Introduction

Bangladesh is a country with an approximate geographical area of 147570 square kilometers and

a population of 141.8 million people (WHO, 2005). The main languages used in the country are

Bengali and English and the main ethnic groups are Bangle and various tribal. Religious groups

include Muslims, Hindus, Christians and Buddies. In addition, there is a small tribal religious

population. The country is a lower middle income group country based on World Bank 2004

criteria. Thirty-nine percent of the population is under the age of 15 and 6% of the population are

over the age of 60. Seventy-four percent of the population is rural. The life expectancy at birth for

males is 62.0 years and 63.0 years for females (WHO, 2005). The healthy life expectancy at birth

is 55.3 years for males and 53.3 years for females. The literacy rate for men is 52.8% and the

44.5% for women. The proportion of the health budget to GDP is 3.4. There are 37 hospital beds

per 100,000 population and 250 general practitioners. Thirty-two percent of all hospital beds are

in the private sector. In terms of primary care, there are 2122 physician-based primary health care

clinics in the country (1822 in the public sector and 300 in the private) and 96 no physician based

primary health care clinics (96 in the public sector.

Mental health

Mental health is defined by the world health organization as a state of well-being in which every

individual realizes his or her own potential, can cope with the normal stress of life, can work

productively and fruitfully, and is able to make a contribution to his own her community. Mental

health includes our emotional, psychological and social well-being. It affects how we think, feel

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and act. It also helps determine how we handle stress, relate to others and make choices. It is

important at every stage of life, from children and adolescent through adulthood.

Mental health situation in Bangladesh

Bangladesh is the most densely populated country of the world, with a geographical area of

approximately 147,570 km² (4). 74% of the population lives in the rural area with an average life

expectancy of 62-63 years among males and females respectively (2). The health system of

Bangladesh is comprised of four main components that define the structural and functional system:

Government sector, Private sector, and Non-Governmental Organizations (NGO) and

International organizations. The Government sector plays the key role, and is responsible by

constitution for policy and regulation of comprehensive health services. The health system of

Bangladesh is mainly coordinated by the Ministry of Health and Family Welfare (MOHFW) and

executed through different regulatory bodies. The MOHFW implements its service, rules and

regulations through two executing authorities: the Directorate General of Health Services (DGHS),

and the Directorate General of Family Planning (DGFP). The DGHS and DGFP manages a dual

system of general health and family planning services through medical colleges with specialized

hospitals, district hospitals, Upazila Health Complexes (Upazila is equivalent to sub district or

borough), Union Health and Family Welfare Centers at union level of villages, and community

clinics at ward. In addition to this, The Ministry of Local Government Rural Development and

Cooperatives (MoLGRDC) supervises the urban primary health care through city corporations and

municipalities, where the primary health care centers (PHCC) are run by partner NGOs. For

example, a meager 0.5% of the total health budget is allocated to mental health. Mental health care

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system in Bangladesh faces multifaceted challenges that include lack of public mental health

facilities, scarcity of skilled workforce, inadequate financial resource allocation and social stigma.

Bangladesh needs a comprehensive mental health policy which can contribute significantly to

strengthen the entire mental health development initiatives in both public and private sectors. In

the recent years the government has done a lot to improve the healthcare opportunities across the

country, but it is still insufficient to address the needs of the demanding and deserving patients up

to the remotest parts of the country. The number of beds in mental hospitals account for only 8 per

cent of the total number of hospital beds for mentally ill patients. On the other hand, there are no

beds earmarked for the mentally ill in forensic units across the country. Consequently, fewer

mentally ill patients receive services from various institutional facilities.

Mental Health services in Bangladesh

There is no specific mental health authority in the country and mental health services are not

organized in terms of catchment/service areas. Mental health outpatient facilities: There are 50

outpatient mental health facilities available in the country, of which 4% are for children and

adolescents only. These facilities treat about 26 users per 100,000 general population. Of all users

treated in mental health outpatient facilities, 44% are female and 7% are children or adolescents.

The users treated in outpatient facilities are primarily diagnosed with schizophrenia (30%), mood

disorders (20%) and neurotic disorders (20%). The average number of contacts per user is four.

