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Armenia :: People with mental health problems lack medical care According to a recent perception survey done by Médecins Sans Frontières, people with mental health problems in Armenia, South Caucasus, are being strongly rejected by their own community. Because of this stigmatisation, thousands of people with mental health disorders are not recognised as being ill and are thus left without appropriate medical help.
The survey was conducted in Spring 2004 in four regions around the Sevan lake, in the east of the country. “As a result of stigmatisation, many people try to hide or deny mental health problems and refuse to seek for professional help for it,” says Luk Van Baelen, expert in Information, Education and Communication in the Médecins Sans Frontières Mental health project in Armenia. The exact number of people in need for treatment is unknown, as official data are unreliable, when available, but the needs are high. “There are no more severe mental disorders in Armenia than in other countries, but the day-to-day problems due the bad social-economic situation and the flux of refugees after the war with the neighbouring country Azerbaïjan contribute to more mental problems, such as depression or anxiety,” explains Dr. Olivier Fenichiu, Médecins Sans Frontières medical coordinator for Armenia. “For these less severely afflicted patients, there are no alternative treatment, the Armenian mental health system being almost exclusively focused on seriously mentally ill persons”. For those looking for medical support, access to adequate treatment for mental health problems is virtually non-existent and there is a lack of affordable medication. Psychiatric hospitals and institutions are overpopulated, local medical staff are underpaid and under-skilled, and specialised care for children is absent. For mildly affected or stable patients with mental health problems, the situation after hospitalisation is worse. These patients can often not be discharged from psychiatric hospitals since families do not accept them after hospitalisation and there are no other facilities where they can be referred to. To tackle this situation, since 2002, Médecins Sans Frontières has been developing a project in Gegharkunik Marz, one of the most deprived regions of Armenia. Médecins Sans Frontières has set up a Mental Health Centre next to the psychiatric hospital of Sevan. Aside from consultations, treatment and follow up of patients, Médecins Sans Frontières also ensures ergo-therapeutic activities, counselling of patients and their families, and provision of information on mental disorders in four day centres located in different towns throughout the province. A total of 65 Médecins Sans Frontières international and national staff is offering these services, including medication, free of charge. This Médecins Sans Frontières mental health project, which provides medical care to 400 patients, has now been recognised by the Armenian health authorities as a national pilot project. “It is a positive sign, but more awareness at the level of local communities and authorities is necessary to break the taboo on mental illness,” says Dr. Fenichiu. “What is needed is appropriate and easily accessible medical support, combined with a comprehensive public awareness program to reduce social stigmatisation”. The challenge is to encourage mental health patients to look for treatment and call on mental health care providers.
A letter from the field :: Marise Denault, Social worker, Sevan Barev Dzes (Hello in Armenian), I’ve been here a few days short of 6 months and I suddenly realized that I didn’t take the time to put down in words what’s been happening to me here. I sincerely apologize and in a way even regret not doing this, because Armenia has given me so much and I feel I owe it not only to this country but also to its people to share my experiences with you. Where to start? Actually, I have no other choice but first to talk about the suffering. It might seem pessimistic to some but I cannot ignore this reality, after all I am working with Médecins Sans Frontières and witnessing and acknowledging are part of the core values of this organization. Suffering I’ve seen here, in various shapes and forms. However, wherever and whenever we intervene I’ve also always experienced demonstration of immense gratitude on the part of our beneficiaries and their families and this has somewhat helped me with cope with all of this, giving me a sense of purpose and satisfaction. I don’t know if there is a more vulnerable group of people than those whose mental health is suffering in Armenia. The stigmatization these individuals face primarily due to ignorance, which, is directly linked to the influence of the past soviet rule, is astonishing. Is it still possible in this day and age that people with epilepsy for example are kept in psychiatric institutions? How about people with very light mental retardation? My grade nine English teacher, to whom I owe my knowledge of English grammar, was epileptic… But the saddest thing of all is how these people are conveniently put away, hidden away and more often than not, forgotten about. Sevan, the city in where I live has the biggest psychiatric institution in Armenia. It is situated on the outskirt of town, out of sight. It’s a perimeter