The demand for services is high and availability is small — just how do countries in South and Southeast Asia support their citizens experiencing high levels of mental distress, mental illness and suicidality with such juxtaposing circumstances?
Consider a young woman from a rural village in Indonesia. She has been silently battling with anxiety and depression for years in a community where mental health issues are stigmatized and misunderstood, creating many barriers to seeking help and support. Access to a psychologist or psychiatrist is almost impossible due to limited resources, so the reliance on the support of family and friends is critical to managing her mental health struggles.
The Indonesian Archipelago comprises some 14,000 islands accommodating 276 million people. While there is a newly established national center for mental health based in Bogor, recent estimates suggest that there is approximately only one psychologist or psychiatrist for every 60,000 people. According to Dr. Sandersan Onie, there is extreme variation in heterogeneity and how they handle people in crises because the techniques many employ are not optimal, based on the latest science.
Onie is president of the Indonesian Association for Suicide Prevention, the country representative for the International Association for Suicide Prevention and research fellow at the Black Dog Institute in Sydney. He says that Indonesia’s mental health services are minimal. “Crisis support lines were set up during the Covid pandemic but there is just no funding to sustain these services,” he said. “We know we need capacity building — we obviously can’t rely on the very short supply of psychologists and psychiatrists — but support lines take a massive amount of effort to not only train up but to have the technology to make it seamless.”
With the cost and accessibility of services being so prohibitive for so many people, it was imperative to develop alternative models of care. Indonesia is a country of deep religious beliefs and has the world’s largest Islamic population. Onie says people prefer speaking with their Imam, pastor or priest before seeing a psychologist. This, coupled with the culture and heritage of caring for their neighbor, has provided the impetus for mental health support to pivot and focus on community-based services and supports.
Initiatives include working with religious leaders and community influencers to raise awareness and promote acceptance of mental health issues. In 2022, alongside the G20 held in Bali, advocates engaged with religious leaders in destigmatization to empower the religious leaders to talk about mental health, crisis care and suicide in a non-stigmatizing way.
Another cultural shift in Indonesia is that to non-religious affiliations among young people. This led to the involvement of social media influencers on World Mental Health Day to talk about mental health in an effort to improve responsible media reporting of suicides, further reduce stigma and encourage help-seeking — an effort that reached over 245,000 people in one week.
Despite this, there are institutional barriers and structural deficiencies in the healthcare system that continue to hinder effective crisis care delivery in the country. Significant policy advocacy is underway to enable a stronger, more robust mental health system. This requires better data systems and a change in legislation that ensures self-harm and attempted suicide are included in the data capture, providing a more accurate picture of the levels of distress in Indonesia. “If we have better data, then our scientists can do better epidemiological studies, identify clear gaps in our knowledge and research how best to care for those in crisis,” said Onie. “This will lead to better care for those in distress.”
Across the Bay of Bengal in Bangladesh, in contrast to Indonesia’s lack of policy development, there is significant policy activity designed to address mental health.
In 2018, the government passed the Mental Health Act, replacing the century-old 1912 Lunacy Act. Four years later, the government approved the National Mental Health Policy and the National Mental Health Strategic Plan 2020-2030. Plans to support and improve services at the district and primary care level are being implemented by the Ministry of Health with the support of the WHO Special Initiative on Mental Health. In 2023, these activities established mental health service centers for mental, neurological and substance use conditions in four districts. However, the training of doctors, nurses and community health workers on mental health needs to be further supported.
Recent policy documents augur well for systemic change, but the 180 million people who live in Bangladesh are largely unaware of the changes. While education programs will help spread the word, like in Indonesia, community-based initiatives are the only way for people in rural areas and other hard-to-reach groups to access support outside the family unit.
Abdullah al Harun is the project manager for community-based mental health at Action on Disability and Development, a disability rights nonprofit. He’s a member of the Global Mental Health Action Network and the International Association for Suicide Prevention. He says strengthening the network of support structures is a critical component of the Mental Health Act, scaffolding that must come in the form of the primary health care network. According to the latest WHO report, in 2022, 18.7 percent of adults and 12.6 percent of children and adolescents had a mental health disorder — more than 90 percent hadn’t received a psychiatric consultation.
Action on Disability and Development provides a training program within villages, including mental health first aid for caregivers, community health workers, school teachers and leaders of community-based organizations. The trainees are linked with community clinics which in turn are linked to the district health complexes where medical doctors are available to provide support. Access to telemedicine support is also available in some areas through the internet and television connectivity in the community clinics.
