Moving forward by addressing the past
by Dr Asanga Fernando, Macmillan Consultant Liaison Psychiatrist & Co-clinical Director of Simulation, St George’s University Hospitals NHS Foundation trust, London
Sri Lanka has faced a unique set of challenges from the mental health perspective. The end of Asia’s longest running civil war in 2009 and the Boxing Day Tsunami of 2004 have contributed to an increasing awareness of mental illnesses across the island, whilst also highlighting the enormous challenges that exist in effective island-wide mental health coverage. In many ways, the major challenge in addressing mental health problems, including depression, is, as it is in many places, stigma.
Regardless of ethnicity or social class, Sri Lankan society is strongly family-based, and as such, it tends to be the supportive families of those affected by mental illness that carry its burden. Families of course want their loved ones to succeed in a society where identity is dependent on having a successful job, which in turn increases the prospects of marriage, and therefore, as in many other places, professional help for mental illnesses isn’t sought as early as it could be due to prevailing stigma. Despite this, there have been notable recent efforts, including use of TV, mass media and social media, which are helping to improve awareness.
Depression continues to be a major cause of morbidity in Sri Lanka. It is notable that there is no word specifically for it in the Sinhala language. The closest word to describing depression is ‘dukha’ which literally translates as ‘sadness’. The presentation of depression across Sri Lanka manifests more commonly as somatisation and often results in extensive medical investigation prior to screening for psychiatric symptoms. Depression continues to be frequently associated with trauma, comorbid with anxiety disorders and also with alcohol misuse in men, with the wider impacts of alcohol misuse tangible in post war Sri Lanka, including increased road traffic accidents.
Although the use of faith and traditional healers to treat mental illnesses has significantly reduced over the years, Ayurvedic medicine remains a popular and often more acceptable alternative to western medicine especially in rural areas. As such, the local ‘native doctor’ or ‘veda mahathaya’ may be the first point of contact for those affected with mental illness.
As Sri Lanka has recently transitioned from a ‘developing’ country to a ‘lower-middle income’ country, the burden of disease is shifting from communicable to non-communicable. As such, people are living longer, often with more mental health sequelae. The impact of the war and the tsunami have increased awareness of trauma, but there remains a dearth of psychologists and other allied healthcare therapists in Sri Lanka. The majority of psychiatrists in the island are based in proximity to the urban western province of the island, meaning that there continues to be limited psychiatric manpower across rural Sri Lanka. Despite this, it is encouraging that the government trains ‘medical officers in mental health’ who are now aiming to provide a frontline service often in rural areas. There is also an increasing acknowledgement of the role of mental health and wellbeing in childhood, with several schools and child-welfare organisations recognising the need for counselling.
Overall Sri Lanka’s long walk in the shadow of mental illness continues, but the resilience of its people, combined with recent steps to tackle stigma, improve knowledge and access to services, means that there are reasons to be optimistic.
Telephone hotline Sri Lanka Sumithrayo – Bandarawela: 011 057 2222662
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