Stigma, Shortages Plague Mental Health Care in Burma

By Tin Htet Paing 31 March 2016

RANGOON — Thant Zin experienced heart palpitations and severe chest pain for about an hour while alone in a hotel room, traveling for work; he had trouble breathing and felt like he was about to die. His first thought was that he was having a heart attack, before later realizing that it was, in fact, an anxiety attack.

Six months ago, Thant Zin, who is in his late 20s, suffered from an anxiety disorder and, for nearly a month, lived in a state of constant unease. After a succession of two anxiety attacks within the same month, he lost confidence in his professional ability. Worried about having another anxiety attack while working, Thant Zin quit his job to get treatment. He wanted regular counseling sessions with a psychiatrist or clinical psychologist to relieve his mental anguish.

He started looking for recommendations by asking his friends and searching online. It took him weeks to reach one. The reason, he explained, was not that Burma has few mental health professionals—although medical practitioners say that too is a problem—but rather that people in Burma don’t like to discuss their mental health, and the process of getting counseling treatment is unfamiliar to most Burmese.

“At first, I didn’t know where to look for recommendations about counseling treatment,” he told The Irrawaddy last month.

“I needed someone to talk to about all my problems—someone not from my family or my friends; someone who wouldn’t judge me over what I told him or her.”

After a week, he got a recommendation from a friend, the contact of a psychiatrist who could provide the counseling treatment he was seeking.

Unlike most Burmese, it wasn’t his first experience with a psychiatrist. Prior to his anxiety ordeal, he had seen three different ones over the last six years because he had also experienced depressive disorder in the past.

The last time he suffered from depression, he found himself struggling to adapt to normal societal routines. He was oversleeping and struggled to work up an appetite for about two weeks. He would isolate himself from others for days, keeping both family and friends at a distance.

“I felt totally lost and didn’t know how to make my life meaningful,” he recalled.

After shutting himself in his room for a week, his father eventually had to break into the room to get him out.

“My father had to physically drag me out of the room to go and see a psychiatrist,” Thant Zin told The Irrawaddy, describing the depths of his depression at the time.

It was thanks to this episode that Thant Zin knew to seek counseling immediately when he felt anxiety disorder last year, but he is part of only a small percentage of the country that knows when to seek psychiatric assistance.

“People here don’t have enough knowledge about mental health, and counseling is not a culture among most of them,” he said.

According to the estimate of psychiatrist Dr. Soe Min, who is general secretary of the Myanmar Mental Health Society, about 90 percent of individuals who suffer depressive disorder do not get any psychiatric treatment, for a number of different reasons and difficulties.

“Some of them aren’t even aware of themselves suffering depressive disorder,” Soe Min told The Irrawaddy via email.

“Others don’t have knowledge that depression needs to be treated while some might have difficulties in getting proper treatment,” he added.

Some patients don’t feel comfortable discussing their mental health with friends or family due to societal stigmatization or concerns of discrimination within their community, which remain major challenges in Burma, he said.

“In some cases, stigma could be more obvious in the work environment of patients.”

A former superintendent of Rangoon’s Mental Health Hospital, Dr. Kyi Soe told The Irrawaddy that patients with minor mental disorders can’t get treatment at the hospital and must seek psychiatric help from outside clinics. Given the extant stigma associated with mental health disorders, that can prove too tall a hurdle for most would-be patients.

“If someone is seeing a psychiatrist, people are ready to label him or her as a fool,” Kyi Soe said.

“That’s the main problem regarding mental health in our country.”

Soe Min explained that psychiatrists typically prescribe medications rather than counseling, the latter being a special field of clinical psychologists—a medical professional in short supply in Burma.

There are currently fewer than 10 clinical psychologists and just over 200 psychiatrists in Burma, a country of some 52 million people, according to Soe Min.

In Burma, problems with access to treatment are compounded by the disparate nature of the populace, which the 2014 census found to be 70 percent rural and living in more than 70,000 villages across the country.

Causes for Concern

Dr. Htay Oung, a psychiatrist who has been practicing in the country for more than 20 years, said depression is a common illness worldwide, and Burma is no exception. Most common causes of depression among adolescents in Burma are parent-child relationships, social pressures and an education system that places emphasis on exam-oriented success, he said. Ways of life, peer relations and social norms among younger generations are undergoing rapid change, he added.

In most cases, the extent to which parents are aware of their children’s psyches has a major impact on the latter’s mental health. The high demands that some parents put on their offspring can cause childhood depression with knock-on effects into adulthood, he said, underscoring the critical role that parenting plays in mentally healthy living.

Factors outside the home are also determinants, however. The World Health Organization (WHO) states: “[A] person’s mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities.”

The consequences of neglecting treatment, at worst, could be fatal, with the WHO noting a link between mental disorders, particularly depression, and suicide attempts.

“Each individual needs to have good mental health and should receive proper treatment when they suffer a mental disorder due to different causes,” Soe Min said.

Burma’s current health care system is woefully inadequate to the task of ensuring mental health patients receive treatment, Htay Oung said.

According to Health Ministry figures, there are two main psychiatric hospitals in Burma. Rangoon’s 1,200-bed Mental Health Hospital currently has over 1,500 patients cared for by about 30 psychiatrists, a ratio of 50 patients per doctor. Furthermore, the hospitals are only providing treatments for patients with major disorders and don’t provide counseling services for outpatients.

For Soe Min, a combination of societal change and policy prioritization are needed to address Burma’s mental health care shortcomings, with the doctor urging a systematic ramping up of both institutional and human resources.

“At the same time, more awareness raising and conversations are needed in our society so that people better know about their mental health, when they should get psychiatry treatment and where to get it.”

One aspect of Burmese society includes a demographic that most other countries need not consider: former political prisoners, who number in the thousands due to decades of repressive rule by the junta that ceded power in 2011. With many tortured or otherwise subjected to inhumane treatment while behind bars, this population is more likely to suffer post-traumatic stress disorder (PTSD) or other trauma-related mental health issues.

Aung Aung, who is also known as Ko Shell, a former political prisoner and member of the so-called 88 Generation community who spent 14 years in jail, said he didn’t know to seek psychiatry assistance for his mental struggles after being released from prison in 2012.

“I thought that I didn’t need such counseling assistance and I didn’t even realize that I had trauma,” the 46-year-old told The Irrawaddy.

In the struggle to rebuild his life, Aung Aung said, other priorities were more pressing.

“Life was very difficult, trying to look for a job to feed our stomachs,” he recalled.

Support did come, however, in the form of peers who had experienced similar sufferings and could offer empathy and understanding. Aung Aung also recently submitted his name to the Mental Health Assistance Program (MHAP) of the Thailand-based Assistance Association for Political Prisoners (AAPP), which is partly funded by Johns Hopkins University of the United States, to receive casual counseling.

Echoing Burmese mental health professionals, Aung Aung said adopting a “counseling culture” was key to overcoming the fear of stigmatization that prevents many from seeking help.

“A counseling culture is very important for everyone who has stress and pressure from everyday life,” he said, “from prostitutes to presidents of a nation.”

Editor’s Note: The name of the patient in this story identified as ‘Thant Zin’ was changed at the request of the source.