Iran has been in the centre of political discourse, posing one of the most significant international geopolitical challenges for the west and its own region since the revolution that created the Islamic Republic in 1979. The country has experienced immense challenges including an eight-year war with Iraq, severe economic sanctions and extreme economic mismanagement leading to high inflation, instability and crippling unemployment.^[1] Iran’s upheaval and political metamorphosis from the disputed presidential elections of 2009 and its ‘Green Revolution’, to the recent signing of the nuclear agreement with the West have been regular news features and continues to bewilder political experts. The agreement has opened new economic opportunities and political challenges that are sure to change the landscape of Iran and the Middle East for years to come.

Behind the cacophony of the deafening political noise, the country has changed dramatically in the last 37 years. Iran is a young nation with more than 70 per cent of the population at under 30 years of age. Almost 50 per cent of university students in Iran are women, however almost 65 per cent remain unemployed after graduation. There have been great advances in women’s education but the plight of women and their rights continues to plague Iranian society. In particular, access to healthcare, specifically mental health support, continues to be a major challenge and crisis in the country.^[2]

Despite many of the political upheavals in the country, there have been some significant changes and improvements in the Iranian healthcare system. The primary health care system in Iran has been seen as an important model of delivery, following a vast expansion that provided access to basic medical and mental care. 3 This is as a result of a national policy that was established in 1986 that focuses on advocacy, promotion, prevention and treatment, along with rehabilitation. Iran has developed a vast network of community health centres and services.^[3] The country spends approximately $40 billion (about 4.2 per cent of its GDP) on healthcare. Some impressive results have been observed, and though life expectancy lags behind some western nations, it is regionally superior with life expectancy of 76 years for women and 72 for men. Given the sanctions, Iran has developed a robust pharmaceutical production sector that manufactures over 96 per cent of its medicines at an annual cost of around $1.2 billion.^[4] There are between 0.5 to 1.1 physicians per 1,000 population depending on location around the country, which is at about the minimum recommended by the World Health Organization and is comparable with other similar countries.^[5] Therefore, despite the improvement in primary health care, Iran still has a shortage of physicians and its healthcare system is struggling to evolve in order to serve a growing population with increasing healthcare demands.

Mental health has also been a beneficiary of the public policy of investment into the primary and the overall health care system in Iran. However, the funding for mental health lags behind, mirroring the financial and resource challenges seen in many other nations where mental health is not prioritized for a variety of reasons. Iran spends only three per cent of its entire health expenditure on mental health (approximately 1,200,000,000 tumans^[6]).^[7] There is no national data on mental health disorders and hence most statistics are from independent sources. This data shows that between 14 per cent to as high as 26 per cent of women and between 7.3 per cent and 15 per cent of men in Iran suffer from mental health disorders. These figures are even more stark for those older than 65 at almost 32 per cent and even more worrisome for those who are widowed or divorced at 43 per cent. Unemployment is a common predisposition for mental health disorders, increasing the odds by 1.8 times. There are an estimated seven million people suffering from mental health disorders in Iran, which is thought to be a significant underestimate due to the lack of proper available national data. In short, women are twice as likely as men to be affected by mental health conditions in Iran, due to a multitude of complex reasons such as gender bias, reporting issues and attitudes about mental health.^[8]

The strengths of the mental health system in Iran include the availability of a national program on mental health, a week in October of each year dedicated to improving mental health awareness, wide coverage in rural areas, and a significant number of the population being covered widely by trained primary health care providers, approximately 28 million people. There is a major emphasis on outpatient versus inpatient treatment, with an availability of major psychotropic drugs to over 53 per cent of the population who have access to at least one class of drugs at a low cost of about 2-4 per cent of the minimum daily wage.^[9] There is a greater integration between mental health providers and primary care physicians in rural areas when compared with urban centres, and a general availability of mental health disaster preparedness. There are approximately 61 mental health care professionals per 100,000, exceeding Iran’s geographic neighbours (including 1.2 psychiatrists, two psychologists, 10.7 non-psychiatric doctors and 7.8 nurses per 100,000). Outpatient facilities are actively engaged in treatment, reaching about one in 100 of the general population.^[10]

Weaknesses of the Iranian mental health system include the lack of legislative or legal parameters to reduce or discourage discrimination against those affected by mental health disorders. The urban poor have persistent issues including lack of access to proper diagnoses and on-going treatment. The chronic nature of mental health needs places many at a disadvantage in receiving long term care, given the health system’s fiscal challenges. Furthermore, the continued stigma associated with those affected by mental health disorders only serves as an added obstacle. In a survey of patients affected by such disorders, more than half felt isolated, discriminated against and crippled by the social stigma attached to mental health problems.^[11]

Women make up 49.6 per cent of the population in Iran and their mental health poses a serious public health issue given their role as primary care givers and educators of children.^[12] Hence, the effect of womens mental health creates ripples throughout their families and through wider society. With reports as high as 25 per cent (as high as 36 per cent in the capital, Tehran) of women affected by mental health disorders, this area of healthcare needs to be a major priority for the country and society.^[13]

There are some unique issues that women in Iran contend with. Women in Iran have enjoyed wide access to education and the ability to vote and participation in the workforce; however, there is a dichotomy in their role in society, their overall standing and rights are inferior to men and subject to arbitrary rules such as on clothing, their roles in society and the household and persistent male dominated attitudes that hinder their progress. There are some determinants that further predispose women to mental health disorders in Iran. The first comprises the social determinants of health, which entitle women to equal social positions with men regardless of their socio-cultural classification. The second area is directly related to the health system and its response to women’s needs; there is a lack of serious prioritization of the mental health of women among other health issues affecting women such as cancer that hampers the dialogue and the opportunity for real, effective changes. The system can prove to be fragmented, overburdened and at times unable to have fully trained and able personnel to deal with the increasing mental health needs of the population.^[14]

Furthermore, there are cultural and social factors that also predispose women to mental health disorders. Worldwide violence against women is an epidemic with almost one in three women being affected. Reports of Intimate Partner Violence (IPV) in Tehran are as high as 36 per cent, realizing that like other parts of the world, this data represents a significant under reporting of cases of IPV. [2 This is a sensitive issue in Iran given society is male dominated with prevalent attitudes that view women’s role predominantly as maintaining and caring of the household regardless of employment. There is a pervasive attitude that is further enforced by the media that women have ‘second-class existence’ in Iran. These forces continue to perpetuate a culture that condones violence against women and laws that protect women are vague and poorly enforced.

