https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article Depression and Anxiety among Iraqi Women: A Systematic Review ABSTRACT INTRODUCTION Women’s mental health is increasingly being recognized as an essential public health subject. This is true considering that by 2020, the World Health Organization (WHO) projects that depression will be the leading cause of disability among women [1]. An estimated 4.4% (322 million people) live with depression and 3.6% (263 million people) live with anxiety globally [2]. Women represent a greater proportion of the population diagnosed with both depression and anxiety [2]. Because the global rate of mental illness diagnoses increased nearly 20% over 10 years from 2005 to 2015, , mental illness in the form Background and objective: Maternal mental health is considered an important subject among leading public health experts. Women are two to three times more likely to be diagnosed with mental illness compared to men. According to the World Health Organization, depression will be the biggest contributor to burden of disease among women by 2020. Chronic stress, experiencing war, and history of abuse are associated with mental illness. Iraq has experienced years of challenging circumstances due to the political and social environment as well as physical barriers to health care services. This paper presents findings from literature about mental illness among Iraqi women. Methods: A comprehensive literature review was conducted using PubMed, Google Schol- ar, and EBSCO Academic Search Complete to identify studies focused on mental illness in Iraq. Search terms included: maternal, anxiety, depression, Iraq, Middle Eastern and North African region, and women. Cross-sectional, cohort, and case-control studies were includ- ed. Results: Five papers were found that focused exclusively on mental illness in Iraq. Two de- scribed maternal mental illness and three focused on mental illness in the general popu- lation, with two of the three including information specific to women. Results suggest that the rate of mental illness among Iraqi women is not different from women in other coun- tries. However, because there is a difference of seven years between the Iraqi- focused study and other global studies, additional new research is required to best com- pare rates. Interestingly, Iraqi women experience maternal mental illness at higher rates than other women. While the global average rate for mental illness in pregnancy or the postpartum period is estimated at 15-20%, 37.5% of Iraqi women experience anxiety and 28.5% experience depression. Conclusion: Additional study focusing on women’s health and maternal mental health is necessary to describe women at highest risk for mental illness and to inform strategies to prevent and manage maternal mental health to promote women’s health. Keywords: mental disorder; women; mental health; Iraq; Kurdistan Kathryn Mishkin; Global Institute for Health and Human Rights, University at Albany, NY USA (Correspondence: kmishkin@albany.edu) Bibi Chaterpateah; Global Institute for Health and Human Rights, University at Albany, NY USA Valerie Bresier; Global Institute for Health and Human Rights, University at Albany, NY USA Jaleen Fraser; Global Institute for Health and Human Rights, University at Albany, NY USA 85 Erbil Journal of Nursing & Midwifery Received: 6/6/2018 Accepted: 22/10/2018 Published: 30/11/2018 https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article of depression and anxiety is important for women’s health [3]. Leading public health experts have begun to recognize maternal mental health as a growing topic of concern [4, 5]. Defined as occurring in pregnancy and up to one year after pregnancy, maternal mental illness in the form of depression and anxiety are estimated to impact 15 to 20 percent of women globally [4]. This is because maternal depression and anxiety impact quality of life significantly through symptomology of loneliness; obsessive thoughts; feeling a loss of control and/or guilt; diminished concentration; loss of interest in activities; and fear of harming themselves and their infants [6]. While rare, women with maternal mental illness are at higher risk of attempting suicide than women without maternal mental illness [7, 8]. Comorbidity of these mental illnesses occurs routinely in the maternal period, with one study estimating that up to 80% of women who experienced maternal anxiety also experienced depression [9]. A 2013 WHO systematic review of mental disorders during pregnancy and the year after birth found that women in low- and middle-income countries including Nigeria, Vietnam, Bangladesh, Pakistan, Ethiopia, India, Zimbabwe, Uganda, and Thailand experienced maternal depression and anxiety at higher rates (20%) than among women in high-income countries (16%) [10]. Women are diagnosed with depression more often than men in both the Middle Eastern and North African (MENA) region and the rest of the world [11]. Depression is consistently ranked among the top 25 leading causes for disability adjusted life years in the MENA region [12], with depression and post-traumatic stress disorder considered the most common disorders. [11].Because of the timeliness of this topic, this paper presents