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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 35-38

Mental health treatment – Still a Stigma and Concern in the 21st Century Stigma to appear normal, Stigma to keep the family drama invisibleStigma to protect the family honor, Stigma to coerce yourself out of the need for help


Principal, SMVD College of Nursing and Dean Faculty of Nursing Shri Mata Vaishno Devi University, Jammu and Kashmir, India

Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. Shailla Cannie
Faculty of Nursing, Shri Mata Vaishno Devi University, College of Nursing, Kakryal, Katra, Reasi, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IOPN.IOPN_15_19

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  Abstract 


People with mental disorders who live in low- and middle-income countries have low access to quality mental health care and are consequently vulnerable susceptible to suffering and incapacitation, human rights abuses, stigma and discrimination, impoverishment, and premature mortality. The more a mentally ill person feels stigmatized; the lower is their self-esteem, convivial adjustment, and quality of life. The aim of the review is to explore the stigma of mental illness and mental heath services in low and middle-income countries. A PubMed and open-access database literature search (English only) was performed using search strings: stigma of mental illness, Ghana's mental health system, community psychiatry in India, mental health awareness in Nigeria, psychiatric stigma and discrimination in South Africa, and stigma and community intervention. Mental health workforce in India is a shortfall of specialist and psychiatric social worker for mental illness; treatment is unavailable or inaccessible even for those who actively seek health care. In Ethiopia, mental health services coverage and financial auspice for people with mental disorders are constrained. In low- and middle-income countries, the causative agent for mental illness in the current decade is still supernatural power or agents and serves as a major barrier to the treatment. The interventions have the potential to reduce stigma in society at large with the appropriate planning and evaluation. Mental health is still a taboo, and no one acknowledges it. The review demonstrates an adaptation to utilize and participate in mental health care facilities remains a policy aspiration, which generally has not been translated into clinical practice.

Keywords: Low- and middle-income countries, mental illness, social isolation, stigma


How to cite this article:
Cannie S. Mental health treatment – Still a Stigma and Concern in the 21st Century Stigma to appear normal, Stigma to keep the family drama invisibleStigma to protect the family honor, Stigma to coerce yourself out of the need for help. Indian J Psy Nsg 2019;16:35-8

How to cite this URL:
Cannie S. Mental health treatment – Still a Stigma and Concern in the 21st Century Stigma to appear normal, Stigma to keep the family drama invisibleStigma to protect the family honor, Stigma to coerce yourself out of the need for help. Indian J Psy Nsg [serial online] 2019 [cited 2019 Nov 22];16:35-8. Available from: http://www.ijpn.in/text.asp?2019/16/1/35/269158




  Introduction Top


People with mental disorders who live in low- and middle-income countries have low access to quality mental health care and are consequently vulnerable susceptible to suffering and incapacitation, human rights abuses, stigma and discrimination, impoverishment, and premature mortality.[1] The neglect of mental health-care ecumenically combined with catastrophic health-care costs due to high out-of-pocket expenditure, the economic costs of being unable to work, and household costs of caring for someone with mental health issues and the inhibited economic opportunities due to social marginalization denotes that people with mental health problems and their families are at great risk of being left behind by development initiatives such as UHC.[2]

The emerging mental health system and delivery of integrated primary mental health care in low- and middle-income countries is still a barrier in identification and improvement of mental health outcomes in a fair and efficient way. Stigma is also a frequent accompaniment of mental illness leading to the number of detrimental consequences. The more a mentally ill person feels stigmatized; the lower is their self-esteem, convivial adjustment, and quality of life. Stigma can adversely affect the family relationship and lead to employment discrimination and general social rejection. Moreover, stigma also influences access to care, because people may be reluctant to seek avail despite experiencing mental or emotional quandaries as this might be optically discerned as cognizance of weakness or failure.[3]

Several studies show that stigma customarily arises from lack of awareness, lack of inculcation, lack of perception, and the nature of complications of mental illness with odd behavior and violence. It is believed that it may originate from personal, social, and family sources and from the nature of the illness itself.[4]

Definition of stigma

It is an attribute that is deeply discrediting that reduces someone from a whole and usual person to a tainted, discounted one. Goffman, 1963. Another definition stated by Dudley,2000 in the social work literature states that stigma is a stereotype or negative view attributed to a person or groups of people when their characteristics or behavior are viewed as different from or inferior to societal norms. Stigma against people with mental illnesses has been demonstrated to negatively impact the lives of those suffering with psychological disorders through social isolation, secrecy about having a mental disorder, and lowered self-esteem. Kaushik Kostaki, Kyriakopoulos, 2016.

