"We simply cannot continue with the one-liners!"

On an Instagram Live, jointly hosted by the Barbados Association of Psychiatrists and Let's Unpack It, ahead of World Mental Health Day, I sat down with two psychiatrists practicing in Barbados, for a discussion on how we can make mental health a global priority for all. The short answer to that question? Less empty talk and more decisive action! But, I wanted to explore how we could achieve this practically.

In their passionate appeal to policymakers and other stakeholders, Dr. Kadisha Douglin and Dr. Elizabeth Rochester called for more openness, more investment, and a scaling up of resources, specialized services and awareness campaigns to address the increasing incidence of mental illness and other mental health conditions in Barbados.

"It's not a new conversation!"

Without a doubt, the experience of the COVID-19 pandemic placed a spotlight on mental health and wellbeing, with buzzwords and terms like 'self-care', 'mental health matters' and 'no health without mental health' gaining popularity on social media. But, the world has been discussing and grappling with the disparities in access to mental health care, a lack of government investment, and the pervasive stigma around mental health for time immemorial.

In response to a question about the state of mental health in the world, Dr. Douglin reminded the live audience, that back in 1998, the US Surgeon-General published a report detailing how a lack of resources and stigma presented 'major barriers' limiting patients' access to mental health care. These barriers remain largely intact today, in spite of the launch of the World Health Organization's Comprehensive Mental Health Action Plan 2013-2020, adopted with an aim to "...promote mental health and well-being for all, to prevent mental health conditions for those at-risk and to achieve universal coverage for mental health services." (1) While the WHO's 194 member states collectively adopted this action plan, and in 2019 granted themselves a 10-year extension to make progress towards the key targets, in 2022, few countries have made any significant headway in local implementation of the plan.

Instead, what has been observed, is a progressive increase in the incidence of mental illness and other mental health conditions, further exacerbated by the onset of the COVID-19 pandemic. Research suggests that globally, approximately 1 billion people are currently experiencing a mental illness.

In Dr. Douglin's estimation, while we have seen this gradual increase in the incidence of common mental illness, what we have not seen, "...is the commensurate increase in resources allocated to mental health." And that, the general psychiatrist argues, is perhaps the greatest manifestation of the stigma surrounding mental health -- a preconceived notion or belief that 'these people' (those struggling with mental health challenges) or 'this sector' does not need the additional investment.

Stigma has far-reaching implications

While mental health advocates in Barbados have been able to build awareness, and, to some extent, establish safe spaces, as a nation we have a lot of work left to do, in terms of dismantling the stigma around mental health.

Though, before we can really make any significant progress in this area, we first have to appreciate that there are many tiers to stigma. It exists at a societal level, where the norms, beliefs and practices of the society ostracize, ridicule or discriminate against people struggling with mental illness, or discourages people from seeking mental health care. It exists at an intrapersonal level, where an individual internalizes the prejudice, overgeneralizations and stereotypes propagated by the society, and turns them on the self. And, of course it also exists on an interpersonal and a systemic level.

So embedded is the stigma, that people often dismiss it as "just a joke", or "not that serious", when in truth, the jokes, myths and misconceptions have a profoundly negative impact.

In our discourse, Dr. Rochester, a child and adolescent psychiatrist, pointed out that stigma has particularly far-reaching implications for the child, adolescent and dependent youth population. "When you are an adult you can choose your own path, do your own reading, and choose to find a safe space so you can explore your mental health." Young people often do not have this luxury of choice, she says, citing that, for the young child, what parents, family members, or religious and school communities think or say, goes! And, very often there are "...too many dissenting voices."

This is particularly concerning when we contemplate the fact that 1 in 7 young people aged 10-19 experiences a mental illness, and suicide is the fourth leading cause of death in the 15-24 aged group.

Another tool in the treatment regimen

I was eager to get these two clinicians to chime in on a specific element of the stigma, that is prevalent in the Caribbean -- the stigma around taking psychotropic medications. There is a narrative out there that people shouldn’t need medication (or any form of treatment) for mental illness, and that taking psychotropics only makes you worse. To offer some clarity on the matter, I asked Dr. Douglin, what is the rationale behind prescribing psychotropic medications for a patient? And, what are the perceived benefits?