The medical system in Iran does not allow for men to be involved in the care of women due to religious limitations in medical schools and beyond, and are therefore not well trained or sensitized to women’s health issues. The majority of medical healthcare providers are selected from these same graduates and doctors, who are neither passionate nor experienced enough when it comes to women’s health, particularly mental health. These are among other significant factors that further complicate and impinge on the development of a proper women’s mental and physical health program.[4

Revolutions, civil conflicts, wars and economic and societal pressures have significantly impacted on women’s mental health in Iran. Research from other countries afflicted with war and instability suggests that women are at a much higher risk of mental health disorders such as post-traumatic stress disorders and depression , in addition to a system-wide lack and sensitivity in addressing such chronic debilitating disorders.^[15] The chronic exposure of women to such stress factors and the continued struggle for basic rights and recognition of equal status places women at higher long -term risk of mental health disorders. Hence, these factors must be considered when public policy is reviewed and resources allocated.

There are no simple solutions to a complex problem that encompasses cultural, societal, economic and structural determinants. However, there are potential solutions that can be reasonably implemented within the constraints of the advantages and disadvantages of the mental and overall health system in Iran.

The primary health care system in Iran is robust and covers a large portion of the population. This expansion has positively impacted rural areas; however, the urban poor, particularly in the capital, Tehran, continue to have serious challenges of access and obtaining proper care from mental health services. The women within these particular populations are at high risk of IPV and economic and social stresses that place them at great risk of suffering from mental health disorders that will, as a knock on effect, afflict not only their children and families, but also the wider community.

An untapped resource in Iran is the large female university population who also currently show a strong sense of social activism. A pilot program engaging this group of women – creating ‘mental well-being promoters'- is one possible approach. The name places the focus on ‘well-being’ rather than ‘disorders’ when it comes to mental health issues; and by changing the vocabulary these women’s narratives can be redefined as their own.

The aim would be to provide training to these ‘mental well-being promoters' in the basics of mental health issues and the crises affecting women in Iran. They would form small citizen groups who would volunteer to be dispatched to a small pilot area, in a poor urban region. Work would be undertaken in collaboration with existing primary health care providers to help identify those women at risk and encourage collaboration with primary health care providers to work to reduce social stigma, improve access to care and enhance awareness about mental health and the need for proper diagnoses and treatment.

This approach could utilise the existing rich resource of primary care providers and tap into the resource of young and socially motivated women who would then help bridge the gap between the healthcare system and women at risk. A simple survey and needs assessment could be carried out in local community health centres to identify those at higher risk of mental health disorders as well as addiction to opiates (which is both an epidemic in Iran given the wide availability of smuggled opiates across the Afghanistan border, and also exacerbates pre-existing mental health illnesses).^[16]The addiction crisis in Iran, which is estimated to be at least between five and seven per cent of the population, with true estimates likely to be much higher, is a recognised public health problem in Iran and hence such efforts combining addiction and mental health may provoke less intense barriers to implementation.

The other approach must be a more comprehensive education of the primary care providers in Iran about mental health disorders and a more systematic recognition through careful surveys that can heighten a clinician’s ability to identify, diagnose and treat such disorders. There is a significant gap in refresher courses for primary care providers in Iran on mental health issues that place them and the population at great disadvantage when it comes to diagnosis, proper treatment and follow up.^[17] This gap can be addressed through sustainable change to the medical education system in Iran.

Another key component is to reduce social isolation and improve treatment follow through by creating small support groups made up of the same university educated women, including women from other strata of society. These groups would help provide a supportive network after the initial diagnosis and treatment to help maintain long term treatment and support plans needed for most women suffering from mental health disorders. This step also reduces the burden on the primary care providers and enables them to have ‘extenders’ that complement their efforts, creating a large support and follow up network necessary for implementing successful mental health treatment programs. There is data to support the case that such approaches may prove helpful in treating long term and chronic health issues.^[18]

The former (the first and only female) Vice-President of Iran, Masoumeh Ebtekar, or other prominent females in Iran should also be approached to be spokespersons for increasing awareness, reducing stigma and improving access to diagnoses and treatment of mental health disorders among women, with an emphases on reducing IPV, substance abuse and addiction. This emphasis on public health awareness can increase pressure on the Ministry of Health and its Minister, Dr. Hassan Qazizadeh Hashemi, to perhaps appoint a prominent female scientist or physician to champion the issues affecting women’s overall and mental health in the country.

This might prove to be a useful tool for discussions to increase the funding available for mental health to be increased from three per cent to at least 10 per cent of the health budget over the next 10 years. The timing for such a move is perhaps opportune as Iran is re-entering the world community after the lifting of sanctions and a pivot towards an intensified emphasis on women’s health, mental health and rights can only increase and enhance the government’s standing with other developed nations. A large network of mid-level trained ‘mental well-being promoters’ of women who can be easily trained to help identify and bridge the gap between the population and healthcare system would empower women and make them part of a solution that can only benefit the system as a whole.