Since the beginning of 2024, the Razi Psychiatric Hospital in Tunis has received about a thousand patients. Leila Chaibi, a resident psychiatrist at the institution and president of the Tunisian Association for the Prevention and Promotion of Mental Health in Youth, comments that cases of anxiety disorders and depression are on the rise. “The increase in the number of patients leads to longer waiting times for an appointment,” she adds.
Naila Ben Saleh, a psychiatrist and president of the Tunisian Association of Private Psychiatrists, confirms that the national production of certain molecules and generic drugs, which are prescribed to treat diseases related to anxiety and depression, does not meet the growing demand, noting that the market shares of pharmaceutical laboratories have increased significantly. This fact was also confirmed by Noufel Amira, president of the Syndicate of Private Pharmacies when we contacted him about the same subject.
Tunisians’ misery is also reflected in Tunisia’s ranking in the 2024 World Happiness Report, published by the United Nations Sustainable Development Solutions Network. Tunisia ranks 115th out of 143 countries, up from 110th in 2023. The ranking is based on several indicators, including a sense of freedom, absence of corruption, income level and social support. In the absence of official statistics in Tunisia, health professionals resort to concrete indicators related to the number of patients, drug prescriptions and some scientific studies, including international ones, to assess the extent of the ordeal that Tunisians are experiencing.
International orientation
The World Health Organization defines depression as a common mental illness characterized by persistent feelings of sadness and loss of interest in activities that used to be associated with the patient, and it is accompanied by an inability to perform daily activities for 14 days or more. This international organization also emphasizes the need to distinguish between depression and normal mood swings and negative feelings resulting from life’s ups and downs.
Globally, 3.8% of the population suffers from depression, including 5% of adults (4% of men and 6% of women), and 5.7% of people over 60 years of age. The Covid crisis has caused a 25% increase in the number of people suffering from anxiety and depression disorders, according to the World Health Organization. Like other countries in the world, Tunisia has not been spared from the increasing prevalence of diseases related to anxiety and depression, especially after the Corona wave.
Wafaa Hajji, a clinical neuropsychologist at the Health and Psychology Association, points out that this pandemic has highlighted the importance of mental health as a real bet in dealing with the issue of public health as a whole, which affects the entire population. She adds: “The Covid pandemic has greatly contributed to the spread of anxiety disorders and depression.”
In the same context, Naila Ben Saleh confirms that since the outbreak of the Corona pandemic, there has been a real collapse in the psychological balance of a growing segment of Tunisians. Anxiety and depression have emerged. It has even reached the point that some of those who were able to achieve a kind of stability in terms of the psychological disorders they were suffering from have relapsed again.
On the other hand, another worrying global phenomenon has emerged: the harmful impact of social media on people. Happiness is no longer a philosophical question, but a necessity. These doses or scenes of happiness, whether in romantic relationships or in the workplace, have never existed.
“Specialists” of all stripes or fields, if you will, offer their “advice” to their followers on all social media platforms for a fulfilling life and to be happy. This type of content floods the internet and garners millions of interactions on social media. However, what is presented to millions of people is based on material concepts and factors for achieving happiness; money, travel, etc. What has become a real happiness industry that negatively affects mental health.
The repercussions of this phenomenon seem more serious for young people. According to the national survey published in 2023, issued by the Ministry of Health in partnership with the Cooperation Group for the Fight against Drug Abuse and Illicit Trafficking, the use of screens, especially social networks and video games that are supposed to provide “potential psychosocial and cognitive benefits,” is linked to an increased risk of anxiety and depression disorders.
Youth are the most vulnerable group
Wafaa Haji explains that the state of mental health varies from one country to another and from one person to another. It is difficult to generalize the diagnosis of the psychological state of an entire people, because the phenomenon varies according to the personal situation of each citizen. However, the specialist notes similarities in the psychological problems they face, which include depression, anxiety, post-traumatic stress disorder, and disorders associated with drug abuse. She adds that this situation did not start with the Covid crisis, but dates back to 2011.
The number of Tunisians visiting the Razi University Hospital for psychiatric illnesses rose from 4,000 to 5,000 patients per year before the revolution, and that number has doubled in recent years. Although the pandemic period saw a peak in patients coming to the medical facility, the number approached 9,400 in 2019, according to Kamal Ben Rahal, secretary-general of the Razi Hospital’s basic union.
Since 2017, the number of requests for medical consultations related to anxiety disorders and depression has increased by 20%, according to the President of the Tunisian Association of Private Psychiatrists.
Young people are not exempt from this dilemma: according to the 2018 Multiple Indicator Cluster Survey, around 20% of 15-17 year olds suffer from anxiety and around 5% from depression. Moreover, the 2023 National Survey, mentioned above, shows an increase in drug use since 2013. Drug use can be considered a form of “self-medication,” according to our interviewee.
The study also indicates that non-prescription anxiolytics are among the substances that are increasingly popular among young people aged 15 to 17. Their use has increased significantly since 2017 and their consumption exceeds the average recorded among adolescents in Europe. Girls represent the largest group of consumers.
The head of the Tunisian Association of Private Psychiatrists adds that women suffer more from anxiety disorders and depression. The extra pressure due to the worsening of the state of tension resulting from the difficulty of reconciling professional and private life plays a role in this.
A strategic document issued by the Ministry of Health to promote mental health 2024 refers to vulnerable groups; children, women, the elderly, minorities and migrants. This strategy also targets specific environments, such as prisons and workplaces. The aforementioned study indicates that among the causes of psychological suffering among these groups are violence, exclusion and difficulty in obtaining the necessary care.
