World Social Psychiatry

PERSPECTIVE/VIEWPOINT
Year
: 2022  |  Volume : 4  |  Issue : 3  |  Page : 187--192

Community-Based Mental Health Services in Bangladesh: Prospects and Challenges


Md Omar Faruk 
 Department of Clinical Psychology, University of Dhaka, Dhaka, Bangladesh

Correspondence Address:
Mr. Md Omar Faruk
Department of Clinical Psychology, University of Dhaka, Dhaka
Bangladesh

Abstract

Estimates inform that mental health problems are on the rise across the globe including in Bangladesh. To reduce the global disease burden caused by mental health disorders, community-based mental health care has gained significant consideration worldwide alongside conventional approaches to treat mental health disorders. In the face of growing mental health problems, limited resources, and centralized mental health facilities, Bangladesh – a low- and middle-income country – has prospects in ensuring mental health care through the implementation of community-based mental health services across the country. This article discusses the opportunities and challenges in implementing community-based mental health services in Bangladesh.



How to cite this article:
Faruk MO. Community-Based Mental Health Services in Bangladesh: Prospects and Challenges.World Soc Psychiatry 2022;4:187-192


How to cite this URL:
Faruk MO. Community-Based Mental Health Services in Bangladesh: Prospects and Challenges. World Soc Psychiatry [serial online] 2022 [cited 2023 Feb 6 ];4:187-192
Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/3/187/364587


Full Text



 Introduction



The burden of mental disorders continues to rise, significantly impacting health, major social, human rights, and economic growth across the world.[1] Estimates show that approximately 450 million people have mental or neurological disorders alongside psychological problems such as those related to alcohol and drug abuse.[2] It is also estimated that approximately 14% of the global disease burden is attributable to neuropsychiatric disorders.[2] In 2017, mental disorders were the second leading cause of disease burden in terms of years lived with disability and the sixth leading cause of disability-adjusted life-years – a critical challenge, especially for low- and middle-income countries (LMICs).[3] Despite the mounting escalation of mental disorders across the globe, health systems have not sufficiently responded to this global burden eventually leading to a gap between the need for treatment and provisions of treatment.[4] The gap is widespread in LMICs with data suggesting that between 76% and 85% of people with mental disorders receive no treatment.[4] Besides, the impact caused by the burden of mental disorders is disproportionately distributed in LMICs in which more than two-thirds of this burden exists.[5] LMICs devote only a small fraction of their total health-care budget (less than 1% in low-income countries) to mental health.[6] Reduced or lack of access to mental health care, disproportionate distribution of available resources, insufficient fund allocated for mental health care, and prevailing stigma and discrimination are some of the barriers in ensuring mental health care worldwide. Amid the upward trend of mental disorders along with the barriers mentioned above, scaling up of community-based mental health services can be a pragmatic approach in this regard, particularly in resource-limited countries such as Bangladesh. Community-based mental health services have shown promising results in adequately addressing mental health problems around the world.[7],[8] Bangladesh, a low- and middle-income country, is also struggling with growing prevalence of mental health problems and scarce resources. This article shades light on the prospects of community-based mental health care in Bangladesh and the challenges that need to be taken into consideration in order to ensure an effective mental health system.

 Mental Health Problems: Bangladesh Perspectives and Resources



Mental health care in Bangladesh is extremely inadequate compared to the gravity of mental health problems due to lack of mental health facilities, skilled mental health professionals, insufficient allocation of finance, and the longstanding stigma and discrimination.[9] The country's first National Mental Health Survey conducted in 2003–2005 revealed that about 16% of adult people were suffering from mental health problems. The nationwide survey conducted in 2019 showed an increase with about 19% of adult people experiencing mental health problems.[9] Mental disorders in children have also increased over the years from 15.0% in 2004 to 18.4% in 2009.[9] The 2019 survey also found a staggering treatment gap as large as 92% and 94% for adults and children, respectively.[10] The specialized mental health facilities and human resources are heavily concentrated in principal cities, especially in Dhaka, the capital city of Bangladesh.[9] There are only 270 psychiatrists available in Bangladesh comprising 0.073 psychiatrists per 100,000 population while the number of psychologists is also profusely inadequate with 0.007 psychologists per 100,000 population.[11],[12] Therefore, a disproportionate distribution of mental health professionals and specialized facilities remains a significant barrier in rural and urban areas. Furthermore, mental health care has not been integrated into the primary health-care system.