a literature review focused on depression and anxiety among women in Iraq. The citizens and residents of this country have experienced years of challenging conditions due to conflict, political issues, and physical barriers to health care because of distance and quality of transportation [13]. Because factors including socioeconomic status [14-16], chronic stress [14-16], and history of abuse [17-21] are associated with mental illness, it is likely that Iraqi women are at especially high risk of developing these disorders. Furthermore, the underdeveloped mental health infrastructure within Iraq serves as a significant challenge to providing patients with needed services, for example there are only four psychiatrists per one million residents [22]. As a result, one Doctors Without Borders study finds that institution-level and community-level mental health services are lacking [22]. To describe women’s depression and anxiety in Iraq, a comprehensive systematic literature review was conducted in 2018 using PubMed, Google Scholar, and EBSCO Academic Search Complete. Studies were included if they were published between 2000 and 2017 and if they indicated an official measurement tool for the mental illness. Search terms were in English and included: “maternal”, “anxiety”, “depression” “perinatal”, “postnatal”, “postpartum”, “prevalence”, “Iraq,” “MENA region”, “women”, “risk factor.” Cross-sectional, cohort, and case-control studies were included. While little is known about mental illness in the form of depression and anxiety in METHODS 86 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article Additionally, depressive disorders were three times more prevalent among females than males, and the lifetime prevalence of severe depression was significantly different by gender, with prevalence higher among women [4.9%] than men (2.1%) [23]. Women were also significantly more likely to experience anxiety disorders compared to men, with 1.26 women experiencing anxiety for every 1 man [23]. Among women, depressive disorders were more common among those with lower levels of education and among those who had been previously married and are now either divorced, widowed, or separated [23]. People who have been affected by war are also at a greater risk for depressive disorders [23]. Research focused on attitudes towards mental illness among Iraqis demonstrates that there are differences in how men and women perceive mental illness. Women are more likely to consider mental illness to be as a result of genetic inheritance or due to social situations, men are more likely to consider mental illness to be due to personal weakness or as a form of punishment from God [13]. Barriers to mental health service provision are due to a shortage of the public health infrastructure in general, where providers, medications, and supply chain are lacking [6]. Maternal mental health has also not been the focus of much research in Iraq. Two studies were identified including one that focused on maternal depression and one that focused on maternal anxiety. These studies are described in Table 2. A maternal depression study was conducted in maternal health centers in Erbil city, Kurdistan region and screened women at six to eight weeks postpartum in Iraq, some surveys have been conducted to estimate the prevalence in the country. In 2015, the WHO estimated that 1,263,249 people were living with depression and 1,520,493 were living with anxiety in Iraq [3]. The only comprehensive national sur- vey that collected prevalence rates of men- tal disorders to-date was the 2006/2007 Iraq Mental Health Survey (hereafter re- ferred to as IMHS 2006/7), which sampled households to estimate mental illness prev- alence overall and by region. Major depres- sive disorder was found to be the most common mental health disorder in Iraq, affecting about 475,000 Iraqi adults aged 18 years and older [23]. Of these cases, 46% were severe or very severe cases, as defined by suicidal thoughts and ideations [23]. However, these numbers increased over the course of eight years. The lifetime prevalence rate for any disorder was 18% on average [24], 21.13% in the Kurdistan region, and 15.69% in the South/Center region [23]. Urban areas had a higher prev- alence rate (4.06%) for severe depressive disorders, compared to rural areas [2.51%] [23]. Furthermore, 3.5% indicated they had considered suicide recently [23]. Among children younger than 16 years, 37.4% were estimated to live with any mental dis- order, with girls affected 22 times more often than boys [25]. Few reports or articles have been written about the prevalence of depression and anxiety explicitly among women. Using reports that exist for adults in general, it is possible to obtain women-specific information. This information is displayed in Table 1. For example, the IMHS 2007/7 indicated that women are significantly more likely to experience lifetime prevalence for any mental illness disorder is (19.5%) compared to men (13.7%) [23]. 