Breaking stigma: The question of mental health reform

Of the 1.4 million Filipinos with disabilities identified in the 2010 National Census, 14 percent – or over 200,000 people – had mental disability. But, once shunned by their own families and communities, largely because of ignorance and prejudice, who will take care of them? What legal and financial resources does the state have to care for one of the most vulnerable sectors in our society?

We see them in our streets, unwashed, strangely aimless and focused at the same time. We pity them in their ragged clothes, their eyes hollow and cheeks gaunt, struggling from the weight of everything they own slung upon their backs. Often, we fear them because we don’t understand them, and because they can sometimes be unpredictable.

Psychotic vagrants, throughout our urban and rural centers, are as gravely misunderstood as they are widespread. Among many derogatory names, they have been called the taong grasa. Today, the stigma of mental illness in our culture remains pervasive. We often hear mental health insults like “Brenda” and “Abnoy” to describe politicians that apparently annoy the general public.

Such attitudes reveal a public view of mental health that is, to say the least, alarmingly simplistic. While mental health covers mental disability itself– which is the third most common disability in the entire country – it encompasses a far wider range of issues like alcoholism, drug abuse, depression, and even phobias.

The distinction between mental illness, on the one hand, and mental disability, on the other, is that the latter is a chronic condition that significantly limits a patient’s social functions altogether; in comparison, mental illness can still be treated on an outpatient basis and can often lead to considerable improvement.

In this country, acute mental disabilities like psychosis dominate the medical discourse on mental health. Two of our largest mental health facilities – the Sanctuary Center for psychotic female vagrants and the National Center for Mental Health (NCMH), both in Mandaluyong City – are devoted to the treatment and rehabilitation of people with varying degrees of mental disorder, but most of whom have psychosis or schizophrenia (which suggests they are potentially a threat to themselves and others, and are often out of touch with reality).

In fact, the mere mention of “Mandaluyong” often leads to jokes about one’s own mental state. This sense of levity and ridicule paints a stark contrast to the painful realities experienced by persons with (mental) disability (PWDs), for whom such conditions, more often than not, are a result of bio-chemical imbalances rather than moral “choices.”

Sanctuary

Inside the halls of Sanctuary, head social worker Margarita Ortega walks about like a proud mother – she knows exactly where each mess hall is, and calls each nurse by her personal nickname. Every now and then a patient grabs her hand for a mano – a traditional request for blessing.

Ortega, along with 34 others, runs this four-hectare facility of the Department of Social Welfare and Development (DSWD). They currently have 132 women in their care, all with various mental and learning disabilities. The long-term goal is to successfully integrate these women back into society by providing them with therapy sessions and livelihood training.

When not in training, the women are free to roam the compound. There is a gazebo in the front lawn where they lounge during sunny afternoons. Also a vegetable patch near the kitchen where they cultivate eggplants and ginger. At night, they huddle inside the shelter, where several hallways have now been converted into sleeping quarters. Each has an altar with a statue of Jesus or Mary standing guard even when Ortega and her team are no longer with them.

The calm is broken each time a woman goes amok. During such potentially violent moments, the women’s medical and psycho-social needs are particularly urgent, and Ortega’s team gets into business.

Never mind that the shelter continuously strains beyond its 100-bed capacity each passing day. “We can never reject referrals,” Ortega says. Even in the shadow of night, they take in abandoned women who have been brought to them by different local government units (LGUs) in Metro Manila and neighboring provinces.

National Center for Mental Health

Many of the referrals, of course, come from just blocks away–from the NCMH itself.

The 4,200-bed NCMH already comprises the bulk of the Department of Health’s (DOH) 5,465-bed capacity for mental disorders. The remaining 1,265 are distributed all over the country. Six regions – Ilocos, Calabarzon, Northern Mindanao, Davao, CARAGA, and ARMM – representing over 31 million people, do not have inpatient psychiatric facilities. Of all the country’s provinces, Cavite is the only one with a psychiatric facility.

Most cases of mental disability, therefore, are referred to the NCMH, which has the unique mandate of caring for and conducting research on Filipinos with mental disability.

The public rarely sees beyond the NCMH’s gates. Only workers and relatives of the hospital’s wards are allowed past the security guards. All others must secure a permit from the hospital administration to enter. Dr. Bernardino Vicente, NCMH’s indefatigable director, oversees the granting of permits – and a great deal more.

The 47-hectare NCMH serves an average of 56,000 outpatients a year. That’s on top of the 3,000 or so inpatients the NCMH shelters in its 35 pavilions at any given day. And yet the DOH can only allot a mere P150 per bed to the NCMH – P60 of which goes to food, P12 for medication, and the remaining P78 divided for utilities such as water, electricity, and fuel.

Perennial underfunding, of course, is the scourge of many of our public hospitals. Often, both Sanctuary and NCMH have had to resort to soliciting donations from the private sector even for the most basic supplies, like bathing soap.

It is no secret that the NCMH had been peddled for privatization as early as 1968. The ballooning number of patients, as well as the rising costs of operation, has put a strain on the country’s health spending. As Dr. Vicente asks, almost rhetorically: “Kikita ka ba sa mental? (Will you earn profit from running a mental hospital?)”

To centralize or to de-centralize?

But, ultimately, the problems seem to be more structural than financial. For one thing, the country lacks a comprehensive mental health law to address many of the country’s mental health needs.

