Inaugural Director of Education at the Kuwait Center for Mental Health - Kuwait’s national mental health hospital. He is the Associate Director of Psychiatry Residency Training for the Kuwait Board of Psychiatry.

Question: What is significant about psychiatry?
Answer: For me psychiatry was more interesting than other brain related specialties because it was the most esoteric – the area where the brain is a black box most- we don’t understand, and I’ve always had this curiosity, I want to understand what can’t be understood. It had this ambiguity to it and so there are a lot of questions to be asked and a lot of discoveries to be made.
Among the brain related specialties, I found psychiatry in fact had the best outcomes for patients. People who have a stroke see little improvement after, but when someone has depression, which a mental illness as much as a stroke, we see them get better with treatment. I saw people getting better and I could make a difference.

Q: What are the most common illnesses in Kuwait?
A: The most common illnesses in Kuwait are the most common illnesses worldwide. The most common psychiatric disorders are anxiety disorders. Things like generalized anxiety disorder or panic disorder or phobias even, though usually that doesn’t need psychiatric care as much as therapy. Then it would be the mood disorders; major depression and bipolar disorder, those are relatively common, and then you get in to more rare illnesses. Schizophrenia is seen in about one in 100 people. Serious eating disorders – we’re talking about very serious anorexia – is about one in 100 as well. Other things that are common but are often ignored are Alzheimer’s dementia. These actually fall within psychiatry, not neurology.
Addiction is common and becoming more prominent in Kuwait. Things like alcohol use, and abusive marijuana is becoming very common and hallucinogenic drugs like amphetamines and captagon, which are very common. It’s more prevalent as students study abroad and come back. They’re using club drugs like XTC, mushrooms and LSD. That’s an area of concern for all of us working in this field because these have dangerous consequences.

Q: How does the mood and anxiety programme help patients?
A: I run the mood and anxiety program in this room we’re sitting in now. In fact I see patients in the chair you’re sitting in. Often what people want you to tell them is ‘it’s not your fault. It’s not because you’re not working hard enough or because someone gave you the evil eye or because it’s a djinn or because you’re not religious enough. You have an illness, and it’s not your fault, just like it’s not my fault I have seasonal asthma’ and I think often it’s very relieving to people when you can tell them that. I find that’s half the treatment, telling them they have an illness and there’s a treatment for it. I often see people sob a sob of relief and people tell me ‘a weight was lifted off of me because I felt like something was wrong, I just didn’t know what it was.’ Often it’s sometimes months at best or even years before someone finally shows up at a psychiatry office.   
People do suffer in silence and I think it’s because there’s a lack of awareness and we need to do a better job of educating people. I think that rests on our shoulders.

Q: What kind of work is the mood and anxiety clinic doing?
A: The whole idea is that in order for mental health services to progress, we need to move in the same direction as medical health services. There are general services and they’re considered front line. In general mental health has moved from a tertiary service to a primary service because the WHO has predicted that in the next decade five of the top 10 most disabling illnesses are going to be psychiatric. It’s a huge shift. It used to be things like anaemia and cholera and heart disease and malaria. For the next decade, within the top illnesses are depression, schizophrenia, and other psychiatric illnesses, which is why general mental health has moved from a tertiary service to a front line service. Within mental healthcare, the area I cover is more of a specialty service; people often go to a general psychiatrist first, and if someone has a complex mood or anxiety disorder they come to me. The service we provide is a very thorough assessment. Sometimes I see people on the front line. If they have a very clear cut depression or bipolar, post traumatic stress, or something like that, they see me or my team for treatment.

Q: What do you do for patients referred to you?
A: What I try to do is put together a holistic conceptual framework. We look at things with the patient in the center, and four axes. We look at clinical care as just one aspect of it, and then education, advocacy, and research. We try to ensure that every encounter we have with anyone has all those parts or is in some way related to all those parts. Clinical care is obvious; people come in and have an hour long assessment with me and my team, and then they have 30-40 minutes of psychometric skills. These are standardized and clinically based, and validated and they’re done in a computerized fashion. That information is anonymized and goes into a research database, so that in a year or two from now we can say the number of people that we saw in Kuwait that have depression are ‘this’ and the things that tend to be correlated with depression are ‘this’ and we can start defining the parameters of mood and anxiety disorders within the Kuwaiti society- whether they may be biological, genetic or affected by the local culture. At that point, the patient has been part of clinical work but has also, in an anonymous way, contributed to understanding these diseases more in our society.

Then there is the advocacy component. One of the programmes we’re doing is psycho-education for families, educating them about psychiatric disorders, for people who are diagnosed with depression or bipolar. We also have the film night I previously mentioned, and lectures. All that fits together, and that is the model we have been using in mood and anxiety that I believe should go on to encompass the whole hospital. Every single clinical encounter should look at the person from these four points; advocacy, education, research, and clinical care, with the patient at the center. 

