War, poverty cause high rates of mental illness in Sri Lanka

By Sampath Perera
9 December 2008

A recent World Health Organisation (WHO) report and a survey conducted by the country's health ministry reveal a high incidence of mental illness in Sri Lanka. Both reports identify the main causes as the island's protracted civil war combined with poor socio-economic conditions—that is, poverty, unemployment, poor nutrition and a lack of basic services.

The mental health update for the WHO country office in Colombo commented: "More than three decades of conflict and the effects of the tsunami [in December 2004] are having a strong impact on the mental well-being of the Sri Lankan population, very especially, on its most deprived sectors. Mental health data from Sri Lanka shows an increase in severe and common mental disorders, in times of armed conflict. This country has one of the highest suicide rates in the world."

The report continued: "It is estimated that 3 percent of the Sri Lankan population suffer from some kind of mental disease." This figure is low compared to other data, mainly because it is limited to those receiving some form of treatment.

The Health Ministry survey, which was conducted in 2007, is yet to be released publicly. However, Dr. Hiranthi de Silva, director of the mental health service department, gave a speech to a seminar in October that provided some of the results. Overall, 12.3 percent of the population suffered some form of mental illness, broadly defined to include not only depression and post traumatic stress disorder (PTSD) but also binge eating, panic attacks and chronic anxiety.

The government's relaunching of the war against the separatist Liberation Tigers of Tamil Eelam (LTTE) in 2006 has greatly increased the physical hardships and psychological stress facing broad layers of the population. The civil war has claimed at least 70,000 lives since 1983 and hundreds of thousands have been displaced in recent fighting.

The worst affected districts in the North and East of the island were not included in the survey due to ongoing military operations. Their inclusion would have increased the survey's findings. In provinces adjacent to the war zones, the stresses produced by the war are evident.

In Polonnaruwa and Anuradhapura districts, which border the northern province, the prevalence of PTSD was 4.2 and 3.6 percent respectively, compared to 1.7 percent overall for the country. De Silva pointed out that PTSD could be caused by many types of exceptionally stressful events. She called for special attention to be given to those suffering the impact of war.

The incidence of serious forms of mental illness was also high in the north-western district of Puttalam. The prevalence of people suffering major depression was 4.2 percent and 11.9 percent for other forms of depression, nearly twice the national figures of 2.1 percent and 7.1 percent. The district also recorded the highest incidence of somatoform disorder—physical pain produced by psychological factors—at 8.9 percent compared to the overall figure of 3 percent.

In a speech last month, health minister Nimal Siripala de Silva claimed that the country's suicide rate, previously second only to Finland, had significantly improved. He provided no figures, however. The latest WHO report indicates that Sri Lanka's suicide rates remain among the worst in the world.

According to the survey, 4.2 percent of the population registered passive suicidal ideation, or wishing they were dead. Some 1.6 percent, or more than 300,000 people, exhibited active suicidal ideation, or persistent thoughts about suicide together with a plan to carry it out.

Speaking at last October's seminar, Dr. Hiranthi de Silva said: "The rate of crime, violence and civil strife, the rate of alcohol and other drug use, the rate of suicide and deliberate self harm" were some indicators of the deteriorating mental well-being of a society. Unemployment, low-income, human rights violations, stressful work conditions and limited education all contributed to stresses that led to depression and anxiety, as well as making it more difficult to cope with these conditions.

Chris Underhill, former director of the non-government organisation Basic Needs, addressed the same seminar. He noted that 42,433 persons were under treatment in Sri Lanka for some form of mental illness. He said the main handicap facing health services was the chronic shortage of trained psychiatrists. There are only 130 qualified psychiatrists and 63 diploma holders for the entire country.

On its web site, Basic Needs declares: "Sri Lanka is a country with a large mental health problem. As well as the fact that mental health services have been ignored and under funded in the health system, the long-term, ongoing, violent civil war has caused lots of mental trauma and one of the highest suicide rates in the world."

The government's health budget for 2009 is just $US533 million, up by only $8 million from $525 million last year. With inflation running at about 30 percent, this figure represents a sharp cut in real terms, even as the government is boosting military spending. The allocation of mental health services is a small fraction of the overall health budget, which fails to address the country's pressing needs.

The lack of basic services and trained professionals only compounds the psychological trauma facing hundreds of thousand of people. Significantly, the six districts identified by WHO as having limited mental health services are directly affected by the country's ongoing war or recently have been active war zones.