87 Erbil Journal of Nursing & Midwifery Maternal mental illness in Iraq Mental illness among women in Iraq https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article the Kurdish language [6]. The study found a prevalence rate of postpartum depression to be 28.5%, with the prevalence lower among younger women compared to older [6]. Postpartum depression was significantly associated with low socioeconomic status, having a prior history of psychiatric illness, having a family history of psychiatric illness, Cesarean section delivery, and a history of physical and/or sexual abuse [6]. This study served as the first validation of the Edinburgh Postpartum Depression Scale (EPDS) in the Kurdish language [6]. A case-control study focused on maternal anxiety demonstrated that women living in Mosul identified a prevalence rate of 43.5% using the American Psychiatric Association scale [26]. Women who delivered prematurely were 1.8 times more likely to suffer from anxiety than women who delivered full term (95% CI: 1.19–2.72; p<0.01) [26]. Adjusting for covariates, women who delivered prematurely were 2.16 times more likely to suffer from anxiety than women who delivered full term (95% CI: 1.28-3.64; p<0.001). 88 Erbil Journal of Nursing & Midwifery Table 1: Mental illness among women in Iraq as identified through national surveys Study Type men- tal illness Year pub. Size sam- ple Year data collect Description Highlighted results Iraq Fami- ly Health Survey Report 2006/7 Depression Anxiety 2009 9345 2006- 2007 Sample one adult per household across country, aged 18+ years using Compo- site Interna- tional Diagnos- tic Interview 19.5% lifetime prevalence women 14.1% lifetime prev. anxiety women 4.9% lifetime prev. depression women; Mental Health in Iraq: is- sues and challenges Depression Anxiety 2013 4332 2007- 2008 Opinion article Est. 100 psychiatrists total in country Barriers to mental health services include scarcity of resources, lack of access, stigma Public perception of mental health in Iraq Stigma of mental illness 2010 418 2010 Non- experi- mental random field research survey in Bagh- dad; system- atic sampling of adults aged 18 years and older Women more likely than men to consider mental illness to be due to: Genetic inheritance [31% vs. 25%]; Bad things happening to a person [45% vs. 40%]; Men more likely than women to consider mental illness to be due to: Personal weakness [39% vs 36%] God’s punishment [18% vs. 14%] https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article This paper presents the first systematic review of the literature describing women’s mental health and women’s maternal mental health in Iraq. While very little literature exists, what has been written suggests that women are at high 89 Erbil Journal of Nursing & Midwifery DISCUSSION Table 2: Literature focused on maternal mental illness in Iraq Study, authors Type men- tal illness Loca- tion Year pub. Size sam- ple Year data col- lect Sample descrip- tion Measure- ment tool Results Risk Fac- tors for pre- term birth in Iraq: a case con- trol study Anxiety Mosul 2006 200 2003 -2004 Women with live preterm birth 29- 37 weeks American Psychiatric Association Scale 43.5% had anxiety symptomology. Preterm birth associated with maternal anxiety Screening for post- partum depression using Kurdish version of Edinburg postnatal depression. Depression Erbil 2011 1000 2010 Women ages 14 to 48 years, 6-8 weeks postpar- tum Edinburgh Postpartum Depression Scale 28.5% had depression symptomology. Depression significantly associated with low SES [p=0.002], unplanned pregnancy [p=0.008], self/ family history of psychiatric illness [p<0.001], Cesarean delivery [p=0.019], physical/sexual abuse [p<0.001] https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article 2006/7 demonstrated that Kurdistan’s prevalence rate was 21% compared to 15% in the South/Center region, and because women were demonstrated to experience symptomology significantly more frequent- ly than men [23], it would be helpful to un- derstand the role that region played in rates among women. This same analysis may be applied for other sociodemograph- ic characteristics as well as behavioral characteristics. Further study related to maternal mental health is needed in Iraq as well. The two studies included in this literature review suggest that Iraqi women experience mental illness at significantly higher rates than women in other coun- tries. Whereas the global prevalence rate for maternal depression and anxiety is be- tween 15-20% [4], the two studies cited reported rates of 28.5% and 43.5%, respec- tively. It is unclear why women in Iraq would report mental illness symptomology at such high rates. Due to the recent vio- lence in wars, women may have been im- pacted through experiencing sexual and physical violence or through widowhood or separation from their husbands [23]. Research has found that physical and sexu- al abuse is closely associated with a history of abuse [17-21] and with chronic stress [14-16], so women may be particularly sus- ceptible to mental illness during pregnancy and one year postpartum. Recommenda- tions include more research focused on maternal mental health in order to under- stand which women are at highest risk and also to inform larger-scale strategies for maternal mental health prevention and management. Finally, development of the Iraqi workforce to identify and treat mental illness is need- ed. Midwives are in the unique situation of being able to provide physical care