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by Nalaka Mendis Professor of Psychiatry, University of Colombo

Mental health arouses a negative attitude in the minds of many including politicians, bureaucrats, professionals and policy makers. Consequently the tendency is to trivialise this important area of health and attach low importance to it.

Others who are aware of the suffering of people, caused by mental illness and who are sympathetic to the cause are unable or unwilling to speak or act on behalf of this group of people due to a variety of reasons.

However, we know that one in four families is likely to have a person with mental health problems needing clinical attention. These mental health problems often lead to personal distress, ill health, death, stigmatisation, shame, marginalisation and economic deprivation to the individual and/or to the family.

In spite of these limitations, over the years many people from different backgrounds who were concerned about mental health, have come to the open to speak out on behalf of those suffering from mental illness with great success, thus promoting the development of necessary services.

There is increasing realisation that development of health (mental health is an integral part of health) by itself is intrinsically good and indeed good health is essential for enhanced economic development, which communities are striving to achieve.

On this World Mental Health Day, at a time when Sri Lanka is going through very significant political, social and economic transformation I felt it is appropriate to review the national mental health services in the context of recent global and local developments. I will briefly review the global developments in the field especially during the last decade, then review the developments in Sri Lanka and finally address the issue of developing this neglected area of health at a national level.

There had been very significant developments in the field of mental health during the last two centuries. In the nineteenth century lunacy was recognised as a health problem and inhumane treatment was replaced by compassionate care. In the twentieth century with better understanding of the nature of mental illnesses specific treatments were introduced and people were treated with dignity either in general hospital or in the community by mental health professionals.

However, the developments taken place globally during the last decade has brought mental health to the domain of a much wider group of stakeholders including patients, advocacy groups, professionals, scientists, managers, economists, welfare workers, international agencies, politicians and policy makers.

This process to a great extent was triggered off by the publication of the world development report in 1993 which showed that mental and behavioural disorders account for more than twelve per cent of global burden of disease, a new measure to assess health status based on disability adjusted life years.

Subsequent work conducted by the World Health Organisation revealed that this figure is likely to go up to twenty per cent in the coming decade. Another landmark was the publication of the World Mental Health Report by the Harvard group which came up with evidence to show that compared to industrialised countries the developing world had a much bigger burden related to mental health.

Since then in view of the high mortality, morbidity, socio-economic impact associated with mental disorders, a special session of the United Nations, World Human Rights Conference and recently the landmark

Beijing Conference identified this aspect of health as a special area needing priority action. In response to these developments the World Health Organisation initiated a series of activities including the publication of the World Health Report 2001 dedicated to Mental Health.

This report titled "New understanding, New Hope" is a very comprehensive document primarily addressed to those in power or have the means to make things happen. It emphasised the need to address mental health as a public health issue. Mental and physical health are seen as two vital strands of life that are closely interwoven and deeply interdependent. Apart from biological factors the importance of psychological and social factors as determinants of mental health and mental illness has been discussed in this report.

In view of the need to develop a comprehensive and a coordinated response to deal with the complex issues of mental health problems the World Health Organisation is of the view that this has to be addressed not only by the ministries of health but also other government agencies such as social services, education, justice, labour and a range of others including non-government organisations, academic bodies, professional groups, community groups and other interested parties.

At the Executive Board and later at the World Health Assembly held in 2002, which was attended by our Minister of Health and senior officials of the Ministry, a unanimous resolution was passed recommending the adoption of the recommendations of the World Health Report. An action plan titled "Global Action Programme" was adopted for its implementation.

In this programme the WHO has addressed the gap between the extent of the problems and the availability of services and the need to bridge the widening gap. It also addressed the need to focus attention on promotion of mental health and prevention of mental illness while attending to the huge mental illness and disability burden especially in developing countries.

Sri Lanka

Based on hospital admissions, clinical experiences and limited studies available, it is clear that mental health problems in Sri Lanka are not only a major problem but are likely to get worse.

Based on WHO estimates about ten per cent of the population suffer from mental and behavioural disorders. Persons suffering from psychosis, mood disorders, anxiety disorders, substance abuse, dementia, learning difficulties, psychological stress, suicidal behaviour, disabilities associated with mental and physical illness are common problems in clinical practice.

Increasing number of people presenting with mental health problems attributed to work place stress, education, family and other social stresses pose problems to services, which do not have the required competence and resources to respond to these needs. In this presentation I do not wish to go into details as to the probable reasons for these changing morbidity patterns apart from stating that epidemiological and socio-economic transitions are likely to play an important part in this development. The people with mental health problems need a range of services varying from acute care, long term care, psychological interventions, rehabilitation, social care.

Developments

It is common knowledge that in Sri Lanka the mental health developments at the national level have been very modest compared to some other areas of health care and certainly no where close to what has been achieved in other Asian countries in mental health care. Our services are predominantly in urban areas with a mental hospital base. There is a severe shortage of mental health professionals including non-medical health professionals. There are very few specialised services for needy groups of patients while promotional and preventive programmes are very few and social care is minimal.

This is very unsatisfactory especially in view of the fact that we have had a relatively good mental health care service in the past. Based on the ratio between facilities and professionals to the population in the sixties and seventies Sri Lanka was at the top among the Asian countries. Today almost all countries have overtaken Sri Lanka.

However, it is heartening to note that there had been significant developments outside the public sector in the universities, non-government organizations and in the private institutions with increased mobilization of non-governmental resources.

Many university psychiatry departments have expanded mental health programmes both in training and service delivery to meet the needs of special groups, Introduction of psychiatry to the medical curriculum by the Colombo faculty as a separate subject is an important development and has been referred to in the World Health Report 2001. A number of non-profit making organisations have been established to provide services, which are not available in the state sector. There has been a considerable expansion of private psychiatric services at the level of outpatient care. A number of agencies in the private sector have started training programmes for mental health professionals.

Apart from the above a large number of foreign non-government organisations have started working in the area of psychosocial rehabilitation in the North-East.

Decline

Many would be tempted to attribute this decline to the indifference shown by the successive governments and of course the Ministry of Health to the development of mental health.

This is more apparent as there had been significant development in the non-state sector. Having dealt with many politicians and senior officials of the Ministry during the last thirty years I find that systematic mental health development at the national level has never been given serious thought by the Ministry since 1960S except perhaps on specific instance by one or two committed officials.

Wherever there had been significant national initiatives there had always been external influences and partnerships between the ministry and other agencies. Establishment of long term rehabilitation units in provinces following Presidential Task Force recommendations, training and posting of medical officers in mental health following initiatives of the National Council for Mental Health and establishment of Diploma in Psychiatry at the Post Graduate Institute of Medicine following initiatives taken by the Minister of Health and the Director General of Health Services are some examples.

It is also important to realise that part of the blame for this sorry state of affairs should go to the professionals, community, advocacy groups, mass media and other influential bodies for not highlighting this issue and getting the government to act with the aim of developing the services.

How can we develop mental health services by incorporating relevant aspects of the international and local development initiatives towards the common good of our people at a national level?

The World Health Organisation 2000 Report has gone into great detail on this issue and talks of stewardship of the government in relation to the development of health services. It specifically talks of the need for the State through the Ministry of Health to influence the direction of health development by policy formulation, regulation and monitoring.

It is absolutely essential that the health ministry and other relevant agencies take cognizance of the importance of mental health and incorporate international and local development into a national programme.

The real challenge is for the ministry to assume leadership to develop, facilitate, monitor and maintain standards of services at a national level in partnership with other agencies. If this change is not brought about provision of public mental health care to meet the emerging mental health problems could be a very distant dream.

Therefore it is for the political and the bureaucratic leadership to identify, recognise and acknowledge the relevant global and local initiatives in mental health development and channel these developments through reformed national institutions and programmes if we are serious in raising the health status of our people. This process is likely to be facilitated if the community groups professional organisations, advocacy groups, media and other agencies continue to bring pressure on the political leadership.

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