 Community-Based Mental Health Services in Bangladesh



Community-based rehabilitation (CBR), an approach promoted by the World Health Organization (WHO), is a strategy aimed at improving access to services including mental health care for people with disabilities through the optimal use of local resources.[13] The 2010 WHO CBR special supplement included the evidence in community mental health subsequently recommending the integration of mental health support for people with psychosocial disabilities into CBR programs. In light of these recommendations, LMICs have started incorporating mental health into their existing work.[13] Community-based mental health services in India, for example, include camp approach, school mental health, nongovernmental organization (NGO) initiatives, media-based interventions, and telephone helplines.[14] The key components of community-based mental health services in China are government leadership in the provision of mental health care, inter-department cooperation and coordination, wider community participation, comprehensive interventions such as medication, counseling, and occupational training.[15] After cultural modification, assertive community treatment has been introduced in many Asian countries such as Malaysia, Japan, Singapore, and South Korea.[6] Disaster-prone countries, such as Indonesia, Myanmar, and Thailand, have included community-focused mental health and psychosocial support in their emergency service provision.[6] In Bangladesh, on the other hand, different NGOs provide psychosocial support by extending community outreach programs (e.g., organizing mental health camps involving psychiatrists and psychologists) and organizing self-help groups for capacity building. Besides, several organizations are working on developing befrienders to support people with emotional distress. Home visit, establishing referral pathways, promoting community awareness, follow-up, and supporting with livelihood are some of the elements included in the community-based mental health service provisions. While these initiatives promote mental health care at the community level in some areas, not all areas across Bangladesh are under the purview of such initiatives contributing to a disproportionate distribution of mental health care.

 Strengths, Weaknesses, Opportunities, and Threats of Existing Initiatives



The following section demonstrates an analysis of strengths, weaknesses, opportunities, and threats in relation to the initiatives in favor of community-based mental health services in Bangladesh.

Strengths

In pursuit of a multitiered and robust health system, Bangladesh has developed the Mental Health Act 2018 replacing the Lunacy Act 1912, and the National Mental Health Policy 2021.[16] The act and the policy have subsequently led to the development of the National Mental Health Strategic Plan 2020–2030 in Bangladesh. The strategy takes into cognizance the comprehensive, intersectoral, integrated, and responsive system to ensure access to quality mental health care and information.[16] The strategy also aims to promote a sustainable and inclusive health-care system across the country contributing to the provision of access to quality mental health services through the promotion of mental health and well-being, prevention, treatment, and rehabilitation. The strategy that is awaiting final approval was formulated in light of the WHO Comprehensive Mental Health Action Plan 2013–2020 in which providing mental health and social care services in community-based settings was explicitly highlighted. The successful implementation of this strategy will ensure community-based mental health services across the country with greater mental health literacy and help-seeking behavior.

Weaknesses

In addition to the shortage of mental health professionals and large treatment gap, the current mental health expenditure in Bangladesh is only 0.44% of the total health budget[9] despite the rapid growth of the economy in recent years. The approach to community-based mental health services requires active governmental participation with adequate fund devoted for mental health care. Lack of adequate fund to mobilize the components of community-based mental health services may result in unsustainable development. Furthermore, there is no provision of mental health-care insurance in Bangladesh[11] that can also be a barrier in accessing mental health-care, especially in the rural areas.