The aim of this review was to explore the stigma of mental illness and mental health services in low- and middle-income countries.


  Methods Top


A PubMed and open-access database literature search (English only) was performed using search strings: stigma of mental illness, Ghana's mental health system, community psychiatry in India, mental health awareness in Nigeria, psychiatric stigma and discrimination in South Africa, and stigma and community intervention. All results were included in the review.


  Results of Review Top


India

India was one of the first countries to develop National Mental Health Programme in the early eighties with a focus on accessible and equitable mental health care. In India, the WHO estimates that the burden of mental health problems is of the tune of 2443 DALYs per 100,000 populations and the age-adjusted suicide rate per 100,000 populations is 21.1. It is also estimated that in India, the economic loss due to mental health conditions is 1.03 trillions of 2010 dollars during 2012–2030.[5] Mental health workforce in India is a shortfall of specialist and psychiatric social worker for mental illness; treatment is unavailable or inaccessible even for those who actively seek health care. There is approximately one trained psychiatrist for every 250,000 people, and overall mental health workforce comprising psychiatrist, psychologists, and psychiatric convivial workers availability is less than per 100,000 populations.[3],[5]

An estimated 36–45 lakh people in India require hospitalization for mental disorders; however, only 6.4–8 dedicated psychiatric beds are available for every 1000 clients in desideratum for hospitalization. The distribution of mental health workforce and facilities is as well skewed toward major cities and leaves no surprise that local healer and nonqualified providers are the first line of care providers even for the serious conditions in India.[5]

Community psychiatry is another aspect of mental health care in India and is around six decades old. In spite of having community outreach services in various cities and states, still, people do not prefer to visit these centers. There could be numerous reasons for not seeking help from these centers. It could be inadequate participation of community due to the stigma of being exposed as mental health client, lack of integration of mental health into general health care, weak link between mental health and convivial development, and nonavailability of services in certain areas.[6]

Ethiopia

In Ethiopia, mental health services coverage and financial auspice for people with mental disorders are constrained, while the adverse economic consequences of these disorders on households are pronounced. Ethiopia has a three-tier health-care delivery system. The Federal Ministry of Health trained and deployed over 42,000 paid female health workers with a ratio of one health extension worker per 2500 population who will focus on early detection, prevention, and promotion of mental disorders.

People with mental disorders such as schizophrenia and bipolar disorders are more liable to be unemployed and their households are at elevated risk of rigorous foodstuff insecurity compared to the general population. The economic burden of households with a person with bipolar disorder was found to be higher than for household with a person with a chronic physical disorder. Caregivers reported that the economic encumbrance of mental disorder is the main concern which is alleviated when care is made available and symptoms resolve.[7]

Nigeria

In countries like Nigeria, mental health care is neglected, and neuropsychiatric accommodations receive low priority in national budget allocation with only around 1% of the health budget spent on mental health. On the other hand, the proportion of the burden of disease attributes to mental illness is around 8% in the region.[8] These funds are as well spent inefficiently, mental health in Nigeria consist mainly of astronomically immense regime psychiatric hospitals. There are eight Federal Neuro Psychiatric Hospitals and a similar number of university teaching hospital psychiatric departments for a population of 170 million people. Nigeria has around one psychiatrist per 1 million population and four psychiatric nurses per 100,000 people. However, the country is commencing to develop community mental health services, which has been shown to advance access to care and clinical outcomes.[9]

Ghana

Mental health services in Ghana are available at most levels of care. The majority of care is provided through specialized psychiatric hospitals with relatively less regime provision, and funding for general hospital and primary health care predicted services. The treatment gap is 98% of the total population expected to have a mental disorder.[5] It is found that 2.4 million population is living with mental health problems, of which 67,780 (2.8%) have received treatment in 2011.

