Poverty is associated with mental health problems – it can be both a cause and a consequence. People and communities living in poverty face a high burden of environmental and psychological stress, which place them at increased risk of mental health problems. Among the stresses they face are:

• Violence
• Limited access to resources
• Unemployment
• Social exclusion
• Insecurity

Poverty may also worsen an existing mental health problem and increase feelings of hopelessness and powerlessness. In turn, people with mental health problems face poverty because they are more likely to encounter barriers to education, employment, housing and inclusion. This creates a vicious circle that is difficult to escape.

Community and economic development can be used to restore and enhance mental health. Communities whose members enjoy good mental health are better equipped to:

• Solve their problems
• Establish social networks
• Promote mutual support

Community development programmes can contribute to the promotion of mental health and prevention of mental health problems by aiming to:

• Reduce poverty
• Achieve economic independence and empowerment for women
• Reduce malnutrition
• Increase literacy and education
• Empower the underprivileged

CBR, as a part of community development, should take into account the mental health needs of all community members, involving community leaders and members in this process. People with mental health problems can also contribute to the development of their communities.

There is often very limited understanding within society about mental health problems. As a result, many myths have developed. They include the following:

Select each myth below to learn more about the real facts that dispel it.

Stigma and discrimination against people with mental health problems is widespread and affects all areas of life including personal, home and family life, work, and even people’s ability to maintain a basic standard of living. People with mental health problems often describe the stigma and discrimination they face as worse than their main condition. Family members of people with mental health problems are also subject to limited understanding, prejudiced attitudes and discriminatory behaviour.

Stigmatization may lead to self-stigma, whereby people with mental health problems and their family members internalize society’s negative attitudes towards them. They may actually start to believe what others say and think about them, often leading to self-blame and a decrease in self-esteem.

Anticipation of rejection due to stigma may result in people reducing their social networks and not taking advantage of life’s opportunities. This, in turn, may lead to isolation, unemployment and lowered income. Experienced or anticipated discrimination is the main reason why many people hide their mental health problems and do not seek help.

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Mental illness in Nigeria

In Nigeria, stigma towards those with mental illness is a strong barrier to inclusion and a challenge for communities. At a local level, there is little known about mental illness. As a result, views of mental illness are often fuelled by myths. In many Nigerian communities it is believed that mental illness is caused by witchcraft or is the result of divine punishment. Consequently, communities have been known to chain people with mental illness or hide family members affected by mental illness as a result of the stigma.

The Mental Health Awareness Programme’s approach to disability inclusive development

The Amaudo Community Mental Health Programme is the only community based mental health service in South-Eastern Nigeria. The project provides accessible, affordable and professional care to people with mental health problems through a network of clinics and directly to homes. The project found that educating communities and challenging traditional beliefs about mental illness is an essential part of supporting people with mental health problems. As part of the program, the Mental Health Awareness Programme (MHAP) was developed to educate community workers and families and provide them with the tools and knowledge to support people with mental health problems in their community. MHAP is a five-year programme delivered to the four states where CBM Australia the Community Mental Health Programme operates.

How is MHAP implemented?

Recognising that access to good health care is an important first step towards community inclusion, the project arranges training for community psychiatric nurses and other government health professionals. Once trained, they deliver awareness and education programmes about mental health problems and human rights to village health workers who directly support people affected by mental health problems in their communities. In each area the government recruits 15 voluntary village health workers to support approximately 200,000 people. The village health workers learn positive messages about mental health and advice on how to identify, refer and support people with mental health problems in the community. In raising awareness about mental health problems and encouraging those with mental health problems to attend CMHP clinics, the village health workers are helping to change community beliefs and prevent discrimination.

What is most effective?

In the six months leading up to the project’s start in a new area, communities are heavily involved in the development of the project. This means meeting with influential community members and government officials to share the importance of mental health. By the time the project officially launches in each community, the community psychiatric nurses, other government health staff and 15 village health workers have already attended training, key community members are supportive of the project and there is a strong sense of community ownership.

Mr Omo is a village health worker for the MHAP. He visits the traditional leaders in local villages to explain his role and provide information about mental health problems, support services and the importance of community inclusion. Each village health worker maintains a close relationship with a psychiatric nurse, and Mr Omo is no exception. He has a strong relationship with the community psychiatric nurse, who supports him, and he requests her support when he has any questions.

Mr Omo found that as more people access mental health care the community has become more supportive as they can see the results for themselves. People are now starting to approach Mr Omo from other communities because they have heard about his work and are hopeful that mental health problems can be treated. This is an important first step in starting to change community attitudes and increase participation of people with mental health problems in the community.

Village health workers do much more than provide referral services; they also help people with mental health problems take part in community life. They encourage family reconciliation and visit schools and workplaces where people with mental health problems are no longer able to attend. In these homes, schools and workplaces they teach people about the challenges of mental health problems and the importance of disability inclusive practices. This component of the project is a vital step towards reintegrating people with disabilities who have experienced discrimination.

