Mental Health

Department of Psychology & Department of Shariah and Law, International Islamic University Islamabad (IIUI), Pakistan has initiated an International Diploma on Mental Health Law and Human Rights with technical support of World Health Organization (WHO). 

The purpose of the diploma is to provide participants with information and skills to bring about change in the area of mental health law and policy by focus on Islamic legal tradition and its interaction with human rights and provisions of international human rights law including United Nation Convention on the Rights of Persons with Disabilities (UNCRPD), in order to develop a distinct identity and role. In addition to this it also aims to develop a distinctive leaders at organization level to play a role of the change agent in order to provide adequate and best services to the individuals already suffering from mental illnesses.

In this regard the launching ceremony was organized at Faisal Masjid Campus, International Islamic University Islamabad, which was joined by Hamd Bin Nasir (Deputy Minister for Education of Kingdom of Saudi Arabia), Sheikh Muhamamd Al-Marhoon (Ambassador of Oman),  Dr. Ahmed Yousif Al-Draiweesh (President IIUI), Diplomats from Islamic countries, Dr Zafar Mirza (Director of Department of Health Systems, WHO Regional Office for the Eastern Mediterranean), Representative of WHO,  and organizers Dr. Tahir Khalily (Director Academics and Clinical Psychologist) and Dr. Aziz ur Rehman (Legal Advisor, President IIUI).

Interdisciplinary ventures and practical projects in all the educational fields are vital for academic and societal excellence, said Sheikh Hamd, the Chief guest. He urged for the practical implementation of the degrees and suggested that medical diplomas be offered across the Muslim world to broaden the exposure of students. KSA education and psychology expert furthered that mental health was important as the physical health.

The event was also addressed by Dr. Ahmed Yousif Al-Draiweesh who maintained that mental health is the subject which is of vital importance in this age of technology when gadgets and indoor routines have caused surge in the psychological disorders. He called upon the Muslim world universities to bring all the psychological experts on a platform and launch a well devised series of such diplomas.

Dr. Tahir Khalily explained the objectives and vision of the diploma and revealed the future plans. He thanked the diplomatic and academic fraternity for attending the event and vowed that diploma would be proved as a millstone for interdisciplinary ventures.

It is expected that the Diploma will equip students to undertake advocacy work in this area and provide them with the knowledge and skills to actively support countries to draft and amend mental health laws in line with the CRPD and other international standards

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Shocking ... "research suggests that the death penalty actually targets those who have mental illnesses. People who are executed have a far higher rate of mental illness than does the general public."

When it comes to mental health, the global health community has failed. 

Mental, neurological, and substance-use disorders are among the leading causes of the global burden of disease. By 2020, depression will be the second leading cause of disability. Suicide is a leading cause of death among adolescents. People with severe mental disorders die decades earlier than others in their community and face grievous forms of discrimination and abuse. Our failure in the global health community is that we have left large proportions of those affected, up to 90% in some low-income countries, without access to even basic mental health care from which they can greatly benefit. Most governments spend less than 1% of their health budget on mental health, a figure also reflected in international development assistance for health. The consequences are grave, not only for the mental health of the individuals affected, but also for their physical health and the wellbeing of families and society at large.

This unmet need for mental health services is greatest among populations affected by conflict and displacement. Our world is currently in the midst of the worst humanitarian crisis since the second world war. But the violence does not end even when people flee the conflict zones. In refugee camps in Greece last month, we saw hundreds of Syrian children too afraid to leave their tents to play, frail elders on a hunger strike to protest abominable living conditions, and suicides that could have been prevented. Similar conditions can be found in refugee camps set up by the Australian government in small Pacific island nations. Millions who have faced some of the worst imaginable adversities and atrocities are exposed to further adversities, including denial of freedom and hope – conditions that undermine mental health among even the most resilient.

Facing an acute shortage of funding and resources, we must act creatively to ensure better mental health outcomes. The most important first step is ensuring that refugees are getting sufficient access to basics such as food. Actively working to normalise the appalling situations experienced by these populations – for example, by ensuring schooling for children and enabling work for adults – is a good strategy to promoting mental health.

