Impact statement
In Somalia, most people struggling with mental illness never receive treatment. This is not only because hospitals and trained staff are scarce after decades of conflict but also because many families believe psychiatric illness is caused by spirits or divine punishment rather than a medical condition. This belief keeps people away from clinics, leads families to stop medication once it is started and leaves patients trapped in cycles of suffering, mistreatment and isolation from their communities. This Perspective shares what psychiatric clinicians in Mogadishu see every day, connects these experiences to research from Somalia and similar countries and offers realistic steps forward. These include simple community education through mosques and radio, brief conversations between doctors and families to correct fears about medication, training general health workers to recognize mental illness and involving families directly in care. None of these steps require expensive equipment or new funding to begin. Somalia is rebuilding after years of war, and mental health cannot wait. Treating it as urgent, rather than optional, could change how an entire generation understands and responds to psychiatric illness, starting with a shift in how people talk about it.
Introduction
Mental disorders affect an estimated 970 million people globally and contribute approximately 13% of the total global burden of disease measured in disability-adjusted life years Ferrari et al. (Reference Ferrari, Santomauro, Herrera, Shadid, Ashbaugh, Erskine, Charlson, Degenhardt, Scott and McGrath2022). In low- and middle-income countries (LMICs), the treatment gap of the proportion of people with mental disorders who receive no evidence-based care ranges from 76% to 85% (Thornicroft et al., Reference Thornicroft, Chatterji, Evans-Lacko, Gruber, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Andrade and Borges2017). Somalia exemplifies the extreme end of this spectrum: between 80% and 90% of Somalis with mental health conditions lack access to adequate care, in a country where decades of armed conflict have simultaneously increased psychiatric morbidity and dismantled health infrastructure (Ibrahim et al., Reference Ibrahim, Malik and Noor2022).
Based on the authors’ clinical observations in Somali outpatient psychiatric settings in Mogadishu, a recurring pattern defines the clinical encounter. Patients present late, with advanced and functionally debilitating illness, after exhausting a sequence of religious and traditional remedies. When biomedical diagnosis and treatment are eventually offered, families may refuse or discontinue pharmacotherapy, invoking spiritual explanations, most commonly jinn possession, as the definitive cause (Ibrahim et al., Reference Ibrahim, Malik and Noor2022). The phrase heard repeatedly “it is the devil, not a disease,” captures the explanatory framework that governs help-seeking in this context and defines the central challenge facing psychiatric care in Somalia (Salad et al., Reference Salad, Malik, Ndithia, Noor, Madeo and Ibrahim2023).
Mental health literacy (MHL): the knowledge and beliefs about mental disorders that aid recognition, management and prevention is a critical upstream determinant of treatment engagement. Where MHL is limited and supernatural explanatory models dominate, misconceptions persist, stigma is sustained and the treatment gap widens (Bhui and Bhugra, Reference Bhui and Bhugra2002; Kutcher et al., Reference Kutcher, Wei and Coniglio2016; Ibrahim et al., Reference Ibrahim, Malik and Noor2022).
The clinical patterns described in this Perspective are drawn from the first author’s engagement with outpatient psychiatric practice at a public referral hospital in Mogadishu over the period 2023–2025, working alongside a consulting psychiatrist during patient assessment and follow-up. Observations reflect direct exposure to these clinical encounters among the consultant, patients, and families, rather than a systematic case series or formal qualitative study, and are interpreted alongside published regional and global literature throughout the manuscript. Accordingly, the Perspective describes the most commonly encountered misconceptions and stigma patterns in Somali outpatient psychiatric settings, situates these within published studies and proposes actionable responses feasible within Somalia’s resource constraints. Understanding the sociocultural and health system context in which these misconceptions and stigma patterns arise is essential for interpreting their clinical significance and is addressed in the following section before the specific patterns are described in detail.
Sociocultural and health system context
Somalia has experienced protracted civil conflict since 1991, generating one of the world’s largest internally displaced populations and exposing successive generations to cumulative trauma, bereavement and economic deprivation (Ibrahim et al., Reference Ibrahim, Malik and Noor2022). Cross-sectional evidence documents significant burdens of depression, post-traumatic stress disorder (PTSD) and anxiety among conflict-affected Somali populations, alongside high rates of khat (Catha edulis) use (Warfa et al., Reference Warfa, Keynejad, Abdullahi, Willott, Budel, Wali, Shiek, Medhin, Hassen, Hussen, Abdinasir, Abdi, Mumin, Salaad Mohamud, Teferra, Al’Absi, Osman, Marshall and Hanlon2026), which is associated with psychosis and dependence (Salad et al., Reference Salad, Malik, Ndithia, Noor, Madeo and Ibrahim2023). Despite this burden, Somalia maintains fewer than 0.5 psychiatric beds per 100,000 population compared to a global average of 24 per 100,000 and has no functional community-based mental health services beyond a small number of critically understaffed urban hospitals (Ibrahim et al., Reference Ibrahim, Malik and Noor2022).
