Introduction

Since the change in government system in Iran in 1357, from monarchy to Islamic Republic, more than 41 years have passed. The reasons and process of this change can be defined and explained from different perspectives. The achievements and losses resulting from this change can also be analyzed and interpreted in the same way. If a success can be imagined, undoubtedly efforts must be made to preserve and continue it, and if a wide damage and loss is imaginable to this land, how can it be compensated and prevented from further harm.

Reflection on concepts such as homeland and motherland, with their perceived infrastructures, is a sense of unity and cohesion that binds us to a political-geographical unit that we call our land. It is ingrained in our beliefs and thoughts, and we hold it in such high regard that it is beyond imagination. This sense of unity and individual feeling towards preserving the political-geographical unit can only be put into action when the human geographical units of that land also share this belief on a larger scale. Where we stand in the land we now call Iran, with an interpretation of the above definitions, requires another form of reflection, which is beyond the scope of this article.

Each of the units related to human geography of this land can and must ask themselves the question: What have we done with our economy? With our culture, our society, our politics, our health, and our people? And now, in each of these fields, where do we stand in this big world?

The following text is a look at the state of mental health in Iran and what perspective can be imagined for it.

Individual mental health and well-being; definitions and perspectives.

The close relationship between the individual and society, and the influence and impact of these two phenomena on each other, has placed responsibilities on the shoulders of statesmen and political and social systems, which, while emphasizing the physical and mental health of every citizen living in their ruled land, must also give importance to the health and hygiene of that society at a macro level. This perspective, while considering the individual as a vulnerable unit, does not see the society as safe from broader psychological harms. The importance of this issue requires a well-defined program and allocation of relevant budgets by statesmen.

With a closer look at the topic of mental health, it can be said that mental health and well-being go beyond individual mental health, or in other words, an individual with a mental or psychological illness resulting from the social, political, cultural, and economic system of that society. A systemic and cybernetic approach to mental disorders sees the society and the system as the sick entity, which, under the influence of unhealthy dynamics, causes the existing elements in that system to suffer from mental and psychological illness. With this perspective, any diagnosis of an individual with a mental or psychological illness within a social and cultural system will also allow for treatment within that system and through interventions in that system.

Healthy individual – Sick individual from a clinical psychology perspective

Perhaps it can be boldly stated that the comprehensive guide to classification and diagnosis of mental disorders, published by the American Psychiatric Association (1) and reviewed every few years, in its latest version known as DSM-5, has provided a comprehensive definition and discussion of all the mental disorders recognized by psychiatrists and psychologists to date. In this guide, which includes hundreds of disorders and diseases, all mental and emotional disorders, mood and affective disorders, such as anxiety, fears, depression, sleep disorders, eating disorders, post-traumatic stress disorder, and disorders with delusions and hallucinations, such as schizophrenia, as well as diseases related to human growth stages, physical, mental, social, and sexual development have been addressed. What is common in the interpretation of all these classifications is the underlying factors that contribute to the development of these disorders, the time of onset, the level of stress caused by them, and environmental triggers, age, gender, social and cultural status, individual’s affiliation with one

Who is a healthy individual from a clinical psychology perspective? It can be confidently said that we do not have an accurate answer to this question without placing that individual in a broader context such as society. This means that all vital and biological functions, as well as psychological aspects of an individual, cannot be interpreted without defining their presence in the family, workplace, among social groups and related roles, and with their role as a citizen.

In diagnosing a mentally healthy individual, the major diagnostic elements include patterns that the individual carries with them in life. These patterns are based on experiences, beliefs, and values that have formed within society, and ultimately manifest in the individual’s thoughts, feelings, and behaviors.
In fact, the discussion of an individual’s mental health, while emphasizing the existence of intellectual and cognitive parameters for understanding, analyzing, and interpreting events, also extends to managing the individual’s emotions and behaviors.

When events and occurrences in society challenge an individual’s ability to analyze and interpret them, the individual will experience a maladjustment with the external and internal forces surrounding them.

The main biological needs of an individual are formed within society, and the individual shapes their relationships with society based on how society responds to these needs. Although there is no global standard for defining a healthy individual versus an unhealthy one in the realm of individual psychology, it can be clearly stated that social, cultural, and political norms can play a significant role in creating a healthy individual and their adaptability to the complexities and challenges of daily life.

The World Health Organization defines health as encompassing three dimensions: physical, mental, and social well-being. These three dimensions together determine an individual’s level of health or illness. In this definition, the presence of a physical or mental illness does not necessarily mean a lack of mental or physical health.

