Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Each week our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #17: An Iraqi Psychiatrist Discusses Depression in his Homeland

VO DOWN & UP INTRO
The Down and Up Show on DepressionisReal.org, a talk show dedicated entirely to the subject of depression and the reality that there is hope for people living with this disease. Now your host, Terrie Williams.

TERRIE WILLIAMS INTROS DR. ROFA
Welcome to the Down and Up Show on Depressionisreal.org, I'm Terrie Williams your guest host filling in for Dr. Ellen Frank. Today we'll be talking with Dr. Yoasif Rofa, an Iraqi psychiatrist who was recently granted asylum here in the United States.

While working in Iraq Dr. Rofa worked for the Iraqi Ministry of Health and had his own private practice. He graduated from Baghdad University's Medical School in 1978. Dr. Rofa is now involved with the Peter C. Alderman Foundation which was established after 9/11. The Alderman Foundation's mission is to alleviate the suffering of victims of terrorism and mass violence in post-conflict countries by providing local physicians and caregivers with the tools needed to treat mental anguish using Western medical therapies and local healing traditions.

He's an amazing man. Today we will discuss with Dr. Rofa the psychological trauma faced by the many people he tried to help in Iraq who have been living for years in a war zone area and how depression is perceived in his homeland. Welcome Dr. Rofa.

TERRIE WILLIAMS / DR. ROFA

DR. ROFA:
Thank you.

TERRIE WILLIAMS QUESTION:
So just a little bit about you, what made you decide to enter the field of psychiatry?

DR. ROFA ANSWER:
Well I have always been fascinated with what motivates human behavior. During my residence years that was about 30 years ago, after graduation I workedÉ with a prominent psychiatrist back home who really made me love that field. And so I decided that I'm going to be a psychiatrist, which I did.

TERRIE WILLIAMS QUESTION:
OkayÉ so can you describe a bit about what it was like working as a psychiatrist in Baghdad? And likeÉ what was like a typical day for you at your practice?

Ok

DR. ROFA ANSWER:
WellÉ concerning my practice, I work in the morning inÉ in a big mental hospital that's like an asylum, about 1000 beds, but most of the cases are chronic cases and the patients have beenÉ patients have been there for many years, some of them for more then 10 to 15 years.

The problem isÉ in many Eastern countries, when the chronic cases of schizophrenia, the family's no longer interested inÉ caring for theirÉ for their loved ones because they would think that he'sÉ a stigma for them and having someone like that in the family wouldÉ minimize the chances for the female members of that family to beÉ to marry.

And so they would like to keep this stigma away from them. SoÉ and it was in thisÉ this style of keeping the mental cases in asylumsÉ through their 40s and 50s and so this hospital might be the only hospital that cares for those patients because the community is not ready to take them.

So I work there, IÉ everyday I see one of my wards, see the patient and check their treatment plans, talk to the nurses, to the residents and theÉ social workers about what's happening to them. AndÉ in the evening I have my own pracÉ I used to have my own practice, my private clinic where I would see maybe between four and eightÉ clients a day.

HereÉ there it is more, I mean more alluring to me because I would see a variety of cases and some of them are acute one or some of them are more what we call (unint.) or chronic. So I practiced general psychiatry.

TERRIE WILLIAMS QUESTION:
I seeÉ yeah, I was going to ask you what was the most common mental health problem that you saw?

DR. ROFA ANSWER:
Well the most common mental healthÉ I think like in every other societyÉ society maladjustment, maladaptive behavior is the most common. Depression is also a very common mental health problem in most societies and I don't thinkÉ the incidence of thisÉ illness in Iraq is different from any other country.

So that'sÉ facing the stresses of life is the most common thing that I have faced but depression comes very near second.

TERRIE WILLIAMS QUESTION:
Yes, so would you say that the Iraqi peopleÉ so they're not really comfortable seeking treatment for depression, what do you think about that?

DR. ROFA ANSWER:
No, no. You know it's always beenÉ because of the type ofÉ life in the Eastern countries, not only IraqÉ always they want someone to be always active and doing work to getÉ bread for his family. And so they would look to depression like it's just like a weakness in character, that's the problem.

I mean theyÉ when they see someone who is depressed, I would say what's wrong with him, I mean he's just sitting like there, not talking, not eatingÉ there's nothing happen to him, no one was killed in his family, so why is he (unint.) that way, it must be someÉ problem in his personality.

