The surge in the number of persons with mental disorders in Sri Lanka recently prompted President Maithrapala Sirisena and the Health Minister to call for urgent interventions to put a halt to this disturbing trend. With current statistics pointing to some 20 to 30 percent of the population afflicted with some form of mental illness, in varying degrees, the need to find the root causes that have caused this surge in mental disorders, and how they could be detected early and treated, has never been more pressing than at present, in the changing fast paced society.The Sunday Observer spoke to one of the most experienced experts in this field who was also the Founder Director of the National Institute of Mental Health, Dr Jayan Mendis, to find out more about such disorders, their health impacts, treatment and the myths that prevent timely detection for more positive outcomes .Excerpts...
Q. The Health Ministry led by the President and Minister of Health is now calling for more awareness raising on mental health problems following recent studies that reveal a surge in mentally disturbed persons across all ages. It has been reported that one in four persons in Sri Lanka suffer from some mental problem which vary from mild, to moderate to severe. Is this correct? Do you have any hard statistics on the exact number of mentally disturbed persons in Sri Lanka?
A. Yes. About 20 to 30 percent of the population has some kind of mental health problem. This includes schizophrenia which is a severe form of mental disorder, constituting about one percent of the population, depressive disorders amounting to 5 to 7 percent, and bipolar affective disorder, about 1 to 2 percent of the population. Of that, some have minor problems, such as, different forms of anxiety disorders, social phobia and other phobic disorders (fear for no reason) and obsessive compulsive disorders which constitute about 5 to 10 percent of the population. Now however, increasingly job related and other forms of stress disorders, and post-traumatic stress disorders are also common. This constitutes about 20 to 30 percent of the population suffering from some form of mental illness.
Yes. There are studies done in different districts of the country which also tally with these figures.
Q. If mental problems are categorized, what in your opinion are the most common such problems we now see in Sri Lanka?
A. Common conditions are, anxiety disorders, social phobia and obsessive compulsive disorders.
Q. Are these issues confined to a particular age group? An ethnic group? Or a district?
A. Yes. These are mainly confined to late adolescence to early adulthood, up to about 30 to 35 years age group. Studies have confirmed that an ethnic group or any district does not have special forms of mental disorders other than in the north where there is a sizable number of people suffering from post-traumatic stress disorders.
Q. Which age group is most vulnerable to mental issues? Children? Adolescents? Elderly? Why?
A. Adolescence and early adulthood are more vulnerable to mental health issues due to various neurochemical changes that occur as a result of genetic predisposition. However, middle aged females, in the 45 to 60 age group are more vulnerable to depressive disorders, and the elderly, after 60 years, are vulnerable to dementia and depression.
Q. With regard to the elderly, would you agree that the breakdown of the extended family unit resulting in elders living alone has led them to feel isolated and depressed? Is it correct that depression is one of the main if not, the leading mental condition now widely prevalent among Sri Lankan elders? Apart from social and economic factors are there other health related conditions that lead to depression?
A. Yes. Elderly depression is also a common form of mental illness which occurs after 60 years of age. Due to various environmental factors such as, living alone, breakdown of extended family and isolation, they are more prone to develop depression. Socioeconomic factors would also contribute to elderly depression.
Q. What are the health impacts of mental disorders in the elderly?
A. The elderly who develop mental disorders are more prone to medical problems such as, heart disease, respiratory tract disorders, skin disorders, etc.., and as a result, they die earlier than expected. As a result of mental disorders they may require a better support system.
Q. Recent news reports have shown that the number of adolescents and youth with mental problems are on a sharp rise. What are the causes for
this?
A. Most of the mental illnesses, about 75 percent develop in the adolescence. This is also due to neurochemical changes as a result of genetic vulnerability. However, various financial and social issues play a role.
Q. Police reports have noted that the tendency for self-harm, especially, among young people has risen compared to two decades ago. Do you see a surge in this tendency?