But we can also look at some more creative approaches. Turning to community-based, non-professional providers to deliver psychosocial interventions can address the acute shortages of mental health professionals. This has been effective in low-resource settings such as Uganda, Pakistan, and India and recently proven more cost-effective than standard treatment.Through short skills-focused trainings, simplifying complex treatments, peer supervision, and using models of illness which are consistent with the experiences of refugees, we can empower lay people in refugee communities to provide frontline psychosocial interventions. Those specialists who are available can design and oversee mental health programmes, as well as train, supervise, and support refugees in using evidence-based techniques to promote resilience and alleviate mental health distress in their own communities. This not only enables greater access to mental health services but, importantly, calls for the harnessing of personal and community resources, thereby giving refugees a sense of empowerment at a time of severe disempowerment.Ultimately, however, there needs to be a structural revision in how those fleeing violence and conflict are welcomed and integrated in safe countries. The cost of doing nothing is immense. Untreated, the impact of conflict on mental health can endure for years, and over generations, at great cost to society. With more than 60 million people displaced by war, conflict, or persecution, now is the time for the global health community to wake up and realise what’s at stake if we keep ignoring mental health.

Laila Soudi is a researcher at Stanford University School of Medicine and director of mental health at the Syrian American Medical SocietyVikram Patel is Wellcome Trust principal research fellow at the London School of Hygiene and Tropical Medicine and co-founder of Sangath.

“You know a broken egg?" Subendra Upadhyay (name changed), finally said after struggling for words to accurately reflect his feelings. "For the family, we're like a broken egg which loses all its value once broken.”

Upadhyay, Madhav Khatiwada, Jagannath Lamichhane - all aged mid-thirties to early forties - are from different walks of life and Nepal’s different terrains. What binds them is their struggle of living with mental illness, and what they have to share from their experiences as mental health patients.

Upadhyay was a second year student of BSc at Tri Chandra Campus in Kathmandu when he was diagnosed with schizophrenia. He passed through the worst stage of the illness and after months of medication, recovered to a state where it became manageable. With constant medication, he could lead a normal life.

Khatiwada was in the second year of BA in English at Ratna Rajya Laxmi Campus in the capital when he began to suffer from panic attacks. The debilitating illness disrupted the normal life experiences of the 22-year-old ambitious student. He’s back to college now, having wrestled through 15-year road to recovery.

For Lamichhane, struggle with depression began in his village in Syangja at a tender age of 10. Now a mental health activist and the founding president of Nepal Mental Health Foundation, his recovery path was also equally challenging, if not more, as his years of suffering.

‘Broken eggs’

What does it feel to be mentally ill? For Upadhyay, life is like a broken egg. It feels like a pile of dishes breaking all of a sudden. Most of the time you look for ways to cope with the state of your own mind even as your life’s goals and priorities change.

And you face an even bigger challenge from the way society views mental illness. Upadhyay’s allusion to a bleak metaphor to describe himself results from deep-seated stigma attached to the mentally ill in Nepal.

His illness shrouded behind a thick veil he and his family formed to ensure that it remained impenetrable for their social circle. It was even hid from his bride-to-be. When she eventually learnt, they had been married for about a year. Her response only added fuel to his vulnerable condition.

“She published a notice on a national daily, accusing me of fraud and detailing my condition with the help of a psychiatrist. She also filed a case against me,” he says.

The stigma penetrated Upadhyay’s professional life also. For fear of rejection, he concealed his condition from employers. But the illness didn’t enable him to work on ends; there’d be episodes when he needed to rest. He’d miss work and would be sacked. Within a matter of few years, he was juggling between jobs – a teacher at one moment, a volunteer the next and a factory labor at other time.

Social stigma was not so direct in its blows to Lamichhane; it found a much subtler way of making its mark. At first, it was not evident for his parents – a boy indifferent to playing and running and instead choosing to stay aloof, constantly losing concentration, or seeking excuses to stay away from school was more likely to pass off as ‘lazy’ for them.

