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Destigmatising mental health

05 Mar 2021

Without thoughts and the ability to think, we would be like machines with no sense of our existence or actions, and to a great extent, what we are is defined by what we think. The topic of mental health has been discussed extensively, for decades, but the discourse on the importance of mental health is a never-ending discussion that will never go stale, as issues caused by and leading to mental health issues are on an upward trajectory and are changing frequently. Over the years, various foreign media have named Sri Lanka as a country with one of the highest suicide rates, even though local and global data suggest otherwise. According to the Directorate of Mental Health, from 2011 to 2016 (the latest available data), suicides have declined in Sri Lanka. However, that is not to say that suicide is no longer a pressing issue Sri Lanka is facing or that Sri Lanka has done its best to prevent suicides. There are more things that can and should be done to prevent suicides. According to the data issued by the Directorate of Mental Health, the number of males committing suicide is more than three times the number of females committing suicide. In 2011, a total of 3,770 persons – 2,939 males and 831 females – committed suicide, while in 2016, a total of 3,025 persons – 2,339 males and 686 females – committed suicide. However, the World Health Organisation (WHO) data regarding Sri Lanka was slightly different; it said that in 2016, a total of 3,034 persons – 687 females and 2,347 males – had committed suicide in Sri Lanka. Global data shows that young people are more prone to face social and personal issues, which increases the risk of facing mental health issues, a leading cause of suicide. Many have claimed that even though there are a large number of institutions providing mental health services, mostly in Colombo, people, especially young people, being reluctant to obtain these services is an issue, and that there is a certain barrier that affects the relationship between people and institutions providing mental health services. The Morning spoke to several persons who are in a position to shed some light on this matter, so as to look into reasons as to why there is a lack of connection between these two parties.   Stigma from society and family   According to Sri Lanka Sumithrayo, one of Sri Lanka’s most prominent organisations that has been operating for decades with a focus on providing emotional support to help those at risk of suicide, when it comes to the topic of mental health in Sri Lanka, the main issues are the stigma associated with mental health issues, and the lack of awareness among the people about the mental health issues that they are going through. “Due to this stigma, even the families of the people going through mental health issues do not want to acknowledge the fact that a family member is having a mental health issue,” Chairperson of Sri Lanka Sumithrayo, Kumuduni De Silva, told The Morning, adding that the key to addressing the issues that deter young people from seeking mental health services, is to educate the people. She added: “We should carry out awareness-raising programmes in order to remove the stigma associated with mental health issues. The mind also belongs to our body; we take medicines for all the other ailments, but not our mental health. It has become a taboo word. If you say that you have a mental health issue, it is perceived as a taboo word and people do not want to talk about it. As a matter of fact, a lot of people want to hide it. This situation has become a big problem, and therefore, we need to do a lot of awareness programmes to educate the people.” She emphasised that it is alright to talk about one’s mental health issues, and that a person can lead a normal life after getting help. Speaking of the mental health issues among teenagers and children, De Silva added that as the first step, parents should learn to listen to their children, and that the parents should take whatever the children have to say, seriously. She further explained that parents should observe their children’s behaviour and be able to notice if there is a difference. “We should talk with children about their issues, and if they are in need of professional support, we should be able to see to it that they get the support they need,” she added. She added that all the above-mentioned factors are pertinent, and that changes should take place in schools as well. She pointed out that schools should educate children to discuss if they are going through stress or depression or facing any difficulties in concentrating on their studies. She added that Sri Lanka should do more with the country’s social welfare and health institutions, and that everyone must collectively engage in educating about the matter. Speaking further about stress factors among children, she said: “Our education system should also change a little bit without pressurising children to do a lot of homework. Both parents and children are under stress. Schools should be geared to help these children. If children do not do well or cannot understand, teachers should be able to identify them and help them, in a humane way. There should be support provided in schools. Teenagers and children are more prone to mental health issues, because of several reasons including competition, peer pressure, and stress. Children are required to attend schools and tuition classes. From one side, their parents are pushing them. From grade one onwards, children are being pressurised because they have to get ready to sit for the Grade Five Scholarship Examination, and they have to get through that amid heavy competition. Like the old days, they do not have time to be a child. We have to allow our young children to be children and allow them to have a nice childhood without any pressures or stressors.”   