No outpatient facility (0%) provides follow-up care in the community, while 2% have mental

health mobile teams. In terms of available treatment, a few (1-20%) of patients in outpatients

facilities last year received one or more psychosocial interventions. Fifty eight percent of mental

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health outpatient facilities have at last one psychotropic medicine of each therapeutic class (anti-

psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the

facility or a near-by pharmacy all year round. Day treatment facilities: There is no day treatment

mental health facilities available in the country. Community-based psychiatric inpatient units:

There are 31 community-based psychiatric inpatient units available in the country for a total of

0.58 bed per 100,000 population. Two percent of these beds in community based inpatient units

are reserved for children and adolescents only. Forty two percent of patients are female and 12%

are children/adolescents. The rate of admissions in these facilities is 4 per 100,000 population. The

diagnoses of admissions to community-based psychiatric inpatient were primarily from the

following two diagnostic groups: 1) Schizophrenia (42%) and 2) Mood disorders (37%). On

average patients spend 29 days in community-based psychiatric inpatient units per discharge. A

few patients (1-20%) in community-based psychiatric inpatient units received one or more

psychosocial interventions in the past year. While 100% of community-based psychiatric inpatient

units had at least one psychotropic medicine of each therapeutic class (anti-psychotic,

antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the facility.

Community residential facilities: There are 11 community residential facilities available in the

country for a total of 0.92 beds/places per 100,000 population. These facilities treat 0.85 patients

per 100,000 population. Fifty-five percent of these beds in community residential facilities are

reserved for children and adolescents. Eighty-one percent of patients are female and 73% are

children. On average patients spend 350 days in community residential facilities. Mental hospitals:

There is 1 mental hospital available in the country for a total of 0.4 beds per 100,000 population

and this facility (100%) is organizationally integrated with mental health outpatient facilities.

There is no bed (0%) in mental hospital reserved for children and adolescents only. The number

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of beds has increased by 25% in the last five years. The mental hospital has at least one

psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood stabilizer,

anxiolytic, and antiepileptic medicines) available in the facility. Forensic and other residential

facilities: In addition to beds in mental health facilities, there are also 15 beds for persons with

mental disorders in forensic inpatient units and 3900 beds in other residential facilities such as

homes for persons with mental retardation, detoxification inpatient facilities, homes for the

destitute, etc. Besides these places, some service centers, NGOs or institutions are providing

mental health services continuously. Such as:

# National Institute of Mental Health (NIMH)

# Nasirullah Psychotherapy Unit

# Department of Educational and Counselling Psychology, University of Dhaka (DECP)

# Dhaka Medical College (DMC)

# Bangabandhu Sheikh Mujib Medical University (PG)

# Shishu Hospital # National Trauma Counselling Center

# United Hospital Counselling Center

# Apollo Hospital Psychiatric Unit

# Bangladesh Protibondhi Foundation

# Healing Heart Bangladesh

# Heal Bangladesh

# Audiology Bangladesh

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# Monobikash Psychotherapy and Counselling Center

# Kaan Pete roi

# Maya Apa etc.

Social Stigma and Mental Health in Bangladesh

Social Stigma and Mental Health in Bangladesh the level of awareness of and medical care sought

for mental illness is very low. Besides there is significant social stigma attached to mental illness

that has severe impact on the health seeking behavior of people suffering from psychological or

mental illness. Many people with serious mental illness are challenged doubly. On one hand, they

struggle with the symptom and disabilities that result from the disease. On the other, they are

challenged by the stereotypes and prejudice that result from misconception about mental illness.

Concept of Stigma Stigma can be described on three conceptual levels: cognitive emotional and

behavioral Types of Stigma Basically there are two common types of stigma. These are...

1. Public Stigma

2. Self-Stigma

1. Public Stigma: Social stigma is also called public stigma. It refers to negative stereotypes of

those with a mental health problem. These stereotypes come to define the person, mark them out

as different and prevent them being seen as an individual. Public stigma is associated with

discrimination.

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2. Self-stigma: Self stigma is the prejudice which people with mental illness turn against

themselves.

Both public and self-stigma may be understood in terms of three components. ●Stereotypes

●Prejudice and

●Discrimination.

Prejudice endorse negative stereotypes and generate negative emotional reactions. Prejudice

turned inward leads to self-discrimination. The behavioral impact or discrimination that results

from public stigma may take forms: withholding help, avoidance, coercive treatment segregated

institutions. Strategies for Changing Public Stigma Through the three approaches, we can change

public stigma. These approaches are.

●Protest

●Education and

●Contact

We can protest against inaccurate and hostile representations of mental illness by sending massage

to media and general people like_

"Stop reporting inaccurate representations of mental health"

"Stop believing negative views about mental illness".

