The present study is the first systematic survey of attitudes towards people with mental illness in Iraq. Its design was constrained by the project's manpower, timeline, cost and security situation in Iraq, and thus the survey was conducted in Baghdad because of the logistic and security issues limiting travel, but the socio-demographic characteristics of our sample are representative of Baghdad and more broadly fairly representative of the urban Iraqi community, although our sample contained a higher proportion of university graduates than the population as a whole .
This baseline survey has shown that there is a high level of contact with people with mental health problems which may reflect a high prevalence of disorder, poor services or the community's acceptance of mentally ill people, or a combination of all three, and warrants further investigation. Attitudes towards mental illness in Iraq are very mixed, with large proportions of the population holding stigmatising attitudes towards people with mental illness in relation to treatment, work, marriage and recovery. The majority put the blame on the afflicted individual, avoided contact with them and would not openly discuss their own psychological problems.
On the other hand, the population did have a fairly reasonable understanding of the aetiology of mental illness, citing genetic factors, negative life events, brain disease and substance abuse as key causes although God's punishment and personal weakness were also viewed as major factors., Understanding of the nature of mental illness, its implications for social participation and management remains negative in general. However the majority accept patients' rights and the view that patients can be managed outside hospital, admit that the services at the PHC level are poor and would welcome developing such services. Social distance was associated with higher educational level, wanting to hide a mental illness problem from the family and not wanting to allow a person with mental illness to take their own decisions.
The limitations of our survey are that it only covered two districts, and did not include rural areas, and that the questionnaire was not previously tested for validity and reliability. We are not aware of a similar study in the Middle East with which to compare these results, but there are relevant studies in other regions of the world .
Most mental health literacy surveys have been largely conducted in western countries, with few studies in developing country contexts. Studies from western societies have shown that biological factors (diseases of the brain and genetic factors) and eventual factors (trauma and stress) are more likely to be considered causal [12–14], while in Africa, supernatural causes are widely considered [15–17], and a recent Nigerian survey found that urban dwelling, higher educational status, and familiarity with mental illness correlated with belief in biological and psychosocial causation, while rural dwelling correlated with belief in supernatural causes.
Adewuya et al 2008 , found that urbanicity, educational status, occupational status, age, and familiarity with mental illness are important independent correlates of multiple perceived causation of mental illness. A study in India of community beliefs about causes and risks for mental disorders, (Kermode et al 2009 , found that the most commonly acknowledged causes were a range of socio-economic factors, while neither supernatural causes nor biological explanation were widely endorsed.
As well as studies on mental health literacy, there have also been related studies about stigma about mental illness. As with mental health literacy, most research studies of stigma has been conducted in western countries but there are a small number in low and middle income countries [20–26]. Culture is likely to influence the experience, expression, and determinants of stigma and effectiveness of approaches to stigma reduction.
In India Kermode and colleagues , found that the main predictors of a variable of social distance from people with mental illness was perceiving the person as dangerous, while the main predictors of reduced social distance was being a volunteer health worker, and seeing the problem as a personal weakness. For depression, believing the cause to be family tension reduced social distance. For psychosis, labelling the illness as a mind/brain problem, a genetic problem or a lack of control over life increased social distance, and this may be due to the central importance of marriage in Indian culture. These findings suggest that promoting explanations around genetic and other physical causes may not always help stigma.