SPECIAL PAPER Stressors and mental in : current situation and future hopes Faruq Alam,1 Rubina Hossain,1 Helal Uddin Ahmed,1 Mohammad Tariqul Alam,1 Mekhala Sarkar1 and Uriel Halbreich2

1National Institute of Mental 89% are Muslims, 10% are Hindu and 1% others; Health, , Bangladesh Bangladesh is a densely populated emerging 38.2% of the population is urban; and migration 2School of Medicine and Bio- country in South Asia. Since its harsh from rural areas to urban centres is substantial Medical Sciences, State University independence war, it has suffered from of New York At Buffalo, USA. and causes congestion and rapid construction. repeated floods and other natural and man- Email: [email protected] In the capital, Dhaka, the population is 21 million inflicted disasters. Internal migration from people and growing.2 The GDP per capita is Keywords. Adjustment disorders; rural areas to the urban centres has increased post-traumatic disorder; $4200, which indicates that Bangladesh is a trauma; transcultural psychiatry; crowdedness, pollution and social conflicts. lower middle-income economy.3 Life expectancy stress. Furthermore, in recent years, the country has is 74.2 years (133rd in the world), the maternal absorbed close to a million refugees from First received 15 May 2020 mortality rate is 173 per 100 000 live births and Final revision 24 Sep 2020 Myanmar. These stressors have been mortality is 28.3 per 1000 live births.2 Accepted 7 Oct 2020 associated with an increase in mental There are only 0.53 physicians and 0.8 hos- disorders and symptoms with which the doi:10.1192/bji.2020.57 pital beds per 1000 population. In rural districts, country is struggling. Lack of resources and a ‘village doctors’ with no formal training provide © The Authors 2020. This is an shortage of human capital have weakened the 65% of healthcare. Open Access article, distributed national capacity to efficiently respond to under the terms of the Creative Modern mental healthcare in Bangladesh is Commons Attribution- situational stressors or disasters. For deficient owing to limited human and financial NonCommercial-NoDerivatives assessment of stress-related mental health licence (http://creativecommons. resources. Only 220 psychiatrists and about 50 org/licenses/by-nc-nd/4.0/), which issues, information available from the Ministry trained clinical psychologists serve the whole permits non-commercial re-use, of Health and the National Institute of Mental distribution, and reproduction in nation.1 According to the World Health Health was collected and supplemented by any medium, provided the ori- Organization (WHO) Assessment Instrument for ginal work is unaltered and is external reports. It is promising that the properly cited. The written per- Mental Health Systems, in 2007 the total number government’s approach of responding to mission of Cambridge University of workers in mental health facilities was 0.49 per Press must be obtained for com- mental health needs only after the occurrence mercial re-use or in order to cre- 100 000 population, among which 0.073 were of a crisis has recently been replaced by the ate a derivative work. psychiatrists, 0.196 psychiatric nurses, 0.007 psy- concept of total management through chologists, 0.002 social workers, 0.003 occupa- primary healthcare. There is a need for tional therapists and 0.029 other health workers development of adequate infrastructure, (including auxiliary staff, non-doctor healthcare logistics and workforce support, as well as workers, medical assistants, and professional and establishment of multidisciplinary teams of paraprofessional psychosocial counsellors) per management and clinical services. 100 000 population.4 Although the number of Collaboration of all related sectors of the mental health professionals has increased since government and an overall increase in then, the population has proliferated even faster. government funding for mental health are The budget allocated for the mental health sector essential. is only 0.44 percent of the total budget.4 There is only one national institute, the National Institute of Mental Health (NIMH) in Dhaka, with post- graduate training, 200 in-patient beds and an out- Background patient service. There is one mental hospital in Bangladesh is a developing nation in South-East Pabna (the northern part of Bangladesh) with Asia that became a separate political and eco- 500 beds.2 There are 50 out-patient mental health nomic entity only 50 years ago. It was a part of facilities, 31 community-based psychiatric the British Raj and then pre-Independence in-patient units and 11 community residential until 1947, when it became an eastern prov- facilities. There are no facilities for follow-up ince of Pakistan. Following its ‘Great Liberation care in the community and no day treatment War’ in 1971, the country became independent mental health facilities in the entire country.4 and was named Bangladesh.1 Covering 147 570 The country is struggling with repeated disas- square kilometres on the Bay of , it borders ters, which have been demonstrated to negatively India and Myanmar. The population of affect mental health. Considering the limited Bangladesh is roughly 163 million. The country resources and shortage of human capital needed has one of the highest population densities in to efficiently respond to continuous stressors the world, at 1102 people per square kilometre: and disasters, current national capacity is limited.