Her response: “What you seek to do when you prescribe medication for mental illness, is to improve symptoms that go along with the mental illness. So for depression, seeking to improve mood, improve ability to get satisfaction from life, enjoy activities, energy levels, sleep, appetite. All of these begin to improve as depression improves." She went on to describe psychotropics as one tool to help patients cope and to navigate their mental illness. "You want to get back to a state of wellbeing, to a state of being productive. [Medication] is a tool that can help you to get there.”

Buttressing Douglin's point, Dr. Rochester proffered that medication can often make it easier for clients to make the best use of the other tools in their treatment regimen. For example, a person on psychotropics may find it easier to "access their psychotherapy, because they may be in a more calm state, or they feel more motivated to attend their sessions and do the work that needs to be done." The optimum treatment regimen she says, is where the selected interventions "all work together."

Driving home the point that a treatment plan is a collaborative effort between the patient and the practitioner, Dr. Douglin explained that medication is not prescribed on an indiscriminate basis. "You don't give a blanket drug to everyone. We get your full history. We understand what happened with you and the symptoms you’re having. And we work with you to choose something that is going to lead to improvement."

Douglin also pointed out that a patient may have to undergo cycles of medications, or take more than one medication, in order to find the best regimen. She says that she often has to get her patients to understand that "...that is ok! It doesn't mean that you are defective or [the treatment] has failed, it just means that we have a number of choices and we have to find the regimen that works best for you."

This point piqued my interest in finding out how this plays out in the treatment of the child, adolescent and youth population. And, so I inquired of Dr. Rochester, how do you deal with the parents who are anxious about their child taking psychotropic medications? Without skipping a beat, she remarked "I don't mind anxious parents. I think that an anxious parent is an interested parent. You should be concerned about what a doctor is potentially prescribing for your child."

She added that she actively encourages parents to do their own research, and provides them with a list of online resources that could help them appreciate the benefits, side effects and rationale behind pharmacotherapy. She continued, "As long as parents feel that it is a collaboration, that makes it easier. We are working together as a team. You bring your expert knowledge about your child, their symptoms and how they respond to things, and we bring our knowledge around mental health conditions and various interventions; and, together we will find solutions." Dr. Rochester further emphasized that at all points in the execution of the treatment plan, parents should feel like they could communicate any challenges to their child's GP, psychiatrist or other clinician, so that they could "work together to adjust the plan."

Mental health as a fundamental human right

In crafting the preamble to the constitution of the WHO in 1946, the authors defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The preamble further contemplated that "the highest attainable standard of health" is a fundamental right that every human being should enjoy. (2)

This right to health and a healthy life has informed several charters and policies. However, too often in our discussion on health today, what is often left out of the equation is the "mental" component, a trend that baffles Dr. Douglin. Mental health, she articulated, "includes the ability to think, learn, work, feel and interact with others in the community. It is required for how we conduct ourselves in society. So, for it not to be prioritized, [instead being] left on the backburner, how will society function and thrive in the way it should?”

Dr. Rochester was equally dismayed by the exclusion and invalidation of youth mental health. She stated vehemently, that mental health is everyone’s right, and that "includes your toddler, your child, adolescent and young people." She pleaded with adults not to disregard young people's concerns. "And, please do not exclude them from the conversation about mental health."

Probing further into the matter of youth mental health, I asked Dr. Rochester about what she says to the people who think that young people don't have any problems. This was her reply: "As long as you experience emotions and thoughts, then there’s always the possibility of having difficulty or distressing experiences that can lead to mental health conditions."

Using an example of a child dropping an ice-cream cone, having an emotional response to that, and then receiving comfort from adults around, she pressed, “if we recognize that very young children experience emotions and we need to respond to that, why do we then skip out the whole primary school age group and most of the secondary school age group, expecting them not to have problems until they get into adulthood? Help me to understand this?"