Q: What does psychiatric treatment entail for the patient?
A: Psychiatric treatment in my view should always include multiple fronts. First of all it does not only depend on the psychiatrist. Ideally a psychiatrist, psychotherapist, social worker, nursing, occupational therapist, nutritionist, physical trainer, the patient’s family and the patient should all be working in perfect harmony. And ideally the psychiatrist doesn’t just prescribe medications- which can be life-saving, but not sufficient for full sustained improvement- but is actually ‘conducting this orchestra’ of treatment. Each of these disciplines represents the multiple aspects of what mental health treatment should entail including biological, psychological and social aspects of treatment. Just like mental illnesses like depression require a ‘perfect storm’ of genetic vulnerability to illness, psychological and social stressors, life transitions and other factors, to manifest as a full-blown disorder, it is thus important to create a ‘perfect wave’ in the opposite direction to ‘right the boat’.

Q: What are patients most afraid of?
A: It’s very hard to answer that question, but a common theme is people are afraid of being labeled as different. There are lots of diseases that have stigma in our society. One of the diseases that has a lot of stigma in our society is cancer. In the west, when people have cancer, they often tell those around them and people rush to their aid and if they survive they’re called a ‘cancer survivor’ whereas here in the Arab world, cancer is called ‘al waram al khabeeth’ which translated means: ‘the cursed’, so people won’t say they have it. People will say ‘sar fee al khabeeth’ meaning, ‘oh he was touched by the cursed disease’, and this happens in mental illness as well. People are afraid of being labeled as different, never getting a job, never getting married, never having kids, never being part of society. The message I often have to say is they don’t have to worry about all this. In many cases that I see, people can live long, productive lives with a full quality and quantity of life if the disease is well treated and people stay on the treatments that work for them.

Q: How do the facilities in Kuwait compare to the facilities you’ve seen and worked in abroad?
A: There are certainly differences. In general facilities in North America are better equipped. In Kuwait we have a lot of patient beds and hospital space, but it is lacking in equipment that is essential to make it functional. Things like computers, connectivity, and rooms equipped for counseling and family meetings and staff safety infrastructure are far behind. We do have a few beacons of progress however; the patient gym at the hospital is better than any I’ve seen anywhere. Our public spaces such as the main hospital atrium and gardens are beautiful and help create a therapeutic milieu. What we need is better utilization of the spaces we have. Sometimes little things like art, comfortable seating, better finishing of paint and floors, and improved technology can make all the difference.

Q: What challenges with practicing psychiatry do you find in Kuwait?
A: There are challenges to working in Kuwait but there’s also a lot of opportunity. It’s a blank slate; you can build whatever you want. You have the freedom to build any system and go beyond the imperfections that you’ve seen in the system in other places. For example, I can look at the system in North America and say ‘that worked pretty well, except for this’ and build a system that goes beyond that, and that’s what I’ve been trying to do. When you do the job and you’re dedicated, you find that the country and the people support you.

Kuwait supported me in all my training, paid for all my scholarships and so on and so there’s an ethical and national obligation to come back and serve, and beyond that it’s an area that I feel like I will impact more, where I feel my job in the scientific community will create the most ripples and touch the most lives. Certainly I can help a lot of people in Canada or the US but I feel like, with my training, I can affect a lot more lives in Kuwait because there are so few people that do this work here.

Q: Are you finding it easy to implement the system you want?
A: Easy is a tough word, it’s not easy, it’s difficult work, but I’m finding a lot of support and that’s something that has pleasantly surprised me. Whether it is people in the ministry or in Kuwait University, my direct supervisors or higher ups have been generally supportive when an idea makes sense, and that I am very pleasantly surprised with. What’s hard is that in many things everyone at the level I’m trained at is working in their own area. I’m the only one in mood disorders and so the problem is that within your area you tend to be an only one-man or one-woman show. The difficulty is training people around you to reach a level where they will be independent. Another difficulty in Kuwait is that stigma is much higher. It’s something we’ve been trying to battle.     

Q: Why do you think there is a stigma within Kuwaiti society?
A: In general, stigma is everywhere, although it’s higher here. Let’s go to the original reasons as to why there’s stigma anywhere in the world; if you had difficulty breathing because you have bronchial asthma, no one is going to say to you ‘why don’t you just breathe?’ they’ll say ‘oh you poor thing, let’s give you your ventalin inhaler, let’s take you to the hospital.’ When something is biological in the brain, but it affects your behavior, it’s very difficult for anyone to understand that how a person is talking to you, how you’re relating to others, if they’re impolite or unrefined, it’s not because they want to be. When they’re responding to hallucinatory voices, it’s not because they’re crazy, it’s because their brain is sending signals that are incorrect. It can be very difficult to separate that.

 In Kuwait specifically the stigma is because there’s a lack of awareness of these conditions more so than in the West. There’s a great book called ‘Paradigms Lost’ which talks about stigma. Originally in Arab and Islamic societies, stigma used to be a lot less than most countries and it’s because our societies are very family oriented. When someone was ‘crazy’ their treatment was to be taken in and spend time in the mosque or a place of worship and people would treat them with compassion and kindness. Unfortunately with time, we’ve lost those values and we’ve adopted other values that are foreign, in fact, to our societies. Those are some of the causes of stigma that we’re trying to battle in this hospital.