surrounded by a thick cement wall, a site that used to be a prison and where one would still think it is. Over 400 patients reside there, divided up into 10 pavilions each with a minimum of 40 patients. When we walk by these wards we can hear people screaming and pleading “please take me out of here” “take me home with you”. They know why we go there, the word has spread quickly; we have taken on the task of discharging patients. We started this almost two months ago now but unfortunately have not yet succeeded. Let me explain : the hospital has provided us with a list of all their most complicated discharge cases, patients who have been in hospital, a majority for 10 to 15 years, (some for 25 and one for over 40), some whose family have not visited in years, and most with families who categorically refuse to take them back. So, as you can imagine, we’ve taken on a huge challenge. I am hopeful however and my wish is that we discharge at least one of these patients; first to prove that it can be done and secondly to make a difference in at least one person’s life. Thankfully, most of my work is with individuals who live in the community and who benefit from the outpatient Mental Health Center Médecins Sans Frontières has created, with confidential and free psychiatric consultations and treatment. The center has a multi-disciplinary approach, with psychiatrist, psychologist, social workers and nurses working together to ensure ongoing care of individuals with mental health problems. This pilot project was set up in the Gerakunik province, in partnership with the ministry of health. If all goes well by the time Médecins Sans Frontières leaves (in 2005), the ministry will implement the project nation-wide. I’ve come here to improve the social work aspect of the project, build it up, make it more functional, operational and most of all credible. Not an easy task in a country that has only recently heard of social work and has no social work professionals. Even harder, when you take into account the medical and directive approach of soviet psychiatry. But NOT impossible! Definitively challenging and at times quite frustrating, but extremely rewarding. We work hard, long hours and with local partners, this being to ensure the chance of continuation of the project. Daily we are confronted with corruption, lack of initiative and motivation, ethical dilemmas and so on. Why do we persevere one might wonder? Without a doubt it’s for the sake of the patients and their families. Defending and advocating for their rights, giving them access to resources, helping them cope and empowering them is what social workers here are learning to do under our supervision. Case management, proper documentation, assessing the patient’s situation and finding appropriate solutions are all part of the daily trainings we conduct. I’ve seen huge improvements since I’ve arrived and this gives me the strength to carry on. I’m also very lucky to work with colleagues who are both knowledgeable and strongly believe in the work Médecins Sans Frontières is doing. Médecins Sans Frontières as an organization is very strong; it has a good reputation in this country and is well respected. Médecins Sans Frontières was the first international organization to arrive here days following the 1988 earthquake that struck Armenia and in which more than 50,000 people died. After dealing with this emergency Médecins Sans Frontières Belgium became aware of the problems in psychiatric institutions; abuse of patients, malnutrition, overcrowding, etc. and decided to address this issue. Initial intervention was carried out in psychiatric institutions; rehabilitation of buildings, staff training, improvement of treatment of patients, nutrition etc… All in all I have to say that it’s quite impressive to see all that MSF has done in this field and what’s even nicer is to see how this organization has vision and dares to venture into new and unknown territories even if there are barriers and the resistance is high. Armenians are very interesting people, they have been through so much, genocide, earthquake, war, and to top it all off the collapse of the Soviet Union. It’s a nation that’s constantly had to adjust to change and which has lost so much. The Armenian Diaspora is huge, in fact there are more Armenians living abroad today than in Armenia itself. Withstanding all this the Armenian culture was preserved and Armenians have remained proud throughout. I’ve been well received here, Armenians are renowned for their hospitality and I can testify to this. I lead a fairly simple life, live in a two bedroom apartment, in a small city that feels more like a village but at 1,9000 feet in altitude, surrounded by mountains and with the biggest lake in Sevan. Sunsets on this lake are amazing. I get to go to the capital every second weekend and this is the place I draw my energy from to be honest; Internet cafes, nice restaurants and cheap calls home. Yerevan is not that big, but it’s got a nice feel to it and there is certainly a lot more to do. Recently I went to Moscow for a one-week holiday, another advantage to being in this part of the world. I had an amazing time there and was taken away by the beauty of this city. The topic of another email perhaps. Better send this one off first. Marise Denault
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