The sociocultural landscape is shaped by Islamic faith, clan-based solidarity networks and collective decision-making structures that place the family and community, rather than the individual, at the center of health choices. Psychiatric symptoms are widely understood through.
Islamic and traditional frameworks: jinn possession, the evil eye (ayn) and divine punishment for moral transgression are among the most prevalent explanatory models encountered in clinical practice (Bhui and Bhugra, Reference Bhui and Bhugra2002). Religious healers, Quranic practitioners and traditional herbalists represent the first point of contact for the majority of affected individuals, and the average interval between psychiatric symptom onset and first contact with a formal health facility has been estimated at 3.5 years (Ibrahim et al., Reference Ibrahim, Malik and Noor2022).
Somalia’s mental health workforce is critically inadequate. The national system relies on a handful of psychiatrists and a small number of trained psychiatric nurses, concentrated almost exclusively in Mogadishu and Hargeisa (Ibrahim et al., Reference Ibrahim, Malik and Noor2022). There are no established protocols for psychoeducation, community outreach or structured follow-up for patients initiated on pharmacotherapy. These system-level deficiencies amplify social barriers, creating conditions in which misconceptions go unchallenged and nonadherence persists without clinical intervention.
Misconceptions and their clinical consequences
The dominant misconception encountered in Somali psychiatric practice is the categorical denial of mental illness as a biomedical entity. Psychiatric presentations including psychosis, severe depression and bipolar disorder are reframed as spiritual events requiring spiritual remedies, not medical attention (Adam Mohamed, Reference Adam Mohamed2026). This is not a fringe belief; it is a widely shared, socially reinforced framework sustained by community narratives in which spiritual healing is perceived to have succeeded where biomedical care failed.
A second prevalent misconception concerns psychiatric medication. Many patients and families believe that antipsychotic and antidepressant medications cause permanent dependence, damage the brain or paradoxically cause the very impairment they are prescribed to treat (Adam Mohamed, Reference Adam Mohamed2026). These beliefs align with documented patterns across Sub-Saharan Africa and other LMIC settings, where limited MHL sustains medication-related fears that are rarely addressed through structured counseling (Atilola, Reference Atilola2015).
A third pattern involves the misattribution of symptom recurrence to treatment rather than to the natural course of illness. When a patient on antipsychotic therapy experiences a relapse, whether due to nonadherence, insufficient dosing or the episodic nature of the condition, families interpret this as evidence that medication caused harm, reinforcing discontinuation and return to traditional care (Read, Reference Read2012; Smit et al., Reference Smit, Kilian, Luckhoff, Phahladira, Emsley and Asmal2026). Without anticipatory psychoeducation from clinicians, this cycle perpetuates itself across successive treatment encounters.
Stigma: Individual, family and community dimensions
Stigma operates across all three levels identified in the conceptual literature, public, self and structural, and each reinforces the others in the Somali context (Warfa et al., Reference Warfa, Hanlon, Abdulahi, Wali, Sheikh, Selamu, Hassen, Hashi, Hussein and Abdulahi2026).
At the individual level, self-stigma is expressed as profound shame, concealment of symptoms and deliberate avoidance of formal psychiatric services even when distress is severe. Patients with depression or anxiety frequently seek neurological evaluation rather than psychiatric assessment, preferring the label nerva, a locally acceptable somatic idiom to avoid psychiatric identification (Boynton et al., Reference Boynton, Bentley, Jackson and Gibbs2010). Self-stigma directly reduces help-seeking, delays diagnosis and undermines adherence once treatment is initiated, with distress often first presenting through somatic complaints or spiritual idioms rather than direct psychiatric disclosure (Adam Mohamed, Reference Adam Mohamed2026).