“The current political, social and economic crisis is making things even more complicated,” explains Naila Ben Saleh. “Previously, patients focused mainly on concerns about their private or intimate life. Today, we hear almost systematically the same discourse. Most of the talk is about the anxiety-provoking environment, such as a sense of instability, insecurity or even a lack of a clear vision for the future.”
The Zionist aggression on Gaza also affected the psychological comfort of Tunisians, according to a survey conducted by resident doctors in the mental health department at Mongi Slim Hospital, revealing the psychological repercussions resulting from following images of crimes committed against Palestinians there.
The survey included 683 people who watched daily media coverage of the aggression. 80.5% of the individuals surveyed reported feeling negative emotions such as anger, despair and sadness. About 12.5% reported feeling guilty.
Stigma is declining but not gone.
Despite the many indicators and data we have been exposed to, they only partially reflect the reality of Tunisians’ mental health. For example, psychiatrist Wahid Malki, professor at the Faculty of Medicine in Tunis and coordinator of the technical committee for the promotion of mental health at the Ministry of Health, explains that the consumption of medications related to psychiatric treatment does not reflect real needs because many do not consult specialists and do not receive the necessary care. The same applies to the real number of suicidal behaviors. The real dimension of psychological suffering is not taken into account. According to a report by the Tunisian Forum for Economic and Social Rights, 121 cases of suicidal behavior were recorded in 2023, which mentioned the obstacles to conducting a census. The report indicates that they are mainly related to “the taboos surrounding this phenomenon.” The majority of suicides are men, including young people, children, and immigrants. Religious factors also play a role in keeping this behavior limited in Tunisia.
It is also difficult to measure the extent of the psychological distress experienced by Tunisians due to the secrecy. Unlike women, and for cultural reasons, men have difficulty expressing their suffering and asking for help. It is considered a sign of weakness that contradicts the concept of masculinity in their culture.
This reluctance to consult specialists when suffering from psychological problems leads to a lack of accuracy in the data available on the mental health of Tunisians. The president of the Tunisian Association for the Prevention and Promotion of Mental Health among Young People confirms that “there is a kind of normalization of this suffering.” The inevitable result will be the continuation of the state of denial about the mental health situation that people face. “People still tend to consult clerics or charlatans instead of going to doctors,” says Leila Chaibi regretfully. In the same context, Neila Ben Saleh adds: “Psychiatric patients are always stigmatized. The very name of a psychiatric hospital is frightening. Stigma sometimes comes from health workers themselves.”
This reluctance to seek help from specialists is evident in the period between the onset of the psychological problem and the date of the consultation. Chaibi warns that this period is 15 months on average and can reach 10 years. In the meantime, the situation is getting worse. This is not without serious consequences for the emotional and socio-economic state of the person concerned.
Here, the psychiatrist notes some developments, as some Tunisians now dare to consult specialists, explaining: “Mood disorders, especially those related to anxiety and depression, are less likely to be stigmatized.” Life coaches are also becoming more common in professional circles, becoming a fashion statement. This widespread phenomenon is causing concern among health professionals.
This concern stems from the fact that consulting with life coaches is viewed as more favorable, says Leila Chaibi. She adds that the obsession with this type of psychological care, if you will, poses “certain risks.” “Coaches see themselves as psychotherapists who can deal with fairly serious illnesses,” she warns.
Stigma and lack of financial resources make it more difficult to obtain the necessary care from doctors, which creates a gap among Tunisians in terms of the ability to obtain psychological care.
under-support
The state’s austerity policy is slowing down the rate of recruitment of psychologists and psychiatrists in the public sector, according to the coordinator of the technical committee for the promotion of mental health at the Ministry of Health. The average density of psychiatrists was 1.26 psychiatrists per 10,000 inhabitants in 2019. It dropped to 1.25 in 2021. The result: the number of specialists in public institutions does not meet the growing demand for psychological consultations, according to Leila Chaibi, who also points to the size of the gap between regions.
The result: some Tunisians resort to private psychiatrists, where the consultation costs 80 dinars, an amount that is not affordable for everyone. Even in the private sector, the situation is not ideal. As the president of the Tunisian Association of Private Psychiatrists points out, “not all patients benefit from social coverage to cover the costs of care.” Moreover, it is unfortunate that the National Social Security and Health Insurance Fund does not cover all medications, some of which have been unavailable in pharmacies for months.
The Technical Committee for the Promotion of Mental Health at the Ministry of Health also noted other shortcomings in patient care, such as a lack of resources, motivation and commitment among frontline doctors in dealing with mental illnesses. It also warned of a lack of awareness campaigns, sensitization and epidemiological data, in addition to the centralization of care at Al-Razi Hospital.
The threat of this situation worsening is increasing with the emigration of psychiatrists and family doctors, according to the strategy of the Technical Committee for the Promotion of Mental Health at the Ministry of Health. They are not the only ones who have chosen to leave the country, as everyone now seeks personal salvation above all else. The president of the Tunisian Association for the Prevention and Promotion of Mental Health in Young People sees the phenomenon as both a symptom and a consequence of mental disorder.
This suffering has significant human, social, health and economic costs. People with severe mental health disorders die on average 10 to 20 years earlier than the general population. The World Health Organization warns that “the economic consequences of mental health problems are enormous. Losses in productivity and other indirect costs to society often far exceed the cost of care itself.”
