The stigma and struggle of mental health in the Maldives

On World Mental Health Day earlier this month, 27-year-old Aisha* Mohamed was eating fried chicken at a seaside café in the Maldivian capital Malé. Her laughter hid the long day she had had. Her humour also concealed issues that affected her more. Issues that affect many Maldivians who have challenges diagnosing and treating them.

“Three years ago in Turkey, I was diagnosed with borderline personality disorder, depression, anxiety and post-traumatic stress disorder,” Aisha said while slowly scratching her arms because of a skin condition. Her whole family was asked to do tests. Her siblings, even her aunts and uncles, have mental health issues.

“I have had doctors make remarks and jokes about how certain mental health disorders are not real diseases. One day I was having an episode and my friend called the hospital, told them I needed immediate care and a psychiatrist.

“But when we went to the emergency room, they said that desire to harm is not an emergency and that it is considered an emergency only if I have physically hurt someone already,” she said.

Her sister Hawwa* has Asperger’s and severe depression. Hawwa, who is 12, stopped going to school a year ago.

“Until one or two years ago, we could not do tests for Asperger’s. We saw signs [of it] since she was four but tests were not available in Malé then,” she said.

“There are no statistics available so, based on practice, I see a lot of patients from both sexes,” says psychiatrist Shanooha Mansoor. “Lots of male patients with anxiety disorders, more females with depression and anxiety. Depression and anxiety would be more common in the Maldives. We do see mood disorders like bipolar and schizophrenia as well,” she says.

Of the 2,052 people on the Health Protection Agency’s registry of psychiatric patients, 132 have schizophrenia and 47 have bipolar disorder. Most have epilepsy and depression.

The Maldives has an acute shortage of qualified mental health professionals despite growing mental health problems among the population. Appointments to consult psychiatrists at the government-run Indira Gandhi Memorial Hospital and the private ADK hospital often take days to secure.

In May 2016, clinics struggled to keep their doors open after the health ministry declared that a Masters degree and 500 hours of clinical experience would be required to register as behavioural analyst psychologists.

Other psychologists, such as those working with children, must have a doctorate and a thousand hours of experience. The penalty for working without a license is a fine of up to MVR50,000 (US$3,200).

There are fewer than five practising psychiatrists in the country – all of them in the capital. In the atolls, where there is a lack of awareness around mental health, those wanting diagnosis and treatment can only get it in Malé.

Consultant Psychiatrist Dr Arif Mohamed told the Maldives Independent there needs to be better mental health services in the regions.

“The difficulty is availability of treatment in terms of medication in the islands (consistent availability of meds is also a problem in Malé) as well as talking treatments which are non-existent in the islands (very expensive in Malé too as mainly in private sector).

“The difficulties posed for travel to Malé due to the need is a major issue, especially when people refuse to accept they have a problem,” he said.

Dr Shanooha proposes awareness and screening programmes.

“Lots of patients come to seek help after a radio programme is broadcast or a news article is published. Training healthcare practitioners can also contribute to more awareness,” she said. “We could hold camps and most of all educating and developing human resources.”

Doctors said another obstacle to seeking help is the stigma attached to mental health.

Dr Arif said the acceptance and perception of mental illness were influenced by negative attitudes.

“Patients and their families often believe that their problems are physical or spiritual in nature, rather than related to the brain and mental processes, because of negative perceptions. It is also commonly perceived that mental disorders are due to personality weakness such as cowardice and laziness or to lack of faith,” he said.

The Maldives’ most recent state mental health survey was conducted in 2003. It recommended that mental health care be made more accessible to everyone affected across the country and that there was a need to expand existing mental health facilities.

It also asked to conduct more research to understand the other hidden factors associated with mental health issues.

“Given the high percentage of positive responses for epileptic fits, it is recommended that an in-depth study on epilepsy be conducted to determine the exact prevalence.”

Aisha has seen a difference between her experience of access and treatment and that of her younger sister. The family took Hawwa to the education ministry, which now monitors student attendance and checks for abuse and mental health. Ministry officials recommended that Hawwa switched from private to public school. The ministry holds workshops for parents who have children with mental health issues and Hawwa’s mother attends these to better support her daughter.

“Hawwa was not showering when we first took her to the ministry, but now we’re seeing improvements,” said Aisha.

*Names have been changed.