Barriers to Mental Health :

There are a variety of factors restraining people to seek mental health care in Bangladesh, which

both are dependent on individual, as well as societal factors. The main barriers are:

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●Lack of relevant knowledge & awareness,

●Significant gap between mental health & physical health,

●Absence of a committee or body overlooking the violation of human rights for mental health

patients,

●Redirection to proper care & delays in process,

●Scarcity of mental health care facility,

●Inequity,

●Majority of the renowned mental health care service centers are city-centric,

●Service cost of skilled mental health practitioners is unaffordable for general people,

●Poor financing for mental health

●Lack of insurance facility

●Malpractices

 Lack of relevant knowledge & awareness: Most of neurotic patients do not prefer to

consult or get admitted into psychiatric units due to social stigma, mental ward phobia, and

poor maintenance of the working environment. Stigma worsens the mental health state of

patients and symptoms are intensified in their dark, locked rooms. Unlike EU countries,

there appears to be hardly any substantial mental health care available at primary or

secondary health facilities in Bangladesh. Primary health care personnel lack the skills to

detect and treat mental health patients, and referrals of patients with mental health problems

to psychiatric providers by general practitioners or other health care providers is almost

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 non-existent. The people of Bangladesh hardly take help from the mental health

practitioner on theirs neurotic disorders.

 Significant gap between mental health & physical health: Bangladesh is improving in

terms of providing care and treatment for physical illness but mental health and associated

illness are not addressed as part of it. Because mental health is very briefly acknowledged

in the medical curriculum of Bangladesh.

 Absence of a committee or body overlooking the violation of human rights for mental

health patients: There is the absence of a committee or body for overlooking the violation

of human rights for patents who are treated for their mental disorders and this is in line

with WHO (2007) report.

 Redirection to proper care & delays in process: People rarely seek for mental health

services until it becomes more severe. The strong bonding prevalent in the collectivist

culture of Bangladesh and how most initiatives to seek help for the patients are taken by

family or relatives. Thus the society plays a major role in help-seeking of the patients.

However, social networks are reported to become smaller in individuals with mental

illness.

 Scarcity of mental health care facility: In Bangladesh, 16.1% of adults and 15.2% of 5–

10 year old children are suffering from some type of mental health problem. The estimated

population of Bangladesh was 161 million in 2015, so it comprises a huge disease burden

if the prevalence is converted to the total number of people affected in the country. WHO

estimates that neuropsychiatric disorders in Bangladesh contribute to 11.2% of the total

disease burden.

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 Inequity: Inequity is profound at a large scale in the healthcare of Bangladesh. For

example: distribution of beds is a barrier, which prevents the access for rural users and

users from other religious, ethnic and linguistic minorities. A study showed that the density

of psychiatrists around the largest city is 5 times higher than whole country. In Bangladesh,

health care services mostly depend upon out of pocket expenses, so does mental health

care; only 0.1% patients get free services.

 Majority of the renowned mental health care service centers are city-centric: Most of

those mental health facilities are clustered in urban areas, particularly in metropolitan

cities. The density of psychiatric beds in or around the capital Dhaka is five times higher

than that in the entire country, even though 70% of Bangladeshi population lives in rural

areas.

 Service cost of skilled mental health practitioners is unaffordable for general people:

The trivial percentage of patients going to trained mental health professional that is out of

affordability. An article posted by ICDDRB states that mental disorders like schizophrenia

are more prevalent in overpopulated urban setting such as slums in the cities rather than

rural areas and among the poor. This illustrates the underlying problem of access to proper

treatment for patients because they cannot afford.

 Poor financing for mental health: Mental health expenditures from government health

department are less than 0.5%. Moreover, around 67% of all the expenditures spent on

mental health are devoted to mental hospitals and rarely for further research and mental

health promotion. Considering human resources, in every 100,000 population, the

accompanying number of human resources involved is only 0.49.

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  Lack of insurance facility: No mental disorder is covered in social insurance schemes

either.

 Malpractices: In Bangladesh there are lots of mental health practitioner those who have

no mental health related degree and training. They are doing malpractices which is a great

threat for the field.

Suicide and mental health

Experts said in general the reason behind most of the suicide attempts are issues ranging from

depressive disorders, bipolar disorders, anxiety disorders, alcohol and other substance abuse,

schizophrenia and other psychoses, personality disorders, aggression, impulsivity, and hostility,

hopelessness, heredity, childhood trauma, past attempts, and ideation. Bangladesh Society for the

Enforcement of Human Rights (BSEHR) Executive Director Mostafa Sohel Ahmed said

impulsivity – hopelessness among youths, drug abuse, childhood trauma and past attempts and

ideation are the leading causes of suicide attempts. These fatal incidents are linked with mental

depression and mental instability following several issues like unemployment, social insecurity,

romantic failure, and family dispute. Prof Kamruzzaman Majumdar, head of the Department of

Clinical Psychology at Dhaka University, said the lack of support from families and communities

is another major source of concern. He said: “Many people believe their suffering is permanent

and the only way to end their misery is by taking their lives.”