Opportunities

Bangladesh has witnessed some progresses in relation to spreading mental health services across the country. These include the adoption of digital means to ease with the difficulty and accelerate access to mental health services, especially from the rural areas of the country. Computerized versions of cognitive behavior therapy (CBT) for depression and anxiety disorders including panic disorder have already been developed and are in effect. Besides, various Apps and emergency helplines are available to assess the severity of mental health problems and manage emergency situations such as suicide. These initiatives are accessible to people across the country which have potential to reduce the burden and promote mental health awareness. Recent developments also include recruitment of psychologists (clinical psychologists) by the Ministry of Health and the Ministry of Children and Women Affairs at district and division levels. Adaptation of the WHO mhGAP-IG Manual aiming to train nonspecialists to identify and deliver treatment in case of priority conditions and refer to specialists for advanced care has gained momentum. The manual has been found to be effective in many countries such as Nigeria after cultural adaptation.[5] Training on the Bangla adapted manual is continuing in Bangladesh spearheaded by the Directorate General of Health Services. These opportunities can promote community-based mental health services across the country, thereby reducing barriers to accessing mental health services.

Threats

While the opportunities may seem promising, there are a few obstacles that can act as threats to the effective implementation of community-based mental health services in Bangladesh. For example, mental health care and stigma alongside discrimination have always shared an inseparable tie resulting in the hindrance of health-seeking behavior. Like much of other South Asian countries, evidence in Bangladesh suggests that mental disorders are believed to be emerging from the possession of evil spirits.[12] People often seek treatment from faith healers in LMICs. For example, in India, people often consult with religious or faith healers as the first contact before seeking medical attention.[17] Faith healers in India use amulets, verses from the Quran, and instruct people to perform rituals to fend off the evil spirits.[17] India and Bangladesh share the same religious practices when it comes to treating mental health disorders by faith healers. Another threat that may jeopardize community-informed mental health care is the lack of mental health literacy. Unlike physical health, people often do not endorse the need of mental health care which may result in refraining from seeing mental health professionals, treatment delay, and further complicating mental health conditions. Finally, mental health care, especially in the rural settings, is largely spearheaded by external funding agencies. Shortage of fund may obstruct community people's access to mental health care.

 Community-Based Mental Health in Bangladesh: Prospects



Community-informed health system

Majority of the population in Bangladesh live in rural areas where the burden of mental disorders is profound owing to limited resources including mental health professionals.[18] Bangladesh is acclaimed for the primary healthcare system and estimates inform that more than 13,000 community clinics (one clinic per 6000 rural people) are currently operational.[18] Integration of mental health into primary health-care system can be achieved through the optimal utilization of community clinics across the country. Some programs in other South Asian countries (e.g., India) have integrated mental health care into the primary care following the principles of decentralization and destigmatization. Significant components of such programs include training health-care personnel at the primary health-care centers, advocacy for sensitizing mental health issues, and facilitating community involvement.[19] Bangladesh can also benefit from proper training and supervision of staff working at the community clinics which may be useful in ensuring affordable and clinically effective mental health care. Primary health-care workers at government and nongovernmental setups along with community health-care providers can be trained in providing basic medication, psychosocial support, crisis management, referral pathways, and psychoeducation to patients and family members and other caregivers.[20]

Task-sharing approach

Task sharing is an approach that aims to address unmet mental health needs in resource-limited settings. Task sharing involves transfer of specific tasks from skilled specialists to other health-care providers with less expertise.[5] Growing evidence suggests the efficacy of task-sharing approach in identifying and treating common mental disorders in primary health-care system.[5] For example, mild, moderate, and severe depression can be efficiently diagnosed and treated in primary health-care settings,[20] especially with group interpersonal therapy (IPT).[21] Transdiagnostic approach that takes into account the identification of underlying maladaptive factors responsible for a broad range of diagnostic presentations has yielded promising outcomes through task sharing involving less experts.[5] People in many Asian cultures such as Chinese, Japanese, and Malayan often somatize psychological and emotional distress in terms of physiological manifestations.[5] Staff working in primary health settings can be equipped with adequate training to identify physical and mental health problems and the interplay between them and to provide care accordingly.

