– primary-care doctors to assist with mental health screening

OVER 200 primary-care doctors have been trained to effectively screen, recognise and manage conditions that contribute to mental health disorders, according to Director of the Mental Health Unit, Dr Util Richmond-Thomas.

Consistent with trends in the developing world, mental health issues have previously not been prioritised, and there have been limited financial and human resources in Guyana to adequately tackle the problem.

However, in an exclusive interview with the Guyana Chronicle, the mental health director said the primary-care doctors were taught to recognise and manage depression.
They were educated to deal with stigma and discrimination, psychosis, dementia, alcohol and substance abuse, manage epilepsy, child and adolescent mental health disorders, amongst others.

Dr Richmond-Thomas explained that the Pan American Health Organization and the World Health Organization (PAHO/WHO) had initially trained 25 trainers and created training manuals with algorithms to ensure that the process is adopted with ease, while some nurses were also trained. Training is also set to commence this week with medical practitioners in Region One.

ADDRESSING STIGMA
As a result of such training, she said many hospitals and health centres now do not segregate persons who are suffering from mental health problems, but they are treated and receive their medication with everyone else in order to reduce instances of stigma.
“No one can point their finger and say someone is a psychiatric patient; they can mix with the general population of patients and receive their care, and this eases the stigma,” Dr. Richmond-Thomas noted.

Although people may interact with mentally ill persons on the roads on a daily basis, the mental health official noted that only three per cent of the cases actually can be considered violent. This category includes street dwellers who are known substance abusers.
“These persons take longer to get well as long as they are on the substance, whether alcohol or illegal drugs. These are the ones who are more likely to be aggressive,” she explained.

Further, she said that about 20 percent of the population at any one time suffers from mental illness, since it is common.

TREATABLE AND INEXPENSIVE
The mental health director explained that the majority of mental illnesses are treatable and difficult cases are directed to a specialist.

She said that treatment is not expensive and if persons visit the public institutions, it will be prescribed for free.

PREVENTING SUICIDE

One of the major mental health issues that bedevil Guyana is suicide, since a life lost to suicide negatively affects the society and economy. Statistics reveal that for every suicide in Guyana, there are approximately 20 to 25 attempted suicides.

In a 2014 report by the World Health Organization, Guyana was cited as the country with the highest suicide rate in the world — 44.2 suicides per 100,000 deaths, four times the global average.

World Suicide Prevention Day (WSPD) was observed on September 10.
However, according to the mental health director, through much work and effort and collaboration with agencies, that number has been reduced to 24 suicides per 100,000 deaths, currently.

Research suggests that suicide is linked to factors such as mental and physical health and social and economic well-being. In the case of Guyana, deep rural poverty, alcohol abuse, lack of access to mental health services, and easy access to deadly pesticides are the leading causes of suicide deaths, according to the World Health Organisation.
But for Govin Munswami, a 31-year-old teacher who speaks out against suicide in his rural community of Black Bush Polder, Corentyne, Berbice, children and adults need to express their emotions and discuss their personal issues with family members, friends and teachers in order to better cope with difficult situations.

Both Munswami’s wife Amanda and mother Yvonne died as a result of suicide. He, almost a victim, overcame after his wife on her deathbed made him promise to finish his degree in education last year.

In February 2016, Govin Munswami contemplated ending his life. He had just returned to his family farm after visiting his wife, Amanda, in the hospital.

The previous day, she had attempted suicide. He sat by her hospital bed for one week as she slowly slipped away. During that time, she asked for forgiveness and apologised. She related that it was a mistake and could not fully comprehend the reason behind her action.
Prior to this, Munswami’s mother also took her own life after a heated argument with his father. Subsequently, Munswami’s father succumbed to a heart attack the following day.
When he questioned his mother before she succumbed, Munswami related that she acted on impulse out of despair and anger.

With such tremendous heartache over a one-year period, Munswami also felt compelled to follow that path. But, he recalled the promise he made to his wife and that gave him the strength to persevere into a brighter future, where he is now seeking to help and educate others to live the best life they could.

BRINGING MENTAL HEALTH SERVICES TO COMMUNITIES
Senior Psychologist at the Mental Health Unit, Ministry of Public Health, Dr Balogun Osunbiyi, said bringing mental health services to patients within their communities is cheaper and more effective than having them visit central hospitals.

