Bridging the gaps in mental health

World Mental Health Day falls today on the theme, ‘Mental Health in an Unequal World’

Consultant Psychiatrist and Senior Lecturer from Kotelawala Defence Univeristy, Dr. Neil Fernando throws light on the widening treatment gap in mental health, calling for a four-pronged strategy to enable wider community access to mental health services.

by Randima Attygalle

Mekala (name changed) made history as the first young person from her village in Sevanagala to enter Medical College. All was going well for the budding doctor until she was diagnosed with Schizophrenia in her fourth year. A chronic brain disorder, Schizophrenia affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others.

It took nine years for Mekala to recover and when she made an appeal to the authorities to let her complete her medical studies, she was turned down on the basis that her grace period to complete her course had expired. With her hopes shattered, Mekala had a relapse.

“Despite experts in mental health making a case for the young medical student to allow her to complete her studies, making an exception to the existing rules, the authorities rejected the case, which was very sad,” recollected Consultant Psychiatrist, Dr. Neil Fernando who was among the specialists that treated Mekala.

While that was the sad plight of a medical student here, the story of the American mathematician, John Forbes Nash Jr. was the opposite. He spent years at psychiatric hospitals being treated for Schizophrenia. When his condition improved, he was allowed to return to the Princeton University to teach. Not only was Nash welcomed by his colleagues but he also won the Nobel Prize in Economic Sciences in 1994. He opened his acceptance speech with the forthright comment, “I’m a Schizophrenia patient.” Nash’s struggles with his illness and his recovery inspired Sylvia Nasar’s biography A Beautiful Mind and later a film by the same name starring Russell Crowe as Nash.

World Mental Health Day was observed for the first time on October 10, 1992. It was started as an annual activity of the World Federation for Mental Health by the then Deputy Secretary General Richard Hunter. Hunter began his career in the mental health field during World War II when as a conscientious objector he joined the Civilian Public Service programme. Hunter, a law graduate, while serving a hospital for the mentally ill patients, was disheartened by the lack of awareness of mental health which drove him to advocate for it.

This year’s theme for World Mental Health Day- ‘Mental Health in an Unequal World’ highlights that access to mental health services remains unequal. This is compounded in a world which is becoming increasingly polarized, points out Dr. Fernando. “The gap between the haves and have-nots is widening each day and the inequality is more prominent when it comes to mental health. Lack of investment in mental health disproportionate to the overall health budget contributes to the mental health treatment gap.”

People with mental disorders experience disproportionately higher rates of disability and mortality proving that ‘there is no health without mental health.’ According to WHO, persons with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population, owing to physical health problems that are often left unattended (such as cancers, cardiovascular diseases, diabetes and HIV infection) and suicide. Suicide is the second most common cause of death among young people worldwide. Yet, health systems have not yet adequately responded to the burden of mental disorders.

As a result, the gap between the need for treatment and its provision is large all over the world, notes the WHO’s Mental Health Action Plan 2013-2030. ‘Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries; the corresponding range for high-income countries is also high: between 35% and 50%. A further compounding problem is the poor quality of care for those receiving treatment.’

One in every four persons develops a mental illness says Dr. Neil Fernando. “Yet the annual investment in mental health is less than US$ 2 per person. In low income countries, it is less than US$ 0.25. In 2019, WHO pointed out that for every dollar spent on mental health, there is a return of four dollars from improved health and productivity.” Although it is accepted that large hospitals are not the best of places for people with mental disorders, 67% of financial resources are allocated to mental hospitals,” notes the psychiatrist who goes onto add that mental hospitals often restrain people unnecessarily resulting in abuse, poor health outcomes and human rights violations.

The tragic story of P.P. James who was confined to the asylum in Angoda for 50 years is one of the worst violations of human rights resulting in restricted hospitalization. Arrested on a charge of killing his father late one night in 1958, James was ruled mentally ill by a judge and was committed to the asylum for the criminally insane and was forgotten for 50 years, never having stood trial. Worst, the father he was charged for having killed was actually alive and died only 23 years after James’ arrest for ‘his murder’. A half a century after his arrest, his case was dismissed and James was finally free. “Although James had recovered decades ago and the courts were informed, there was no response as his file had been lost,” recollects Dr. Fernando who was serving in the hospital’s criminal ward at that time.

The absence of mental health legislation in the country to suit the present day needs is also cited by the senior consultant as a drawback in realizing mental health from a human rights perspective. The proposed Mental Health Act has remained only a ‘draft’ for decades, he says.

Stigma and discrimination, very often within families of patients (even after recovery) compounds the unequal access to mental health care and impedes the quality of their lives. Problems of knowledge, attitude and behaviour contribute to stigma. Many people even after recovery are abandoned by their families and are often deprived of their rightful inheritance.

In our setting, the stigma is even extended to the very locality where the hospital for the mentally ill stands- commonly referred to as pissan kotuwa in derogatory terms. When posted to Angoda as a young psychiatrist in 1984, Dr. Fernando took the bus from Kandy to Fort and from there to Angoda. “As the bus approached Angoda, the conductor was shouting Pissan kotuwa bahinna- pissan kotuwa bahinna and nobody got down from the bus. At the next bus halt half the passengers got off the bus and opted to walk back,” he recollects. The hesitancy of residents from the area to be identified with a hospital, drove authorities to rename the areas as ‘Mulleriyawa New Town.’ Angoda Mental Hospital was renamed ‘National Institute of Mental Health.’

Migration of qualified psychiatric specialists to other countries is another challenge points out Dr. Fernando. Sri Lanka’s failure to deliver mental health care services to a larger population is attributed to four broad reasons by Dr. Fernando:

1. The centralized services limited to large hospitals

“We need to decentralize mental health care and take it to primary health care or to the village level and integrate it to normal health care services.”

2. Services are all hospital-based

“The majority of people who need mental health services do not come to hospitals, hence the treatment gap is further widened,” remarks the senior consultant who calls for a ‘complementary community-based’ system. “Like in the case of maternal health, we can develop a system where patients are seen at home. We already have psychiatric nurses and this cadre can be further strengthened.”

3. The treatment is largely disease-based

“Instead of looking only at the disease, we should have a patient-friendly service which looks at a person holistically addressing his/her other needs as well.”

4. Services are delivered on one-to-one basis

“When we know that one in four people will be affected by a mental health problem during his/her lifetime, one-to-one delivery will not be adequate,” says Dr. Fernando who says the involvement of patients as well as their care givers in mental health services is essential. The effort could make them active partners in the process, so that they too can be empowered to take ownership to the delivery of care, he says.