Community and family involvement

The role of families and communities can be recognized and utilized through proper training and supervision. From seeking care by means of appropriate channels, acquiring illness-related knowledge (e.g., nature and prognosis of the illness) to ensuring CBR with employment and other life decisions (e.g., marriage and geographical migration), families, and communities can play a significant role. In addition, their roles can be successfully utilized in normalizing psychopathology and reducing stigma and discrimination.[5] Small-scale research has shown the effectiveness of CBR programs in Bangladesh in which improvements in symptoms, social relationship, and daily functioning was observed.[13] Primary health-care staff can impart such knowledge among family and community members with and without persons experiencing mental illness at a designated place in the settings on a regular or occasional basis. India has established a system in which family members provide extended psychosocial support.[22] Awareness materials such as posters, leaflets, flashcard, and video clips can be useful in disseminating the knowledge.

Developing paraprofessionals

People who have recovered from mental illness or have experience working with people experiencing mental health problems can work in synergy with primary health-care staff as paraprofessionals or peer responders (The term, Peer Responders, was coined by the Centre for Disability in Development, Savar, Dhaka, Bangladesh). Their tasks include sharing personal experiences, encouraging others to speak up, and working as a bridge between the persons with mental disorders and health-care facilities. A recent study in India demonstrated that paraprofessionals were found to be a viable solution to reducing the treatment gap.[23] From reducing stigma to delivering evidence-based treatment for mental disorders, paraprofessionals were able to add to the workforce.[23] Involving paraprofessionals or peer responders in primary health-care settings in Bangladesh can also result in increased mental health literacy, improved well-being, and increased empowerment.

Involvement of faith healers

Seeking help from faith healers is widespread in LMICs, especially in rural areas.[21] Inclusion of faith healers including religious leaders will inform an alternative pathway to ensure time-befitting mental health care. Thailand is an example where temples are working as the first port of call-in case of any emotional distress. Besides, religious aspects (e.g., Buddha's teachings) were also incorporated in psychiatric hospitals and community mental health work.[21] Bangladesh can benefit from this approach as faith healers and religious leaders play a crucial role in forming public opinion.

Adaptation of therapeutic approaches and manuals

Cultural adaptations of dominant therapeutic approaches such as low-intensity CBT and IPT have been shown effective in treating mental disorders such as depression in primary and secondary health-care system (e.g., Pakistan).[21] Evidence also suggests that family members can deliver such evidence-based interventions with appropriate training.[18] Adaptation and application of these therapeutic approaches can reduce the treatment gap, especially in the rural areas. In addition, training on the mhGAP-IG Manual can help medical professionals provide primary mental health care.

Embracing telepsychiatric services

Telepsychiatric services help people to seek mental health care removing the barrier of travel, long wait, and stigmatization. People living in rural areas with limited or no access to mental health care, can seek mental health support from community clinics and union health centers that are equipped with mobile phones and Internet connectivity. Evidence suggests that telepsychiatric services had positive outcomes in LMICs.[24] Telepsychiatric services in Bangladesh have started their operations earlier in 2016.[19] Evidence showed that community members, community leaders, and health-care providers were willing to accept services provided through telepsychiatry.[25] The prospect of telepsychiatry service lies in considerable attention as well as expansion across the country. With the increasing access to mobile phones and the Internet, people irrespective of geographical location including those living in the remote hill tracts and coastal areas can avail mental health care. Emergency services stemming from sexual assaults, suicidal attempt, and domestic violence can be ensured through telepsychiatry services. Child and adolescent mental health problems, improving parenting skills, and anti-stigma campaigns can also be incorporated into the telepsychiatry service provisions.

Implementation of the aforementioned activities is likely to result in increased mental health literacy and access to mental health care, and improved well-being through the promotion of community-based mental health services across Bangladesh.

 Community-based Mental Health in Bangladesh: Challenges and Way Out



Absence of community-based mental health guidelines

Different nongovernmental stakeholders are currently implementing community-based mental health services in Bangladesh. The idea or concept of community-based mental health services must be defined or re-defined keeping the sociocultural contexts into account. Lack of uniform approach to community-based mental health services may hinder the prospects. Therefore, a national guideline or a task force devoted for community-based mental health services is required. The task force can be tasked with formulating policies, allocating and mobilizing resources including sufficient fund, establishing an effective referral pathway, and developing evaluative plans against specific benchmarks to measure successes and to identify potential challenges. The task force may consider indigenous people with distinct values and customs and persons with disabilities that require tailored mental health services. Finally, coordination between government and nongovernmental stakeholders is a key.