That's the idea and I think, I might think that many people even in the Western countries might share these ideas, these (unint.).

TERRIE WILLIAMS QUESTION:
Well I was going to say Dr. Rofa, I would agree with you. I'mÉ I'm an African-American woman who has lived with depression over half my life and I know that forÉ I mean it's a stigma generally here. But I think withÉ with African-Americans, there's another level of it, it's almost as if we would rather tellÉ tell people that we have a relative in jail or on drugs before we would speak about you know depression openly.

DR. ROFA ANSWER:
So you seeÉ I mean it's a general thing, I don't think there's any part in the world where people come for and say we have someone who has depression in our family andÉ we are taking care of him. I mean it's mightÉ it happens but I don't think people are veryÉ forthcoming with that.

TERRIE WILLIAMS QUESTION:
Do youÉ how do you think we could begin to reduce that, minimize stigma?

DR. ROFA ANSWER:
I think very good work is being done in the United States and theÉ the Western countries. There was this movement I think, I don't it startedÉ I was not part of it when I was in Iraq, so I think it started in the Ô80s where they are making itÉ communityÉ community services, community-based services forÉ such cases.

I mean I'veÉ I've seen it in the United Kingdom, in Britain, where these people are not just sentenced to long life in asylums, they are given houses in certain communities and people go and visit them in their houses andÉ help themÉ they follow-up their treatments.

SoÉ I think lots of work is being done apart from certain organizations andÉ and you know thisÉ where people who had at that affliction with certain, theyÉ these organizations to help people who have the same problem but they are not very comfortable with it. I meanÉ lots of work, the community work isÉ is the answer.

And increasing theÉ social awareness, the public awareness of the problem through the media isÉ I think will also help in that respect.

TERRIE WILLIAMS QUESTION:
Can you tell me a little bit, Dr. Rofa, about how depression and post-traumatic stress disorder are related?

DR. ROFA ANSWER:
Well depression is a very common problem, I meanÉ many societiesÉ about 10 to 20 percent of the people might have an episode of depression during their life. Now post-traumatic stress disorder is something else. Here someone will face psychological trauma like a death of someone orÉ being exposed to a horrible incident where one might haveÉ could have lost his life.

And it depends on various factors. He might adapt and with timeÉ I mean conquer thatÉ that illness. But if he doesn't, it might end in depression. So it could be also depression is a sequel of post-traumatic stress disorder.

TERRIE WILLIAMS QUESTION:
Yeah, you know I wanted to ask you and we're going to transition a little bit to you new life in the states but I wanted to ask you, you know, in your practice both inÉ in Iraq and here in the StatesÉ have you considered or seen any psychiatric similarities between those who suffer with mental and emotional issues, whether they stem fromÉ you know the traumatic experience of exposure to political warfare in Baghdad and those whoÉ if you willÉ participate in street warfare as in like America's gang violence?

Have you given any thought at all to that?

DR. ROFA ANSWER:
Well noÉ actually you knowÉ I haven't practiced in the United States, I'm not licensed to, I've just been recently granted asylum. But IÉ I talk aboutÉ my experience back home. I would say that living in a dangerous zone, dangerous time, when someone goes out to work and he doesn't know what will happen to him.

Or when heÉ more fear of mothers when they send their children to school and don't know whether they were coming back for sure it's increased the incidence of mental health problems there.

I would say that ifÉ if a certain zone, there are zones withÉ I mean the gang warfare, I would think it will be a similar thing. I mean whenÉ when the lack of expectation of what's happening when there is no sense of security, of safety for one's self or for the family, I think these are, these factors will make mental health deteriorate.

TERRIE WILLIAMS QUESTION:
OkayÉ so let's transition a little bit to your life in the States. Why did you seek asylum and if you would tell us a bit about the work that you're doing with the Peter C. Alderman Foundation.

DR. ROFA ANSWER:
Well I came here in a visit by the Foundation to address their board of directors aboutÉ my workÉ in Baghdad. But you know, the doctors at back home, I don't know if you have heard about that, are targeted and when I came here, it made many people back homeÉ who are not very friendly to America, look at it asÉ as if kind of collaboration withÉ with them (unint.).

So my wifeÉ only has said she's receivingÉ some threats, phone threatsÉ about me coming here soÉ in the end I decided that for the bestÉ to stay here. I applied for asylum and I was granted because I think ifÉ if I went home, I don't know if I would be safe there or my family would be safe.

