Gearing mental health care to meet modern day needs


By Randima Attygalle

At a professional forum where ‘breaking-the-ice’ was in progress, several of us were privy to the discomfort of a colleague whose admission that she lives in Angoda was mocked by the facilitator. His mocking response to her place of abode, "pissan kotuwa langada?" (is it close to the lunatic asylum?) is a fine reflection of the stigma and archaic social attitude attached to the mentally ill in the country, sparing not even those who live closer to the location of the National Institute of Mental Health! The term ‘pissan kotuwa’ is so embedded in the Sri Lankan social psyche, so much so, all mentally ill people, despite their degree of the disease are labeled ‘pissa’ or a lunatic for the rest of their lives. Making the situation worse, even their own kith and kin disown them in fear of social prejudice.

Limited access

Despite the global mental health care sphere moving along the lines of ‘seamless network’, Bio-psycho-social model’ and the ‘Recovery Model’, sadly the Sri Lankan attitude towards mental health is still largely modeled on a custodian mechanism synonymous with the institutes at Angoda and Mulleriyawa, geared towards chronically ill and acutely disturbed patients, oblivious to the need of encompassing people suffering from mental distress and a range of milder forms of mental illnesses including depression and anxiety.

"A plethora of social and natural causes including poverty, migration, domestic violence, child abuse, substance abuse, trauma and natural disasters can alter the human life dramatically. The life stressors related to the above situations result in major psychological disturbances commonly referred to as psychosocial distress with serious impact on the quality of life and perhaps even triggering the development of mental illnesses. Mental health care has transcended globally to address these issues, but unfortunately, due to social stigma, poor mental health literacy and inequitable distribution of services in the country, only a small percentage accesses mental health care in Sri Lanka," explained Prof. Nalaka Mendis, Emeritus Professor of Psychiatry, University of Colombo.

Centralized system

Mental illnesses impact society significantly with 2-5 % of the Sri Lankan population being affected by them. Nearly 6,000 people commit suicide annually, the majority of them are known to suffer from a mental illnesses. As Mendis reveals, the impact of mental illnesses in rural areas of the country is felt more due to poverty, stigma and lack of mental health literacy. This situation is a manifestation of the fact that despite having moved from tertiary level care to secondary level care, mental health services in Sri Lanka still remain largely centralized, requiring primary level or village level expansion. "The centralized mental health care system in Sri Lanka has been found to be undesirable to meet modern mental health care needs. The District Mental Health Movement which has been unfolding during the last decade has taken great strides in providing comprehensive services to those living within the boundaries of each district," observed Mendis who perceives this uniquely and locally developed movement as a shift from an ‘institutional and psychiatric focus’ to one which is ‘community-oriented and person-centered’. As he further observes, by strengthening the emerging District Mental Health Movement which holds a lot of potential, many disparities in the mental health care sphere in the country can be bridged.

District Mental Health Movement

According to Mendis, the District Mental Health Movement which is steered by the Senior District Psychiatrist and the Regional Director can be further fortified by establishing a cadre of psychiatrists, junior doctors and other professionals based on the population. Psychiatrists and the handful of other mental health professionals are very unevenly distributed between districts, Colombo and few other urban centres having the largest number.

"Allocating the staff on the basis of the population is becoming increasingly popular in many public mental health systems globally. On the basis of having at least one psychiatrist for a population of 200,000 people, Sri Lanka needs 80 psychiatrists. There is a dearth of mental health professionals including psychiatrists in very densely populated districts. For instance, Gampaha which has a population of 2.39 million, presently has only four psychiatrists and ideally it is in need of nine. While Sri Lanka claims only 37 psychiatrists at present, there is a dire need for more personnel, at least 80 in near future."

Identifying a network of facilities per district including inpatient, outpatient and intermediate care facilities; establishing a new District Mental Health Management mechanism of the services at district level; setting up a coordinating mechanism at the Ministry of Health with the objective of strengthening the directorate of mental health; adopting a new Involuntary Treatment Act and raising the capacity of the general health services to facilitate prevention, promotion and early recognition and follow up of those with mental illnesses are other measures proposed by Mendis to add muscle to the District Mental Health Movement.

A multisectoral approach

Mental health being strongly linked to social and cultural fabric of Sri Lanka, the treatment process is naturally complicated. Moving from a disease-related, patient-related model or what is clinically defined as ‘Bio- Medical Model’, the time has dawned to adopt a more proactive approach in tune with globally accepted models such as the Bio-psycho social model and the Recovery Model - the latter which helps people with mental health problems to look beyond mere survival and existence, thereby encouraging them to move forward, set new goals and add meaning to their lives. This model provides a holistic view of mental illness which focuses on the individual as opposed to focusing on symptoms alone.

Moving beyond the traditional health-delivery system and adopting a more holistic approach towards mental health care is paramount. "The scope of mental health has changed dramatically with new interventions being made. It has taken vast strides from drug-induced mechanisms to psycho-social therapies, thereby acknowledging that mental health is an integral part of the public domain," observed Mendis who perceives the Sri Lankan experience as very much a ‘secluded domain’. A multisectoral approach, harnessing the expertise of health as well as non-health personnel including social workers, community leaders as well as the legal fraternity is assured to address the phenomena of mental illnesses in the country more effectively and above all, more humanely.

"A compartmentalized attitude has a negative impact on mentally ill individuals, the reason why even non-health personnel such as lawyers and judges need to be more sensitive to those with mental illnesses. In the event of such individuals being parties to a judicial proceeding, the legal fraternity will be more equipped and more sensitive to the needs if they are more mental health literate," he said.

As he further reveals, ‘close-to-home’ treatment recommended on health, social and economic grounds has proven to be a successful method of addressing mental illnesses with more positive results. This process of integrating mental health services into public health services and social welfare has not only enhanced the skills of community level health workers and other leaders but it enables more people to access mental health care without being shunned.

Mental health literacy

The inadequate mental health literacy is one chief contributory reason for late presentation of mental illnesses. While some family members or care givers may not know where and how to seek help, others will regard it a taboo, turning a blind eye to the suffering individual who is subjected to secondary victimization by resorting to silence. "Addressing mental health issues is a national responsibility. In order to raise a collective voice, it’s imperative to disperse mental health literacy, thereby dispelling misconceptions and prejudices attached to mental illnesses," Mendis concluded.

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