At the family level, mental illness is perceived as collective shame with concrete social consequences. A psychiatric diagnosis may compromise marriage negotiations, damage clan alliances and attract social avoidance; concerns about family reputation and community standing consistently discourage open discussion of psychiatric treatment and push families toward informal or private support first (Adam Mohamed, Reference Adam Mohamed2026). Families therefore actively manage information about a member’s psychiatric condition, restricting access to services, obstructing pharmacological treatment and pressuring patients toward traditional or religious care exclusively (Adam Mohamed, Reference Adam Mohamed2026). In a society where family networks exercise decisive authority over health decisions, family-level stigma constitutes a structural barrier that no individual-level intervention can overcome in isolation.
At the community level, public stigma is expressed through discriminatory language – the Somali term waali (madness) is applied broadly and pejoratively to anyone receiving psychiatric care – and through the social exclusion of individuals with visible psychiatric illness (Abdi Abdillahi et al., Reference Abdi Abdillahi, Ismail and Singh2020). Evidence from Ethiopia’s Somali Regional State confirms that psychiatric facilities themselves carry stigma, with community members identifying attendance at mental health services as a public disclosure of waali that invites social penalties (Warfa et al., Reference Warfa, Hanlon, Abdulahi, Wali, Sheikh, Selamu, Hassen, Hashi, Hussein and Abdulahi2026). This structural dynamic deters presentation and sustains the treatment gap independently of individual beliefs.
Gender intersects meaningfully with stigma in this context. Women with mental illness face compounded vulnerabilities: appearance-related scrutiny, restrictions on mobility and heightened family control over health decisions (Gonzalez et al., Reference Gonzalez, Humberstone and Willott2024). Girls and young women with depressive or anxiety disorders may be married off early as a perceived solution to behavioral changes, foreclosing opportunities for diagnosis and treatment, since child marriage removes girls from education and leaves them without the resources or independence to seek care later in life (Hassan, Reference Hassan2023).
Nonadherence and its consequences
Systematic evidence from Sub-Saharan Africa indicates that nearly half of patients with schizophrenia are nonadherent to antipsychotic medications, with stigma, lack of family support, medication side effects and cost consistently identified as the principal drivers (Addisu et al., Reference Addisu, Demsie, Tafere, Siraj, Yazie, Yimer, Alemu, Milikit, Wabela, Yismaw, Ayal and Beyene2025). In Somalia, these factors are amplified by structural constraints: irregular medication supply chains, absence of follow-up systems and lack of structured psychoeducation create conditions in which even motivated patients cannot sustain treatment (Adam Mohamed, Reference Adam Mohamed2026). Among Somalis with disabilities who self-identify a need for mental health support, only 15% are able to access it, with cost and the unavailability of local services identified as the most common barriers (Zemp et al., Reference Zemp, Vallières, Jama, Ali, Young and Jagoe2024).
Sustained nonadherence carries profound consequences. Untreated or inadequately treated mental disorders in Somalia are associated with human rights violations including physical restraint with chains, confinement and social exclusion (Watch, Reference Watch2020). At the population level, an estimated 80–90% of Somalis with mental health problems lack access to good-quality, affordable care, contributing to lost productivity, caregiver strain and intergenerational psychosocial adversity in a country already fragile from conflict (Islam et al., Reference Islam, Siyad and Malik2024).
Recommendations
A practical, evidence-informed response to Somalia’s psychiatric treatment gap is achievable within existing resource constraints, provided interventions address social, clinical and structural drivers simultaneously.
Structured psychoeducation as a clinical standard (Priority 1)
A brief myth-focused message at every psychiatric encounter clarifying that mental illness is a medical condition, that medication does not cause dependence and that symptom recurrence reflects illness course rather than treatment harm should be a mandatory, documented clinical step (Ibrahim et al., Reference Ibrahim, Malik and Noor2022; Addisu et al., Reference Addisu, Demsie, Tafere, Siraj, Yazie, Yimer, Alemu, Milikit, Wabela, Yismaw, Ayal and Beyene2025). This requires no additional resources beyond a trained clinician and a standardized protocol, and can begin immediately within existing consultation time. Success can be measured through documented psychoeducation delivery rates and three-month medication continuation rates.
Mental health literacy and community education (Priority 2)
Brief, culturally adapted messaging delivered through mosques, schools and community radio can normalize care-seeking and clarify the distinction between spiritual well-being and treatable psychiatric illness, without dismissing faith (Kutcher et al., Reference Kutcher, Wei and Coniglio2016; Hussein and Yusuf, Reference Hussein and Yusuf2026). Imams, religious scholars and respected community figures are credible messengers whose sustained engagement is essential for attitude change at scale. This is feasible using existing community infrastructure and volunteer religious leaders at minimal cost. Success can be measured through pre/post community surveys of MHL and self-reported willingness to seek care.