In an exclusive interview with this publication, he said scores of doctors and medical practitioners throughout the country have now been trained to make this happen.

“It not only makes sense in terms of access to service and delivery of that service, but it makes sense also because a lot of times people don’t come to the hospital or the health centre for treatment. It is now a case where one has to go to the community rather than wait for the community to come to us,” Dr Osunbiyi noted.

Underscoring that community-based mental health is more feasible, Dr Osunbiyi said it is less burdensome to the budget to go to the communities to perform preventative mental health care, rather than wait for persons to come, after having a challenge and then curative health care, which is more costly would need to be taken.

Sharing his perspective on suicide, the senior psychologist explained that early identification and effective management are key to ensuring that people receive the care they need.

Adding that there are two important aspects to prevention, he said one is understanding the factors associated with suicidal thinking/ideation with a view to reducing distress.
Secondly, he said, in order to reduce the likelihood of a suicide attempt or death by such act, there is a psychological process underlying and each aspect of interventions must be tailored in order to specifically target and prevent the progression to suicide attempts.
He explained that current training is part of a Mental Health GAP Action Programme (mhGAP), which offers a non-specialist programme providing a lower-level psychiatric education. This started in 2017 and another programme called PM Plus has been rolled out, targeting community and religious leaders to deal with mental health issues.

Minister of Public Health, Volda Lawrence, who is in full support of such initiatives, believes mental health patients should preferably access services on an outpatient basis, rather than being admitted to a psychiatric facility, because in many cases, they are afraid of the discrimination attached to seeking help in that manner.

Junior Public Health Minister Dr Karen Cummings, had pointed to the multidisciplinary team which was formed by President David Granger to address the issue.

The Ministries of Education, Social Protection, Agriculture, Indigenous Communities and Public Security make up the National Task Force which covers four strategic areas: (1) Risk Factors Reduction, Health Promotion and Prevention; (2) Reduction of Access to the Means of Suicide; (3) Health Systems response to Suicide Behaviour; and (4) Surveillance and Research.

EACH LIFE IS VALUABLE
Meanwhile, former Managing-Director of the Guyana Foundation, Anthony Autar, said suicide-prevention work proceeds from the basic premise that every human life is valuable.
He explained that a big part of this work involves crisis support to individuals who are already in significant distress – by being present for them, listening non-judgmentally, gently letting them know that they are not alone, removing access to poisonous chemicals and other tools they could use to attempt to harm themselves, etc.

“Each life saved is something we should be grateful for, something to celebrate, so I do not want to overlook the dedication of selfless individuals – in government, and in the private sphere – who are doing amazing things to help people in difficult situations,” he said.

DECRIMINALISING SUICIDE
However, Autar highlighted several areas that he is still concerned about when it comes to suicide prevention and the mental health system.

“I worry about whether we are serious about suicide prevention because our leaders are aware of the need to decriminalise suicide; they have the power and the means to do so, some of them have acknowledged the importance of decriminalisation, and yet, the law remains on the books,” Autar, who is also a U.S.-licensed lawyer who is passionate about mental health advocacy, said.

He continued: “I am baffled by the sloth in getting this law repealed. Perhaps it is not an important issue, because our leaders are distracted, and do not realise that the people of Guyana are its most valuable resource.”

He reflected that there is only one piece of mental health legislation in Guyana – The Mental Hospital Ordinance of 1930. This legislation is extremely outdated, and refers to an individual with mental illness as a “person of unsound mind.” That term is defined as “an idiot or a person who is suffering from mental derangement.”

As in other countries, he said death by suicide in Guyana results from a series of complex, interrelated personal, social, psychological, cultural, biological and environmental factors.
Some of the contributing factors he listed, include: Poor coping skills leading to difficulty handling life challenges; a history of trauma and violence in its various manifestations – physical, sexual, psychological etc; a history of abuse and isolation; Harmful alcohol use/drug abuse; an underlying mental illness — most commonly, depression — which is often undetected in Guyana because of the lack of education about mental illnesses; a culture that can be extremely judgmental — shame/blame.

