What do we need to integrate mental health into mainstream healthcare?

Physical and mental health are both crucial to live a full life and contribute to the world around us. The definition of health, according to the World Health Organization (WHO), is ‘a state of complete physical, mental and social wellbeing’, and not merely as the absence of disease. The definition of mental health takes the definition of health to the next level: mental health is ‘a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.

What makes us mentally unhealthy? We can divide the factors into two broad groups – environmental factors and physical factors – both of which can affect our mental health at any stage of life. Research shows that situations such as early childhood abuse, trauma or unhealthy or toxic parenting can culminate into fragile mental health of a child, which can worsen in adolescence or adulthood.

Social disadvantages like poverty, unemployment, social isolation, discrimination, natural calamities and man-made disasters, stigma, domestic violence, bullying or any significant trauma and chronic diseases, as well as neurological conditions are associated with mental disorders of anxiety, depression, substance abuse, post-traumatic stress disorder, psychotic disorders and suicidal tendency.

Disease burden is the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. Depression and anxiety disorders ranked among the top 25 leading causes of burden worldwide, according to the Global Burden of Diseases, Injuries, and Risk Factors Study in 2019.

A door-to-door survey by the National Institute of Mental Health with technical support from the World Health Organization found that of a representative sample of Bangladesh citizens, nearly 19% of adults and 13% of children experience some sort of mental disorder. The report estimated a 92% ‘treatment gap’- meaning most people with mental disorders do not seek any professional help.

The extent of the problem does not match with the measures to address it; level of awareness, availability and accessibility of services, and investment into mental healthcare remain low. With 0.49 mental health caregivers per 100,000 population, Bangladesh faces a severe shortage of human resources to provide psychosocial or psychiatric support. Expenditure on mental health is only 0.44% of the total health expenditure.

Considering the shortage of skilled human resources, BRAC developed a group of para-counsellors. who work under close supervision of psychologists. Their task is to talk to people, understand their problems, provide mental health first-aid and basic counselling sessions

To overcome the discrepancy between the problem and investment in terms of resources and policy level attention, some actions which are underway in Bangladesh, need a quantum leap. It is, no doubt, a difficult task to get done, but two things should happen in parallel.

One, advocacy needs to happen for more investment in mental healthcare. Two, a clear roadmap is needed to address the existing issues starting from human resource development, addressing social stigma and lack of awareness, integration of mental health in the mainstream healthcare system and other relevant sectors.

Bangladesh has recently passed the National Mental Healthcare Act 2018, revoking the century-old Lunacy Act, and is on the verge of finalising the National Mental Health Strategy. This strategy is surely a breakthrough and contains some clear guidelines for achieving some of the global mental health targets set by the WHO.

However, as there is no simple solution for such a complex issue, we should focus on working with different models to find solutions effective for our contexts, under the leadership of the Ministry of Health and Family Welfare and involving relevant stakeholders.

Child-friendly space for children who survived violence and trauma. © Kamrul Hasan, 2018.

BRAC has successfully implemented several models of mental healthcare for specific target groups, such as migrant workers, violence survivors, mothers and children from the Rohingya community who experienced trauma after fleeing persecution in their home country, Myanmar. Considering the shortage of skilled human resources, BRAC developed a group of para-counsellors who work under close supervision of psychologists. Their task is to talk to people, understand their problems, provide mental health first-aid and basic counselling sessions, and if necessary, connect them with psychologists for higher level care.

We have found that the majority of mental health issues can be overcome with assistance from the para-counsellors, while a small percentage need referral to psychologists. This model may act as an interim solution to the human resource shortage until adequate psychologists are available.

Guided by the Directorate General of Health Services, BRAC is also going to test a model of integrating mental health in primary healthcare with assistance from the para-counsellors and community health workers to destigmatise the issue and bring mental healthcare to the doorsteps of families. This is for the long haul.

To make it a reality, all the four sides of mental healthcare, ie, prevention, promotion, care and awareness must have adequate focus. An upgraded healthcare system equipped with the adequate measures in capacity development, supportive supervision and referral support will be able to deliver what is needed. Finally, a strong stewardship from the Ministry of Health and Family Welfare is imperative to develop a sustainable, well-supervised and monitored system which involves all the relevant stakeholders.

BRAC is integrating mental health in its primary healthcare services, to provide people with community-based, culturally-relevant and ethical mental health support, using the experience of providing psychosocial support through para counsellors. 444 trained para counsellors from BRAC are currently working in the community to address mental health challenges in Bangladesh.

To learn more about BRAC’s approach in mental health visit the website. Find more blogs on what BRAC is doing through health interventions on The Good Feed.

Morseda Chowdhury is the director of BRAC’s health, nutrition, and population programme.