The World Health Organization confirms that the human being has the ability to tolerate stress, anxiety, and failures to a limited extent. However, if the levels of these stresses and anxieties are so high that they have a significant impact on the individual’s daily functioning, it can seriously endanger their life.

Apart from biological and environmental factors that can shape an individual’s abilities and disabilities, psychological, cognitive, and personality factors can also have a significant impact on a person’s mental health in the presence of biological elements.

The World Health Organization emphasizes the importance of mental health in society for improvement and growth, particularly in children, and states that their future lives depend on having good mental health during childhood and adolescence.

The World Health Organization defines mental health as a dynamic interplay between biological and psychosocial factors. The foundation of this definition is a person who has the ability and potential to establish harmonious relationships with others and their surroundings, understands their social environment, recognizes their abilities, and works constructively and collaboratively with others to bring about social change for the betterment of their environment. “Mental health is the ability to communicate effectively and harmoniously with others, to adapt and improve one’s personal and social environment, and to resolve conflicts and personal desires in a logical, fair, and appropriate manner.” This definition focuses not only on the diagnostic and pathological aspects of a healthy individual, but also on their mental and emotional well-being, intellectual and practical independence in relationships with others and society, and striving for personal growth and fulfillment.

Mental health and global disease indicators studies

Unfortunately, the existing statistics at the global level and in member countries of the United Nations are not generalizable to all member countries due to lack of adherence to a measurement and standard system. The diversity of measurement methods, as well as economic, cultural, political, and social barriers, have deprived the global health system from achieving an acceptable statistic. Different definitions of health and mental illnesses have also been effective in the lack of access to acceptable indicators for prevention and treatment of mental and psychological disorders.

According to studies published by the “Global Burden of Disease” which provides an annual comprehensive assessment of deaths caused by diseases worldwide, in addition to communicable diseases and deaths caused by them, neurological and mental disorders account for more than 10% of the global mortality rate.
In statistics published by “Our World in Data”, in the year 2017, 10.7% of the world’s population suffers from one of the mental disorders, which includes a population of nearly 792 million.

9.3% of this population are men and 11.9% are women. When this statistic is combined with the number of people affected by drug use, psychotropic drugs, and mental illnesses, it reaches 13% of the world’s population and close to 970 million people.
In the latest article published by “Our World in Statistics”, it is estimated that more than one billion people in the world are affected by one or more mental illnesses and drug addiction, and these statistics emphasize the fact that the estimated budget at the level of all United Nations member countries to address this humanitarian crisis is very low.

In the classification of mental disorders, according to available statistics, anxiety disorders with 3.8% and depression with 3.4% have the highest rates of affected individuals.

Iran, mental health

According to the latest statistics published by the Statistical Center of Iran, the population of Iran, based on the results of the 1395 Housing and Population Census, was 79,926,270. With a population growth rate of 1.4% until the end of 1398, the country’s population has reached close to 83 million. By accepting that the global rate of mental illness and drug use can affect 13% of a country’s population, in the best case scenario we are faced with a population equivalent to 10.79 million people in Iran.

The trend of political, social, economic, and cultural events, as well as crises and natural disasters, all indicate that the percentage of people with mental and psychological disorders and drug use in the presence of stress and anxieties resulting from the aforementioned crises must be significantly higher than the global average.

The country’s Statistical Organization has also announced a decrease in Iran’s population growth rate from 1.4% to 0

In a research conducted by a group of psychologists in the field of measuring justice in health during the years 2009 to 2011, the prevalence of mental disorders in Tehran city was 34.2%. According to statistics published by the World Health Organization for the same period, it was around 4.3%.
Dr. Farid Fadaei, a neurologist and psychiatrist and a member of the Iranian Psychiatric Association, says that 20% of the population suffers from one of the types of mental illnesses or disorders, ranging from mild to severe. He also states that although many mental illnesses have a genetic origin, some of them are caused by environmental factors, such as poverty, unemployment, and forced migration due to war, which increases the rate of mental disorders and exacerbates them.

In this regard, Abbas Ali Nashehi, the director of the Office of Mental, Social and Addiction Health at the Ministry of Health, says that the examination of the prevalence of mental disorders at the national level, which has been conducted in recent years, shows that 26% of women and 15% of men suffer from these disorders. This figure, in the most optimistic scenario, includes one-fifth of the total population.

Kourosh Mohammadi, the head of the Iranian Association of Pathology, says that Iran is among the top 10 most depressed countries in the world. He says that “anger in society” is one of the main reasons for creating depression among citizens.