Family-inclusive care (Priority 3)
Given the decisive role of family networks in Somali health decision-making, family members should be included in psychoeducation and treatment planning at every opportunity (Betancourt et al., Reference Betancourt, Berent, Freeman, Frounfelker, Brennan, Abdi, Maalim, Abdi, Mishra, Gautam, Creswell and Beardslee2020). This requires only a scheduling adjustment to include family members during consultations, at no additional cost. Success can be measured through the proportion of clinical encounters with documented family participation and subsequent adherence rates.
Anti-stigma interventions (Priority 4)
Educational and social-contact approaches reduce public and self-stigma in LMICs, with evidence indicating that positive changes in attitudes and stigma-related knowledge can be sustained where follow-up assessments are conducted (Gronholm et al., Reference Gronholm, Bakolis, Cherian, Davies, Evans-Lacko, Girma, Gurung, Hanlon, Hanna, Henderson, Kohrt, Lempp, Li, Loganathan, Maulik, Ma, Ouali, Romeo, Rüsch, Semrau, Taylor Salisbury, Votruba, Wahid, Zhang and Thornicroft2023). Contact-based interventions featuring individuals with lived experience of recovery are feasible without specialist infrastructure, as such approaches commonly rely on an educational component delivered face-to-face or through filmed testimonies, requiring only community coordination and willing participants (Gronholm et al., Reference Gronholm, Bakolis, Cherian, Davies, Evans-Lacko, Girma, Gurung, Hanlon, Hanna, Henderson, Kohrt, Lempp, Li, Loganathan, Maulik, Ma, Ouali, Romeo, Rüsch, Semrau, Taylor Salisbury, Votruba, Wahid, Zhang and Thornicroft2023). Success can be measured through validated stigma scale scores administered pre- and post-intervention, with follow-up assessment recommended to determine durability of effect.
Integration of mental health into primary care (Priority 5)
The World Health Organization’s mental health gap action program (WHO mhGAP) framework offers a validated, task-appropriate model for integrating mental health screening into primary care, expanding reach without requiring specialist personnel (Organization, 2021). Somalia has begun adapting this framework through primary healthcare worker training, reflecting its severe shortage of psychiatric specialists (Ibrahim et al., Reference Ibrahim, Abdulwahab, Malik, Noor, Cheng, Mohamed and Ndithia2025). Implementation requires only initial training investment, not new infrastructure. Success can be measured through the number of primary care sites actively screening for and managing common mental disorders.
Task-shifting to non-specialist health workers (Priority 6)
Community health workers and primary care nurses can be trained to identify common mental disorders, provide structured psychosocial support and facilitate referral (Van Ginneken et al., Reference Van Ginneken, Tharyan, Lewin, Rao, Meera, Pian, Chandrashekar and Patel2013). This requires a structured training program and ongoing supervision, representing a moderate resource investment relative to the other recommendations. Evidence from Ethiopia and South Africa demonstrates that task-shifting significantly reduces human resource barriers to closing the treatment gap in comparable fragile settings (Van Ginneken et al., Reference Van Ginneken, Tharyan, Lewin, Rao, Meera, Pian, Chandrashekar and Patel2013; Ibrahim et al., Reference Ibrahim, Malik and Noor2022). Success can be measured through the number of trained non-specialist workers actively conducting screening and referral.
Policy advocacy for mental health financing
Somalia’s National Mental Health Strategy 2019–2022 acknowledged the treatment gap, developed jointly by the Federal Ministry of Health and WHO to scale up quality mental health services and integrate mental health care into primary health services (Organization, 2021). However, implementation requires sustained, transparent allocation of government and donor resources to community services, workforce training and medication supply chain reinforcement. Clinical teams bear a professional responsibility to advocate for this allocation through every available channel.
Table 1 summarizes the six recommended interventions, their rationale, implementation strategies and supporting evidence.
Evidence-informed recommendations to reduce the psychiatric treatment gap in Somalia
Table 1. Long description
The table consists of six rows representing priority recommendations:
* Priority 1: Structured psychoeducation as a clinical standard. Rationale: Medication fears and misattribution of relapse drive nonadherence. Strategy: Brief myth-focused counseling at every visit. Evidence: Ibrahim et al. 2022 and Addisu et al. 2025. Indicator: Proportion of encounters with documented psychoeducation and three-month medication continuation rate. Strength: Systematic review or meta-analysis.