She implored parents and other adults to recognize their responsibility to be safe spaces for youth. "When they were little, you understood that they could have really raw emotions and you needed to be the people to help them regulate these emotions.”

I also asked the child and adolescent psychiatrist to expound on some of the mental health challenges plaguing young people. She reiterated what we all know to be true. That is, that adolescence, in particular, is a period of changes -- hormonal, physical, social and otherwise. It is a period that Dr. Rochester describes as "formative, but also potentially turbulent." This is a period, she says, where youth are “most vulnerable to the effects of stress and adverse childhood events", including verbal, emotional and physical abuse, and death.

Beyond adolescence and into young adulthood, mood disorders are the predominant mental health condition affecting youth. This of course includes anxiety, in all of its forms, and major depressive disorder. Rochester remarked that the research suggests, in any given population, 25-33% of the adolescent to dependent youth population experiences some form of anxiety, many times untreated.

It's about time that we lay the myth that 'young people don't struggle' to rest. I go as far to say that our progress on health equity and on mental health as a priority, will continue to be stymied and lie beyond our reach, so long as we continue to delegitimize the challenges young people face and/or leave them out of the conversation.

Scale up the Resources

If we are in fact serious about prioritizing mental health, then we need to have a holistic conversation about bolstering mental health services and ensuring that they are accessible, affordable, and of the highest quality. In other words, it cannot be that a person's ability to access quality mental health care is determined by their socioeconomic status.

To explore this idea, I asked Dr. Douglin and Dr. Rochester to talk me through the existing mental health services in Barbados. Dr. Douglin shared that Barbados has expanded its offerings, moving away from the 'custodial model' to incorporate community-based services and a number of specialized services. In the public sector, this includes care through the Psychiatric Hospital, referrals by a GP to the community mental health services stationed at each of the 8 polyclinics, and care through the A+E and the Psychiatric Services Department of the Queen Elizabeth Hospital. There are also a number of private sector mental health services across the island.

She remarked, that while the stigma attached to the main mental health care facility remained thick, “...the reality is that in the public system, the Psychiatric Hospital is where you can get a referral to see a psychologist, see an Occupational Therapist, and where you can go to an Outpatient Clinic and get your prescription medications for free." In an attempt to assuage any remaining angst around seeking help at the facility, she encouraged Bajans to see the mental health facility as a 'resource', rather than an "automatic lock up and inject.”

Speaking on the stratification of the healthcare system into public and private practice, Dr. Rochester rejected the notion that public healthcare offerings are substandard. Clinicians in both sectors, would apply the best possible care in accordance with their training, she stated. Additionally, she emphasized that the consultant psychiatrists that patients would see in the private sector are, more often than not, the same consultants patients see in the public sector.

Moreover, Rochester called for an appreciation for the 'fluidity' in the healthcare system, positing that "from time to time [clinicians] work with [complex] cases where a lot of different interventions are required." This she said, could often be difficult on the patient, not only in terms of financing, "but also in terms of time required and physical movement from place to place to access the resources required for management." She described the Psychiatric Hospital as a "one-stop shop with a lot of the specialties and human resources you need, inclusive of psychologists, therapists, community nurses and psychiatrists."

In no uncertain terms, both psychiatrists called for existing services to be expanded. Dr. Douglin called for more to be done, especially in terms of training and upskilling mental health clinicians. She also emphasized the need for training of "general practitioners and those in primary care to provide basic mental health care", alongside community-based awareness campaigns, so that ordinary Barbadians could look out for warning signs, and provide basic emotional support. In her intervention, Dr. Rochester called for critical steps to be taken to assure the delivery of the highest standard of mental health care, across the board. This she said, would ensure that "when we are in a crisis situation we would be in a much better position to respond."