“Sure a time came when they realized that I had mental health issue,” he says. “But they didn’t accept it because the stigma that came with the mental illness tag was too scary for them. They instead took me to different doctors, seeking treatment for physical symptoms.”

Mental health practitioners are unanimous in their views that social acceptance is perhaps the most crucial factor needed for the recovery of people with mental illness.

“Stigmatization of mental illness is so entrenched in Nepali society that the very word mental seems to elicit an attitude of rejection among people,” says Dr Saroj Ojha, senior psychiatrist and head of Department of Psychiatry & Mental Health at the Tribhuvan University Teaching Hospital (TUTH). “Such attitude further augments patients’ problems.”

Lamichhane opines that social acceptance for physical disabilities comes easily. However, this is not the case when it comes to those living with mental health issues although they suffer from physical and mental conditions that limit their social interactions and impose limitations on their abilities. This condition, termed as psycho-social disability becomes a part of patients of depression, anxiety or other mental health illnesses. Although such condition might not be permanent, Lamichhane says that in times of depressive or anxious episodes, patients feel very weak, vulnerable and humiliated.

Dr Ojha explains that the condition is marked by impaired concentration ability and frequent alterations of mood and physical symptoms of weaknesses and fatigue. So, especially during the illness, patients might need complete rest, but even as they gradually recover, they still exhibit these symptoms.

“This is where society’s role becomes important. Friends, peers and family, co-workers should understand their situation and extend support to make them return to normal situation at the earliest,” he suggests.

According to him, work or engagement gives a sense of fulfillment to the patients, but if someone with the illness is rejected from the workplace, then it creates a negative viscous cycle.

Lamichanne’s own road to recovery comprised engagement with Leo and Rotaract clubs. For Khatiwada, luckily the principal of the school where he taught knew about his issue and accommodated his working schedules, allowing him breaks and leave for rest. He says that this support was one important factor that helped him recover.

But this is not to say he had untarnished, smooth journey to recovery. For him, the challenges lay in tackling the procedure of his diagnosis and medication.

Absent holistic approach

Soon after starting medication for panic attacks began Khatiwada’s roller coaster experience of coping with the medicines’ strong side effects that impacted him severely at physical, mental and emotional levels.

“I checked up with a well-known psychiatrist, after a year of living with suffering and fear,” he says. “Five minutes was all he took to diagnose and prescribe me medicine. He neither explained me the medications and their side effects, nor told what I was suffering from.

“If I knew about the side effects, I’d be somehow prepared to face them. But I didn’t, and so became more fragile and fearful. Under such circumstance, it was easy to lose hope that I would recover, because doctor was the last hope I had.”

He constantly changed doctors, who prescribed him different medicines. “I feel the problem was not the medicine’s side effects as much as it was not being psychologically prepared to face them,” he says.

His recovery prolonged to ten long years. But he admits that it only became possible due to holistic approach integrating medicine with yoga, meditation and other changes in lifestyle.

Psychologist Suraj Shakya of the TUTH says that a lack of adequate human resources is one of the primary reasons why a holistic approach is missing in the treatment of mental health issues in Nepal.

“A patient to psychiatrist doctor or a psychologist ratio is extremely low in Nepal. A doctor has to cater to tremendously large number of patients,” he says. Therefore, the doctor might not be able to take as much time as he would want to with individual patients when a long queue of patients has formed outside his room.”

This is not the only reason though. According to Shakya, a large proportion of Nepal’s population is still not educated and lack awareness, and so are unable to understand the guidelines and instructions of a holistic approach that integrates medicinal treatment with counselling and other adjustments in family, working environments.

‘Awareness is key’

Dr Ojha stresses that by the term mental illness, most Nepalis understand very strong forms of mental illnesses such as psychosis. This is one reason for attaching strong social stigma to related health issues.

“Most cases of mental illnesses in fact comprise those suffering from depression, anxiety and other stress-related illnesses,” he says. “What’s happening is strong stigma attached to anything to do with the word mental is impacting these people who hesitate to get treatment and so are likely to plunge into more serious issues.”