But as for the Alderman FamilyÉ I just, they are good friends. I am veryÉ I like what they are doing, the human (unint.) work they're doing. I think it'sÉ somethingÉ magnificent. They're giving these services thatÉ making life better for so many people in more then 15 countries, most conflict countries.

And they address the wounds of vulnerable people who are exposed to mass torture and mass violence, so I was always ready to speak for themÉ and to promote their work in the media. But IÉ I don't officially work for them, they're just good friends and they're an example toÉ

I would love to work for them but I don't think they have many activities inside the United States, it's all in the other countries.

TERRIE WILLIAMS QUESTION:
WhatÉ what do you consider your greatest achievement or accomplishÉ accomplishment in life?

DR. ROFA ANSWER:
I thinkÉ I think myÉ my small family is my greatest achievement. I haveÉ a beautiful wife, she's a dentist and haveÉ a son who is 21 years old, he's studyingÉ he was studying mechanical engineering back home. I have a lovely daughter who's 16 years old. But at the moment they areÉ they are waiting for the approval that they be approved to come and join me here.

So if they come and I feel that I haveÉ I could insure their safety, this will be also a great achievement for me.

TERRIE WILLIAMS QUESTION:
Yes, I can understand that. Would you want to practice psychiatry here in the United States?

DR. ROFA ANSWER:
Well I would have liked to, if I were… about 10 years younger because this practicing psychiatry isÉ needs to go through lots of examinations in our residency program which might last more then four years. I'm 52 now, I don't know if that'sÉ practical at this age.

TERRIE WILLIAMS QUESTION:
It's practicalÉ it sounds like you have a lot to give. So I'm 52 and I'm notÉ

DR. ROFA ANSWER:
Only as aÉ maybe not as aÉ just as a clinician, maybe perhapsÉ I'm keeping my options open maybe to go in some kind ofÉ training courses inÉ in psychology, psychological therapiesÉ but not as a clinicianÉ and this might takeÉ shorter periods and myÉ I mightÉ I'm considering that.

But at the moment I am a bitÉ not veryÉ I mean decisiveÉ I haven't been able to decide because I'm thinking of my family.

TERRIE WILLIAMS QUESTION:
Yes, understood. May I askÉ I know you miss them terribly, what do you most miss about Iraq or love most about Iraq?

DR. ROFA ANSWER:
WellÉ I lived there for 50 years, I miss everything there. I mean the people, the people of Iraq generally are very peaceful. The problem is that they wereÉ they were very unfortunate to haveÉ bad leaders andÉ someone, an American who has visited Iraq and if you could speak to an American who has visited Iraq in the Ô70s or the Ô60s, they would say it was a magnificent country.

People there are very friendly, they like foreigners and they try always to help them as much as they could and I've lived through that period andÉ that's why I missÉ about Iraq, the old Iraq, the Iraq of the Ô70s and theÉ part of the Ô80s where people were happy andÉ and helpful and trustworthy of each other andÉ

You know evenÉ for example, I'm a Christian there, I'm a minority there, butÉ I never had a problem living in Iraq and that time. But I wouldn't say that the same thingÉ these days.

TERRIE WILLIAMS QUESTION:
The thought occurred to Dr. Rofa, is thereÉ is there anything that you could see changing about the Iraqi culture to make it easier for people to get treatment for, you know, depression or other mental illnesses?

DR. ROFA ANSWER:
Well first of all you haveÉ to have aÉ I mean there must be some kind ofÉ safety and security in the country to start doing media programs and public awareness programs aboutÉ teaching people that mental illness, like any physical illness, anybody can be afflicted and treatment be available for most of theÉ mental illnesses, what it needs thatÉ a commitment from the side of the patient andÉ a great deal of help from the patients' families.

I meanÉ in psychiatryÉ the families ofÉ of any patient, they have very big part to play inÉ in the treatment and even inÉ failure of treatment. And soÉ what I would like to change is that idea that notÉ the work of demons, it's just an illness like any otherÉ

It would have been much easier you know, it would have been much easier during the Ô70s because we had very goodÉ cultured community. At that time most people would go to school and colleges (unint.) and a society can go back toÉ like in Iraq toÉ I don't know whatÑhow to say it.

Words fail me here. Like going backwards, not forward.