This has been exacerbated by the fact that the Local Government Code of 1991 had devolved the provision of health care to LGUs. While this was meant to be a move against “imperial Manila” and to reflect the growing worldwide trend of decentralizing health care services – eventually advocated by the World Health Organization itself – it also implied that the task of implementing many of the DOH’s programs fell on LGU officials, many of whom lacked training and expertise, particularly in the area of mental health.

In 2001, then-DOH Secretary Manuel Dayrit drafted a national mental health policy, broadly outlining the goals of mental health care in the country. The National Objectives for Health: 2005-2010, following the WHO, specified strategies for reform from an “institutionally-based mental health system” to one that was more “consumer-focused.”

But it was only in 2007 that Congressman Prospero Nograles would file House Bill 6679, which sought to transfer the administration of mental health services from NCMH to a “Philippine Council for Mental Health.” Though the Council could hypothetically be attached to the DOH, it would also be composed of representatives from the academe and the private sector, not all of whom were necessarily answerable to DOH.

The bill, in calling for a more community-based approach to mental health care, suggested that budgetary and legal power should be slowly taken away from DOH and NCMH altogether. Perhaps because of its lack of inclusivity vis-à-vis critical stakeholders in the mental health field, the bill was eventually scuttled due to lack of support.

Vicente himself doubts just how ready barangay health centers currently are to care for people with mental disabilities. “Many doctors in our communities do not know how to treat the mentally ill,” he explains. “Meron dyan, pangatlong suicide na, hindi pa nire-refer sa psychiatrist (In some cases, they still don’t refer a patient to a psychiatrist even if it’s already their third suicide attempt).”

Vicente adds that, in many provincial hospitals and rural health clinics, there are no available positions for psychiatrists whatsoever.

Today, there are fewer than 500 certified psychiatrists in the country, 91 of them already employed by the NCMH. This means that there is less than one psychiatrist for every 150,000 Filipinos.

The solution, Lopez thinks, is not an either-or, mutually exclusive response to the question of centralization versus de-centralization. She advocates striking a balance between a centralized mental health facility with expertise in dealing with advanced cases, on the one hand, and community health centers, which can help decongest centralized hospitals and provide patients with community support, on the other. She further recommends the creation of different types of inpatient and outpatient mental health facilities that will cater to patients with varying degrees of mental illness.

Natural disasters

These problems, as you can well imagine, are further exacerbated by natural disasters. Lopez, who has recently been elected to the United Nations Subcommittee on the Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, is also the lead convenor of the Citizens’ Network for Psychosocial Response to Disasters (CNETPSR)—a broad coalition of more than 20 organizations seeking to institutionalize psychosocial services in times of disasters and calamities.

“Complex emergencies are often part of our everyday lives,” Lopez says, highlighting the fact that people in affected areas need psychosocial services just as much as they need food or medicine. The CNETPSR was among the many collective NGOs who flew to Tacloban in the aftermath of supertyphoon Yolanda to provide counseling and debriefing not only to victims but to health and social workers themselves.

NGOs like the Philippine Mental Health Association (PMHA) can also help fill these gaps. In 2012, the PMHA pioneered a tele-psychiatry program, where general practitioners in the provinces were able to consult, via video conferencing, with psychiatrists in Manila to prescribe psychiatric medication for their patients.

The absence of a law

Despite such laudable initiatives, Lopez stresses that it is still critical that a comprehensive mental health law be crafted in this country, particularly since the Philippines is a signatory to the Convention of the Rights of Persons with Disabilities (CRPD). At the moment, the country is also governed by laws with different goals, like the Penal Code, Magna Carta for PWDs, Family Code, and the Dangerous Drugs Act.

Similarly, mental health patients can be found in any number of government facilities covering very distinct mandates. For instance, the Sanctuary is run by DSWD, while the NCMH is run by the DOH. This has resulted in a mental health care system that can be disjointed and often inaccessible to those with little knowledge of psychiatry.

On the upside, the current national mental health program is already being revamped. Dr. Jasmine Peralta, who oversees the DOH’s program on the treatment and prevention of dangerous drugs, admits that mental health has not always been given budgetary priority.

“That, and the lack of law, are limiting factors kung bakit ‘di tayo makalipad (That and the lack of a comprehensive law are limiting factors that may explain why the mental health program still remains unable to take off),” Peralta adds.

Consultations and assessment are under way, however. Among the more critical options being studied is the establishment of rehabilitation centers at the regional level, to solve the problem of small municipalities that refuse to consider mental health important enough to invest in.

Medical requirements

Vicente believes that the impasse on the mental health law is ultimately a reflection of medical education in the country. Even within the medical community, he notes, many look down upon psychiatry as a field of practice.

In the current curriculum, students of medicine are required to take no more than one hour of psychiatry and psychopharmacology. The grueling physician licensure exams ask a total of only six questions – all of them multiple choice – about psychiatry. Despite this, most such questions tend to deal with psychosis alone, since that happens to be the mental disability most often requiring institutional incarceration. Unfortunately, this suggests that many Filipino psychiatrists are not always adequately trained to deal with depression, substance abuse or phobias.

“Psychiatry has to be given some credence,” Vicente says with a sigh. Despite these overwhelming odds, Vicente, Lopez and Peralta remain undeterred. They know what the problems are, and they quietly point to specific solutions. And they look forward to the day when their work will finally be recognized, supported and institutionalized – by no less than an actual law on mental health in this country. — KBK/HS, GMA News