Developing Countries Struggle with Treating Mental Illness

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JAKARTA, Indonesia -- They stretched their arms between the bars of their cells, yelling out for cigarettes from those passing below. When an attendant came by with a megaphone to announce lunch time and unlocked the gates, they snaked into a line, some absent-mindedly exposing themselves, and shambled toward the dining hall. That is, except for those housed in wards for those deemed "not yet cooperative," who were housed to the side of the manicured compound, many of whom lay naked in their cells throughout lunch hour.

The nearly 400 people who live in Yayasan Galuh, a mental health facility on the outskirts of Jakarta, are not prisoners, but patients. They have been diagnosed with any number of psychological conditions, such as schizophrenia, bipolar disorder or debilitating depression. One man named Eko says his condition had him falling into deep silences and ceasing to provide for his family. About two years ago, Eko says his wife took him to a doctor, eventually ending up at Yayasun Galuh. He is still waiting for his family to take him home, or at least visit.

Until around three years ago uncooperative patients at the facility were chained to bars to prevent them from running away or causing other disturbances -- a practice known locally as "pasung" that is common for difficult-to-manage schizophrenic patients in Indonesia as well as in other developing nations. But it would be a mistake to think that the wardens here don't care about their patients.

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Nina Mardiana, Yayasan Galuh's chief secretary, has no college degree and limited formal training. Her facility handles people brought by distraught families, state social services and the police. Yayasan Galuh was founded in 1982, but it wasn't until 2013 that licensed psychiatrists from the University of Indonesia came to offer advice and train the staff here. "We weren't yet professional," Mardiana explains.

She says the psychiatrists improved treatment, including insisting that no patients be chained. They taught her to always soften her voice when speaking to patients and to ask patients the same polite questions -- "How are you?" "Have you already eaten yet" -- that she would ask a mentally healthy Indonesian. "Before that we just didn't know," Mardiana explains.

'A huge burden of illness unaddressed'

The problem that under-trained community health workers like Mardiana grapple with is an immense one: While mental disorders are distributed relatively evenly across the globe, funding for mental health treatment is not. And Indonesia, a huge developing country of 250 million people, faces the same challenges as other under-resourced nations when it comes to providing mental health care. According to data from the World Health Organization, high income nations on average spend 5 percent of total health spending on mental health; for lower middle-income countries the figure is less than 2 percent and for Indonesia the figure is believed to be less than 1 percent.

"There are huge barriers around access to care" in under-resourced countries, explains Giuseppe Raviola, an assistant professor of psychiatry at Harvard who works with Partners in Health, a global health organization.

One basic problem is that developing nations have few trained psychiatrists, and the psychiatrists that exist tend to cluster in major urban centers. Indonesia has 700 psychiatrists -- one for every 350,000 people -- and well over half live on the main island of Java. Haiti, a country of roughly 10 million people, has around 10 licensed psychiatrists, Raviola says; Rwanda has about five. Even for a comparatively wealthy country like Mexico, which has around 2,000 trained psychiatrists, "1,000 work in a four-block radius in Mexico City," says the Harvard professor. The result is that in each of these countries, "There's just a huge burden of illness unaddressed."

Lacking psychiatrists is just the tip of the iceberg when it comes to under-developed mental health systems. Without trained professionals leading the effort it's difficult to design the entire infrastructure of a mental health system, from primary care providers up to psychiatric hospitals.

Experts also say developing countries don't see mental health care as a priority, and so don't fund it sufficiently. Indonesia, like many other low-middle income and low income countries, has turned a page in treating communicable diseases like tuberculosis and malaria that once killed millions. In theory this should free up funding for mental health programs. But Harry Minas, director of the University of Melbourne's Centre for International Mental Health in Australia, says developing countries, "face a tide of non-communicable diseases, such as respiratory illnesses from smoking, cardiovascular diseases, the incredible prevalence of diabetes. Health ministries are not blind and they can see what these will do to health systems and national budgets."

With so many looming public health threats and limited health budgets, developing world governments continue to treat mental health care like a first-world luxury, Minas says.

Movement toward increased treatment

In Indonesia, however, there are signs of progress. Indonesia passed a landmark mental health bill in 2014 that will provide a blueprint for developing the country's mental health infrastructure. The country is now on its way to establishing the first national center for mental health research.

Nova Riyanti Yusuf, a former legislator and trained psychiatrist who is credited with shepherding the 2014 bill through parliament, says a huge part of the battle is persuading bureaucrats in the country's health and finance ministries that mental health problems can be successfully and economically treated. "We still need more evidence-based programs, otherwise the government won't give us money," she explains. Nova is hopeful that research about the economic burden of untreated mental illness will persuade key bureaucrats to take treatment more seriously.

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There is increasing evidence that countries can do much better at managing mental illness even with limited funding. Raviola, the Harvard professor, has helped organize programs in Rwanda and Haiti where a few psychiatrists train nurses and other local health workers to diagnose and treat mental health conditions. He says early results from these programs are promising. Similarly, Nova Riyanti Yusuf says Indonesia is developing a model where even primary-care centers "provide at least a bit of screening for mental health" with a referral system that will send extreme cases to available doctors.

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But until these reforms are funded and implemented, human suffering will be immense.

Resta, a 19-year old woman with a back-turned baseball cap and a friendly, jocular manner, serenaded visitors to love songs from her accommodations at the mental health clinic. Resta has been diagnosed with bipolar disorder and on the day of visiting the facility she was having a good day. She was sent here a couple of weeks ago after a bad fight with her mother, who told her she was "deeply crazy."

"How can anyone who cares about you say something like that?" Resta asks. Still, Resta has come to believe she was mad.

"You can tell I'm crazy. People say they can see it in my eyes."

But bipolar disorder is a manageable condition, and Resta's eyes were normal. What she needed most of all was a supportive environment and someone trained to take care of her.

Jon Emont is a journalist based in Jakarta, Indonesia. You can follow him on Twitter here.