The MHAP monitoring processes are integrated into the existing Community Mental Health Program’s monitoring where possible. A monitoring and evaluation team is established at the beginning of each period of village health worker training with the aim of reviewing attendance, content and the quality of training. This team conducts pre- and post-training tests to assess the change in attitude and knowledge of the village health workers. Information, including the number of referrals made to clinics and awareness-raising activities in the community, is also collected by community psychiatric nurses from each village health worker.

Footnote:

This case study is an excerpt from CBM’s booklet ‘Addressing Poverty through Disability Inclusive Development: 8 Partner Case Studies’, a booklet that provides eight honest partner reflections on the inclusion of people with disabilities and their families in development initiatives, sharing their successes, challenges and key lessons learnt.

In many countries, people with mental health problems routinely experience human rights violations. These violations frequently occur in psychiatric institutions through inadequate, degrading and harmful care and treatment, as well as unhygienic and inhumane living conditions. Violations can occur within society, where people with mental health problems are unable to exercise their civil liberties and have limited access to education, employment and housing. Violations can even occur in their own homes, where lack of knowledge about mental health problems and lack of access to proper medical care can lead to neglect or chaining and restraining.

Every person, including people with mental health problems, has human rights. All general international human rights conventions are applicable to people with mental health problems and protect their rights through the principles of equality and non-discrimination, as described through the Universal Declaration of Human Rights. In addition there are also more specific conventions that are applicable to people with mental health problems, as stated in the Convention on the Rights of Persons with Disabilities (CRPD).

While policy and legislation are needed in countries to ensure international human rights standards are met for people with mental health problems, all communities can take action now and work towards protecting, promoting and improving the lives and well-being of people with mental health problems.

People with mental health problems may require access to specialized health care and/or general health care.

For mental health problems:

There is a range of health-care interventions available to promote the recovery of people with mental health problems. Medical interventions may include the prescription of psychotropic drugs (antipsychotics, antidepressants, mood stabilizers) and treatment of associated physical health conditions. Psychological interventions can include one or more of the following:

• Education about the condition and treatment options
• Counseling
• Individual or group psychotherapy
• Family interventions

In many cultures, the concept of mental health is associated with religious, spiritual or supernatural beliefs. Therefore faith leaders and traditional healers are often consulted first. It is important to be aware that the practices of traditional healers, such as certain conventional practices, can vary widely – some treatment methods may be harmful, while others are not. Culturally sensitive approaches to health care are required with consideration of local healing traditions, exchanges of experience and development of mutual understanding.

While effective interventions have been identified for mental health problems, there is very limited availability of specialized health care. Shortages of psychiatrists, psychiatric nurses, psychologists and social workers are among the main barriers to providing treatment and care in low and middle-income countries. Where available, prices of medicines and professional fees are often very high, and therefore many people in low-income countries have limited access.

When specialized health care is available for people with mental health problems, it is often inappropriate. Human rights violations of psychiatric patients are routinely reported in most countries, and include physical restraint, seclusion and denial of basic needs and privacy. Many people with mental health problems are reluctant to seek health care for fear of being admitted and treated in mental health facilities against their will. Users and survivors of mental health care services often feel patronized and humiliated by mental health professionals; they often do not receive information about their condition and are assumed to be unable to take responsibility for their lives or make decisions.

General health care:

People with mental health problems often have increased rates of physical illness compared with the general population. They are more likely to have major health problems, such as obesity, high blood pressure and diabetes. People with schizophrenia have been shown to have higher morbidity and mortality rates from cardiovascular disease than the general population and also have higher than expected rates of infectious diseases, respiratory diseases, some forms of cancer and HIV infection. The reasons for this may include factors related to the specific mental health problem (including the effects of medication), health behaviours such as smoking and physical inactivity, and the health system.

Reduced access to health care for people with mental health problems is a global phenomenon and results in increased likelihood of significant health risks and major health problems. The reasons for limited access to health care are complex but include social deprivation, difficulties with physical access, under-diagnosis of physical illness, unmonitored treatment, and poor organization of health services.

Recovery is a concept that has emerged from people who have first-hand experience of mental health problems. There is no universal definition of recovery, as it is a personal process that has different meanings for different people. While many health professionals consider “recovery” to mean “cure”, the concept of recovery goes beyond this and considers all aspects of functioning. Recovery is a process of personal growth and transformation beyond suffering and exclusion – it is an empowering process emphasizing people’s strengths and capabilities for living full and satisfying lives. Recovery may be described by people with mental health problems as enjoying the pleasures life has to offer, pursuing personal dreams and goals, developing rewarding relationships, learning to cope with mental health problems despite symptoms or setbacks, reducing relapses, becoming free of symptoms, staying out of hospital, or getting a job.

