History and context

The Kurdistan Region of Iraq (KRI) is a semi-autonomous region in federal Iraq, comprising four governorates and home to over 6 million people. Before gaining semi-autonomy, Kurds experienced atrocities under Saddam Hussein’s Ba’ath regime, including the Halabja chemical attack that killed over 5000 people and the Anfal Genocide, which claimed 50 000 to 100 000 lives. Between 1968 and 1991, many in the region faced exile, displacement and torture until a Kurdish uprising liberated the area. ^{Reference Bozarslan, Gunes and Yadirgi1} Thus, the region experienced years of conflict and instability, the last of which was the war against ISIS, influencing mental health outcomes.

Health system context

The KRI has a regional government where the Ministry of Health (MoH) manages health policy and services at various levels. Healthcare is delivered through primary care hospitals, district hospitals and specialised centres, with government services being more affordable. However, privatisation, which is becoming more common, increases the financial strain on low- and middle-income individuals, ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} and health insurance is not widely used. Although public and private healthcare facilities are growing, the system primarily focuses on treatment, with limited public health prevention efforts. Budget information for health and mental health is scarce, and there are challenges in collecting and publishing health data. ^{Reference Moore, Anthony, Lim, Jones, Overton and Yoong3} Statistics regarding the number of practitioners are also scarce. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2}

Mental health services and policy

Public mental health services are primarily offered through psychiatric hospitals in major cities, leading to service gaps in rural areas. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} This is especially challenging for women and children who face travel barriers. In-patient treatment in public hospitals is limited compared with the demand. ^{Reference Saied, Ahmed, Metwally and Aiash4} In these hospitals, care is primarily biomedical, with limited psychotherapy services. Psychiatrists oversee patient care, but the facilities lack proper therapeutic environments, including good lighting, outdoor space and social areas. Out-patient private mental health clinics and non-governmental organisations (NGOs) provide a range of mental health services. Private clinics are increasingly incorporating psychotherapists into their care model, which follows a biopsychosocial approach. However, there is a shortage of professionals such as case managers and social workers. In contrast, NGOs adopt a more holistic approach to mental healthcare.

There is a significant gap in integrating mental health services into primary emergency care in the KRI. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} Management of mental health crises is often inconsistent and relies heavily on individual approaches because of the absence of official guidelines. Additionally, first responders lack mental health training, delaying recognition and intervention. Admission to psychiatric hospitals is referral-based, complicating access for cases without specialist referrals in emergency situations. ^{Reference Moore, Anthony, Lim, Jones, Overton and Yoong3}

The lack of clear policies and procedures significantly impacts mental healthcare in the region. ^{Reference Böge, Hahn, Strasser, Schweininger, Bajbouj and Karnouk5} Although psychiatrists undergo a licensing process, there is none for psychotherapists and clinical psychologists, leading to unqualified individuals practicing psychotherapy. There is a local psychiatric association, but no professional body for psychotherapy or clinical psychology exists. Although national and regional mental health legislation exists, documentation and implementation of localised ethical governance and rights-protection oversight appear limited, which can reduce patient awareness of rights and confidence in redress mechanisms when harm occurs. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2,Reference Saied, Ahmed, Metwally and Aiash4}

Education and research

The KRI has universities with medical colleges and limited psychology departments that form the core of the mental health workforce. Psychiatry is available through postgraduate residency training, but there is only one undergraduate clinical psychology programme at Koya University and a single Master of Arts in psychotherapy at the University of Duhok. ^{Reference Beckmann, Wenzel, Hautzinger and Kizilhan6} Both programmes enrol a few students and are the only options for psychological treatment education in the region. The KRI lacks psychiatric nursing, postgraduate social work programmes and doctoral programmes in clinical psychology and psychotherapy. Additionally, issues such as insufficient qualified faculty and outdated curricula diminish the quality of education, particularly in areas like crisis intervention and psychosocial skills.

Research and development in mental health remain neglected in the KRI, with no dedicated research centres. This has led to challenges, such as a lack of localised knowledge and care models that rely on Western approaches without scientific validation. ^{Reference Magidson, Lejuez, Kamal, Blevins, Murray and Bass7} Additionally, accurate data is scarce because of the absence of recent population-representative prevalence studies, and there is limited longitudinal research on psychosocial determinants of mental health.

Burden of mental disorders

The last representative population-based mental health survey was conducted by the World Health Organization in 2007. This survey indicated that the lifetime prevalence of any disorder in the KRI is 21.3%, indicating a substantial need. ⁸ Additionally, cross-sectional studies that explore mental health issues usually report elevated rates of depression, anxiety and post-traumatic stress disorder. ^{Reference Hama Amin and Mohammad9,Reference Taha, Taib and Sulaiman10}

Social perception, stigma and faith healing

Despite recent progress, there is still a stigmatised social perception toward mental health in general. Visiting mental health clinics is still associated with shame, stigma and the fear of reputation destruction. ^{Reference Ahmed, Saber, Naif, Hamad, Ahmed and Abdullah11} Additionally, supernatural explanations (i.e. attributing mental disorders to supernatural entities or as a sign of weak faith) for mental disorders still exist in the region. It can be argued that, in some cases, faith healers are the first point of contact because of the region’s predominant religious influence. ^{Reference Rahim, Saeed, Farhan and Aziz12}

Principles of care

In a region shaped by conflict and ongoing social and public health challenges, improving mental healthcare requires a stronger rights-based approach across sectors. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2,Reference Ahmed, Saber, Naif, Hamad, Ahmed and Abdullah11} Although some community-based mental health and psychosocial support models and capacity-building initiatives have been implemented (including training and supervised delivery of psychosocial interventions), these practices are not consistently embedded across public and private services. ^{Reference Beckmann, Wenzel, Hautzinger and Kizilhan6,Reference Magidson, Lejuez, Kamal, Blevins, Murray and Bass7} Practitioner perspectives highlight system constraints that can undermine quality, including limited workforce capacity, high caseloads and weak routine-monitoring. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} Shared decision-making and patient input are not consistently incorporated, and treatment options are not always communicated clearly. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2,Reference Böge, Hahn, Strasser, Schweininger, Bajbouj and Karnouk5} Confidentiality safeguards may be stronger on paper than in routine practice; limited private consultation space, inconsistent staff orientation and variable implementation can increase perceived or actual privacy risks and reduce trust. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} Formal, documented informed consent processes for psychotropic medication are also reported as inconsistently used in high-volume settings, reflecting time pressure and lack of standardised procedures. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2}

Policy recommendations

To improve mental health services and outcomes in the KRI, policy efforts should prioritise feasible system-level actions measurable through routine indicators. First, integrate mental health into primary care by expanding training and supervision, establishing clear referral and follow-up protocols, and adopting culturally appropriate screening tools with demonstrated reliability and validity. Progress can be tracked through the number of trained primary care sites, screening coverage, referral completion and documented treatment initiation. Second, institutionalise standards for confidentiality, patient communication and shared decision-making by strengthening privacy safeguards and ensuring that treatment options and care pathways are communicated clearly to support informed choice. Indicators include patient-reported privacy and understanding, the presence of written procedures and staff orientation records, and the number and resolution of related complaints. Third, standardise emergency and crisis pathways by implementing guidance for crisis identification, rapid assessment, referral and follow-up; indicators include time to assessment, protocol use and follow-up. ^{Reference Jaff, Abas, Leatherman, Seidi and Ankamah2} Finally, these reforms require stronger routine data systems and annual reporting based on a minimum mental health data-set, to support accountability and quality improvement.