More Bangladeshi women commit suicide than men. In contrast to most Asian countries, the

suicide rates lean more towards women than men in Bangladesh. According to the police, around

7,671 women died unnaturally between 2012 and 2017. Among them, 3,444 incidents took place

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at their parents’ homes while 3,927 incidents occurred at their in-laws’. In contrast, about 9,212

men were victims of unnatural death. But accidents contributed heavily to the number.

Teenagers who are emotional and strongly susceptible to negative inputs. They were found

committing suicide over romantic failures, family disputes, failing exams, or rebuking by parents.

For married women, family disputes and insecurity in the workplace was the leading cause. For

elderly women, depression and loneliness were the key factor. Joyosree Jaman highlighted the lack

of proper women empowerment and a skewed view towards women contributing to the rise in

suicide attempts by women. She further added that the worst is the existing data might be able to

provide a clear indication of more women committing suicide but it cannot be supported by any

scientific data or research which could be used to formulate counter-suicide measures

In 2014, the World Health Organization published a report titled “Preventing suicide: A global

imperative” where it noted that suicide rates worldwide had fallen. Bangladesh ranked 10th on the

list; with nearly eight suicides for every 100,000 people. The WHO developed an action plan to

further reduce global suicides by 10% by 2020. Many countries proceeded to introduce measures

and projects to help reduce suicides, but unfortunately Bangladesh was not among them. Despite

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the fact that in 2014, Prime Minister Sheikh Hasina had directed an institution dedicated to

studying suicides to find a way to resolve them be set up, the project has yet to see the light of day.

There are no government institutions which support people who struggle with issues which may

lead to suicide. There are no helplines.

The only assistance comes from private NGOs like Kaan Pete Roi, the country’s first emotional

support centre helpline. Kaan Pete Roi has listed 22 facilities in Dhaka city where people can find

support, including educational institutions and clinics. Joyosree Jaman said the Bangladesh

government does not observe the International Suicide Prevention Day and stressed its importance

in creating awareness among people. Police sources said suicide cases are dispatched to hospitals

or merely recorded if family members proved unwilling to allow for autopsy.

The Bangladesh Police are the only authorities who keep track of the suicides in the country.

According to their 2017 statistics, on average around 30 people commit suicide every day.

Statistics show that 9,665 people committed suicide in 2010. In 2011 the number was 9,642, in

2012 the number rose up to 10, 108, in 2013 the number was 10,129, in 2014 the number was

10,200, in 2015 the number was 10,500, in 2016, the total number of suicide was 10,600 and the

number rose to 11,095 in 2017. But the police, activists, and experts concur strongly that the actual

numbers would be much higher as many incidents go unreported.

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National mental health act and national mental health policy development

Mental health policies and laws are absent or inadequate in most countries of the world and yet

they are critical to improving conditions for people with mental disabilities. . Bangladesh signed

the CRPD on 9 May 2007 and ratified it on 30 November 2007.5 Bangladesh passed a bill called

the Persons with Disabilities' Rights and Protection Act 2013, which implemented its obligations

under the CRPD.6

The National Mental Health Act 2017 was approved by the cabinet in January 2018 and will

replace the 105-year-old Lunacy Act 1912. Updated legislation will provide a legal foundation to

ensure service provision for care and treatment of persons with mental disorders which upholds

human rights and maintains respect and dignity.

The National Institute of Mental Health has developed a national mental health policy for

Bangladesh with technical support from WHO. A mental health policy is an essential step towards

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improving the mental health of the population. A standard policy can specify a framework to

ensure quality mental health care, from prevention of mental disorders to mental health promotion.

A specific policy will also enable identification of priority mental health activities. To review and

finalize the draft policy, a three-day-long working group meeting was held in May 2018 followed

by a consultation meeting in July 2018 at NIMH with key stakeholders and experts. The meetings

were chaired by Ms Saima Wazed Hossain, WHO Champion for Autism in South-East Asia

Region. The policy will be finalized based on the review and feedback, after which it will be

submitted to the Ministry of Health and Family Welfare.

Bangladesh’s mental health policy was last revised in 2006. Mental health policy is incorporated

in policy, strategy and action plan for surveillance and prevention of Non-Communicable Diseases

(NCD). The policy includes the following components organization of services, developing

community mental health services, organization of services: developing a mental health

component in primary health care, human resources, involvement of users and families, advocacy

and promotion, human rights protection of users, equity of access to mental health services across

different groups financing, quality improvement, monitoring system. Strategy and work plan for

community based activities in mental health in Bangladesh was also approved in 2006. In addition,

a list of essential medicines is present which includes antipsychotics, anxiolytics, antidepressants,

mood stabilizers and antiepileptic drugs. The last revision of the mental health plans was in 2006.