BJPSYCH INTERNATIONAL page 1 of 4 2020 1 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 18:17:05, subject to the Cambridge Core terms of use. The aim of the current report is the assessment of connection with social support, information on the situation of stress-related mental health ser- coping and linkage with collaborative services. vices in the country in order to assist in proper Hypnotics and anxiolytics (e.g. clonazepam, initiatives to improve mental health and pre- diazepam, propranolol and sertraline) were also paredness for future anticipated stressful given for a short time. situations. Pertinent data were collected from the Mental health of refugees Ministry of Health and the Dhaka NIMH by elec- Since 2017, Bangladesh has absorbed 915 000 tronic searches of their databases supplemented refugees from neighbouring Myanmar; most of by manual searches. them are Muslim Rohingya. An assessment of fl the refugees from Myanmar by the UN High Major natural and man-in icted disasters Commissioner of Refugees indicated that many According to a government report,5 in a sample of them were experiencing acute stress reactions, of 10 years (1988–1998), fatal natural acute disas- grief reactions, adaptive stress reactions, post- ters occurred almost annually. This included mul- traumatic stress symptoms, and feelings of rejec- tiple, consistently almost annual, floods that from tion and sadness.10 Mental health was integrated 1988 to 1998 cost over 1000 lives. Fatalities from within basic health services for the refugees cyclones in 1988, 1991 and 1997 were 5704, from Myanmar according to the WHO Mental 138 868 and 550, respectively. In 1989, 800 peo- Health Gap Action Programme (mhGAP) guide- ple died from drought, and a 1996 tornado lines, particularly the humanitarian version. caused 545 deaths. Tsunami is considered to be Primary healthcare (PHC) providers have been a new threat. In a recent one there were several trained with mhGAP methods. Cases of severe fatalities. mental disorders are referred to nearby district Poverty and population congestion contribute hospitals, which were recently enhanced with psy- to building collapses, fires, and road and river chiatrists and psychologists. The vulnerable refu- traffic accidents.5 Violence at various levels is gee population adds to the strain on the almost a daily occurrence. professional services that especially in rural areas The independence war of Bangladesh in 1971 are limited. This causes resentment among the left many people dead, injured, homeless and local residents, who perceive the refugees as com- mentally traumatised. It is of note that more petitors for limited economical and public services than half of the injured freedom fighters resources. (51.6%) had subsequent mental disorders; 31.3% of them developed post-traumatic stress disorder Bangladeshi immigrants abroad and (PTSD) and 76.77% were diagnosed with major their effects on the native country depressive disorder (MDD).6 Unemployment and under-employment have A UNICEF-supported survey of victims of a caused extensive migration of labourers to other violent tornado in Bangladesh in 1996 revealed countries, mostly to the Middle East.2 However, that 66.6% were ‘psychologically traumatised’ have migrated to the USA and the and required emergency psychological services.7 UK since the 1950s and constitute significant On average, women were more psychologically minority communities there. affected than men. Eighty per cent of the victims Most of the Bangladeshi immigrants living below 12 years old also needed such services. abroad leave their families behind in the native The prevalence of mental disorders among child land. Frequently, they send some of their earn- and adolescent victims following the 2007 ings back home, thus contributing to the local Bangladesh cyclone Sidr was 48.1%. Common economy. However, their detachment from their mental disorders included separation anxiety dis- families result in difficulties for them as well as order, specific phobias, social phobia, panic attacks for their families. Immigrant labourers frequently or agoraphobia, PTSD and MDD.8 Psychosocial visit Bangladesh for short periods, and some seek support was provided to the cyclone victims by mental health interventions during their visits. the Dhaka NIMH and the Bangladesh Association Often, families suffer acute stress reactions upon of Psychiatrists in collaboration with the WHO their departure. The magnitude and severity of and other non-governmental organisations. these stressors is still awaiting a systematic investi- An NIMH WHO-supported study of the vic- gation, but the additional workload on local tims of the collapse of a nine-storey building in health services is apparent. 2013 found that 26% were suffering from PTSD, Bangladeshi immigrants to the UK were a 12% from acute stress disorder, 11% from sleep focus of a study of patients of King’s Cross and disorders and 4% from panic attacks.9 Regent’s Park community mental health team in Psychological first aid (PFA) was provided to the 2001. The main diagnoses were schizophrenia affected individuals with the support of the (51.8%), depression (22.2%) and bipolar affective WHO, following the standard international field disorder (7.4%).11 Somatisation is a major issue operation guide for PFA. The principal compo- among people of Asian communities. Common nents included contact and engagement, safety socioeconomic factors contributing to psychiatric and comfort, stabilisation, information-gathering, morbidity among immigrants in Britain include current needs and concerns, practical assistance, low income, unemployment, housing problems,