Lack of mental health professionals

Mental health professionals including other allied professionals are low in number compared to the growing number of people with mental health problems. Lack of skilled mental health personnel may jeopardize integration and sustainability of the service. Therefore, efforts to increase the number of mental health and allied professionals need to be undertaken. Training primary health-care staff on delivering primary mental health care and developing paraprofessionals taking the task-sharing approach into account may help reduce the shortage of mental health professionals. Coordination among allied mental health professionals will inform a multidisciplinary treatment approach.

Lack of monitoring and access to supervision

Delivering evidence-based mental health services with fidelity, task-sharing programs must include established system for ongoing training, supervision, and mentorship.[26] While initial training is necessary, it may seem insufficient to building confidence and competence of mental health professionals.[27] Therefore, supervision and mentoring have been considered essential to developing feedback loops while correcting negative behaviors and reinforcing affirmative behaviors in the process of learning and reflecting.[28] Evidence also suggested that lack of access to supervision and mentoring resulted in low intervention fidelity and reduced clinical competency.[29] In contrast, supervision and monitoring have been shown to improve emotional support and reduce burnout.[30] Therefore, adequate supervision of primary health-care staff by mental health experts should be facilitated for a successful and sustainable integration.[20] The task force can ensure mental health professionals including staff working at the primary health care have access to supervision and mentoring.

Insufficient allocation of fund

Many LMICs allocate less than 1% of their total health-care budget to address mental disorders.[21] India and Pakistan spend 0.06% and 0.4%, respectively, of their total health-care budget on mental health. On the other hand, Bangladesh spends 0.44% of its total health-care budget on mental health.[9] Lack of proper allocation of financial resources from tertiary care to primary health-care system including the availability of psychotropic medication can impede the progress. Sufficient financial allocation and equal distribution of financial resources on mental health care is necessary.

Barriers accessing telepsychiatric services

Lack of technical knowledge is required to avail mental health care through telepsychiatric approach. Previous research has shown that illiteracy, lack of English language proficiency, and technical incapability were identified as major barriers in accessing telepsychiatry services in rural areas.[31] Training for community people is required to equip them with the necessary set of skills to access the service. Efficacy and sustainability of the service will remain a major concern unless technical knowledge is increased.

