(by Daam Barker)
In 2003, when I moved to Guyana from the United States, popular opinion was that it would be impossible for me to do any work in my field. I was told that counselling was not something Guyanese do.
Although I secured a position at the University of Guyana as Guidance and Counselling Officer, few individuals approached to engage the services I offered. It was contrary to Guyanese custom to discuss personal business with someone outside of family or religious circles. It seemed as if naiveté had gotten the best of my ambition even in the face of what clearly appeared to be pervasive need.
I knew that mental illness was just as prevalent in Latin America and the Caribbean as it is throughout the rest of the world and that it must be affecting Guyanese in a similarly negative, if not worse, way.
In 2001, the World Health Organisation estimated that at least one in four people will suffer one or more mental health disorders in a lifetime. The Global Burden of Disease Report for 1990 and predicted until 2020 indicated that mental and neurological disorders were accountable for 14% of diseases around the world and that this substantial need was not being met with an adequate treatment response.
In Latin America and the Caribbean, this treatment gap was considered to be 58.9% for depression, 64% for bipolar disorder, 63% for anxiety disorders and 74.1% for alcohol related disorders.
The Guyanese context proves to be one of the most challenging for mental health in this hemisphere. In fact, according to Leon C. Wilson’s “Race and Health in Guyana” study conducted in 2004 surveyed individuals’ dissatisfaction with life circumstances as a measure of mental health, 80% of the sample reported dissatisfaction. Beginning in the 19-29 age group, 64% of Afro-Guyanese, 58% of Indo-Guyanese and 75% of Mixed-Guyanese in the sample reported extreme dissatisfaction.
These figures grew progressively worse in each cohort with age. The gross disparity in mental and physical health between developing countries like Guyana and developed countries is attributable to differing levels of poverty, social inequity, gender differences, education, access to health care, racism, segregation and discrimination.
In 2008, the World Health Organisation recognised the impact of social justice on psychological well-being. It acknowledged its clearly deleterious effects on the way people live, increasing the possibilities of getting sick and the risk of death. The effect of poverty, in particular, is well established as a strong contributing factor to mental illness but it should also be recognised that mental illness can lead individuals into poverty as well.
Certain social problems as visible as domestic violence should make it apparent that mental health is at least at high-risk in Guyanese society. However, most underestimate the seriousness of enduring the pressures of everyday life here. In fact, Wilson noted that the collective struggle with poverty and deprivation may influence people to experience poorer levels of health than they otherwise would.
The Ministry of Health’s 2009 Statistical Bulletin offers that high blood pressure/hypertensive diseases were among the top five leading causes of death for all Guyanese in that year. Even in 2004, it was the second leading cause of death for Mixed-Guyanese between the ages of 30 and 39.
For the over-50 cohort, 46% of Indo-Guyanese, 45% of Mixed-Guyanese and 40% of Afro-Guyanese reportedly suffered from hypertensive diseases. Additionally, the incidence of death caused by hypertensive diseases is higher in Guyanese women than it is for men. People bemoan the stress of day to day living but are reluctant to ascribe it the importance it deserves in the wider spectrum of health concerns in Guyana.
Depression is just as grave a response to trying to manage the pressures of life in Guyana as hypertensive diseases are and is likely to go unreported given reluctance to recognise it as a legitimate illness. In its worst form, depression results in suicide. PAHO estimates that approximately 63,000 people commit suicide annually in the Americas elucidating the crisis.
The Health Ministry’s 2009 Statistical Bulletin indicates that death by intentional self-harm/suicide was the cause of at least 157 deaths, 24.1% of all deaths recorded that year. It was also the eighth leading cause of death for all Guyanese.
Further, mental illness makes individuals vulnerable to contracting or developing other diseases in addition to influencing intentional and unintentional injury. Depression is one reasonable precursor to the development of substance abuse and addiction as individuals turn to substances to escape the way they feel.
Cirrhosis of the liver is a disease that results from alcoholism and is notorious for taking the lives of Guyanese men. Wilson found that between 2002 and 2004, cirrhosis ended the lives of 3.3 times more Guyanese men than woman.
According to 2009 Health Ministry’s Statistics, cirrhosis and other chronic liver diseases or heart failure ranked 10th on the list of causes of death among Guyanese men. This suggests that in the absence of systemic change, these numbers may have continued to grow and could be even higher today.
Vulnerable populations that are at even higher risk of experiencing psychosocial challenges and mental illness than the normal population include women, children, the elderly the homeless, orphans, victims of violence, LGBT, disabled, addicts, indigenous people and victims of natural disasters.
WHO has discovered that women suffer from depression at twice the rate men do and that it is the primary cause of death for women globally. It purported that in 2005, 10% to 15% of children and adolescence suffer mental and behavioural disorders around the world and that in the Caribbean and Latin American regions this translates into a prevalence rate of between 12.7% and 15%. To make matters worse, it states that the treatment gap for children and adolescence exceeds that of adults. The elderly suffer higher rates of mental illnesses, especially depression, due to the deterioration of mental faculties through the aging process.
The statistics that inform the mental health landscape and this region’s paltry response to it, paint a grim picture of Guyana’s reality. It is no surprise that the life expectancy for Guyanese, and a few other Caribbean countries, has not surpassed the 60s. Without question, the evidence is conclusive that the mental health need in Guyana is formidable.