The ‘power gap’   Speaking about this matter, Prof. Subhangi Herath of the Colombo University’s Sociology Department, said that when it comes to young people being reluctant to seek the assistance of mental health service-providing institutions, there is a big gap between those seeking services and those providing services. She identified this gap as a “power gap”, which causes the distance between the service seekers and service providers. She added that a power gap should not be there. She told The Morning that when people seek mental health services from service providers, they should not feel like they are being looked down upon or treated as clients or sick people. “Instead of a service provider-client relationship, there should be a service provider-service user relationship,” she said, adding that they (service seekers) should not feel like they are at the mercy of the group with the power (service providers). She added: “Those who have come to the point of committing suicide are on the verge of abandoning all social relationships, including with their families and friends. These service-providing institutions should try to fill that gap at least at the initial stage, and make the service seekers feel that these institutions are ready to help them. Service-providing institutions should give the idea that they are ready to be with them, instead of merely helping them. The approach involving being available to ‘help’ service seekers should change, and instead, the abovementioned connection should be built and strengthened.” She emphasised that mental health service providers (professionals) should get rid of the idea that they are employees and are providing services as part of their jobs. Such an attitudinal change will give the service seekers the idea that they are not alone and are obtaining a service. She added that at times, communication issues, especially language barriers, also hinder people from seeking such services.   Changes taking place, but there is a need to do more   Speaking of young people’s reluctance in accessing the existing mental health services, Health Ministry Family Health Bureau Director of Maternal and Child Health Dr. Chithramalee De Silva said that mental health services should be provided in a manner that is acceptable and attractive to young people, and acknowledged that young people show an unwillingness to register with a health professional in order to obtain services. She added that due to this reason, promoting newer methods such as disseminating information via social media and electronic media would be more beneficial in strengthening the relationship between young people and mental health service providers. She added that even though there are hotlines, it has been observed that there is a lack of young people reaching out to access services via these hotlines. “The issue of young people being hesitant to access mental health services provided by government and private hospitals is mainly caused by the stigma associated with mental health issues. In Sri Lanka, when it comes to those living with mental health issues, there is a taboo and discrimination, and it hinders them from accessing these services,” she told The Morning. When queried about the situation of suicides among young people, she added that relationship issues is one of the major factors that causes suicides among young people, adding that this issue is prevalent among married couples as well. She added: “Family disputes and relationship issues are among the major issues that cause suicides among young people, as seen in the recent years. Matters related to love affairs can also be identified as a severe issue, especially among adolescent youth. Suicides triggered by exam failures annually have declined significantly. The health authorities have set up young people-friendly service centres such as the Yowun Piyasa and therefore, young people who are going through stressful situations such as suicidal ideation, can reach out to these centres and obtain assistance to deal with their situations. To promote emotional support, centres called community support centres have also been established. Using different names to refer to institutions providing mental health services is more suitable, as the priority here is promoting mental health, rather than giving medication to those with mental health issues. In fact, instead of giving medication, we need to strengthen promotional activities for seeking help for mental health-related matters.”   