Adding that failures within the mental health system also play a significant, maybe an outsized role, Autar said there are insufficient resources allocated to the sector, few trained mental health professionals, and large sections of the population that have limited access to basic mental health services.
“Extremely limited aftercare services are available for individuals who have attempted, but not completed suicide…So we have a convergence of factors, socio-economic, psychological, cultural, biological and environmental stressors that push people along the path of suicidality,” he noted.

He said if Guyana is to make a meaningful impact on reducing the large number of deaths by suicide, society needs to stop and observe what is happening to people.

“Stressors contribute to overall poor mental health, and in the absence of a robust mental health system, sometimes result in a downward spiral for affected individuals,” he noted.
“There are links between some forms of mental illness, though not all, and suicidal ideation. And improving one’s mental health, and mental well-being, is crucial to helping someone struggling with thoughts of self-harm. So any discussion of suicide must necessarily include discussion of mental health,” Autar said.

Meanwhile, on the topic of self-harm, Director of the Mental Health Unit, Dr Util Richmond-Thomas, explained that due to the alarming number of self-harm cases, a decision was taken to launch “The National Self-Harm Surveillance” project last year.

The doctor said self-harming cases are also known as non-suicidal self-injury. The National Self- Harm Surveillance project is on in Regions Two, Three and Six, since these regions attracted the most cases.

She explained that initial social workers dispatched to these regions have made a tremendous impact, since home visits are also carried out and there has been a significant reduction in suicide cases.

Adding that Region Two still has the highest number of cases, she explained that the reason for that is because there is no social worker there currently, and no psychiatrist as well.

“Self-harm is the strongest indicator of future suicide,” Dr Richmond-Thomas stated. She further explained that many persons who commit suicide would have had several incidents of self-harm in their past, “It means therefore that if the self-harm was being treated while it was occurring, it may not have led to suicide.”

The programme director explained that the National Self-Harm Surveillance project will work. All cases of self-harm must be reported to the Mental Health Unit within one week of presentation. Once reported, persons will then have to see a psychiatrist or mhGAP doctor. There are scores of mhGAP doctors locally.

Each case will receive psychotherapy by a psychologist and then followed up by a social worker until they are no longer high-risk patients.

The unit will also be implementing a self-harm screening tool, which is a questionnaire. The questionnaire will aid in the fight against suicide. The screening tool is being used in all major hospitals and health centres.

Further, it was explained that The National Self-Harm Surveillance follows closely on the heels of the mhGAP Intervention Guide (mental health GAP-IG) programme which is part of Guyana’s National Mental Health Action plan, 2015-2020.

Also, it is the intention to train school teachers how to identify a child who is having mental health distress. There will also be a mental health focal point in schools.

In addition, she explained from 2017 there is a list of all cases of suicide and social workers continue their family visits methodically and the entire family is assessed.

Anand Boodram, the Executive-Director of The Caribbean Voice (TCV) said over 90 per cent of the people who die by suicide have a mental illness at the time of their death, so they would not have been thinking clearly or logically.

“Suicide is a decision made out of desperation, hopelessness, isolation and loneliness. The black hole that is clinical depression is all-consuming. Feeling like a burden to loved ones, feeling like there is no way out, feeling trapped and feeling isolated, are all common among people who suffer from depression,” he said.

He explained that as loved ones of suicide victims, as suicide survivors, as suicide- prevention activists, and as clinical psychologists and counsellors, various members of The Caribbean Voice know through experience that suicide survivors had experienced mental health issues that affected their thinking process.

According to Ministry of Public Security records, approximately 70 percent of the country’s suicides occur in rural regions, since in these communities many people turn to alcohol and self-harm to cope with feelings of hopelessness, poverty and economic despair.

A Pan American Health Organization (PAHO) study done in 2010 reported nearly 80 per cent of Guyanese adolescents had their first drink before the age of 14, and some children try alcohol for the first time in elementary school. And while the relationship between alcohol and suicide is vastly under-researched, studies suggest that alcohol-use disorder is a likely contributor to suicidal thoughts and attempts.

The suicide hotline numbers are [592] – 223-0001, 223-0009 and 623-4444. The toll free number [600-4444] and 623-4444 are also active Whatsapp numbers that persons in need of counselling can access.