Mental health services in Sri Lanka

Abstract

Relative to its economic indicators, Sri Lanka has a high health status. The life expectancy in the year 2001 was 70.7 years for males and 75.4 years for females. Maternal and infant mortality rates have shown a downward trend over the past half century and now are around 2.3 per 10 000 live births and 16 per 1000 live births, respectively. These trends are mainly due to the high literacy rate and comparatively large investments made in health and social welfare.

Negative attitudes to mental illness, social stigma and a lack of appreciation of the suffering and disability caused by mental illness have resulted in low priority being given to mental health care services in Sri Lanka.

The situation regarding mental health care services is very different. As in many developing countries, negative attitudes to mental illness, social stigma and a lack of appreciation of the suffering and disability caused by mental illness have resulted in low priority being given to mental health care services in Sri Lanka. This situation is, however, beginning to change.

Overview

Major psychiatric illnesses form the bulk of the clinical load of psychiatrists in Sri Lanka. The suicide rate, though declining, is still higher than global average rates (De Silva & Jayasinghe, 2003), and alcohol-related problems are rising (World Health Organization, 1999). Drug misuse, which appears to be less of a problem than alcohol misuse, is mainly confined to heroin and cannabis (Ratnayake & Senanayake, 2002).

Long-term mental illness has a considerable social, economic and health burden (De Mel, 2001). The fast-growing elderly population, which will amount to 21% of the overall population by 2020, is likely to pose enormous mental health problems. Thirty years of civil disturbances coupled with ethnic violence have resulted not only in trauma but also a range of other problems, including loss of life, refugees, displacement, the disruption of the physical and social infrastructure as well as the poor economic performance of the entire country. The inevitable mental and psychosocial distress associated with the above problems, especially in the north and the east, compounds the existing mental health burden.

In the absence of a formal referral system, patients have the liberty to consult any mental health professional – or any other type of healer – in any part of the country. In view of the concentration of services in urban areas and also because of the perception that services in urban areas are of better quality, many patients gravitate towards these centres.

Increasingly, the majority of acutely disturbed patients tend to seek psychiatric help early; however, others, especially those with somatic manifestations, tend to seek psychiatric help when the initial treatment by a range of healers, including those in the general health care services, fails.

Most psychiatrists working for the government or for a university additionally engage in private practice after their contracted working hours. Almost all patients prefer to seek private services at least initially and resort to public services only when they are pressed financially to do so.

Mentally ill offenders and those coming under the Mental Health Act are directly referred to mental hospital for admission and care. Police and social care agencies are generally reluctant to force the involuntary admission of patients living in the community.

Responsibility for the development of mental health services belongs to the Director of Mental Health Services, who works with the Advisory Council on Mental Health. Because all health services are organised in a very complex and bureaucratic manner, taking decisions and implementing them is a tedious process. However, attempts are being made to implement, in stages, both the recommendations of a presidential taskforce set up 1998 and the National Plan to strengthen mental health services, which was prepared by a consultant from the World Health Organization (Ministry of Health, 2001).

The present public mental health services are organised around hospitals, which have no direct formal responsibility to a catchment area or a community.

In-patient services

Major psychiatric illnesses form the bulk of the clinical load of psychiatrists in Sri Lanka. The suicide rate, though declining, is still higher than global average rates and alcohol-related problems are rising.

The two large mental hospitals located in the suburbs of Colombo provide nearly 2500 in-patient beds. Long-stay patients occupy more than half of these. In addition to voluntary patients from all over the country, those referred by the courts, other units and involuntary patients reside in these institutions. The mental hospitals at present operate with severe staff constraints, as many positions are vacant. It is inevitable that, under these circumstances, the quality of patient care often has to be severely compromised. Although the need to develop provincial mental health services while phasing out the mental hospital facilities in Colombo is accepted by all stakeholders, practical steps towards realising this have not been taken.

The teaching hospitals and provincial general hospitals have a total of about 500 mental health beds in open wards. The average duration of an in-patient stay in a general hospital unit is around one to two weeks.

Out-patient services

Most major hospitals and some small hospitals offer outpatient clinics and day facilities. Basic psychotropic drugs and facilities for electroconvulsive therapy are available in most of these, while almost the whole range of drugs is available at the teaching hospital units, including newer drugs, which are also available in the private sector.

Non-medical mental health professionals carry out mainly psychological interventions. However, except in a few academic departments there are no clinical psychologists working in the publicly funded mental health services.