Help Seeking Behaviour
There are a number of factors that contribute to the treatment gap that prevents those struggling with mental illness in this region from obtaining the care they need including political unwillingness, uneven distribution of resources and the lack of human resources, gender differences, desensitisation, ignorance, stigma, culture of self-reliance, religious coping, familial coping and socio-cultural values. Each of these factors applies to the Guyanese context.
The absence of qualified professionals to deliver effective mental health services represents a tremendous problem in the region and in Guyana especially. The WHO reports that globally the median number of psychiatrists in developing countries is .01 per 10,000 compared with .92 per 10,000 in developed countries.
In Guyana, in Region IV, there are three locally based psychiatrists available to respond to mental health needs and all of them are located in Georgetown. There are two psychiatrists posted at the Psychiatric Hospital in Region V but they cater exclusively to patients not the wider public. I am aware of one locally-based psychologist who is active even if foreign-based psychologists visit different parts of the country inconsistently.
To my knowledge there are no other professionally trained counsellors based in Guyana and social workers being produced domestically are only now beginning to receive the depth of training necessary for them to respond to clinical concerns.
Given the country’s population of approximately 740,000, there should be roughly 74 psychiatrists or, adequately trained mental health professionals, to sufficiently meet the treatment needs. The limitation of human resources makes it exceedingly improbable that, even if everyone in need of mental health care sought it, they could receive it.
Gender differences play a role in shaping help seeking behaviour as well. Women engage mental health counselling services in higher numbers than men. This is evident in my experience both at the University of Guyana and privately where approximately 90% and 95% of visitors are female respectively.
Wilson et al. in their study and analysis of Guyanese mental health attributed women’s more positive assessment of their living circumstances (i.e. including physical and mental health) to their greater ability to manage (i.e. resourcefulness) living in a depressed economy than men. They reasoned that men rated their living circumstances more poorly than woman because they seldom present for physical or mental health care unless the situation is advanced.
Men’s attempts to adhere to the gender role stereotype of being strong, independent, fixing problems and not asking for help readily interferes with them getting the mental health assistance they require.
It is human nature to try to avoid situations that produce hardship and discomfort analogous to the effects of the public’s misunderstanding and stigma attached to mental illness. Research supports the position that many across the English-speaking Caribbean do not understand mental illness and that this feeds negative opinions about those suffering with it. The same phenomenon has complicated the HIV epidemic in Guyana.
Ignorance breads fear and stigma that discourage individuals from risking being perceived as HIV positive. It is every counselling recipient’s prerogative to keep their interactions with a therapist confidential. However, it is shameful to witness individuals withdraw from therapy to address their issues because someone has discovered their “secret”. Having witnessed the hate and destruction that my visitors have endured enables me to attest to the significant obstacle ignorance and stigma generate.
This article would be incomplete if it did not include the influence of socio-cultural values on help-seeking behaviour because they may be considered even more difficult to overcome. Guyanese socio-cultural values seem to derive from the emphasis placed on family as well as religion. There is nothing inherently wrong with either of these aspects of Guyanese culture.
However, many times suffering mental illness is interpreted as bringing shame on one’s family. Unfortunately, loyalty to one’s family in this instance restricts individuals from doing what is responsible to attend to their psychological needs. The strength of religious beliefs in Guyana translates into the fact that many individuals turn to clergy, when they encounter emotional and psychological impairment. These religious leaders, though, are not necessarily qualified to treat mental health concerns.
Regardless of the factors that dissuade individuals from pursuing mental health treatment, it is crucial to understand the implications for delayed treatment. First, the earlier the intervention the greater the reduction in the symptoms the individual experiences. Second, it increases the speed of recovery and return to functionality (e.g. returning to work, managing children). And third, it produces a better prognosis as well as lower rates of reoccurrence.
The way forward appears to involve training nurses and community health care workers to respond to emotional and psychological concerns. A greater number of more easily accessible practitioners facilitate earlier interventions. It has already been determined that decentralised, preventative, community-based care is better suited to treat people with mental health issues and that decreasing reliance on psychiatric hospitals is prudent. Furthermore, Belize has demonstrated success ameliorating its human resource deficiency and its ability to more effectively respond to its people’s emotional and psychological issues utilising this approach. Other countries in the English-speaking Caribbean with greater financial resources like Trinidad, for example, have continued to adhere to the large psychiatric hospital model with less success.
Another facet of the solution is to tackle the ignorance and stigma related to mental illness through public awareness campaigns. The on-going campaign against stigmatising and discriminating against individuals infected with HIV serves as a rich example of the effectiveness such efforts can make. Research indicates that raising awareness of mental illness, its causes and treatment does improve help-seeking behaviour in the Caribbean.
These efforts have proven fruitful in schools and through workshops for adolescence as well. The initiation of a consumer family association, like those that exist in three other Caribbean countries, to enable family members to advocate for higher standards of care for relatives would function to discourage stigma as well.
It is likely that raising public awareness of mental illness will also positively affect the gender and socio-cultural values that influence individuals not to engage the care they need. What is definitive is that with timely and quality intervention, those suffering with mental illness can recover to lead productive lives and make meaningful contributions to their families and communities.