2 BJPSYCH INTERNATIONAL page 2 of 4 2020 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 18:17:05, subject to the Cambridge Core terms of use. language difficulties, isolation, and family stress need for adequate resources, enhanced human including strained relationships with children, as capital and recognition of the importance of a well as gender issues. Women complained of comprehensive integration of all aspects of well- high stress due to a lack of integration with society being, as well as establishment of functioning and experiencing racism.11 partnerships for well-being.13 As is the case in The mental health of Bangladeshi transient many countries, Bangladesh does not have migrants in the Persian Gulf countries is of con- enough psychiatrists to fulfil its needs. Young cern. There have been media reports that at medical graduates need incentives to take psychi- times of population needs, these migrants did atric residencies, and primary care providers not receive the same support as citizens. Most need to be proficient in recognising mental symp- are single men and women who may need mental toms and giving basic treatment. There is also a rehabilitation upon their return home, a fact that challenge in involving traditional healers, ‘village causes an additional strain on , doctors’, nurses and other healthcare providers which the government is attempting to solve. in the management of mental well-being issues. Interdisciplinary teams for well-being should be Recent developments evolved to improve healthcare capacity. Their The approach of responding to needs only after implementation requires outside assistance and the occurrence of a disaster or crisis has been budgeting. This assistance has been partially replaced in Bangladesh by the concept of total available during crises and should be activated disaster management involving prevention and for preventive and routine operations. mitigation, preparedness, response, recovery and development. The government of Conclusion Bangladesh has expressed total commitment to Assessment of stressors and mental health issues reduction of the human, economic and environ- in Bangladesh illuminates gaps in knowledge mental costs of disasters by enhancing the overall and services in stress-related mental health. disaster management capacity. Post-disaster men- Some progress has been achieved by replacing tal health is included in this programme. The the approach of responding to mental health government has established one-stop crisis centres needs only after the occurrence of a crisis by a at various hospitals and locations in the country, concept of total management through a PHC with a proper referral system for victims of approach. Further development of infrastructure, abuse. They have also made special arrangements improving logistics, and enhancing workforce for taking care of female workers returning from support and training have been planned. abroad with a history of abuse and exploitation. Multidisciplinary teams for planning and imple- Several mental disorders have been included mentation of services, as well as collaboration ’ fi in the government sde nitions of disabilities fol- with other related sectors of government, are lowed by allocation of funding. The Mental essential elements for success. Owing to current Health Act, Bangladesh, 2018, contributes to the deficient resources, support from national and development of mental health services, including international agencies is needed. disaster- and stress-related mental health.12 The goal of the government is to integrate mental Funding health services in PHC and thus provide cultur- None. ally sensitive cost-effective services even during periods of crisis. No Essential Service Package of Author contributions ’ fi the government s health sector is speci ed for All co-authors contributed to ideas and data. The article was people with mental illnesses. The government’s initiated by U.H. who outlined and finalized it. R.H. pursued the safety net programme covers a portion of indivi- work under close supervision of the local co-authors. The group duals with neurodevelopmental disorders and is currently working on the ramifications of this article. some patients with chronic mental illness such as schizophrenia, but support to persons with men- tal illness living at home is still in planning. Declaration of interest The Ministry of Relief and Disaster has devel- ICMJE forms are in the supplementary material, available online oped its own policy and programme for disaster at https://doi.org/10.1192/bji.2020.57. management, including a mental health policy and strategic planning in anticipation of, during and following a disaster. References 1 Rabbani G, Ahmed H, Desai G, Bhugra D. The Bangladesh Need to improve capacity of mental perspective. In: Routledge Handbook of Psychiatry in Asia (ed D health providers and services Bhugra). Routledge, 2015. The Bangladeshi government shows sensitivity 2 Central Intelligence Agency, USA. The World Factbook. 2020. ’ towards people s physical and mental health 3 . Economy of Bangladesh. 2020 needs. Several mental disorders have been (https://en.wikipedia.org/wiki/Economy_of_Bangladesh). included in government definitions of disabilities, fi 4 World Health Organization, Ministry of Health & Family with budgeting and funding rami cations. Welfare. WHO-AIMS Report on Mental Health System in However, for productive progress there is a Bangladesh. 2007.

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