There were 18 psychiatrists, 1068 registered mental health nurses, 19 psychologists, 72 community mental health officers, and 21 social workers working in mental health which is an unbalanced workforce of the country in the mental health sector. Health-care delivery is provided by both public and private partnership. An incipient mental health act passed in 2012 has re-focused the services of mental health being provided peregrinating from an institutional model to a community-based approach. The incipient act is additionally designed to combat stigma and discrimination against mentally ill people which is as rife in Ghana as elsewhere.[10]


  Factors Contributing to Stigma Top


In low- and middle-income countries, the causative agent for mental illness in the current decade is still supernatural power or agents and serves as a major barrier to the treatment. A prevalent understanding of the cause of mental illness in the community was the credence that people with mental illness have been bewitched. Due to this belief system, many families seek care from African traditional healers (sangomas: people with the first port of call in seeking for solutions to problems relating to health and general well-being) before they visit the clinics. The fear of being stigmatized makes them unable to live and move around their neighborhood or carry out normal activities like other members of their community.[11]

One of the most important misconceptions about mental illness that emerged is the notion held by community members that people with mental illnesses are deliberately pretending to be sick and deliberately acting out the symptoms of mental illness they exhibited. This perception as well contributes to a delay in availing medical help.[11] Poverty is one of the determinants of mental illness. Along with that, the possibility of incremented stress from social factors associated with poverty or the impoverished nutritional state may be causal.

A number of studies revealed that sodality between indicators of penuriousness and the risk of mental disorders is with low levels of education. The patients feel rejection from the family members. People with mental illness experience stigma during the course of their illness and treatment which is an important factor for the relapse of symptoms and noncompliance to treatment. These factors may lead to life threatening and humiliating consequences and often to death by self-neglect or suicide.

While stigma is a cross-cultural phenomenon, there are differences in experiences, understanding, and meaning of mental illnesses between countries due to different historical, cultural, philosophical, and religious value. Infringing the norms can lead to loss of identity and as a result of abashment, isolation, shame, convivial sanctions, and depreciation. Furthermore, different cultures may hold different etiological concepts of mental illnesses. In some cultures and their traditional beliefs, mental illnesses are a penalization for an antecedent's misconduct.[12]


  Intervention Top


  • The interventions have the potential to reduce stigma in society at large with the appropriate planning and evaluation. Edification about mental illnesses involves overcoming the myths of mental illnesses and superseding them with facts. This could be documentary films and seminars, pamphlets, print and electronic media, and community meetings about myths circumventing mental illnesses
  • In the same vein, the edification of family and community members as well as accommodation users themselves was highlighted as key to reducing stigma. The family, community members and health-care providers were reported to require education to avail them understand what they are actually going through to incentivize the sufferer rather than ignoring them or having them beaten or treated with disrespect[10]
  • Acceptance and support should be expressed in the quality of care as an important tool to reduce stigma. The support groups with members going through the same experience should provide the opportunity to share their experience and perhaps learn from one another
  • Psychoeducation and psychosocial rehabilitation of family and community members have proved to be an effective measure in reducing the stigma of mental illness and enhancement of their mental health and well-being
  • Coming toward action in the context of India, large scale initiatives toward stigma is still a big challenge. Collaborations need to be strengthened with social groups to develop and implement concrete programs for law enforcement personnel, general practitioners, medicos all of which will assist in reducing stigma. The limited funding and sources should be taken care of a better outcome and to assess the efficacy of the outcome data[13]
  • In parallel with people with physical disabilities, people with mental illness-related disabilities, plausible adjustments are required at the workplace. Several changes are obligatory such as the development of psychological services for people with mental illness in work
  • There is no simple remedy to the abstract stigma of mental illness. The roots of stigmatization and reasons for its continuation are quite intricate and embedded in the sociocultural norms of each society. Besides health-care professionals, other consequential channels should play a key role in dealing with stigma.



