by Gergana Manolova, MSc Global Mental Health candidate, manolova.gergana@gmail.com
Designated as an upper-middle income country, Bulgaria nevertheless has a long way to go in its mental health services in order to live up to the label. This is most visible in the insidious epidemic of depression, which affects about 15-17% of the population of the country.
The Bulgarians suffering from depression are often the working sick, because sick leave for mental health issues is not well received by demanding employers. An unhelpful and disorganized healthcare system compounds the situation. Doctors are either unable to diagnose mental disorders and offer treatments, referring patients onwards, or else only too willing to prescribe a course of benzodiazepines to ‘settle the nerves’ and forget about the issue. Diagnostic thinking is mechanistic and patients rarely receive in-depth investigation of their complaints, which may sometimes have an underlying organic cause.
The stigma of visiting the psychiatrist is pervasive, because that officially puts the person into the category of mentally ill. In their view, mentally ill people are permanently excluded from all normal behaviour or enjoyment of life. Self-stigma is often an obstacle to help-seeking.
Unfortunately, there is little understanding in Bulgaria towards people with depression from those around them. People are told to just snap out of it and get on with their lives, and are branded as sensitive and fragile. Often friends would pull back from the sufferers of depression, not comprehending why their personality and behaviour have changed. Without the support network and compassion needed for recovery, many people sink into deeper depression and despair, where they can linger for years.
But people’s awareness of mental health issues is growing – with that more people, usually women, start visiting psychologists and psychotherapists, who are in the private sector. Men and women express their depression differently in the Bulgarian culture – men tend to abuse alcohol and show agitated depression, while women show predominantly melancholia. Depression among the elderly, presenting in somatic complaints such as hypertension and bad sleep, is almost never diagnosed, although it is widespread because of their social isolation and often dire financial straits.
Children’s well-being receives a little more attention, although there is a severe lack of child mental health specialists in the country. There are new small-scale initiatives to improve detection and treatment in primary health care, which are slowly taking hold.
Depression has festered in the society because of deep social divides, stalled economic growth and oversimplified governance, which all contribute to chronic daily stress and a leaden feeling of hopelessness. Those affected often turn to the only environments that they feel receive them openly, searching for solace and relief – New Age practices, circles for ‘personal growth’,
Neuro-linguistic Programming, holistic healers. Many of these places have a genuine intention to help, but the end result is often patchy and temporary, sometimes detrimental to the relationships and finances of the sufferers. Weak regulation of the mental health sector makes the quality of services rendered by private practitioners uncertain as well.
A strong response to depression everywhere in the world needs to be structural, with improved financing and training of primary care doctors and nurses, campaigns for tackling stigma and promoting good mental health. The work in Bulgaria is just starting now; but hopefully we can turn the tide soon.
112 is the national emergency number in Bulgaria.
0035 9249 17 223 is the number for the Sofia Hotline.
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