A. These graphs show the suicide patterns in Sri Lanka from 1976 to 2011. In 1995, the suicide rate in Sri Lanka was the highest in the world. Thereafter, it dropped to 25 per 100,000 a few years ago and to 14 per 100,000 in the last year.
This drop in suicide rate is mainly due to President Chandrika Bandaranaike’s presidential task force for suicide prevention, which produced ten main recommendations related to improvements of emergency care services throughout the country. However, there is an exponential increase in self-harming behaviours that is a worrying problem for psychiatrists and the mental health workforce in Sri Lanka.
Q. At a recent seminar on suicide, at the Family Health Bureau, you noted that young people most at risk of self-harm were aged 15 to 30. What drives these young people to self-destruction? Unemployment, inability to cope with life pressures or lack of self-esteem,
A. Various reasons play a role here. The main issue is, lack of development of self-esteem and the inability to cope with the various pressures they undergo in early adulthood. Unemployment may not be playing a big role in Sri Lanka. But, there is an association between unemployment and suicide.
Q. What about family relationships that have eroded due to divorces or absentee parents? In your experience are more young people now less willing to trust their parents with personal problems?
A. Yes. Nowadays we see more families than two or three decades ago coming to psychiatrists with various family relationship issues. Some of them resort to divorce for the slightest reason. As a result children have to face enormous pressure, being forced to undergo various kinds of abuse. I cannot say that nowadays children do not trust their parents; but, life situations have changed and is complicated due to computers, the internet, facebook and various other computer related issues.
Q. We also heard that the number of new mothers who suffer from post-traumatic disorders contemplate taking their lives. Is this a new trend?
A. The new mothers are not really suffering from post-traumatic stress disorder, in fact, the burning issue is that after childbirth they develop various kinds of psychiatric problems, such as, depression (10%), about 1 to 2 percent develop major psychiatric disorders. Not detecting maternal depression and other psychiatric problems would lead them to resorting to suicide called maternal suicide. They may even take the life of the baby, and sometimes, the older children too. That is why immediately after childbirth, the mother should be kept in a vigilant state.
Q. We are also hearing a disturbing trend where even children in school suffer from mental stress. What is the reason for this? Too much homework, over ambitious parents pushing them to perform well, lack of exercise and healthy recreation,
A. Yes. We have lots of different children in schools. As I told you earlier about 70 percent of mental disorders develop in late adolescence. These adolescent mental health problems could be misinterpreted as, learning difficulties, irritability or angry outbursts may present as fights with other students or the teachers or rebellious behaviours in classrooms or schools. They misinterpret these behaviours and people think it is due to too much homework or parents pushing them. Bullying at school is also another reason.
Q. Take the Grade five Scholarship exam, it is now necessary for such young children to shine academically at the cost of becoming nervous wrecks due to overstudying, and anxiety about failing the exam.
A. The Scholarship examination was introduced to Sri Lanka to filter students for admission to secondary schools to undergo different kinds of advanced training to sit the O/L and A/L exams. However, most children not gaining entry to popular schools has created this condition of pressurizing children to pass the exam in order to get into popular schools. This has led to unwanted complications such as, some percentage developing various anxieties about exams. I think this is the time for the Education Ministry to rethink about whether to continue this exam or introduce some other examination where children and parents do not have to undergo unnecessary pressure. I have seen some parents who have been affected with mental health problems as a result of their children who do not perform well at the Grade five Scholarship examination.
Q. What are the symptoms to look for in mental stress among?
1. Children
2. Youth
3. Elderly
A. 1. Symptoms of mental stress in children include nightmares, trouble concentrating and completing school work, increased aggression, bedwetting, hyperactive behaviour, withdrawing from family and friends, eating or sleeping disorders and overreaction to minor problems.
2. Symptoms of mental stress in adolescents include depression or general unhappiness, anxiety, agitation, moodiness, irritability, anger, feeling overwhelmed, loneliness, isolation and other mental or emotional problems.
3. Common symptoms of mental stress in the elderly include insomnia, nightmares, loss of appetite, palpitation, frequent urination, muscle pain, tiredness, anxiety, fear, frustration, depression, restlessness, poor concentration and forgetfulness.
