STRATEGIES FOR REFORMING MENTAL HEALTH
IN DEVELOPING COUNTRIES
Mental health is defined by the world health organization in its constitution as
" A state of complete physical, mental, and social well-being and not merely the absence of disease"
The importance given to the mental and social aspects in the WHO constitution is not an accident of drafting but an affirmation of the holistic nature of the concept of health. Man is not a bundle of tissues that functions purely by physiological process. Even the most concrete among men must realize that man is a social and a thinking being with feelings and reactions in the society that he lives in Even animals and are thinking beings with a host of emotional reactions and effects of stresses whether they are physical or mental. As such the mental aspects of health can be easily seen to those who are observant , to be acting in everyday life in healthy people as well as unhealthy persons.
The unfortunate practice, therefore to separate the physical aspects of health from the mental , are an artificial practice based on ignorance and unfortunately prejudice.
The Seeds of Prejudice
The reasons why the mental aspects of health in practice however, are given scant importance in the scheme of things, in many countries, from their teaching curriculum, their health budgets and their relationship with the physical aspects of health, are complex. While many who work in mental health see the gross discrimination of the mentally ill and all things mental by administrators as well the lay public as being the result of stigma and prejudice, the real reasons may be related to the concept of mental illness in the eyes of the world (including many mental health professionals). Unfortunately mental health as a concept has for too long been allied with only psychosis (madness) which merited admission to mental hospitals, which were specially built for the severely mentally ill. The ordinary hospital looked after the mildly, moderately, and the severely physically ill , but not the mental patient. The milder and moderately mentally ill, however were not only not in an ordinary hospital, but they were not even noticed as being ill and remained untreated. So it appears that all of mental illness, was simply madness. This concept was prevalent the world over but remains particularly entrenched in developing countries.
This may seem simplistic and naive but even mental health personnel from nurses to psychiatrists today have difficulty recognizing mild depression or anxiety that are distressing to many patients but not severe enough to merit admission to a mental hospital. It is the absence of recognition of these mild and moderate mental illnesses and the excessive emphasis on the severe mental illnesses especially the psychosis that has given rise to the erroneous concept that all mental illness was simply madness and nothing else. And as there is a strong entrenched fear and consequent prejudice against the psychotic who are judged to be dangerous and unpredictable, they are given little importance and in fact discriminated against in numerous ways. The incarceration of the mental patients in asylums and the incarceration of criminals are in lay minds and unfortunately the minds of many mental health professionals much the same. Indeed there are often mental hospitals and prisons built side by side are parts of the same building, in many developing countries and directors of prisons are sometimes on the boards of mental hospitals .
The prejudice against all things mental is now easier to understand, from the highest level of health care systems to the lowest man on the street.
Primary Care Psychiatry.
The overemphasis on the severely mental ill has damaged the name of the word mental in the eyes of all people so that the stigma of being mentally ill is today far worse in many ways than tuberculosis, leprosy and even AIDS in many regions of the world. Even the severely mentally ill are not always severely ill, dangerous, violent or unpredictable as those who work closely with them will testify. And yet the myth of mental illness has replaced the reality of mental illness. All it requires is one act of violence by a psychiatric patient to bring on the wrath of more barbed wire and locks and more grilles.
Although the psychoses constitute only 10 % or less of all mental illnesses they are in the minds of many the only mental illnesses. In actual fact the 90% of all mental illnesses are those that are seen ( but not recognized ) in primary care settings. These include anxiety or depressive illnesses usually related to stresses of living. Often these present as physical symptoms such as palpitations, gastric discomfort, headaches, tiredness or insomnia . The physical nature of the complaints in these mental stresses is related to the physical reactions to stress, such as autonomic nervous system hyperactivity causing the gastric secretions to increase or the heart to beat faster , or the muscles to contract causing discomfort. While these are common symptoms of mental anxiety, depression or stress , they are often similar to symptoms of physical disease of the heart, or stomach or hypertension. Therein lies the confusion between the physical medicine and the psychological medicine . Having had very limited knowledge of psychological medicine and often that too of only the psychoses the practitioner may automatically associate these physical symptoms with physical diseases only thus ignoring the underlying mental problems, stresses and diseases in favour of a possible physical cause for these symptoms.
There is therefore a need to appraise doctors that there is a need to look for psychological possibilities as well as physical ones when confronted with symptoms which are common to both conditions. The failure of undergraduate teaching of psychiatry to familiarize doctors with anxiety and depression in primary care settings has resulted in their non recognition in primary care. Thus the recognition of mental problems is limited to less than half of all patients who have mental problems in primary care and treatment limited to less than a third of them.
With this in mind, the World Health Organization in 1991 embarked on a programme to develop a classification of mental illnesses that will be useful in primary care settings.
The ICD-X-Primary Health Care was launched in 1996 and a training kit in 1998. These contain 24 common primary care psychiatry conditions (out of the over 500 mental conditions in the mother classification in chapter V of the ICD X) and simple treatment options useful in primary care settings. A further modified 6 diagnoses list in colour coded cards is available in the kit.
Teaching User Friendly Psychiatry.
As all of psychiatry was mistakenly identified with just 10% of all mental illnesses who filled 90% of mental hospital beds, it was assumed that teaching medical and nursing students should also conveniently, be based on the same patients. And so generations of doctors had their introduction and indeed their only exposure to the mental in health seeing the severest of mental illnesses which would hardly be seen again in most of their clinical lives. It was akin to teaching internal medicine to medical students by teaching them only cancer patients in the late stages of cancer or cardiac patients on life support systems or dying patients. While this would be unthinkable as a method of teaching a discipline the same extreme bias was the norm in the teaching of psychiatry for the better part of a century and continues to be so in most medical and nursing schools the world over at the turn of the new millennium.
Is it surprising, therefore that psychiatry continues to generate among health professionals , both young and old, a negative response and the care of the mentally ill remains alienated from the mainstream of medical care in profile, priority, and budgets .
Clearly the 90% of psychiatry that lies outside the psychiatric ward which is often filled with the severely mentally ill out of necessity in a developing country, must form the bulk of the basis for teaching nursing and medical students. To do this an effort must be made to seek out the anxiety and depression , the psychosomatic, insomnia and parasuicides and other stress related mental problems that occur often enough in the hospitals primary care clinics or the internal medicine and surgical wards to use as the basis of teaching .The relationship of mental stress to insomnia, smoking, heavy drinking, violence, accidents and marital problems are other areas that need to be taught. Patients who come repeatedly for coronary artery disease, hypertension, accidents or smoking related chest diseases also need to be screened for mental and social stresses. These efforts will make the teaching of psychiatry more meaningful rather than the almost exclusive emphasis on the severe psychoses that are not related to the practice of primary care that most of the students will enter on graduation. It is sobering to note that todays new found emphasis on the so called life-style diseases from coronary artery diseases and obesity to lung cancers have little input from mental health or psychiatry.
There is another important benefit in the use of general medical and surgical ward patients in the teaching of psychiatric illnesses. Many specialities in Medicine do not know or recognize emotional problems in their patients. Patients who develop puerperal depression may not be recognized to be ill be simply thought to be lazy for not taking care of the child. Post operative psychosis may be thought to be simply being stubbornness on the part of the patient.
The teaching of psychiatry in these settings often helps staff in these settings to learn psychiatry first hand .
The severe mental illnesses must be given the proportion of teaching priority as is their due in actual clinical practice in the community. The practice of teaching conveniently on severely ill patients in the psychiatric ward cannot be the norm in undergraduate teaching if the actual mental problems in primary care and other non psychiatric settings are to be the basis of teaching at undergraduate level.
The students should spend more time seeing the patients with emotional problems in medical, surgical, paediatric, or orthopaedic clinic rather than in the psychiatry.
Reforming Mental Hospitals.
Clearly many mental hospitals in the developing world are, given the low priority that mental health enjoys in the health care plans sorely in need of reform. Many are not fit for human habitation and remain prominent in the minds of people only as reminders of all that is negative about mental health. The locked wards, the grilles, the guards and the penal atmosphere of many a mental ward or hospital are not conducive to recovery let alone a cure from the illness the patient came with.
A move away from long stays, restrictive measures and inhumane methods of detention rather than treatment should be implemented with the use of newer medicines and energetic social and psychological treatments in general hospital short stay wards rather than large overcrowded mental hospitals or asylums with high walls and forbidding gates. Most mental illnesses can be well controlled with energetic management in 2 to 3 weeks of inpatient care to be managed in outpatient clinics or in day treatment centres. As such the resort to lengthy and restrictive hospital stays of 2 or 3 month and in some countries 6 to 12 months only adds to the original illness by insitutionalising the patient.
Mental hospital reform is not only changing the atmosphere of the hospitals by making them more user friendly but also changing the attitude of the staff. Archaic ways of thinking have to be replaced by more humane ways of treatment with patients being treated as persons and not inmates under custody. Voluntary admissions should be the norm and compulsory admissions kept to a minimum and limited to a strict period only for those who are a danger to themselves or others temporarily. The treatments should be along the philosophy of healing and caring, rather than of control. Medicines should be used always in conjunction with social and psychological therapies aimed at healing the inner self. Merely reacting to behaviour by restrictions and chemicals is not treatment but control and not conducive to healing and recovery. Retraining of staff often poses the greatest challenge
Public Education and the Mental Health Movement
The public attitude to the mentally ill is also the result of misconceptions and prejudice thereof. This too like the education of the professionals in mental health needs to be done to overcome the stigma that shrouds the future of the mentally ill. One of the best ways to break down the wall of prejudice is to involve the public in the care of the mentally ill rather than as is often merely exhort them to change their attitudes. The mental health movement was started as a partnership between the patient , the family, the professionals and the community to understand and offer support the mental health of the community. Public education, through the print and electronic media, open days, and support of mental hospitals all go to de-mystify the mental in health, and go along way to reduce the prejudice against the mentally ill mentally ill and mental illness. Educating the public on stress and stress management and how mental stress is related to smoking, heavy drinking, accidents and coronary heart disease also bring the mental closer to health. The mental health movement is an integral part of any progressive mental health programme, contributing in both educating and supporting the public in the field of mental health. Despite popular notions of stigma, most people who come into close contact with the mentally ill who have recovered or rehabilitated successfully are not prejudiced but instead full of praise. The mental health movement can help both in the process of rehabilitation in the community as well demystifying the popular but erroneous concepts of mental illness. Indeed many community based mental health and rehabilitation centres today in some developing countries are today run by NGOs rather than by ministries of health.
Rehabilitating the Recovering Mentally Ill.
One of the realities of severe mental illness is the tendency for the illness to relapse in vulnerable individuals who with repeated episodes are left with lives that are emotionally and socially shattered and unproductive. Their almost total dependence on their families at an adult age is often yet another reason for the rejection, prejudice and stigma that haunts the mentally ill. While modern medicines can control the severe symptoms of most severe mental illnesses they can rarely make a person return to a full productive life after an illness. In these persons, a graduated process of healing using psychological , social, occupational and medical techniques of rehabilitation can produce remarkable changes in the persons functional ability. The rehabilitation of recovering mental patients is best carried out in the community setting on a day basis . Discharging mental patients because they are symptom free but non functional, without rehabilitation is no longer acceptable as good management.
The current state of mental health in many developing countries is the result of decades of neglect, through ignorance, prejudice and resultant stigma and marginalizing of all that is mental in health.
The time has come to roll back the shroud of neglect to allow mental health to contribute to the quality of care and also life. This process of change cannot be achieved by exhortations alone but by a systematic process of change in the way psychiatry is taught, practised and accepted in society and among professionals in mental health. It is not an easy task to reverse long held prejudices based on myths, but a beginning has to be made and made strongly if the mental is to be put back in health.
M Parameshvara Deva
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