Prepared for a Crisis

A discussion around emergency preparedness and response to a natural disaster, a pandemic or some other emergency, is one that is necessary, particularly now in the wake of a pandemic, where the prevalence of mental health challenges skyrocketed, but the crucial mental health support and services seemed to be inadequate. In fact, many governments failed to regard mental health services as "essential", evidenced by a global failure to increase funding for the provision of mental health services. Some even cut off critical mental health services.

I was eager to get a take on this from these two learned clinicians. In her response, Dr. Rochester shared her belief that in anticipation of more crises and disasters, we need "more prevention-oriented tactics". She asserted that if we can start putting in the right resources in the right places, at the right time, then "that puts us on a more solid foundation to deal with these kinds of issues as they come up." A good foundation, she posited, would include public health campaigns, more personnel and better facilities; but, must also provide more resources where young people can access them. This she said, "means going into our schools." Assigning more qualified mental health care practitioners to our schools, she said, would allow us to "look at mental health in a more holistic way -- looking at the behavioral and social patterns, and other factors, like housing and poverty, that can affect the environments where we are asking parents and caregivers to nurture and nourish the emotional wellbeing of children."

Rochester proffered that we need not be laser-focused on planning for emergency/crisis situations. Instead, she articulated, “..we need to be planning for providing a good, quality, sustainable mental health care product". That kind of product, she argued, must allow mental health professionals to grow in their clinical training and experience, seek to establish the necessary support structures to provide emotional and administrative support that Mental Health Workers need, as well as, encourage continued training to make sure that they are at the top of their game.

Dr. Douglin added that addressing mental health and psychosocial support in communities was crucial to disaster preparedness and response. “It doesn't always need to be a specialized mental health provider that you are turning to in the face of a disaster. It can be persons in the community who are trained to provide emotional support, and who can link people with basic resources." In times of uncertainty and disaster, she said, people really just need to feel safe; they need to get clear information; and, they need access to necessities like food, shelter, water, and security. In her estimation, "when you plan ahead to cover these basics in an emergency, that does help with mental health and psychosocial support.”

So! What is needed now?

This discussion really put things in context, and gives us a good starting point from which we can contemplate what actions are necessary. Here are 3 key actions I propose we take as a nation:

1. Launch a rigorous national education and awareness campaign around mental health.

We need every Barbadian citizen to realize that their mental health is a priority. And, it is a fundamental right that they should be able to enjoy. An impactful campaign would make people aware of the risk factors, signs to look out for, and the list of mental health services available on island. It would also seek to dismantle the stigma, encourage the sharing of experiences, and empower young and older people alike, to seek help for their mental health, as they would for their physical health.

2. Increase investment in mental health:

If we are going to create that quality baseline mental health product, and expand access to these services, then we need an increase in government investment in mental health. The 2-4% of the healthcare budget, is simply not sufficient. Not if we hope to encourage research, broaden awareness and develop and implement crucial mitigation strategies. Moreover, an increased investment in mental health has an inherent benefit, in terms of shaping public opinion, as Dr. Douglin proffered "..if [the public] sees the people in charge saying mental health is important and we are investing in it, then that changes the narrative for everyone else as well.”

3. Prioritize Mental Health at all levels:

At the individual, community and national level, we need to be intentional about creating an environment where people can enjoy mental wellness. We can do this, by introducing mental wellness strategies in our places of work and in our schools; taking a pause every now and then to check in with ourselves; normalizing discussions about mental health; revamping the HFLE Program in our schools; and, making mental health a policy issue.

If we can accomplish these three things, the outlook for Barbados will be bright. I am hopeful that we are making the steps in the right direction. (Albeit, not at the pace I would like.)

What say you? What actions would you like to see taken to make mental health a lived reality for all? Share your thoughts and ideas in the comments section below!

Written by David Johnson

Originally Posted October 12, 2022

Many thanks to Dr. Douglin, Dr. Rochester and the Barbados Association of Psychiatrists for facilitating and participating in this discussion!

References

(1) WHO (2021). Comprehensive Mental Health Action Plan 2013-2030. https://www.who.int/publications/i/item/9789240031029

(2) Office of the UN High Commissioner for Human Rights. The Right to Health. https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf