A look at reform, innovation and shortcomings in mental health from six countries across the globe
By: Sam Mathers, News Editor
According to the World Health Organization, facilities that are specific to mental health care services are “few and far between.” While mental health is included in the basic package of health care services in Afghanistan, it fails at the delivery level. WHO cites “financial, human, infrastructural and information resource constraints” as the major challenges for providing “accessible and acceptable mental healthcare service.” Stigmatization however, seems to be the greatest barrier. The stigmatization of mental health not only affects the people suffering, but extends to mental health care providers as well. Mental health is also largely misunderstood by donors, resulting in little allocation of funding to mental health care projects. In 2011, Afghanistan’s ratio of psychiatrists for the population was 0.16 per 100,000.
Suicide by self-immolation, or burning oneself to death, has become a massive crisis in Afghanistan, particularly among young women. Some have suggested that Afghanistan is the only country in the world where the female suicide rate is higher than that of males, however reliable data on suicide in Afghanistan is scarce. Some figures estimate a yearly rate of 3,000 suicides, with 80% by women. Other figures purport the self-immolation rate to be somewhere in the four thousands. Mental health is currently a “first tier” priority in Afghanistan – one of the Ministry of Public Health’s top five concerns.
Brazil began to reform their mental health care system in the 1990s from an institution based system to what is now a largely community based system. Previously, mental healthcare consisted of large psychiatric hospitals with poor conditions and human rights violations. Brazil has tripled the investment in community based services since 2002, and currently invests more than 79% of federal funding for mental health in community based services. According to the World Health Organization’s 2014 report, Brazil has 30.8 mental health workers per 100,000 people. Stigma associated with mental illness is one of the major challenges in Brazil. Private health care generally has a limit of ten therapy sessions a year and people tend to visit psychiatrists for medication only. In 2003, Brazilian federal law implemented the “Going Back Home” program, which is financial support in the form of a monthly payment for individuals who have had a lengthy stay in a psychiatric hospital. This is to ensure patients are discharged with sufficient resources to reintegrate back into society. The program benefitted 4,349 people between 2003 and 2015.
Canada is failing its Indigenous people when it comes to mental health. Suicide and self-inflicted injury are the leading causes of death among First Nations, Métis, and Inuit people under 45. The suicide rate among First Nations communities is double Canada’s national average, with First Nations youth experiencing suicide at a rate 5 to 7 times higher than non-Indigenous youth. The suicide rate in Inuit communities is estimated to be 11 times the national average. This epidemic, however, is not new. The suicide crisis among Indigenous people has been an ongoing occurrence; a result of the intergenerational trauma of the residential school system and the Sixties Scoop, as well as a lack of access to mental health care.
In 2016, ten children in Wapekeka First Nation were discovered to have formed a suicide pact. Leaders in the community called on the federal government for help, submitting a proposal for $376,706 to hire and train a team of four mental health workers to bring into the community. Health Canada denied the request, citing an “awkward time” in the budget cycle. Several months later, two twelve-year-old girls took their own lives. Four other children identified in the suicide pact were flown out of the community for medical treatment, and another twenty-six children were considered to be high risk. Five months later, another twelve-year-old girl died by suicide. In Pimicikamak Cree Nation last year, four teenagers died by suicide in a span of three months. Nunavut, a territory with a population of 30,000, has 1,000 attempted suicide calls each year.
An Indigenous Affairs Committee studied the Indigenous suicide crisis for more than a year and released its report in June. The committee recommended better mental health care services in Indigenous communities, improved suicide strategies, government funding to allow communities to find their own solutions, as well as more investment in housing, more employment opportunities and improved access to education.
Mental health care in Egypt relies heavily on large psychiatric hospitals. The Abbasiya Mental Hospital, Egypt’s oldest psychiatric institution was opened in 1883 with the adoption of the Western asylum system. The name “Abbasiya” has become synonymous with “madhouse.” There is a criminality associated with mental illness in Egypt; a cultural perception that those suffering need to be locked up –and they are usually given a life sentence. A large number of patients never leave these facilities due to a lack of acceptance by their families and by society. In 2009, legislation was enacted that began to reform mental health care in Egypt. The Mental Health Act protects patient’s rights and requires consent of treatment. In 2011, the Franco Basaglia Center opened in Cairo, becoming Egypt’s first community based facility. It is an alternative to the asylum model of mental health care that integrates mental health care services within primary healthcare units at the district level. Today, the Franco Basaglia Center remains the only community based facility in the country.
In Finland, there is a popular approach to the treatment of mental illnesses, such as psychosis and schizophrenia, called “Open Dialogue.” In development since the 1980s, this approach is not to find a quick solution, but rather to begin a dialogue that will help create an understanding of the patient. Focused on early intervention, the key principles of this approach are that patients be seen within 24 hours of being referred or becoming unwell, that meetings with the therapeutic team be held in the patient’s home, and that the meetings include the patient’s network of family and friends. This approach is said to reduce the need for long-term medication or hospitalization. Figures state that 80% of patients do not need antipsychotic medication, however, some are critical of Open Dialogue. There has been no high quality, independent study of the program and such figures come from studies that lack control groups.
Finland is taking another provocative approach to mental health care in the form of online treatment. In response to the difficulty of accessing mental health care in rural areas in Finland, Professor Grigori Joffe and Dr. Matti Holi set up Mental Hub – an online service specializing in “information, support, and treatment related to mental health and psychological well being.” The program is funded by the hospital district of Helsinki and Uusimaa, as well as the government. With a doctor’s referral, individuals can receive remotely provided therapy online, with therapists available 24/7. Patients complete one segment at a time through informational content, examples, and exercises. A therapist monitors the progress of the treatment by providing support, giving feedback and driving the advancement of treatment. Patients are able to message their therapist throughout the course of their treatment with any questions or concerns. Last year, the program had 535,000 unique users. That translates to 10% of Finland’s population. While Mental Hub is “particularly suited for treating problems in their early stages,” it is only effective in addressing those mental health concerns that don’t require intensive treatment.
In 2002, Japan changed the name for schizophrenia from seishin bunretsu byō, meaning “split-mind disease” in Japanese, to tōgō shitchō shō, or “integration disorder.” This change came in response to the massive stigma associated with schizophrenia in the country. Prior to 1950, people suffering with schizophrenia were essentially incarcerated with restraints, leading to widespread negative attitudes toward mental illness. Prior to the name change, only 7% of doctors were informing their patients of their diagnosis of schizophrenia, in fear that the individual would refuse treatment based on preconceived and inaccurate notions surrounding the condition. By 2004, almost 70% of people with schizophrenia were informed about their diagnosis.
Currently, Japan is seeing high rates of suicide, leading to the implementation of a training program where non-mental-health professionals can become inochi no monban, or “gatekeepers for life.” This program is an effort at the local level, where citizens from all walks of life receive training to improve the detection of at-risk individuals. Gatekeepers can identify someone who is at risk of suicide through the conversations they engage in, the clothes they wear, and their general attitude. The idea is that in their everyday interactions with people, gatekeepers for life will be able to identify when someone is at risk, and refer them to the proper channels to get help. A 2015 study found promising results in the gatekeeper program at a Japanese university. Suicide is the number one cause of death for students in college and university in Japan. 85% of students with moderate to severe depression do not receive treatment and 80% of students who died by suicide were unknown to campus mental health professionals. After receiving gatekeeper training, the study found significant improvement in the competence of university administrative staff to handle situations with suicidal students. One third of the participants had at least one opportunity to utilize their skills within a month of completing the program.