Although context, the attendees of BH had shorter courses of mental disorders than their counterparts in Ibn-Rushd, which comes in terms with the public designation as the exemplary place for treatment and follow-up for chronic mental disorders mainly schizophrenia which was prevalent contrary to the (BH) group who were mainly first-time visitors rather than the follow-up, moreover, it is believed that psychiatric medications are more likely to be available and assorted being specialized mental hospital surprisingly, the attendees who were satisfied with their treatment outcomes: good & partial improvement comprised 48.7% of the (BH) attendees versus 90.9% of (IRH) attendees, also negative responses were higher in the former. Although such responses were not measured in detail or re-tested and some of them may be arbitrary, they reflect the patient's attitudes towards psychiatric services in general. The differences in patient satisfaction between the two hospitals could be attributed to multiple factors like the social stigma about mental illness, insufficient knowledge of the scope of mental health services in the general hospital, public perception, and the quality of psychiatric care, and should be considered for future health policies [15,16,17]. The evidence and experience from Iraq highlight the high level of mental health needs associated with a country going through long periods of trauma and violence. Poor access to services is to be expected where the need is great and the provision is limited. The experience also provides a useful model for improving psychiatric services.
It may sometimes be challenging to refer such patients to a mental hospital, and psychiatric services serve within the convenience of a general hospital [1,8,9]. And psychiatric hospital users who tend to show more severe symptoms of psychotic or mood disorders with longer courses expect to receive prompt consultations at a tertiary-level clinic without going through protracted referral formalities. Referral and consultation patterns vary widely depending on many factors and services features. Other determinants of referrals are patients’ perceptions of their own health, patients’ personal requests, general physicians’ negative attitudes towards mental patients, poor outcomes of previous treatment, unclear diagnoses, somatic presentations, comorbid conditions, presentation of major depression and acute anxiety disorders, high current symptoms ratings (i.e. patients with several symptoms involving multiple body organs), serious psychotic mental disorders, organic brain disorders and mental retardation, incompetent patients (i.e. patients with severe psychiatric disorders unable to give consent for medical procedures), and service acceptance criteria for appropriate referrals. [8,9]
Our study showed a lower ranking of satisfaction among attendees of general hospitals than those of mental hospitals indicating that patients acknowledge the quality of care that they are receiving in the outpatient setting but that a gap remains between patient expectations of the service and the actual service delivered, this contradicts the finding of some similar studies. (2, 10, 11).
The successive wars, economic sanctions, and conflicts caused a remarkable decline in the quality of mental health care in Iraq during the last three decades manifested by decreasing number of senior junior psychiatrists versus an increasing number of needy patients. This calculated reduction in expert manpower with no sufficient resources made available to meet people's demands leads to a heavy workload at psychiatric units in general [12,13].
The prevalence and characteristics of mental disorders among both groups of outpatients come in line with previous studies apart from methodological variations and selection biases affected by environmental situations and vulnerable security. Depression, anxiety, and psychotic disorders prevailed over outpatients attendees at different periods reflecting a relatively constant work profile of tertiary clinics [1,8,9,14].
Referral pattern in both groups depends on self or/and family motivation and advice reflecting a porous appointment and referral protocols for which the post-conflict situation might be blamed, moreover, the existing health system lack implementation of liaison services regardless of the concerned medical specialty. The basic concept of seeking another's medical opinion is valid and in action, however, it's still brief, not fully documented, and not up to international standards but in a brief. The workload of IRH is much heavier than BH manifested by the annual number of attendees and the average daily attendance which come along with the given data about the higher prevalence of psychotic disorders and higher rates of follow-up reflecting the patients and their family's preference for psychiatric services provided by specialized psychiatric hospital rather than one clinic in a general hospital. There were variations in monthly attendance in the same hospital due to days off related to religious occasions also Covid-19 pandemic precautions were still valid during 2021.
Mental health services in Iraq has faced significant challenges due to decades of political instability, conflict, and underinvestment in healthcare infrastructure. The country's mental health system has struggled to meet the needs of its population, particularly in the aftermath of the Iraq War and ongoing security concerns [15].