Q: What information is available for people?
A: Until recently there was very little information available in schools, and that’s something we’ve been working on. One of the things we’re doing in my unit is creating a set of very well designed brochures on mental illnesses that emphasize that they’re illnesses, that they’re disorders in Arabic. For example the one we’re working on now never mentions the word “ikti’ab” which is depression in Arabic, without saying “marad al ikti’ab” meaning the ‘illness’ depression because the ‘illness’ depression is different to the feeling depression. We can feel depressed; it’s a normal human emotion. If you never feel depressed, how do you know what happy feels like? But depression as an illness has a lot more things than just feeling sad. It involves changes in your appetite, in your sleep, in your concentration, in even motoric function of your body, and so you need that written in a way that’s very easily digestible for people to understand that.

One other thing that my unit is working on is a ‘mental health’ movie night where once a month we show a movie. It can be a Hollywood movie that has a character that has a mental health condition, even If the movie is not about the mental health condition. After we watch it we discuss the movie with the audience. We’ve been planning that for months, but our first trial was a few weeks ago, and it went relatively well. It went so well that now we are in negotiations to take it to a bigger level and possibly host it in one of Kuwait’s cinemas once a month and have a bigger audience, which would be a great way to achieve awareness. There are other people working at this hospital, besides myself, at going to schools. That’s something that’s going to be starting in September; we will be going to universities and high schools and sending experts to all these different schools to talk about what is depression and what is anxiety, and when does it become a disorder, and when should you seek help. I think eventually we will get billboards and television spots and walkathons and all these things, to create a culture where it’s ok to come out with the fact that you’re suffering and that you need help and going to the doctor is no longer stigmatized.

Q: Is there a system implemented in Kuwait where cards are given to patients considered mentally unstable?
A: I’ve been in Kuwait for coming up to a year now, and this is one of the biggest urban legends in Kuwait over and over again, that people diagnosed at the Kuwait Center of Mental Health as mentally ill get cards and these cards get them out of trouble. I’m one of the lead psychiatrists at this hospital and I’ve never seen those cards and I’ve never seen them in any operational policy or dispensed to someone, or seen anyone dispense the card, so it’s a complete myth that’s totally made up and it’s been propagated through social media and so on.

Q: Why does the information for treatment of psychiatric illnesses change so often?
A: I would say in medicine in general, a lot of things in other fields like with the heart have already been discovered. All the brain related specialties are developing at such a quick rate, not just psychiatry. In the brain we have a hundred billion neurons- about the same number of neurons as stars in the Milky Way galaxy. Each neuron has about a thousand connections, so we’re getting to an order of trillions when we’re talking about connections in the brain and we haven’t mapped out any of this.
One of the biggest myths is that we use ten percent of our brains. That’s absolutely false, we use 100 percent of our brains, but we probably only understand only ten percent of it, and so I would say even when I started training in psychiatry which was about 9 years ago now, things have changed so many times since my training that I’m constantly reading and keeping up and it’s because the brain is still being discovered.

Q: How does teaching help your work in the Kuwait Center of Mental Health?
A: My primary job is being an assistant professor at Kuwait University. I often work with senior medical students in their final year and residents who are doctors training for psychiatry, who sit with me in the room while treating a patient. There’s reasons why in all the top universities in the world you will find the best expert in a field with students; the superficial reason is that they want to see who will be the next best doctor of the next generation. The other reason is that it has been shown that when top notch doctors have students nipping at their heels all the time, it forces them to stay up-to-date, and always be teaching. It forces them to always be well read, up to the last week. I had a patient here and I said ‘according to a study published last week, we should be doing this, this, and this’ and that’s a direct consequence of teaching all the time so I have to stay up-to-date.

Q: What do you hope will be your ultimate impact on the mental health of Kuwait?
A: While I work on many aspects of mental health care in Kuwait, my ultimate hope is that I would be able to help create a culture of excellence in this area. What I mean is that I hope that my lasting impact is that individuals I treat, or teach, or interact with or supervise, adopt a holistic view of mental health, which is patient-centred at its core, but relies on the very best interventions on clinical, educational, research and advocacy fronts. When and if that becomes the pervasive language and culture in mental health in Kuwait and the wider region, I would feel that my vision is realized. But of course this will take years of focused, well-planned, teamwork. 


Dr Mohammad Alsuwaidan, 35, grew up in the United States, but completed high school and medical school in Kuwait. He then went on to complete his psychiatry residency, mood & anxiety disorders fellowship and medical education fellowship at the University of Toronto. He also trained in mood disorders at the Stanford University bipolar clinic and the Tufts Medical Center mood clinic. He completed a Masters of Public Health (MPH) at Johns Hopkins University. Dr Alsuwaidan is a Fellow of the Royal College of Physicians and Surgeons of Canada and a Diplomate of the American Board of Psychiatry and Neurology.

By: Dr Mohammad Alsuwaidan

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