Learn about how a one family’s lives were changed through the help of CBR.

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Radhakrishnan is a 48 years old man from Sulthan Bathery Panchayat in Wayanad, Kerala.  He is married and has two children, a boy and a girl. 

A period of agony

Radhakrishnan was a paranoid schizophrenic but his family did not understand much about it and did not disclose it to others. He was very suspicious about everything. His wife Saraswathi came to know about his illness only after she became pregnant. She was the only breadwinner in the family and earned income by making pappad. Radhakrishnan stopped her from doing this work and exhibited aggressive behaviour. His family admitted him in a psychiatric hospital, but there was no visible change in him. They then tried witchcraft but that too did not work. The family members persuaded him to go to Shabrimala temple in Kerala, but he went missing and did not return home.  

In transition

In the year 2006 the CBR team of Shreyas learned about Radhakrishnan and helped the family to find him. They found him wandering near the temple and brought him back home. The CBR team gave counselling and other psychological support to his family. He stayed with the family but his suspicious behaviour continued.  In 2007 he was enrolled in the District Mental Health Programme and got medicine and counselling through them. The CBR workers through follow up visits ensured that he took the medicines regularly. As a result there was a tremendous change in his life. 

Radhakrishnan and his wife joined the nearest DPO called Navajyothi. A mental health awareness programme offered to the family members, neighbours and members of the DPO brought a positive outlook among them. Shreyas gave financial support to the family to make pappad and to get a regular income. Saraswathi plays the major role in this business and Radhakrishnan supports her. 

All is well now

Radhakrishnan and his family are leading a normal life now. He takes medicines regularly and his family members, DPOs, and the neighbours support him. The family now has a regular income and they also got assistance for house construction. His wife is active in the Caregivers group and supports her husband in his recovery.  

Children and adolescents

Like adults, children and adolescents also experience mental health problems, but their problems are widely neglected and/or are often wrongly diagnosed as an intellectual impairment. Approximately 20% of the world’s children and adolescents are estimated to have mental health problems, with similar types of problems reported across cultures. The lack of attention to child and adolescent mental health may have lifelong consequences.

The mental health status of children and adolescents is influenced by their family and their social and cultural environment. Experience of poverty, violence, physical and sexual abuse, neglect and lack of stimulation may all have an impact. There is evidence for a link between a mother’s mental health and the cognitive, social and emotional development of her child. Children who care for parents with mental health problems are also vulnerable, as they may not receive adequate attention and care and, in contrast, often assume a level of responsibility for their parents that is beyond their capacity.

While it is important to address mental health problems in children and adolescents, care must be taken not to over-diagnose and apply psychiatric labels to problems that are associated with normal living and development during this period, as this can have negative consequences for both children and families. In addition, children with mental health problems rarely need medications apart from the cases of epilepsy, and it is important not to over-medicate and to instead, focus on family dynamics and stressors.

Gender

Although the overall prevalence of mental health problems is similar between men and women, there are gender differences when considering specific problems:

• Women are more likely to experience common mental health problems, such as anxiety and depression.
• Men are more likely to develop alcohol dependence and be successful in any suicide attempts.

There are gender-specific risk factors for common mental health problems that disproportionately affect women:

• In many societies, women have lower social status than men, which may lead to several factors that contribute to depriving them of necessary coping skills:
  • Submissive behaviour
  • Feelings of inferiority
  • Low self-esteem
  • Helplessness
• Women generally have less of several resources, including:
  • Power (as compared with men)
  • Access to resources
  • Control of their lives
• Gender-based physical and sexual violence against women leads to humiliation, subordination and feelings of being trapped.
• Sexual abuse is quite common for women with mental health problems.
• Women experience greater discrimination than men in their interaction with health services.

Crisis situations

In the aftermath of crisis situations, the mental health needs of survivors need to be considered, as the experience of war and other major disasters is associated with increase in mental health problems. Often, existing resources are insufficient and the time needed for coping with severely traumatizing events is underestimated. People with mental health problems related to trauma may need nonintrusive emotional support, education and encouragement of positive ways of coping.

Some groups, such as people with disabilities, including those with pre-existing mental health problems, are more at risk of developing social and/or psychological problems following crisis situations. People with mental health problems may not seek support during crisis situations owing to isolation, stigma, fear, self-neglect, disability or poor access. Social supports that previously sustained them may have been lost as a direct result of the crisis, or they may be at increased risk of abandonment by families stressed by the additional burden of care. In addition, the interruption of medicine supplies for those with chronic mental health problems who need long-term medicines can result in an increased risk of relapse, particularly during such a stressful time.

It is important that CBR programmes focus on people with mental health problems during crisis situations, as without special attention they may be neglected or forgotten. For more information, see CBR and humanitarian crises.