The research results presented by the annual congress of the Iranian Society of Psychiatrists in Mehr 1396 showed that 23.44% of the studied individuals have mental disorders. This study was conducted on 36,000 people in six age groups over 15 years old. The study confirmed that mental disorders are more prevalent in cities compared to villages and rural areas, and have a direct correlation with education and poverty.

Mental health challenges in Iran:

Mental health in a society requires macro-level planning by government systems and legislation in that society. Unfortunately, the officials of the Islamic Republic, who are a major cause of psychological disorders in society and the creation of a mental health crisis, are neither able nor willing to address this widespread crisis. The wide range of challenges in this area has reached such an alarming level that there is no hope for any of the haphazard programs of the Islamic Republic to combat these crises.

One of the social science researchers describes the existing challenges in the way of mental health in Iranian society as follows.

The challenge in nature and name
The challenge in causality
The challenge in prevalence
The challenge in diagnosis
The challenge in treatment
The challenge in stigma
The challenge in costs and overall burden
The challenge in attention from policymakers
The challenge in dealing with support institutions
The challenge in dealing with media
The low level of mental health in Iran is indicative of the fragmentation of society.

Although comparing an individual’s reactions to events, crises, failures, and life perspectives with society and generalizing these reactions in a broader dimension to all members of a community is not a common practice, it can still be found as a concrete example in smaller dimensions.

The occurrence of transformations resulted in changes in the political and social system of Iran, while also creating high expectations among Iranian citizens, it has also led to a wide gap in existing structures. Although it was not long after the uprising of the Iranian people that the new rulers, rejoicing in their victory, imposed their beliefs on other citizens of this land. Executions without trial in the early days of the uprising under the name of executing the leaders of the former regime, the execution of leaders of the Baha’i and Jewish faiths, and the brutal attack on Iranian citizens in Kurdistan, Turkmen Sahara, and other parts of Iran, resulting in the massacre of innocent people, the execution of freedom-seekers, and the suppression of democracy, human rights, and freedom in Iran. It wasn’t long before the cultural and political arenas of Tehran and other major cities turned into scenes of political settling of scores. The Iran-Iraq war, the displacement and homelessness of citizens, the migrations caused by

In the midst of these political, social, cultural, and economic crises and disasters, if we add the environmental catastrophes, the crises caused by earthquakes, floods, widespread unemployment, destruction of the country’s workforce, destruction of economic infrastructure, corruption and theft at a macro level, we can imagine a better picture of the tragedy of the collapse of mental health structures, both on an individual and societal level.

Environmental stresses and increasing pressures at an individual level and at a larger societal level.

Hans Selye, an Austrian psychiatrist residing in Canada, who is considered the founder of scientific research on stress, defines stress as an environmental factor that can directly affect an individual’s psychological system and cause severe physical harm, and its effects can be well defined and explained in the range of physiological functions of the body. In his research on stress, Hans Selye introduced the term “general adaptation syndrome” and reminded us that an individual goes through three stages when faced with stress, and the level of their response depends on the intensity of the environmental stress. It is also important to consider what physiological response an individual will have at each stage. The idea that we live in a country where for the past 41 years there has been a wide range of environmental stressors, affecting a large portion of the population, can paint a devastating picture of the overall mental health of society.

The psychological model of mourning and grieving for losing loved ones and its application to society.

Although there are documented statistics of national disasters resulting from the Iran-Iraq war, widespread massacres in Kurdistan and other regions of Iran, large-scale and systematic massacres of dissidents and political prisoners, unjust executions of a wide range of people in this land under various titles such as fighting drug traffickers, killing and slaughtering of porters and fuel carriers, etc., there is no mention of these examples at a smaller scale, which mourns the individuals associated with the victims, and at a larger scale, mourns the entire society.

Although comparing individual mourning stages with the effects of national disasters on society is not a common practice, in comparing psychological and sociological studies of war-torn and disaster-stricken communities, the process of national mourning shows many similarities with individual mourning on a large scale.

Elizabeth Kubler-Ross, a Swiss-American psychiatrist, says that when we are faced with the death of a loved one, we will go through five distinct stages, which are denial, accompanied by characteristics of shock and intense emotional pain. The second stage is anger. Numbness and rigidity resulting from shock can lead to anger towards oneself and feelings of guilt and blame, as well as anger towards others who may have been influential in the death of the loved one; or could have prevented their death. This state can have profound effects on the individual’s biological responses and functions, and can also bring deep feelings of fear and terror. The individual may cling to behaviors that are not noticeable in the real world, or may not have shown a tendency towards in the real world.