 Conclusions



The government and nongovernmental stakeholders in Bangladesh are giving due consideration and working with a set of visions to deal with the growing mental health problems across the country. In this pursuit, embracing community-based mental health approach deems useful in ensuring mental health care for all irrespective of geographical locations. While the prospects have far-reaching implications, efficacy and sustainability of the services will also depend on how well the challenges are addressed and taken into consideration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mental Disorders. World Health Organizations. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-disorders. [Last accessed on 2022 Jan 04].
2Saxena S, Sharan P. Mental Health Resources and Services. In: Heggenhougen HK (Kris), editor. International Encyclopedia of Public Health [Internet]. Oxford: Academic Press; 2008. p. 418-30. Available from: https://www.sciencedirect.com/science/article/pii/B9780123739605000435. [Last accessed on 2022 May 12].
3India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India: The Global Burden of Disease Study 1990-2017. Lancet Psychiatry 2020;7:148-61.
4Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007;370:841-50.
5Abdulmalik J, Thornicroft G. Community mental health: A brief, global perspective. Neurol Psychiatry Brain Res 2016;22:101-4.
6Ito H, Setoya Y, Suzuki Y. Lessons learned in developing community mental health care in East and South East Asia. World Psychiatry 2012;11:186-90.
7Van Citters AD, Bartels SJ. A systematic review of the effectiveness of community-based mental health outreach services for older adults. Psychiatr Serv 2004;55:1237-49.
8Thornicroft G, Wykes T, Holloway F, Johnson S, Szmukler G. From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study. 10. Br J Psychiatry 1998;173:423-7.
9Hasan MT, Anwar T, Christopher E, Hossain S, Hossain MM, Koly KN, et al. The current state of mental healthcare in Bangladesh: Part 1 – An updated country profile. BJPsych Int 2021;18:78-82.
10Hasan MT, Anwar T, Christopher E, Hossain S, Hossain MM, Koly KN, et al. The current state of mental healthcare in Bangladesh: Part 2 – Setting priorities. BJPsych Int 2021;18:82-5.
11Hossain MM, Hasan MT, Sultana A, Faizah F. New Mental Health Act in Bangladesh: Unfinished agendas. Lancet Psychiatry 2019;6:e1.
12Alam F, Hossain R, Ahmed HU, Alam MT, Sarkar M, Halbreich U. Stressors and mental health in Bangladesh: Current situation and future hopes. BJPsych Int 2021;18:91-4.
13Koly KN, Abdullah R, Shammi FA, Akter T, Hasan MT, Eaton J, et al. Mental health and community-based rehabilitation: A qualitative description of the experiences and perspectives of service users and carers in Bangladesh. Community Ment Health J 2022;58:52-66.
14Hans G, Sharan P. Community-based mental health services in India: Current status and roadmap for the future. Consortium Psychiatricum 2021;2:63-71.
15Li K, Sun X, Zhang Y, Kolstad A. Mental health care in China: Review on the delivery and policy issues in 1949–2009 and the outlook for the next decade. Acta Neuropsychiatr 2014;26:134-45.
16Mental Health Strategic Plan for Bangladesh: An Overview. Available from: http://www.ipsnews.net/2021/10/mental-health-strategic-plan-bangladesh-overview. [Last accessed on 2022 Jan 05].
17Housen T, Ara S, Shah A, Shah S, Lenglet A, Pintaldi G. Dua Ti Dawa Ti: Understanding psychological distress in the ten districts of the Kashmir Valley and community mental health service needs. Confl Health 2019;13:59.
18Khan MZ. Development of Rural Mental Health in Bangladesh. Mental Health and Illness in the Rural World; 2020. p. 183-94.
19Padmavati R. Community mental health care in India. Int Rev Psychiatry 2005;17:103-7.
20Funk M, Saraceno B, Drew N, Faydi E. Integrating mental health into primary healthcare. Ment Health Fam Med 2008;5:5-8.
21Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, et al. Mental health service provision in low- and middle-income countries. Health Serv Insights. 2017;10:1178632917694350.
22Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in India. Br J Psychiatry 2004;184:366-73.
23Abraham A. The Role of Paraprofessionals in the Mental Health Structure of India. Senior Theses; 2020. p. 387. Available from: https://scholarcommons.sc.edu/senior_theses/387. [Last accessed on 2022 May 10].
24Acharibasam JW, Wynn R. Telemental health in low- and middle-income countries: A systematic review. Int J Telemed Appl 2018;2018:9602821.
25Soron TR. Telepsychiatry-from a dream to reality in Bangladesh. J Int Soc Telemed eHealth 2017;5:e53.
26Kemp CG, Petersen I, Bhana A, Rao D. Supervision of task-shared mental health care in low-resource settings: A commentary on programmatic experience. Glob Health Sci Pract 2019;7:150-9.
27Herschell AD, Kolko DJ, Baumann BL, Davis AC. The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clin Psychol Rev 2010;30:448-66.
28Beidas RS, Koerner K, Weingardt KR, Kendall PC. Training research: Practical recommendations for maximum impact. Adm Policy Ment Health 2011;38:223-37.
29James IA, Milne D, Morse R. Microskills of clinical supervision: Scaffolding skills. J Cogn Psychother 2008;22:29-36.
30Edwards D, Burnard P, Hannigan B, Cooper L, Adams J, Juggessur T, et al. Clinical supervision and burnout: The influence of clinical supervision for community mental health nurses. J Clin Nurs 2006;15:1007-15.
31Khatun F, Heywood AE, Ray PK, Bhuiya A, Liaw ST. Community readiness for adopting mHealth in rural Bangladesh: A qualitative exploration. Int J Med Inform 2016;93:49-56.