Adolescent mental health in the MENA region: spotlight on Tunisia

Tunisia is a small country in North Africa with a population of 11 million, known since 2011 as the birthplace of the Arab Spring. Although 99% Muslim, Tunisia comes from a mix of cultures and traditions, and lives between East and West.

Tunisia, subject to French colonization since 1881, became independent in 1956. Its first President, the charismatic Habib Bourguiba, set up an ambitious modernization program from which Tunisia benefits until today. Thus, he generalized public school education for boys and girls, established women’s rights with considerable equality between men and women in the civil and labor world (the most modern in the Arab-Muslim world to date), and an efficient birth control policy.

Since the revolution in 2011, Tunisia has been experiencing a period of political instability against a backdrop of economic and financial crisis, aggravated by the COVID-19 pandemic and the global economic situation. Thus, despite considerable progress in terms of individual freedoms, gender equality and the democratization of society, a large proportion of Tunisians are faced with financial difficulties, unemployment, corruption, and a deterioration of the public health and educational system. Therefore, many Tunisians are confronted with a decline in living conditions.

For the young Tunisian generations who must navigate in a society undergoing demographic, cultural and political transition, this poses additional challenges.

According to official figures, in 2021, the unemployment rate among 15–24-year-olds was 43%.      These are often young people with no qualifications. However, even the unemployment rate for higher education graduates in 2019 was 27.8% according to the National Institute of Statistics. Thus, young people who were on the front line during the 2011 revolution find themselves excluded and marginalized from society due to unemployment and inactivity.

All these difficulties lead a growing proportion of adolescents and young adults to emigration: clandestine for those without diplomas, and official for the most educated, in particular engineers and doctors. It is estimated that currently about 6500 out of 8500 engineering school graduates leave the country, particularly for Europe.

These difficulties also impact the mental health of young people.

Globally, according to the latest WHO data (November 2021), one in seven young people aged 10 to 19 suffer from a mental disorder, which represents 13% of the global burden of disease in this age range. Depression, anxiety, and behavioral disorders are among the main causes of morbidity and disability in adolescents. Suicide is the fourth leading cause of death among young people aged 15 to 19.

Although there are few national figures on the mental health of young people, Tunisia is most likely no exception.

According to the 2018 Multiple Indicator Cluster Survey (MICS6), almost 20% of young Tunisians aged 15 to 17 suffer from anxiety and around 5% from depression.

Since the revolution, the suicide rate has increased, spurred initially by the suicide of the young day-laborer Mohamed Bouazizi, who set himself on fire on December 17, 2010, protesting against the harsh living conditions. This date is now considered the beginning of the Tunisian revolution. According to the Ministry of Health, the incidence of suicide in 2016 was 4.23 in the 15-19 age group, and 4.5 in the 20-24 age group. This rate is still low compared to many Western countries; however, it should be noted that the suicide rate is generally lower in the Mediterranean and in Islamic countries.

Another public health problem on the rise in Tunisia since the revolution is the consumption of psychoactive substances. Preliminary results of a national survey in school settings (MedSPAD III – Tunisia 2021) in more than 6,000 high school students aged 15 to 17 revealed that tobacco, alcohol and cannabis were the most consumed substances. One in four young people smoked at least one cigarette in their lifetime; boys are 4 times more likely to smoke than girls, but the prevalence among girls is increasing. More than one in four teenagers has vaped, and one in five has smoked hookah at least once. Another frequent phenomenon in Tunisia is the use of inhaled substances such as glue or gasoline, more than 5% of young people have already used it at least once, as well as anxiolytics without medical prescription, used by about 8 % of young high school students.

Similar to more developed countries, the use of social media plays an increasing role in the lives of young Tunisians. Indeed, according to the same MEDSPAD III study, one in three high school students uses social media more than 4 hours a day during school days, and one in two uses them more than 6 hours a day during weekends and holidays, thus exposing them to the risk of cyberaddiction.

Although, as of 2021, 98% of children were enrolled in primary school, and the illiteracy rate in the 10-14 age group was 2.8%, school dropout is a widespread phenomenon in Tunisia. The risk is particularly high for young people from poor families, rural areas, young people with disabilities and young people whose mothers have little education. The high dropout rates can be explained by several causes, amongst them psychological or psychiatric disorders.

According to a study by Missaoui et al. (2010), more than two thirds of included children with learning difficulties had one or more psychopathological disorders. The most common disorders were respectively: current or former language disorders (apart from intellectual disability) 22%, anxiety disorders 19%, elimination disorders 16%, attention deficit hyperactivity disorder 11%, and adjustment disorders 10%.

Over the past decades, Tunisia has made considerable progress in the management of child and adolescent mental health problems.

Since the establishment of child psychiatry as a separate specialty in 1996, the number of child psychiatrists continues to increase, being a highly sought-after specialty among young doctors. In 2017, Tunisia had 45 child psychiatrists, which is equivalent to a rate of 0.39 per 100,000 people. By comparison, the global average of child psychiatrists in low- and middle-income countries is 0.02. Since the revolution, a significant number of psychologists have been hired in the public sector, especially to meet the needs of the young population. Thus, in 2017, more than 20% of the 549 Tunisian psychologists worked in schools, universities, university residences, and institutions for vulnerable children and adolescents. The rate of psychologists per 100,000 inhabitants is above the world average (2017).