Lamichhane points to a lack of policy development and their implementation as one setback to addressing mental health issues. However, he also agrees that mental illnesses are not big problems in their own right, but are made to appear so due to stigma attached to them.

As compared to somatic illnesses, mental illnesses can be addressed on very less resources. However, difficulties arise due to the labels, tags attached to the illness, he says.

“Mental health issues are not as severe as society make them appear to be,” Dr Ojha stresses. “Public awareness is the most important factor to address the issues of mental health problems.”

AHMEDABAD: The mental condition of his 26-year-old sister Neeti had brought Dinesh Chaurasiya (names changed) — a resident of Dhuliya in Maharashtra — to Mira Datar Dargah in Unava, two years ago. The shrine, located around 100 km from Ahmedabad in Mehsana district, is famed for its capacity to cure illnesses and 'possessions'. Thousands from across the country visit it to seek answers and remedies.

"Initially we had to chain Neeti as she would smash things and beat up people," recounts Chaurasiya (29), who spends four months a year at Unava with his mother and sister. "We consulted doctors but nothing worked. Now, she has become much calmer. The bouts still erupt but they last, at the most, for 10 minutes."

The shrine of Hazrat Sayed Ali Mira Datar, a general of Ahmedabad Sultan Mahmud Begada, has attracted devotees for over 500 years. It is one of the many places of worship in India where thousands of mentally ill patients seek divine remedy. The fabled powers to cure mental illness, which has a huge stigma attached to it, also draws Hindus who consist of 50% of the visitors.

But today, the shrine is not known just for dua but also for dava. The Dava and Dua Project (DDP), initiated in 2008, has ensured that almost half of the visitors to the shrine also consult a psychiatrist and accept an amalgamation of faith and science to treat their mental illnesses. This is one of the pioneering initiatives in which traditional faith healers work in close association with psychiatrists and psychologists, creating a model of social psychiatry that has attracted the attention of organizations such as the World Health Organization and the National Human Rights Commission. The organizations have even recommended the project's replication in other places.

Dr Ajay Chauhan, the medical superintendent of the Hospital of Mental Health, Ahmedabad, said that the model has already been implemented at shrines in Erwadi in Tamil Nadu and Hyderabad in Telangana. Another shrine in Nagpur, Maharashtra, will be part of the DDP later this year.

"In Erwadi, 25 persons in shackles had died in a 2001 fire accident," Chauhan said. "The tragedy had stoked outrage and spurred a nationwide drive to prevent practices such as chaining patients and beating them up to cure mental illness. We had identified the Unava shrine as sharing a number of such practices."

The going was tough as mujawar (faith healers) vehemently protested when a team of doctors and others tried to inspect the premises in 2002, and police had to intervene. The medical practitioners did not lose hope and succeeded in starting the DDP formally in 2008.

"Eight years down the line, we have reached out to over 38,500 patients who would not have gone to doctors anyway," said Milesh Hamlai, the managing trustee of Ahmedabad-based Altruist, an NGO that manages the DDP. "In India, mental illness is stigmatized and thus studies estimate that 82% patients of common and 47% of severe mental disorders never come into contact with medical practitioners. In such a situation, places like Mira Datar provide an opportunity to reach out." His brother's schizophrenia had introduced Hamlai to the world of mental illnesses. Today, Hamlai also runs Aastha, a helpline catering to patients with mental disorders in Ahmedabad.

The practitioners don't scoff at the believers. Dr Yatin Bhushan, a psychiatrist from Mehsana who volunteers with the project, said that most people have beliefs that gives assurance to the family that everything would turn out fine. "We have observed that the combination of faith and medicines has improved the success ratio," Bhushan said. "Patients spend one week to three months here, which assessment and observation possible."

In the end, for the believers, it is about the divine will. Sayed Waris Ali, a trustee of the shrine and a descendent of Hazrat's family, said that the establishment of the DDP is also Hazrat's wish. "Our goals are the same — to treat those who come to us. The practitioners have earned our respect and we extend all support," he said.