Mental health plan is incorporated in the policy, strategy and action plan for surveillance and

prevention of non-communicable diseases (NCD). Mental health plan is also incorporated in the

strategy and work plan for 2 community based activities in mental health in Bangladesh. This plan

contains the relevant components of the mental health policy but also includes budget, a timeframe

and specific goals. Some of the goals identified in the last mental health plan have been reached

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within the last calendar year. A disaster/emergency preparedness plan for mental health has been

prepared and submitted to government for approval and necessary action. Draft version of mental

health act, Bangladesh has been prepared and submitted to proper authority in 2002 but still it is

not approved and enacted.

Strengths and Weaknesses of the Mental Health System in Bangladesh

Providing mental health services through trained primary health care physicians and health

workers using existing government health network that is extended up to grass root level is the

ongoing programmer of the government. There is one 500 bedded mental hospital in the country,

where most of the patients remain admitted for long time leading to service provision for small

number of people with bigger investment. The spectrum of community mental health facilities are

increasing but the existing service is quite inadequate. The inpatient service is inadequate in

comparison to outpatient care though the outpatient care is also insufficient. There are no

mechanisms for supervision and protection of human rights of mental patients in the country.

Mental health services are accessible to all people of the country irrespective of social class,

religion, language and ethnicity. Special efforts are needed to make it more accessible to poor,

tribal minority and the vulnerable. Less than 0.5% of government health budget is spent for mental

health and about 67% of that is spent for mental hospital serving a small number of long stay

patients. Training on mental health for primary health care physicians and primary care health

workers are ongoing government programmers for more than two decades but the number of

trained staff is still less than required number. Essential psychotropic medicines are satisfactorily

available in Mental Hospital and the National Institute of Mental Health, but not widely available

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in general hospital psychiatry units. There is only one small family association in the country and

no consumers’ association exist. No good interaction exists between the family association and

mental health service facilities. Mental health service is a formal activity of health ministry.

Linkage with education, criminal, justice and other relevant sectors are informal which needs to

be officially linked. Mental health care providers interact with primary care staffs during their

training on mental health, out-reach programmer awareness meeting with public, field survey and

such other related activities. Initiatives have been taken to maintain continuous communication

with four model upazillas (sub districts) around capital city to develop community mental health

services. A mental health policy and plan has been approved by government in 2006. A draft of

mental health act is yet to be approved and enacted by government. The mental health information

system is yet to start functioning formally, but its importance is intensely felt for development of

evidence-based psychiatry in the country. Progress is being made in overcoming the weakness of

mental health service system but it should be accelerated keeping pace with the need of the time.

Absence of separate mental health wing in the health ministry, inadequate awareness among

people of relevant sectors, unsatisfactory co-ordination system, limitation of manpower, logistic

and financial support are among the prime barriers to progress. The factors facilitating progress

are an emergence of new leadership, increasing attention by relevant sectors including WHO,

increasing number of qualified and trained manpower and recent development of policy and plan

on mental health.

Promoting Mental Health

In order to promote good mental health, there must be action. Mental health promotion covers a

variety of strategies, all of which have the aim of making a positive impact on mental health.

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Actions taken to promote mental health include strategies and programs to create environment and

living conditions to support mental health and allow people to adopt and maintain healthy

lifestyles. There is no one-size-fits-all program for promoting good mental health. The range of

choices available increases the chances for even more people to experience the benefits of good

mental health – or improving their mental health.

Interventions to Promote Good Mental Health

Promoting good mental health doesn’t have to involve multi-million dollar budgets. There are low-

cost and cost-effective interventions that can raise the level of individual and community mental

health. These are some evidence-based, high-impact interventions that help to promote good

mental health:

●School mental health promotion activities – These include child-friendly schools, and programs

that support ecological changes in schools.

●Early childhood interventions – Examples include pre-school psycho-social interventions, home

visits to pregnant women, and combining nutritional and psycho-social interventions in

populations of the disadvantaged.

Community development programs

●Support to children – Such programs may include skills-building or child and youth development.

●Housing policies – designed to improve housing.

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●Violence prevention programs – such as community policing initiatives.

●Empowerment of women – Socio-economic programs to improve access to education and credit,

for example.

●Social support for the elderly – including day and community centers for the aged and so-called

“befriending” initiatives.

●Mental health interventions in the workplace – including programs to prevent and reduce

workplace stress.

●Programs targeted for vulnerable groups – These groups may include migrants, minorities,

indigenous people, and people

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