The current process in primary healthcare   The Morning also looked into the process adopted by primary medical care institutions when dealing with persons having mental health issues. According to the Directorate of Mental Health-issued guidelines for the assessment, diagnosis, and management of persons with mental disorders in primary medical care institutions, when assessing a person’s suicide risk clinically, five factors are taken into account, namely, recent self-harm suicide attempts (under which planned attempts, attempts to hide attempts, not seeking help, and the lethality of the methods used are evaluated), depression (under which other psychiatric disorders are also considered), alcohol use disorders, mental state examination (under which depressed mood, current suicidal ideas, hopelessness ,and psychotic symptoms are considered), and ongoing stressors. If a person has a history of self-harm or suicide attempts, the nature of such attempt/s would be evaluated, taking into account the following factors: planning the attempt, making attempts to prevent being found out, using a more lethal method, and not asking for help. Under the current Mental State Examination (MSE), the presence of the following factors are considered to be signs that increase the risk of suicide: depressed mood on MSE, still expressing suicidal ideas, plans of suicide, and the presence of hopelessness and psychotic symptoms. The guidelines also emphasised that the assessment of suicide risk is not a black and white absolute measure and that it is an estimate, based on clinical assessment. With regard to the management of the risk of suicide, it says that a person with a high suicide risk should be offered inpatient treatment and should be referred for further psychiatric assessment as soon as possible, and also, depending on the presentation, relevant treatment can also be started. It also emphasises that ensuring the safety of the patient and early psychiatric assessment, is important. The guidelines also say that patients with a low risk of suicide can usually be managed in the community as an outpatient, emphasising that counselling would be useful, and in cases where the risk of suicide is moderate, the guidelines recommend assessing each patient individually and deciding on how best to ensure the safety of the patient. It also recommends that the persons who have a history of self-harm should be referred for assessment by a psychiatrist. According to these guidelines, repeated self-harm indicates an increased risk of suicide, and each patient must be assessed on a case-by-case basis, and that they should therefore be referred for assessment by a psychiatrist. Also, repeated attempts of self-harm, especially high-intent repeated self-harm, is more likely in people with a psychiatric disorder such as depression, or a substance use disorder. Furthermore, such attempts can occur in the context of certain personality disorders such as borderline personality disorder.   Suicides declining, but still a pressing issue   According to the WHO’s 2019 analysis of suicides in the world, suicide was among the top 20 leading causes of death in the world, and the number of deaths caused by suicide was more than that of malaria, breast cancer, war, and homicide. The WHO also estimated that close to 800,000 people die by suicide every year. The WHO also said that suicide is the third leading cause of death among young people between the ages of 15 and 19 years, and that suicide was the second leading cause of deaths in 15-19-year-old girls after maternal conditions, and the third leading cause of death in males after road injuries and interpersonal violence in this same age group. It also stated that globally, the majority of deaths by suicide (79%) had occurred in low and middle-income countries, where most of the world's population (84%) lives, and with regard to age groups, more than half of the global suicides (52.1%) had occurred before the age of 45 years. The WHO, in its analysis, noted that most adolescents who died by suicide (90%) were from low and middle-income countries where nearly 90% of the world’s adolescents live. The South-East Asia region, according to the WHO, had a much higher female age-standardised suicide rate (11.5 per 100,000) compared to the global female average (7.5 per 100,000), while in males, the regions of Africa, the Americas, South-East Asia (15.4 per 100,000), and Europe, all had suicide rates which were higher than the global male average (13.7 per 100 000). The WHO data also showed that between 2000 and 2016, suicides in the South and East Asia region had declined by 4.2%, and the overall global age-standardised suicides by 9.8%. It also concluded that even though the global age-standardised suicide rate is somewhat on the decline, this is not observed in all countries around the world, and that should the decline continue at its current rate, global targets to reduce suicide mortality will not be met. Life can be hard for any one of us; nobody is immune to mental health issues, and nobody knows when they will need emotional support. Obtaining support to maintain your mental health is as normal as doing so to maintain your physical health. If you feel that you or someone you know may be dealing with mental health issues and/or suicidal thoughts, the following institutions would assist you to deal with it.   The National Institute of Mental Health: 1926 Sri Lanka Sumithrayo: 0112 682 535 Shanthi Maargam: 0717 639 898 Courage Compassion Commitment (CCC) Foundation: 1333


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