MENTAL HEALTH OR STRESS MANAGEMENT Monday, 16 March 2015
Dr. M Parameshvara Deva Professor of Psychiatry
THE STIGMA ENIGMA Asia & Pacific Region STIGMA IN MENTAL HEALTH: THE REAL REASONS WHY IT CONTINUES
Mental health and stigma have been together for centuries. The practice for managing mysterious mental illnesses thought for centuries to be due to evil spirits and charms was to lock or chain the mentally ill so that others were safe from the unpredictable behaviour of the mentally ill. Numerous concoctions and so called remedies were tried and did not work. Some remedies actually did more harm and may have killed the sufferer. Ignorance of the nature of mental illness led to theories and beliefs that did not do the sufferer any good, due to the fear of the mentally ill and mental illness. In the name of religious treatments, many were subject to exorcism and even beatings to drive out evil spirits. The advent and widespread availability of chlorpromazine in the 1950s should have diminished the use of cells and chains and all but closed down mental asylums - but the newer powerful drugs were used with caution and often not used at all despite their availability even in low-income countries. It appears that the ignorance, fear and strong prejudice against the mentally ill continued the incarceration of the mentally ill - even until today – in 2015. Examples abound of health care staff underutilisation of available psychiatric medicines and continued building of more cells and even large penal-style mental hospitals. Feeble attempts at de-stigmatisation backed by ignorance, often rely on slogans (such as "mental illnesses are like any other illnesses") but yet are demolished by operating psychiatric units like the one below. If indeed psychiatric illnesses are like any other illnesses then why are the psychiatric units surrounded by high barbed wire fences, locked gates and steel bars and chains used to restrain patients? These Psychiatric wards resemble Prisons not Hospitals. Slogans cannot equate to patient abuse that is plain for all to see.
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
1
Professor of Psychiatry
This barbed wire guarded building is a Psychiatric ward as an outhouse of a large general hospital
The public rejected this purpose built psychiatric unit of a general hospital with no fence, locks or gates. Who built this cell and what made this possible?
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
2 Â Â
Professor of Psychiatry
This is not a post mortem slab in a Mortuary but a concrete bed of a Psychiatric ward. Made to prevent aggressive patients breaking the bed. Obviously the staff were not trained to use readily available medicines that prevent outbursts of violence in mentally ill patients with psychoses
This is an open Bath stall where mentally ill patients were unclothed and bathed by attendants, with areas to be washed, soaped, washed again and then blow dried and dried with towels.
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
3 Â Â
Professor of Psychiatry
Newly built psychiatric ward in 1990s with no access to drinking water
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
4
Professor of Psychiatry
OTHER DISEASES AND HOW THEIR STIGMA DISAPPEARED
Leprosy was a far more stigmatised disease since even biblical times. With parts of the body being infected with the leprosy bacillus and falling off leaving gaps in the face, missing fingers and toes. This leprosy colony founded in 1930 was the reportedly second largest in the world, with over 2,000 inmates. With no known cure, inmates were incarcerated in a huge colony out of sight and mind of the people. Their children were isolated for 6 months from birth to prevent them getting leprosy.
They lived in small chalets like this and had early treatments with limited improvement. With discovery of new medicines like dapsone, the illness was brought under control. The Leprosy asylum closed in the 1990s as few new patients were admitted as almost all treatment could be done early, from their own homes, with rare treatments done in any clinic or hospital. The stigma disappeared almost overnight and ---the colony became the largest garden town in the country! The former inmates became businessmen and women selling lovely flowering plants, decorative plants, fruits and engaging in lucrative landscaping and turf contracts – even employing foreign labour.
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
5
Professor of Psychiatry
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
6
Professor of Psychiatry
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
7
Professor of Psychiatry
BUT, the nearby modern general hospital and allied health sciences training centre still has no psychiatric ward...........
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
8
Professor of Psychiatry
The Key difference between Mental Illness and Leprosy related to the damaging effects of stigma may lie in the lack of commitment by health care professions to educate about mental illness. With modern medicines available, the missing link lies in the education doctors and nurses receive in their training. Curricula can be archaic and teachers and nursing and medical schools marginalise the teaching of psychiatry by making it a minor part of the curriculum. Passing psychiatry education is often not a prerequisite for becoming a nurse or a doctor. Our attention is often on the public’s stigmatisation of the mentally ill but the reality is that health care professionals and administrators themselves give less priority to the mentally ill through poor training, prejudice and fear. This Cell (below) for housing mentally ill in a hospital was donated by a doctor who felt sorry for the mentally ill - but yet, he did not know the proper treatment for the mentally ill among available medicines. This ignorance and stigma keeps patients suffering instead of being treated.
This 30-year old patient weighed less than 25 Kilos and was chained in the house for 4 years until he became cachexic and could not even stand up. He was often seen by a community nurse - who was not trained to know that a mentally ill patient like him could be treated with available medicines.
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
9 Â Â
Professor of Psychiatry
This mentally ill patient (below) was tied to a tree in the hope that the nearby grave of a saint could cure him - when in the same village, there were medicines that could control his behaviour.
Families are often desperate to control the psychotic behaviour that persists despite treatment in hospitals, often due to poor services for discharged mentally ill patients as now provided by health care services. A family built its own cell outside their house for their ill family member (below).
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
10 Â Â
Professor of Psychiatry
Unfortunately even modern psychiatric hospitals in well-to-do countries have locked cells with no windows - called “Serene Rooms”. Limited training is responsible for this state of affairs.
A brave psychiatrist seeing the tragedy of poor services for the mentally ill started a campaign against stigma by opening a rural psychiatric clinic – to train Family Doctors. They created a Stress Management Day Centre and printed posters to educate the public
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
11
Professor of Psychiatry
The real solution lies in offering basic services for the mentally ill in every primary health care facility, with clinics for day treatment and rehabilitation, even in small rural hospitals – and staff them with trained staff taught by experienced teachers in psychiatry.
One such project has been highly successful in Cook Island
To reduce stigma: •
IMPROVE TRAINING OF HEALTH CARE PROFESSIONALS •
IMPROVE TRAINING OF PSYCHIATRISTS
•
IMPROVE PSYCHIATRIC UNITS TO MAKE THEM USER FRIENDLY - NOT MINI PRISONS
•
EVEN WITHOUT SLOGANEERING CAMPAIGNS, STIGMA WILL REDUCE AND DIE OUT
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
12
Professor of Psychiatry
WE HAVE A CHOICE:
OR KEEP THINGS AS THEY ARE, OR MODERNIZE TREATMENT & DE-STIGMATIZE! Researched & Written by
Dr. M Parameshvara Deva Professor of Psychiatry Universiti Tunku Abdul Rahman Malaysia (Former WHO Asia-Pacific Region Mental Health Services) More to come!
For more information: Email: devamp37@gmail.com
Asia-Pacific Region: THE STIGMA ENIGMA
Dr. M Parameshvara Deva
13
Professor of Psychiatry