260 million people and less than 1000 psychiatrists: Indonesia's mental health worker shortage
For its size, Indonesia has a severe shortage of mental health practitioners. The biggest economy in Southeast Asia, Indonesia has a population of 260,000 million but only 773 psychiatrists and 451 clinical psychologists.
In 2008, the Indonesian government recognised psychologists as health workers. But placement of a psychologist at a public health post, or Puskesmas, in Indonesia has not been considered crucial, in contrast to placements of doctors, nurses, midwives, nutritionists and sanitarians.
There are sporadic attempts to provide a psychologist in Puskesmas. The city of Yogyakarta, for example, has successfully placed a psychologist in all of its 18 Puskesmas since 2010. But no other cities or districts have similar policies.
Mental health disorders in Indonesia
Mental health disorders are often hidden from view. People often think of mental disorders with images of a naked homeless person in the street. But there is a wide spectrum of these problems.
There is a stigma around mental health problems. Among the general public this ranges from stereotyping and prejudice to discrimination against people with mental illness. People with mental health problems are often considered dangerous, possessed by demons or affected by black magic.
The resulting fears lead to the belief that they should be kept away from the communities. Consequently, in 2017, 28.1% of people with mental illness were still locked in or shackled in or around their house. Self stigma turns the sufferers against themselves, hindering them and their family from seeking help early and therefore preventing them from receiving proper treatment and care.
Victims of disasters are also very prone to mental health problems. With Indonesia being located in a region with high risks of earthquakes, tsunami and volcanic eruptions, a lot of people have been affected by disasters. They need psychological support to go through the difficult times of losing their loved ones, their belongings and the fear of future disasters.
Another mental health issue, rarely addressed in Indonesia, is peripartum depression, occurring during pregnancy and after delivery. The World Health Organisation (WHO) reports that in developing nations 15.6% of pregnant women and 19.8% of lactating women experience this condition.
Not only can depression lead to suicides but it also reduces mothers' ability to care for their children. Given that the country is focusing on efforts to reduce stunting, detecting peripartum depression and helping mothers seek treatment can help them raise healthy and smart children.
Mental health problems occur in people of all ages. Mental disorders are prevalent among youth, as this is the time when people face many different transitions in life. The WHO 2018 World Mental Health Day (October 10) recognised this by making this year's theme "Young People and Mental Health in The Changing World".
But mental problems also affect the middle-aged population. A national survey in 2013 showed that the proportion of mental and emotional problems increased with age. The problems are also common among the poor.
Training health cadres to detect depression in mothers
To help address mental health problems among mothers, we carried out a project called Kenal Ibu – loosely translated as Know Mothers – in Banyuwangi and Banda Aceh. The project attempts to help health cadres and midwives detect pregnant and lactating women with depression using adapted screening tools.
We developed training modules and trained 103 health workers in Banyuwangi and Banda Aceh, comprising health cadres, midwives and mental health nurses. After the training, health cadres were able to use the tools to detect women with problems and refer them to midwives or mental health nurses for further tests and counselling.
The village health cadres, the women in the village, said that learning about the screening tools and using them made them able to identify problems that they were unaware of in the past.
A midwife mentioned that she once had a patient, a new mother with behavioural problems, who wasn't able to feel love for her newborn baby. The midwife did not know how to help. She didn't know that her patient was suffering from depression. The scope of her work was only to make sure that the mothers and the children were physically healthy.
But after the training and field implementation the midwife can now identify women with potential problems. She's now able to put a name to the condition and know that these women need further help from professionals.
A recent study published in The Lancet by Nafsiah Mboi reported that the number of years people suffer ill health or disability (DALY) for non-communicable diseases including mental disorders has risen. DALY for depressive disorder rose 37.5% from 1990 to 2006 and continued to rise by 19.8% from 2006 to 2016. This makes mental disorder number 19 of the leading causes of disability in 2016, up from 29th in 1990.
To raise public awareness of mental health issues, the Ministry of Health has provided online content and an Android-based application Sehat Jiwa (Healthy Soul) that can be used for self-screening various mental health problems. The app has more than 1,000 users to date.
Screening tools are available to help health practitioners and individuals to detect mental health problems. But Indonesia still needs to refer those diagnosed with mental health problems for treatment.
It is estimated that 76-85% of people with mental disorders in low-income and middle-income countries receive no treatment. Globally, there are only nine mental health workers per 100,000 people. It is estimated Indonesia needs 7,500 mental health workers to provide sufficient psychiatric services for its population.
If Indonesia is serious about ensuring its population of 260 million people are healthy and resilient to disaster, the nation should start investing in mental health. It must work to ensure every community health post (Puskesmas) has trained staff to detect, treat and care for people with mental disorders.