Rehabilitation services

With the assistance of the Nations for Mental Health programme, a project has begun to settle long-stay patients from the mental hospitals in the community. Recently, the Ministry of Health initiated a programme to develop intermediate-stay units at provincial level. Already about five such units are functioning. A few non-governmental organisations conduct residential rehabilitation programmes in the community.

With the assistance of the Nations for Mental Health programme, a project has begun to settle long-stay patients from the mental hospitals in the community.

An organisation called Sahanaya has been conducting a community-based rehabilitation programme since the early 1980s through its community mental health centre in Colombo. In addition, a number of innovative community-based programmes are being conducted in the central, north and eastern provinces at the initiative of psychiatrists and other mental health professionals.

The general health services provide detoxification and support for those with alcohol- or drug-related problems. In addition, a few state and non-governmental facilities provide residential care.

Specialised mental health services

Two child psychiatrists provide a specialised service in the children’s hospital in Colombo, while a general psychiatrist with training in forensic psychiatry provides a forensic service at one of the mental hospitals. Residential facilities run by the social services tend to house children with severe learning difficulties and behaviour problems.

During the past two decades there has been a steady growth of counselling centres in the country, mostly in the non-governmental and private sector. There has been a phenomenal growth of counselling programmes conducted by foreign organisations in the north and the eastern provinces, many of which are directed at war-related issues.

Most non-governmental organisations are engaged in providing of a range of services, but advocacy and activism in mental health receive minimal attention.

Promotion, prevention and social care

Health programmes – such as school health, maternal and child care and adolescent programmes – have been successful in incorporating aspects of mental health.

The Ministry of Social Services has been increasingly active in supporting the social needs of those with mental illness, especially those with a long-term illness.

The Mental Health Act and mental health budget

The Mental Health Act, amended in 1956, focuses on involuntary treatment and it mandates a mental hospital to house all patients coming under the Act. The inability of the present Act to meet the needs of those with mental illness was recognised as far back as 1971 and since then a number of committees have produced drafts at various times.

At national level, the budget for mental health care, which amounts to about 1% of the overall health budget, is wholly allocated to the mental hospitals. However, individual general hospitals meet their own mental health care expenses.

At national level, the budget for mental health care, which amounts to about 1% of the overall health budget, is wholly allocated to the mental hospitals.

Training

The academic departments of psychiatry in all six medical schools have undergraduate training programmes, which feature one to two months of clinical attachments as well as classroom teaching. The five-year postgraduate training programme in psychiatry initiated in 1981 at the Postgraduate Institute of Medicine, University of Colombo, has so far produced more than 70 psychiatrists, but Sri Lankan mental health services have been able to retain less than half this number.

The requirement of a research thesis as a part of the postgraduate programme in psychiatry has resulted in trainees being introduced to research. The numbers of research presentations by psychiatrists at scientific meetings and publications in local and international journals have increased over the past 10 years. Suicide, trauma, epidemiology, alcohol and long-term mental illness are some of the areas focused on.

In order to take psychiatry to the secondary care level, Sahanaya, with the support of the Ministry of Health, initiated a three-year training programme for doctors in 1999. At present, nearly 40 medical officers in mental health serve at secondary care hospitals, thus complementing services rendered by psychiatrists. In 2001, at the request of the Ministry of Health, a one-year diploma programme was initiated and already 10 people have graduated. They are to be posted to secondary care hospitals to develop new hospital and community services.

The general nursing programme includes training in psychiatry for two months at a mental hospital. A postgraduate training programme established in 1965 unfortunately continued only for two years; however, a similar training programme was initiated in 2001.

Professional bodies

The Professional Association of Psychiatrists (which is to be renamed the College of Psychiatrists), established in the 1970s, has become more active in the recent past. There are a number of civil society or non-governmental organisations working in the area of mental health, the National Council for Mental Health being the oldest and most active. Most non-governmental organisations are engaged in providing a range of services, but advocacy and activism in mental health receive minimal attention.

Future challenges

During the past few decades there have been significant developments in the field of mental health. Most of these have been on the initiative of local groups in universities, non-governmental organisations or in the private sector.

There is an urgent need to provide accessible basic services of good quality to meet the emerging needs of people living in the community. In order to realise this objective, there is a requirement for a coordinated development strategy at national level, with political leadership and the support of an effective mental health planning and implementation unit.

The challenge for the Ministry of Health is to strengthen its leadership role in the development of mental health at a national level and to work towards a common goal in partnership with other government agencies, non-governmental agencies, universities, other groups and international agencies.