The fourth stage of Kubler-Ross is depression. Restlessness, insomnia, and feelings of guilt and blame can lead to sadness, grief, and depression. Although it is expected that time and going through the natural stages of mourning will help overcome these feelings, returning to the emotional, mental, and physical state before the loss of a loved one is not possible in the short term. Kubler-Ross believes that reaching the stage of accepting the death of a loved one is dependent on going through four previous stages.

Although there is no specific time standard for going through these stages, individual differences can completely change the process of mourning from one person to another.

Unfortunately, Iran has faced repeated disasters, both at the level of individual citizens and at a larger scale, which have added to the peak of the previous tragedy.

The oppressive suppression of the people’s demands in the past few years has pushed society to a high level of anger and collective depression. The desires and aspirations of the people for change in the revolutionary fervor have led to suppression and death of the movement, and now the people, as survivors of this movement, are mourning their suppressed desires and aspirations. It seems highly unlikely that the people can accept the death of their desires and start a new life. The consequences of these changes on the mental health of society include increased public dissatisfaction, increased violence at a wide level of society, increased suicides, and a decrease in overall societal efficiency.

Dr. Ahmad Norbala, a clinical psychology professor at the university, writes in his article on mental-social health and solutions for its improvement: Based on the predictions of international researchers, the burden of depression, accidents and disasters, war consequences, violence, and self-harm has risen from fourth to second place and from ninth to third place, respectively, from 1990 to 2020 (it is worth mentioning that our country is currently in the worst situation in this regard). In this article, Dr. Norbala mentions: “In Iran, the burden of mental illnesses and mental-behavioral disorders has risen to second place after intentional and unintentional accidents in 2003 (Naghavi, 2007). All of these predictions indicate the importance of global attention to mental health in the next two decades.”

In another study conducted in Iran by Rafiei, Samiei, Amini Razani, and Akbarian, it has been stated that “from the perspective of Iranian experts, the indicators of social health include: absence of poverty, violence, sexual discrimination, unemployment, and ethnic-racial-regional discrimination; population control; equality before the law; adherence to human rights treaties and other relevant human rights treaties; compulsory and free education until the end of secondary school; universal access to health services; presence of security and freedom of belief; satisfaction with life; insurance coverage for all people; fair distribution of income (where everyone has the right to earn income and equal opportunities for income generation); legitimacy of government among the people; selection of rulers in a democratic manner and oversight by the people (Rafiei, Samiei, Amini Razani, and Akbarian, 2010).”

Iranian professors and researchers who have studied the topic of mental health and its challenges in Iran in the fields of psychology and sociology, have paid attention to certain points in their research findings that have all been highlighted as prominent issues in the field of mental health crisis in Iran.

The prevalence of addiction in Iran

Dr. Nourbala, along with a group of colleagues, has dedicated 10 months to developing a comprehensive plan for mental health in Iran. The results of this plan have been published in the Iranian Journal of Psychiatry and Clinical Psychology. In this plan, Dr. Nourbala addresses some psychological and social realities in Iran, including the trend of addiction in the country.

Dr. Noorbala believes that in the past 20 years from 1357 to 1377, the average rate of substance abuse has increased by 8% annually, which means it has doubled every 12 years. Comparing this rate to the population growth rate, which has been an average of 2.63% in the past 20 years, shows that the rate of substance abuse growth is three times higher than the population growth rate. Additionally, the rate of injection drug use has increased by 330% in the past 10 years, which means an average growth of 33% per year (Rahimi Moghaddam, Mohammad and Razeghi, 2002).

If we increase the growth rate of substance consumption and the trend of increasing addicts by 33% in the following years after this research, we will reach the peak of addiction disaster as one of the parameters of mental health.

Based on a qualitative study of social problems in Iran (Modini, Vameghi, & Rafiei, 2007, cited in Modini, 2008), using the Delphi method, 15 issues were identified by experts as the top priorities. These issues include addiction, unemployment, violence, social distrust, economic poverty, corruption, social discrimination, injustice in power distribution, decline in values, increase in crime rates, economic policies, traffic problems, education and upbringing issues, lack of respect for citizens’ rights, and inequality in law enforcement.

Citizenship feeling

As mentioned in the introduction of this article, the feeling of citizenship and lack of discrimination towards other citizens in a society can be a sign of mental health in a political-geographical unit.