* Priority 2: Mental health literacy and community education. Rationale: Supernatural explanatory models dominate public understanding. Strategy: Culturally adapted messaging via mosques, schools, and radio involving imams. Evidence: Kutcher et al. Reference Kutcher, Wei and Coniglio2016 and Hussein and Yusuf 2026. Indicator: Pre and post community survey scores on literacy and willingness to seek care. Strength: Expert consensus or conceptual framework.
* Priority 3: Family-inclusive care. Rationale: Family networks exercise decisive authority over health decisions. Strategy: Routine inclusion of family in psychoeducation and treatment planning. Evidence: Betancourt et al. 2020. Indicator: Proportion of encounters with documented family participation and adherence rates. Strength: Feasibility and acceptability trial.
* Priority 4: Anti-stigma interventions. Rationale: Self-stigma and public discrimination deter presentation. Strategy: Educational and social-contact programs using individuals with lived experience. Evidence: Gronholm et al. 2023. Indicator: Validated stigma scale score change pre and post intervention. Strength: Protocol or multi-country partnership framework.
* Priority 5: Integration of mental health into primary care. Rationale: Geographic and workforce barriers prevent specialist access. Strategy: Scale-up using the W H O mental health gap action program framework in primary centers. Evidence: W H O 2021 and Ibrahim et al. 2025. Indicator: Number of primary care sites screening and managing common mental disorders. Strength: Mixed-methods implementation study.
* Priority 6: Task-shifting to non-specialist health workers. Rationale: Psychiatric workforce is insufficient and concentrated in two cities. Strategy: Training community health workers and nurses to identify disorders and provide support. Evidence: Van Ginneken et al. 2013 and Ibrahim et al. 2022. Indicator: Number of trained non-specialist workers conducting screening or referral. Strength: Systematic review.
Conclusions and future perspectives
The phrase “it is the devil, not a disease” is not merely a cultural curiosity but a clinically consequential explanatory model that drives delayed presentation, treatment refusal and premature discontinuation of effective pharmacotherapy. Misconceptions framing mental illness as supernatural possession, and stigma operating simultaneously at individual, family and community levels, interact with a critically under-resourced health system to produce a treatment gap that leaves the majority of affected Somalis without adequate care.
A practical response exists within current resource constraints, centered on culturally respectful community education, structured psychoeducation, primary care integration, task-shifting, family engagement and policy-level advocacy. Looking forward, these interventions must be tested through locally led implementation research that measures sustained adherence, functional recovery and stigma reduction in Somali clinical and community settings. Building a domestic evidence base using methods that are culturally valid and locally owned is both a research priority and a prerequisite for sustainable mental health system strengthening in Somalia.
Abbreviations
- LMIC(s)
-
low- and middle-income country/countries
- mhGAP
-
mental health gap action program
- MHL
-
mental health literacy
- PTSD
-
post-traumatic stress disorder
- WHO
-
World Health Organization
Somali-language terms used
- jinn
-
Spirit/supernatural possession
- ayn
-
The evil eye
- waali
-
Madness
- nerva
-
Somatic idiom for psychological distress (used to avoid psychiatric identification)
- khat (C. edulis)
-
A stimulant plant linked to psychosis and dependence
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10306.
Data availability statement
No primary data were generated or analyzed in this Perspective. All referenced data are available in the published sources cited in the reference list.
Acknowledgments
The authors express their sincere gratitude to the Center of Research and Development, SIMAD University, for their guidance and valuable recommendations.
Author contribution
A.M.H.: Conceptualization, manuscript drafting, critical revision, and final approval. F.Y.Y.: Critical revision, intellectual contribution, and final approval. Both authors agree to be accountable for all aspects of the work.
Funding statement
The authors received institutional support from SIMAD University.
Competing interests
The authors declare no conflicts of interest.
Ethics and approvals
This manuscript is a Perspective based on clinical observations and published literature. No primary data were collected and no identifiable patient information is reported; therefore, institutional ethics approval and informed consent were not required.
Inclusivity statement
The authors recognize that the populations described in this Perspective, particularly women and individuals from marginalized communities, have been under-represented in global mental health research. This work intentionally draws on clinical experience embedded within the Somali context and incorporates evidence from comparable African and LMIC settings where locally relevant data are unavailable. The recommendations proposed are designed to be responsive to Somalia’s sociocultural, resource and gender-specific realities.
Open access