  Conclusion Top


This demonstrates that inadequate participation in mental health care remains a policy aspiration, which generally has not been translated into clinical practice. The perpetuated lack of impact on policy on the distribution of mental health care suggests that change may have to be community driven.[14] Mental health is still a taboo, and no one acknowledges it. At one side, the numbers of patients are increasing day by day, and on the other side, fewer cognizance put them in miserable situations to suffer. Most of the families ignore it and do not fortify the way they should.

Moreover, there is a shame to approach medicos as well. People consider it a mental disorder and prefer to make them better by ignoring them, which is consummately erroneous. In most of the countries, families bear a paramount proportion of these economic costs because of the absence of public-funded comprehensive mental health accommodation networks. In the context of South African countries, the decentralization and shift of integration of mental health services into primary health centers are the need of the hour for antipsychiatric stigma intervention.[11]

Families additionally incur gregarious costs, such as emotional encumbrance of looking after incapacitated family members, diminished quality of life for careers, convivial omission, stigmatization, and loss of future opportunities for self-amelioration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
United Nations, Sustainable Development Goals. 17 Goals to Transform Our World. New York, United Nations: United Nations, Sustainable Development Goals; 2015.  Back to cited text no. 1
    
2.
Hanlon C, Alem A, Lund C, Hailemariam D, Assefa E, Giorgis TW, et al. Moving towards universal health coverage for mental disorders in Ethiopia. Int J Ment Health Syst 2019;13:11.  Back to cited text no. 2
    
3.
Barke A, Nyarko S, Klecha D. The stigma of mental illness in Southern Ghana: Attitudes of the urban population and patients' views. Soc Psychiatry Psychiatr Epidemiol 2011;46:1191-202.  Back to cited text no. 3
    
4.
Shrivastava A, Johnston M, Bureau Y. Stigma of mental illness-1: Clinical reflections. Mens Sana Monogr 2012;10:70-84.  Back to cited text no. 4
[PUBMED]  [Full text]  
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6.
Sidana A. Community psychiatry in India: Where to Stand. J Ment Health Hum Behav 2018;23:4-11.  Back to cited text no. 6
    
7.
Kebede D, Alem A. Major mental disorders in Addis Ababa, Ethiopia. I. Schizophrenia, schizoaffective and cognitive disorders. Acta Psychiatr Scand Suppl 1999;397:11-7.  Back to cited text no. 7
    
8.
Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet 2007;370:878-89.  Back to cited text no. 8
    
9.
Eaton J, Nwefoh E, Okafor G, Onyeonoro U, Nwaubani K, Henderson C, et al. Interventions to increase use of services; mental health awareness in Nigeria. Int J Ment Health Syst 2017;11:66.  Back to cited text no. 9
    
10.
Roberts M, Mogan C, Asare JB. An overview of Ghana's mental health system: Results from an assessment using the World Health Organization's assessment instrument for mental health systems (WHO-AIMS). Int J Ment Health Syst 2014;8:16.  Back to cited text no. 10
    
11.
Egbe CO, Brooke-Sumner C, Kathree T, Selohilwe O, Thornicroft G, Petersen I, et al. Psychiatric stigma and discrimination in South Africa: Perspectives from key stakeholders. BMC Psychiatry 2014;14:191.  Back to cited text no. 11
    
12.
Buechter R, Pieper D, Ueffing E, Zschorlich B. Interventions to reduce experiences of stigma and discrimination of people with mental illness and their caregivers. Cochrane Libr 2013;https://doi.org/10.1002/14651858.CD010400.  Back to cited text no. 12
    
13.
Sagar R, Pattanayak RD. Stigma and community intervention: Has enough been done. J Ment Health Hum Behav 2014;19:1-3.  Back to cited text no. 13
    
14.
Stomski NJ, Morrison P. Participation in mental healthcare: A qualitative meta-synthesis. Int J Ment Health Syst 2017;11:67.  Back to cited text no. 14
    




 

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Introduction
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Results of Review
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