Science of the soul
Earlier this year, researchers from India and the Netherlands published a paper on the Dava and Dua Project in the journal 'Transcultural Psychiatry', charting the journey and studying the reasons why people participate in the project. The paper says that in the Indian context, mental health has a treatment gap (scope of mental health and the availability of medical intervention) and a setup like the one in Unava helps to reach out to people. It also identifies mechanisms important for such a collaboration, including building trust, highlighting complementary aspects of both systems, mutual referral, consistent dialogue and identifying shared goals.

A faith healer counsels a family with traditional methods to seek solution for their health problems.

India-wide scope

According to the figures released by Altruist — the NGO running the Dava and Dua Project — most patients were diagnosed for depression followed schizophrenia, epilepsy, somatoform disorders, mental retardation, and general medical conditions. In eight years, the DDP has reached out to an average of 400 patients per month. In 2015-16, patients from Rajasthan, Maharashtra, Madhya Pradesh, Karnataka and West Bengal formed a major part of the visitor population, apart from those from Gujarat. In all, patients from 17 states had benefited from the DDP. 

“Are you on the same page as your child?” A neon sign board advertising new mobiles at a traffic junction asks. A smart way to win new consumers, that advertisement, but an unsettling one at the same time. Are we really on the same page as our kids? Perhaps yes, perhaps no, I think and let my mind wander to those growing up years — most of them good, some stressful — in the10 seconds before the traffic light turns green. Yes, we were on the same page, I would have liked to believe, till, like scores of mothers, my heart too missed a beat and broke out in a cold sweat when a 14-year-old ninth standard student from Bengaluru took the extreme step of committing suicide after being bullied in a private school van.

Bullying brings forth a range of emotions among parents of school-going children who have now opened up about the malaise and discuss it with specially appointed counsellors and teachers. Often, they tell their children to pull up their socks and take care of the matter. A child cannot understand that forms of bullying vary: Tearing notebooks, pouring water over the school bag or even sticking glue in the hair. Beyond the show of strength by the bully — demanding money during the short break from a particularly shy child or a persistent wrestle mania during lunch hours — bullying has got meaner in cybertimes.

Bullying can make a child lose interest in school and result in low self-esteem, depression and yes, in extreme cases, suicides. In 2014, the National Crime Record Bureau reported 50,000-60,000 youth suicide deaths in a year but going by the Million Death Study (2012) this could be an underestimate. Actual numbers may even approach one lakh deaths a year. The findings of the Lancet Commission on Adolescent Health and Well-being, this year, drive home the point that suicide was the leading cause of death among youngsters aged 10-24 in the country: 62,960 such deaths were reported in 2013.

In “Loss of Hope” a study by the London School of Tropical Hygiene and Medicine and Public Health Foundation of India, mental health expert Vikram Patel counters theories about the brain completing most of its development by middle childhood and youth behaviour being “guided by hormones”. The fact is that the “front” of the brain matures last, as late as the mid-20s and during youth, the brain offers major advantages — for example, high rates of learning and memory due to plasticity — on the one hand, but presents unique vulnerabilities on the other. The interaction of adversity, especially in the context of social change, with the neuro-developmental changes in adolescence leads to mental health problems and suicide, Patel concludes.

Can then there be a change in reducing this toxic environment as the bully is not just bad news for his victims but also for himself? Violence can mar the quality of his own life — he is usually a poor team player and can have relationship problems in later years. Most schools have installed video cameras and taken measures to curb bullying; several colleges have anti-ragging cells — some, though, are, only on paper.

The stigma gets worse in rural areas where mental health issues are still taboo. For instance, a newly started Maharashtra government helpline number had over 2,000 calls from the youth in far flung areas in 2015-16. Counselling for irritability, anxiety, not going to school and parental expectations were just part of the worries of the young.

The World Health Organisation’s (WHO) 2014 Health for the World’s Adolescents report showed that of the 109 national health policies reviewed, 84 per cent made any mention of adolescents. Only a quarter discussed mental health. Such findings are a wake-up call for not only preventing suicides but picking up issues right at the beginning. At the end of the day, bullying cannot and should not be tolerated.