Q. How do you treat mental disorders? Does treatment differ according to the age group? Explain in detail.
A. Treatment of mental disorders not only comprise medications. Mental disorders could be treated well if they present for treatment when they notice any behavioral or emotional changes, early. Earlier the treatment, better the outcome. It does not mean we cannot treat them effectively when they present late. However, the family also needs counselling, and will be taught how to recognize illness early, and how to monitor medications. Patients will also be taught not to take alcohol and drugs which would complicate mental disorders.
If any family member is responsible for the maintenance of mental disorder, the family will be told how to deal with such a situation. It really means giving advice to the family, patient and caregivers.
Q. As the Founder Director of the National Institute of Mental Health (NIMH) tell us about your institute providing relief and care to both OPD patients and in-patients.
A. The National Institute of Mental Health, Angoda, was built during the Victorian era in 1925, and opened for patients on January 31,1929. At present, it is the largest tertiary care hospital in Sri Lanka caring for patients with mental illness. The former Mental Hospital was upgraded to a National Institute in 2008. The halfway home, Mulleriyawa (HWH) and the school of nursing, Mulleriyawa, are also under the administration of NIMH since 2008.
Among the many services offered, in addition to general adult psychiatry, the institute has different specialized units. They are, the psycho geriatric unit, general medical ward, perinatal psychiatry unit, learning disability unit, adolescent psychiatry unit and forensic psychiatry unit. It also has a psychosocial training centre to train all staff categories in the area of mental health. In addition, a research centre is also attached to the hospital.
Q. The Health Minister has mentioned that starting next year there will be counselling services for students due to reports of increasing numbers of students dropping out of schools due to their inability to cope with pressure and bullying. Is this a good thing?
A. Yes. This is good. However, the success of the program would depend on the person providing counselling services, kind of training the counsellor should undergo, the confidentiality aspects, etc. Bullying and the inability to cope with it could definitely result in various mental health problems.
Q. What are the plans the NMICH has to help all mentally disturbed persons to have access to health care?
A. Sri Lanka has about 100 mental health specialists working in all districts in the country. Each district has 12 to 20 mental health clinics and care provision services. There are psychiatrists working in the private sector as well. Therefore, now, unlike 30 years ago, the families with mentally disturbed patients have better access to mental health care.
Q. What are the myths and other obstacles that prevent proper access to health care for the mentally disturbed?
A. There are various myths associated with mental health problems. The stigma attached to mental health issues adversely affects the suffering. Myths related to religion, and various rituals are also attached to mental health issues. They would prevent people access to health care. However, it is difficult to develop mental health services, as some health planners cannot understand the prominence and importance given to mental health. This is also a reason why mental health has not developed in comparison to other health services in Sri Lanka.
Q. Are there sufficient psychiatrists, trained counsellors, psychologists?
A. At present, we have about 100 psychiatrists. All of them have returned to Sri Lanka after their training. However, sadly there are no nurses similarly trained in mental health. In fact, mental health nurses, occupational therapists, trained social workers are more important than counsellors.
Recently, the Health Ministry has been trying to enrol a few psychologists. They have also not yet been stationed to work in the mental health teams. Psychologists work with mental health teams in all developed and developing countries.
Q. Your message to parents, teachers, carers, regarding the detection and care of mentally disturbed persons?
A. Mental disorders as I told you early need to be detected early, treated early and treated adequately. Some may have to be treated for a long term. That’s what parents need to know.
Teachers also have a role to play as children spend most of their lively time at schools. Good teachers would know how to support children, understand children, prevent them from bullying and detect their illnesses.
In years to come, we need to have trained carers as the family structure is falling apart. Carers must look after mentally ill patients the way they would look after one of their family members. All the rights of the mentally ill should be preserved, and they should be treated like any other human being. Just because they are afflicted with mental illness doesn’t mean they are unemployable. As far as possible, they should be given a chance to apply for jobs where they could perform.