However, the coordination between the different actors of the mental health sector remains challenging. In addition, prevention and promotion of mental health still take up too little space.

Aware of these issues, the Ministry of Health is developing, together with various stakeholders, a national multisectoral plan for the mental health of children and adolescents. This plan, announced publicly on 2 April 2022, has the following six axes:

1/ detection and care for children with autism spectrum disorders
2/ well-being at school and management of neurodevelopmental disorders at school
3/ prevention of suicidality in children and adolescents
4/ prevention of violence towards children and adolescents and multi-sectorial care for victims
5/ prevention and care for addictive behaviors at school
6/ Integration of mental health into the perinatal period

This plan, albeit ambitious given the difficult economic context, is vital for the well-being of Tunisia’s future generations and we welcome the opportunities this plan offers young people and the emphasis of intervening early in youth mental health.

Dr. Uta Ouali
Uta Ouali is an Associate Professor of Psychiatry at the Faculty of Medicine of Tunis and works as a senior psychiatrist at Razi University Hospital La Manouba in Tunisia. Her clinical and research interests focus on early intervention in psychiatry, stigma reduction, mood disorders, and psychotherapy. As such, she is the current Vice President for the MENA region of the IEPA and the director of the Tunisian Clinical High Risk Program (CHiRP), aimed at detecting and providing early intervention for young people at risk of mental disorders. She is also the site lead for Tunisia and a co-investigator of the INDIGO-Partnership Research Program, a large multi-national project aimed at reducing stigma of people with mental health problems.

Professor Ahlem Belhadj
Ahlem Belhadj is a Professor in child and adolescent psychiatry at the Faculty of Medicine of Tunis and Head of the department of child and adolescent psychiatry at Mongi Slim University Hospital La Marsa, Tunisia. She is the President of the Tunisian Association of child and adolescent psychiatry and the coordinator of the research laboratory “mother and child health”. Apart from her scientific, clinical and teaching commitments, she has been an advocate for women’s and human rights for many years. As such, she is a member and the former President of the Tunisian Association of Democratic Women (ATFD) and the current general secretary of the Medical Doctors trade-union at the General Union of Tunisian Workers (UGTT). Her clinical and research interests lie in the area of autism spectrum disorders, genetics, mother and child health, and reduction of discrimination against vulnerable population groups.

References:

Indicateurs de l’emploi et du chômage  du troisième trimestre; Communiqué de Presse (2021) Statistiques Tunisie, Institut National de la Statistique

Indicateurs de l’emploi et du chômage Quatrième trimestre 2019; Communiqué de Presse (2020), Statistiques Tunisie, Institut National de la Statistique

African Manager: 6500 ingénieurs tunisiens prennent le chemin de l’exil. 23/10/2022 https://africanmanager.com/6500-ingenieurs-tunisiens-prennent-le-chemin-de-lexil/, retrieved 5 Nov 2022

World Health Organisation: Adolescent mental health: Key facts. 21/10/2021
https://www.who.int/news-room/factsheets/detail/adolescent-mental-health#:~:text=Key%20facts,illness%20and%20disability%20among%20adolescents., retrieved 5 Nov 2022

Institut National de la Statistique et UNICEF: Enquête par grappes à indicateurs multiples (MICS), 2018, Rapport Final Tunisie (2019): le Ministère du Développement de l’Investissement et de la Coopération Internationale (MDICI)

République Tunisienne, Ministère de la Santé: Statistiques Nationales du Suicide Tunisie–2016. 25 décembre 2017.

Kapitalis: La consommation des drogues dans le milieu scolaire en Tunisie est en hausse; 23/12/2021; http://kapitalis.com/tunisie/2021/12/23/la-consommation-des-drogues-dans-le-milieu-scolaire-en-tunisie-est-en-hausse/; retrieved 5 Nov 2022

République Tunisienne, Ministère de l’Education: Statistiques scolaires pour l’année scolaire 2020-2021. http://www.education.gov.tn/?p=688&lang=fr;  retrieved 5 Nov 2022

Jelassi MK: Deux millions de tunisiens analphabètes: une bombe a retardement sociale. La Presse.tn 10/01/2022; https://lapresse.tn/120234/deux-millions-de-tunisiens-analphabetes-une-bombe-a-retardement-sociale/  ;retrieved 5 Nov 2022

Ben Said F: School dropout risk in Tunisia: Impact of facilities and neighborhood characteristics. Journal for Critical Education Policy Studies (JCEPS) . Sep2021, Vol. 19 Issue 2, p484-511. 28p.

Missaoui S et al: Prévalence des troubles psychopathologiques dans une population tunisienne d’enfants en difficultés scolaires. Neuropsychiatrie de l Enfance et de l Adolescence 58(6):426-430

Charfi F et al: Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources. J Ment Health. 2021 Feb 14:1-9.

République Tunisienne: Stratégie Nationale Multisectorielle de Développement de la Petite Enfance 2017 – 2025, septembre 2017, https://documents1.worldbank.org/curated/ru/217441546641114515/pdf/ECD-strategy-document.pdf; retrieved 5 Nov 2022