Social networking giant Facebook has introduced tools and educational resources to help people in India who may be struggling with self-injury or experiencing suicidal thoughts.

These tools are already available in countries like the US, Australia, New Zealand and the UK.

First launched in the US with the help of Forefront, Lifeline and, the tools were developed in collaboration with mental health organisations and with inputs from people who have personal experience with self-injury and suicide.

“We are rolling them out in India in collaboration with local partners (AASRA and The Live Love Laugh Foundation) in English and Hindi,” Facebook said in a statement.

With the help of these new tools, if someone posts something on Facebook that makes a user concerned about the person’s well-being, they can reach out to the person directly and can also report the post to the US-based firm.

“We have teams working around the world, 24/7, who review reports that come in. They prioritise the most serious reports like self-injury and send help and resources to those in distress,” it said.

Vulnerable users will then be encouraged to connect to the AASRA India helpline or the Live Love Laugh Foundation or a friend or seek self-help advice from resources and tips provided on how they can work through these feelings.

Help a Friend in Need

Facebook has also introduced ‘Help a Friend in Need’ guide to help people identify when someone is distressed and what steps to take to get help.

The guide also offers suggestions on how to approach their friend, what to say, how to react and what to avoid. It gives people the skills to reach out without fear of making the situation worse.

The guide will be available in English, Hindi, Bengali, Kannada, Malayalam, Punjabi, Sinhalese, Tamil, Telugu, Urdu and Marathi.

“Often, friends and family who are the observers in these types of situations don’t know what to do. They are concerned, but they are worried about saying the wrong thing or somehow making it worse. Socially, mental illness and thoughts about suicide are just not something we talk about,” Facebook India, South and Central Asia Public Policy Director Ankhi Das said.

Facebook is a place where people connect and share, and one of the things the company has learnt from the mental health partners and academics is that being connected is a protective factor in suicide prevention, she added.

“We care deeply about the safety and well-being of the 148 million people in India who use Facebook to connect with the people who matter to them and recognise there is an opportunity with these tools and resources to connect someone who is struggling with a person they already have a relationship with,” she said.

Speed read

  • Specialists in poor nations must deal with poor resources and social barriers

  • They train non-specialists, work with healers and use ICTs to pool expertise

  • Movie clips also help to illustrate conditions such as depression

Specialists struggle with poor resources and social barriers. But they’re being creative to get people proper care.

One word — gap — shows up persistently in discussions about mental health in the global South. There is the ‘treatment gap’ between how many people are affected by mental illnesses and the number who receive care for them. There is the gap between the need for services and resources allocated for them, fuelled by yet another gap between the volume of scientific studies that come from high-income compared with low- and middle-income countries (LIMCs). [1]

And, in response to these, there is mhGAP: the WHO’s Mental Health Gap Action Programme, which offers evidence-based guidelines to help poorer countries better prevent and manage certain disorders.

The collection we publish today puts global mental health under the spotlight. It looks at evidence about the scale and neglect of mental illness, the complex issues that prevent care from reaching vulnerable people and some innovative strategies being used to help.

Burden and barriers to care

In an overview article with facts and figures, psychiatrist Neerja Chowdhary — who also advised us on this collection — and journalist Vijay Shankar explain the various mental disorders, their causes and impacts. They also outline the social and resource pressures that prevent people receiving proper care.

Just one statistic conveys the toll in the developing world: the WHO estimates that three-quarters of suicides occur in LMICs.

separate feature written by Chowdhary and journalist Penny Warren adds to the evidence, rounding up key documents about mental disorders and organisations working in the field.

As part of their overview, Chowdhary and Shankar highlight innovative strategies that can go some way to break the barriers to care — among them training non-specialists and using technological tools that are already available.

These issues are explored in separate features.

Journalist Barbara Axt finds that a lack of resources means psychiatrists in many poor countries resort to training either staff who don’t specialise in mental health, or people in the community who can then help each other manage mental illness.

In a Q&A, Somali doctor and mental health researcher Djibril Handuleh explains what it takes to use information and communications technologies to draw on global expertise and train health workers in a fragile state with weak infrastructure.
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