In a research conducted by Mojgan Azimi Hashemi and Ali Yousefi at Mashhad University under the title “Citizenship Feeling in the Provinces of Iran”, citizenship is seen as the result of a two-way relationship between the individual and the government. On one hand, this relationship includes the individual’s loyalty to the government or political system, and on the other hand, the government’s obligation to protect the individual. This research focuses on three aspects of citizenship rights, namely participatory equality, legal equality, and political identity.

The results of this study show that: “Among the findings, two points are more noteworthy: firstly, the weakness of citizens’ sense of equality in terms of opportunities, distribution, and participation. These three elements are considered to be among the most important resources of the legitimacy of a government, and a gradual decline in these resources can challenge the legitimacy of the government. Other indicators that have been of interest to Iranian researchers in the field of mental health include: instability in structures, management, values, and decision-making in Iran. The trend of marriage and divorce in Iran has faced a 37% increase in divorce rates and a decrease in marriage rates. The consumption of psychotropic drugs in Iran, especially anti-anxiety and antidepressant drugs, has also increased. Suicide rates have also increased, which is considered one of the social problems in Iran. According to official statistics from Iran, which have been obtained by the World Population Information Center, the suicide rate in 1390 was 4.1

The Human Rights Organization of Hengaw reports the number of suicides in the month of Farvardin 1400; 24 Kurdish citizens have ended their lives in various cities of Kurdistan.

According to the statistics of the Legal Medical Organization, the provinces of Kohgiluyeh and Boyer-Ahmad, Ilam, and Kermanshah have the highest rates of suicide in terms of population, while the lowest rates belong to Razavi Khorasan, South Khorasan, and Sistan and Baluchestan. It is worth noting that the majority of suicide victims were between 30-39 years old, followed by 18-24 years old.

According to official statistics from the National Registration Organization, suicide is the fifth leading cause of death among adolescents and young adults in the country. 3.89% of deaths in this age group are due to suicide.

Increase in internal migration from peripheral areas to the center.

According to reports published by the International Monetary Fund in 2006, Iran has the highest rate of brain drain among 91 developed and developing countries.

Dr. Norbala writes in her proposed plan to the officials of the Islamic Republic of Iran:
1. The importance of mental and social health has been largely overlooked in the healthcare systems of countries, including Iran. Therefore, there is concern for the future of global and Iranian mental and social health.
2. The statistics of mental disorders in Iran are not favorable compared to other countries.
3. Iranian society is described as emotional, anxious, sad, disrespectful, unpredictable, and, according to some leaders and officials, immoral, lawless, and unaccountable. These are all risk factors for the development of mental disorders and psychosomatic illnesses.

He adds in another part of this plan:
– If fundamental and essential actions are not taken at the family and societal level to prevent the emergence of stressors, an unpleasant future is predicted for the country.

Special budget for mental health in Iran and the world.

Budget allocations in Iran over the past 41 years have never specifically allocated funds for the prevention and treatment of a wide range of mental and psychological illnesses. In fact, part of the challenges in mental health is that the budgets allocated for mental health have been allocated to other areas.

The World Health Organization in an article published in their bulletin refers to the fact that most developing or underdeveloped countries allocate less than one percent of their annual income to this matter. The same article adds that advanced countries often allocate up to 5 percent of their annual income for the purpose of prevention and overall treatment of mental illnesses.

The World Health Organization has reported that up until 2003, between 40 to 50 percent of member countries, including Iran, did not have a formal mental health program. The lack of specialized treatment personnel such as psychiatrists, psychologists, therapists, and social workers alongside psychiatric hospitals and daily clinics is among the factors that have been mentioned by the World Health Organization in their studies comparing several countries.

Sources:

About DSM-5 and the development/website of the American Psychiatric Association
The mental health of Iranian society is at risk/website of Deutsche Welle
23.6% of Iranians suffer from mental disorders, including depression/website of Deutsche Welle
Domestic violence against single and married women in Iranian society/website of Academia
Institute Ki Aar
The life of Elizabeth Kubler-Ross
Evaluation of the World Health Organization’s measurement tools for mental health systems by comparing mental health policies in four countries/website of the World Health Organization
Global health statistics/website of the World Health Organization
Global mental health/website of the American Psychiatric Association
Global mental health: Five key insights from data/website of Our World in Data
Hans Selye (1907-1982): Founder of the stress theory/website of the National Center for Biotechnology Information
Mental health information in Persian/website of the Royal College of Psychiatrists
Mental