THERE was a time when illnesses of the mind were not considered illnesses. They were thought to be the result of the Devil at work, the result of charms spells and evils done by others.
Late in the 19th Century with much controversy the scientific reasoning process with its supporters like Freud and Jung felt that mental illnesses resulted from suppressed and repressed emotions and trauma, including sexual ones. Theories abounded, though short on the burden of scientific proof.
More advances in science in the 1950s with the discovery of Chlorpromazine, the first real medicines for mental illnesses opened the gates to scientific studies on the brain — and less on the mind or evil spirits. The science of mental health and illnesses was on the march, and boldly so.
But prejudices die hard, fear even more so.
Mental asylums started in the 18th century by magnanimous kings still reigned supreme. Mental patients were mentally ill — not physically ill. Mental illness was an area of darkness even in health care circles. The medically ill were different.
The mentally ill, well â€¦ they are not the same. Even as science progressed, medicines flowed off the laboratories that made millions few countries dared to open psychiatric wards in their erstwhile physically ill persons only hospitals. Even then the wards were locked, barred and manned by burley staff in the fear of violence legendary in mental institutions of the previous century.
Science had advanced and newer medicines used properly could prevent and control all those aggression. But even the physicians were not convinced. They gave low dose in the mistaken belief that the medicines were dangerous. Even today that fear exists in many countries including developed ones.
The pervasive culture of fear, prejudice and misconceptions actually emanated from the late entry of psychiatry as a medical and nursing subject in training. When it was finally added after the second world war it was as a token and tiny part of internal medicine — and taught in the high security mental hospitals.
These jail-like mental asylums turned medical and nursing students against mental illness. Adding to this was the fairly common practice of transferring staff with poor or bad work records to mental hospitals. Mental hospitals were often the lowest priority in health care with limited budgets and poor leadership.
It was only in the 1960s that moves were made to improve mental health care by de-institutionalisation — even in developed countries and students to start learning about mental illnesses in general hospital settings.
Even then the entrenched views of senior physicians on this move was negative. In Singapore, the first division of psychiatry in the Department of Internal Medicine was only established in the mid 1980s and a university hospital psychiatric unit started in 1990s. Today there are psychiatric units in all general hospitals in Singapore. In Fiji, the position of the venerable St Giles mental institution that started in 1883, a year before the Fiji School of Medicine, remained strong not only in the perception of doctors and nurses as the 'be all and end all' of anything mental but even accepted by the FSM and Fiji School of Nursing, as the place of training of young minds on mental illness. Generations of Pacific island doctors today see psychiatry as synonymous with St Giles and chronic and severe psychoses — almost exclusively.
The reality is that the World Health Organisation in its 2001 World Health Report reports that less than 10 per cent of all mental illnesses are related to psychoses. The paradox is that the remaining 90 per cent of all the mental illnesses in any community are largely anxiety and depression related — and very treatable and not needing institutionalisation, like those with psychoses — and poorly detected in health care settings and therefore poorly treated. For every one patient in a mental hospital, there are reported to be 100 in the community.
About half of that hundred will probably be seen by a general practitioner or in primary care clinics but only a quarter will be recognised as having "some" mental problem and perhaps 5 per cent receive appropriate treatments for the non-psychotic stress related illness.
In a country like Fiji with 850,000 people, around 15 per cent have a mental illness that requires treatment. Of those over 125,000 in Fiji, only about 12,500 are thought to have psychoses but the 112,000 have anxiety, depression and other stress related illnesses. In fact, by 2020 depression will be the second biggest burden of disease, only second to coronary heart disease.
The Watchword in today's health world is NCDs or Non-Communicable Diseases. These include, obesity, diabetes, hypertension, coronary heart diseases, cancers — and almost as an after-thought, mental illnesses! The preventive strategy put forward is to eat healthy, do not smoke, exercise more, do not drink too much alcohol and go for regular medical checks.
Even the annual Hibiscus Festival last week was sponsored strongly by the NCD division of the Ministry of Health with the aim of spreading awareness on the NCD epidemic affecting so many in the country. Eating unhealthy foods like fatty lamb, fatty sausages, fast foods, barbecued pork and beef with very sweet fizzy drinks and beer was all around the Hibiscus Festival.
Why? Those who indulge in these in excess are not all ignorant. Many are educated, knowledgeable and not a few, medical and nursing students and health care professionals.
The reason is that fatty foods sweet drinks, fast foods full of salt have inherent attraction to taste buds — all over the world. The attraction is there but becomes more when lives are unhappy. Cigarette smoking is high in the Pacific and even among women whereas most will think idyllic islands are wonderful places to relax close to nature and be stress free. Cigarette smoking is a known stress reliever.
Unemployment among the young is high in the Pacific and a source of stress. People who are stressed and depressed are preoccupied with their own woes and not receptive to health messages no matter how evidence based these may be.
They have to be in the right frame of mind to work on health. Heavy regular and irresponsible drinkers of alcohol and takers of cannabis or drinker of kava are often trying "self treatments" for internal stresses — at home and work. These drugs make them feel better in an unhappy world they face.
The solace they seek through substance abuse — or instant gratification of the inherently attractive foods (fatty, sweet, fast) — only brings them a second disease. Depression, if not treated, can lead to the NCDs all are desperately trying to control, and wipe out.
The medical-mental illnesses that no one notices
In 2011, medically ill persons supposedly mentally healthy were interviewed using a World Health Organisation validated questionnaire and over 20 per cent of them turned out to have significant stress related problems based on symptoms and histories no health care persons detected.
None was psychotic and therefore not ever admitted in St Giles. A similar study in 2012 yielded over 40 per cent. Those figures show that the persons were suffering from emotional stresses that no one detected — or treated. Some of these might seek the so-called lifestyle disease related, fast foods, fatty foods and avoid exercise and become prone to the NCDs.
Better training and more trained health care workers in the field of mental health needs to be available to cater for stress related problems that go unnoticed and can lead to more physical consequences — ending in medical clinics and wards and merely being treated when there for only physical illnesses (that are also complications of psychological stress).
The reluctance to recognise these huge numbers of ill persons who account for at least one in five outpatients has been a tragedy for sufferers of emotional stress. Despite the doubts expressed by physicians in Fiji, the Mental Health Decree 2010, decreed the setting up of three Divisional Stress Management Wards (SMW) in Fiji by June 30.
These have been functioning since last year and the two units in Labasa and Lautoka with only a total of just 16 beds, two doctors and nine clinics have seen over 2000 outpatients and admitted over 200 patients in just 14 months. By contrast, the St Giles mental institution with 130 beds in 2011 saw 450 mostly psychotic inpatients and over 8000 outpatients.
The concept of Stress Management Wards had a difficult birth — almost a caesarian section to be born. But as the response from the community and doctors and nurses in these two units shows, Fiji is accepting SMWs wholeheartedly.
Thank you Fiji for your faith in modern mental health!
* Dr M Parameshvara Deva is a consultant psychiatrist currently working with the Ministry of Health in the area of mental health.