Recognizing the need to work at a number of levels to build capacity, the nonprofit is implementing programs to address the mental health of children and young people in primary and secondary schools. Training in mental health for community volunteers and family support programs have been designed to build capacity for providing support and home-based follow-up support after a diagnosis of mental illness is available. The primary healthcare system is being boosted by training non-psychiatric medical doctors to provide some mental healthcare support.
Finally, Harun says the approach is multi-level with a focus on prevention as well as improving supports. “But we are but one agency and there needs to be much more done,” he said. “On this basis, we also act as a pressure group for a multi-stakeholder approach to accelerate the government’s plans for implementing the strategy and its policies.”
In Malaysia, a major advancement occurred in 2023 with the decriminalization of attempted suicide. This has created an appetite and urgency for training frontline officers, including police, social welfare officers, firefighters, marine officers and civil defense officers. “It was a big win for the whole nation and it has created renewed interest in service improvements,” said psychiatrist and vice president of the International Association for Suicide Prevention Professor Dr. Lai Fong Chan.
As with Bangladesh and Indonesia, in Malaysia, the landscape of mental health crisis care is shaped by many factors, including cultural beliefs, healthcare infrastructure, policies and access to services. There is a significant shortage of qualified psychiatrists and psychologists. Malaysia has fewer than one psychiatrist for every 100,000 people, which is well below the recommended ratio from the WHO of one per 10,000. This means that family and community supports are a key partner in mental health crisis care, particularly in rural areas. It is these areas where access is very difficult not only because of the lack of qualified professionals but the existing geography is challenging. Some places are only accessible by boat or helicopter. Psychiatrist Dr. Ravivarma Rao Panirselvam had the experience of having to fly a person to see him in order to provide an assessment. “I had to use whatever limited information I could get over the phone or via text,” he said. “Sometimes, there is not the data strength even for phone calls.”
There is an opportunity for support in communities through the traditional healer network. There are healers who are literate in mental health care and they can work with the family to provide support and education and explain why it is important for the person experiencing distress to see a health professional. Once a person engages with the mental health system, Chan says that Malaysia has a strong universal healthcare system covering up to 80% of the population. “This covers not only access to services but also to medications,” she said. “Despite all the challenges, if somebody in crisis lands in the emergency department, they won’t be turned away.”
However, until a person does access healthcare, it is a bumpy road to ride. As with many countries, law enforcement is often the first to engage with a person experiencing mental distress, causing further distress for both the person and their family. This may result in the unnecessary and excessive use of force. There is hope that this will change in time. Crisis intervention officers have been appointed as a result of the revised 2023 Mental Health Act and they will support additional training for police and other uniformed services, including social welfare officers, firefighters, maritime officers and civil defense personnel. “The aim will be to have all the agencies working hand in hand with healthcare professionals to smoothen the road to care and recovery,” said Chan.
For Chan, a greater challenge is once a person is well enough to transition and assimilate into society. The absence of intermediate care options between inpatient and outpatient services can lead to difficulties in transitioning people from acute care settings back to the community, potentially affecting their long-term recovery and well-being. This is another reason that the support and education of families and communities is critical in the longer term. Peer-led initiatives and family support groups can play a significant role in providing empathetic and understanding care to people in crisis situations.
Panirselvam added another challenging dimension experienced in his area in East Malaysia. It is not uncommon for young people to be living in their village but their families actually work far away — for example, in timber camps. In these circumstances, a teacher may connect a young person to health care services. In this situation, the health service is required to connect with a family member, which can take a whole day to identify and find them. “That is a challenge,” he said. “We use all our time and resources finding the family member because we don’t have allied health professionals in more rural regions.”
One area that requires advocacy to bring about change is private health insurance. Currently, insurance companies are both discriminatory and stigmatizing towards mental health illness in their refusal to cover inpatient care most of the time. Most individual healthcare insurance policies do not include mental health services. “Not only that, to further rub salt into the wound, if you have a severe mental illness and are in remission, just that diagnosis of a mental health disorder may disqualify you from actually getting a health insurance policy,” said Chan. “That’s something I wish the government would take some initiative and mandate that insurance companies cannot do such things.”
In Malaysia, Bangladesh and Indonesia, the direction of mental health crisis care is improving, albeit slowly. The scarcity of mental health professionals, stigma and cultural misconceptions surrounding mental health and the need for more education to help families understand and address mental health distress are global challenges not unique to South and Southeast Asian countries. Similarly, enhancing peer and family involvement, expanding community-based crisis care services and strengthening collaborative efforts between policymakers, healthcare providers, faith groups and communities are essential to drive positive change and foster more supportive and inclusive mental health crisis care environments.