and emotional support to women in pregnan- cy, labor, and after delivery [5]. risk of mental illness because of social and cultural norms and events. There are also significant barriers to receiving mental health services because of infrastructure challenges and perceptions of stigma at the population level. The prevalence rates of mental illness among women suggest that Iraqi women suffer from mental illness about as frequently as women in other areas of the world. Globally, the WHO estimates that the average prevalence rate for mental illness is higher in low-income countries (20%) compared to women in high-income countries (16%) [10]. This proves to be true for Iraq, a low-income country, as the prevalence rate of mental illness for women is 19.5% [23]. It is worth noting that the most recent national survey of mental illness among women occurred over 10 years ago in 2007 [23]. Because other countries have reported mental illness prevalence much more recently, comparing the prevalence rates of Iraq and other low-income countries might not be useful, especially as prevalence rates of mental illness have been increasing since 2003 [3]. New comprehensive research exploring mental illness throughout the country is needed to update our understanding of how many in the population is impacted by depression and anxiety. Without this research, it is nearly impossible to appropriately make cross-national comparison of rates of mental illness. Additionally, new research is needed to focus exclusively on women. While the IMHS 2006/7 presented mental illness rates by gender and across regions, age groups, etc., it did not stratify rates by gen- der and other factors. Without stratified rates by gender, it is difficult to describe how women within different regions may be disproportionately affected by mental illness. For example, because the IMHS 90 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.11 Erbil j. nurs. midwifery, Vol. 1, No. (2), Nov, 2018 Original Article [1] World Health Organization. Mental health aspects of women’s reproductive health: a global review of the literature . Geneva: World Health Organization; 2009. [2] Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Preva- lence and determinants of common per- inatal mental disorders in women in - and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization. 2012;90(2):139g- 49g. [3] World Health Organazation. Depression and Other Common Mental Disorders Global Health Estimates. Geneva, Swit- zerland: WHO; 2017. [4] World Health Organization. Mental health aspects of women’s reproductive health: A global review of the literature. Geneva: WHO; 2009. [5] Humberstone S. Mental illness in preg- nancy: midwives supporting women and safeguarding babies. Practicing Midwife. 2015;18(9):18-20. [6] Ahmed HM, Alalaf SK, Al-Tawil NG. Screening for postpartum depression using Kurdish version of Edinburgh post- natal depression scale. Archives of gyne- cology and obstetrics. 2012;285[5]:1249- 55. [7] Wallace ME, Hoyert D, Williams C, Men- dola P. Pregnancy-associated homicide and suicide in 37 US states with en- hanced pregnancy surveillance. Ameri- can Journal of Obstetrics and Gynecolo- gy. 2016;215(3): e1-364.e10. doi: 10.1016/j.ajog.2016.03.040 [8] Appleby L, Mortensen PB, Faragher EB. Suicide and other causes of mortality after post-partum psychiatric admission. The British Journal of Psychiatry. 1998;173:209-11. [9] Kendig S, Keats JP, Hoffman MC, Kay LB, Miller ES, Simas TAM, et al. Consensus Bundle on Maternal Mental Health: Peri- natal Depression and Anxiety. Obstetrics While organizational barriers to midwives providing mental health services exist in the form of heavy workload and time con- straints, findings from one study conducted in the United Kingdom suggest that 50% of midwives reported inadequate knowledge about maternal mental health as a key bar- rier for deliveries mental health care [27]. Investment in education for midwives and health care providers attending pregnant women should be a priority in order to im- prove delivery of mental health services, especially in Iraq. Furthermore, it is recom- mended that cultural appropriateness and competency should be a top priority of the training, especially among highly stigma- tized populations [27]. In conclusion, this paper presents findings from literature about mental illness among Iraqi women. Results from this literature review suggest that the prevalence of men- tal illness among Iraqi women is not differ- ent from women in other countries. How- ever, much of the literature is out-of-date. New research is needed to compare de- pression and anxiety prevalence among women between Iraq and other countries. Interestingly, Iraqi women experience ma- ternal mental illness at higher rates than other women. While the global average rate for mental illness in pregnancy or the postpartum period is estimated at 15-20%, nearly 40% of Iraqi women experience anx- iety and nearly 30% experience depression. New research focused on women’s health and maternal mental health is required to describe women at highest risk for mental illness and to inform strategies to prevent and manage maternal mental health to promote women’s health. 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