TERRIE WILLIAMS QUESTION:
You know there's so many questions that I have to ask you. Let me just ask you this. You know, when you were practicing as a psychiatrist and having to listen to a lot of heart-wrenching stories and pain, how did you manage so that you didn't become emotionally attached or engaged?

Did you ever experience, you know, fatigue from being overwhelmed?

DR. ROFA ANSWER:
Yeah. You knowÑyou know, hearing so many sufferingsÉ I mean, one can identify with these patients so easily, especially in cases where someone who isÑhad this (unint.) losing one of his family by an accident, by a bomb, by being kidnapped. Immediately one can put them in hisÑin his pants.

I mean, I would say, well, that could happenÑhave happened to me. Just by chance it happened to this unfortunate guy or a woman. So, yeah, it wasÑit was very difficult, especially in theÑin the last three years there. But, you knowÉ And sometimes they say that psychiatrists are most medical professionsÑprofessionals that might commit suicide.

It's notÉ It might be because they hear so much of the miseries ofÉ

TERRIE WILLIAMS QUESTION:

Yes.

DR. ROFA ANSWER:
other people thatÉ I don't know. I wouldn't do that. I mean, I thinkÑI don't think I would ever do that, hopefully. But during theÑduring the practice, one cannot help hearing very sad and traumatic stories and I think every psychiatrist could write a book about the human miseries, a very large book about human miseries.

ButÉ And then it will depend on how his personality can absorb all those sufferings and he can reflect some kind of hope to the people he's listening to.

TERRIE WILLIAMS QUESTION:
Yes. It's interesting that you've mentioned that because I have a number of friends who are psychiatrists and psychologists and I'm a clinical social worker, and I know that I haveÉ

DR. ROFA ANSWER:
You know what I'm talking about.

TERRIE WILLIAMS QUESTION:
Yes, I do. And I know that I have to be very careful because I absorb other people's pain a little too quickly. So I'm learning that when I hear something, I hear it and make a conscious effort not to absorb it and let it go because it would just be really detrimental to my spirit.

TERRIE WILLIAMS QUESTION:
Are there any closing thoughts that you might have for our listeners, anything that you would like to share? And one of the things I wanted to ask you is how do you think trauma contributes to depression and how is depression a trauma in and of itself?

We didn't get to talk as much about trauma as I would have liked.

DR. ROFA ANSWER:
When someone faces a big problem, a disaster in his life, it might require all his coping mechanisms to try to feelÑI mean, to heal this wound. It takes time. And the mostÉ I think theÑa very decisive factor in this process is the social support, the family support that one can get.

And that's why I would say that this is the difference between going into a depression after a trauma or getting overÑgetting the trauma. So it's always worthwhile to increase the public awareness, the family awareness, social awareness about how to cope, not only with the trauma but the people who had had those traumas and how to help them get through life.

So I think it's quite connected mentallyÉ Sometimes that mental illness can just come out of the blues but always there is some kind of an incidence, a stressor (ph.) that made it appear.

TERRIE WILLIAMS QUESTION:
Okay. Just before we go would you leave usÉ Do you have any inspiring words that you might like to share with our listeners who might be looking for a ray of hope? That's [sic] the Depression is Real Coalition really focuses on offering help and hope. So do you have any perhaps closing inspirational words or anything? What keeps you going?

DR. ROFA ANSWER:
I wouldÑIÉ You know, having seen so many people with depression back home, I was alÑI have always thought that itÑhowÑthe guy who was asking for help or was having this problem can be more patient and take the time to try to cooperate with the therapist and in..

The feeling of hopelessness is the detrimental factor here. It'sÉ Someone thinks that no one is able to help them. This isÑthis is a big problem. And it might be the job of a therapist to try to show the flicker or the light at the end of the tunnel to theÑto the client.

But it's always worthwhile for someone who has that problem to try and take the time and commit the time necessary for the treatment plan to work out. So I would say to people with depression don'tÑtry not to panic, try not to lose hope so quickly.

And sometimes the start of treatment might beÑmight be the most difficult period of the treatment because you might see that his symptoms have actually worsened when he started the medication, but it's only a temporary thing. And if he gives it about four to six weeks, most of the cases he will start feeling that he's becoming better and better.

TERRIE WILLIAMS CLOSE:
Okay. Thank you so much, Dr. Rofa, for sharing your unique experience and perspective with us.

For the Depression is Real Coalition, I'm Terry Williams. Join us next time for another segment of the Down and Up Show on Depression is Real.org. Stay strong.

VO CLOSE
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