Paging... the Jamaican psychiatrist
Public sector mental health specialists in short supply
THE public mental health sector is reeling from a chronic shortage of psychiatrists the Sunday Observer has learnt.
In fact, not even 30 of these specialty doctors are available to service the large group of Jamaicans with mental problems, which includes almost 300,000 persons diagnosed as schizophrenic.
Quoting a prevalence study undertaken a decade ago, forensic psychiatrist Dr Clayton Sewell said "One in every 100 Jamaicans has schizophrenia", and that serious mental illnesses like pshychosis were "more common than you think". As such, he said there ought to be significantly more psychiatrists.
"For a population of almost three million, ideally, we should have 200 psychiatrists to adequately serve the in-patient and community mental health populations, but we only have about 25, and that doesn't include psychiatric nursing aides or mental health officers," Sewell said.
At the University Hospital of the West Indies (UHWI), where he is a consultant, there are six psychiatrists (three in the general area, one for child and adolescent psychiatry, one for forensics, and one for substance abuse), plus psychiatry residents and mental health officers.
Bellevue Hospital, on Windward Road in Kingston, has five psychiatrists; four of whom are assigned to the community mental health programme. That's a total of 15 specialists for the south east health region which encompasses St Catherine, Kingston & St Andrew and St Thomas.
But those institutions are the exception: UHWI is a teaching hospital and Bellevue is the island's sole residential psychiatric facility.
In the other regions, the figures plummet. The western health region which comprises Westmoreland, Hanover, St James and Trelawny, has two psychiatrists; the southern region -- St Elizabeth, Clarendon and Manchester -- has three; and the north east region -- St Ann, St Mary and Portland -- has two.
When stacked up against other countries in the Caribbean, Jamaica falls way behind.
The World Health Organisation's mental health atlas for 2005 showed that the number of psychiatrists per 100,000 population for Cuba, the Bahamas, Barbados, The Dominican Republican and Antigua & Barbuda were 10, four, three, and two, respectively.
The atlas did not present data on Jamaica, but given the country's population of near three million and the roughly 25 psychiatrists in the government service, the ratio of doctors for every 100,000 Jamaicans would be an estimated 0.83.
As bad as it seems, however, consultant psychiatrist at Bellevue, Dr Myo Oo, said things have improved "significantly" over the years.
"The number of psychiatrists is a significantly low number, but in recent years we have more graduates coming in, so we have more psychiatrists available now," he told the Sunday Observer.
"In the 1990s, psychiatric services were limited to Kingston and St James. "Right now we have all regions (covered). All regions have a psychiatrist assigned. That is a significant improvement. In the southern region, we have at least three, in the northeast, we have two, and in St James we have two, and many more are coming because the graduates from UHWI are coming out." he said, indicating that this applies to the government service, but there are other psychiatrists in private practise.
Another reason things might not be as bad as they seem, said Oo, is that "the majority" of people afflicted by mental illnesses are treated privately by general physicians.
"From what we see, the trend is that many persons who have psychological issues or psychiatric issues, they usually see their private physicians in the private practises," he said
"The majority of the general population are seeing their own general family physicians and they can get treatment from them, and if the physicians think the problem gets worse, or becomes larger than they can handle, they will refer them to psychiatrists who are trained in the speciality area to get further treatment or admission to hospital," he said.
A doctor who once worked in the north east health region, who asked that her name be withheld, did not discount Dr Oo's position, but said it did not diminish the fact that those not wealthy enough to bypass public hospitals are often left in the lurch.
"My main problem is that patients are very often neglected... The area is very, very understaffed," she told the Sunday Observer.
"If a patient is to come in for medication and doesn't (come in) for like two months, there's nobody to follow up and realise that he is missing. That causes people to fall through the cracks," she said.
She made comparisons with Cuba, where she, like the majority of Jamaican doctors in the field, studied.
"The way things are organised in Cuba, there is one psychiatrist for one (cluster of communities), not for three, four parishes. So you don't have anybody falling through the cracks there. If you miss your medication they will come and knock on your door," she said.
That, she said, was one reason mentally ill people roam the streets in the numbers they do in Jamaica.
Dr Sewell agrees.
"If we are not able to visit those people who don't come in for their outpatient visits, or to get to who may not be able to come to the hospital, then they may be out there. Even a few days might be quite significant in terms of the level of deterioration and the possible destruction to the lives of family and to persons in the community," he said.
Hence the need for community mental health services, a programme which the ministry of health has been pushing since the 1960s, according to Dr Oo.
"In the Ministry of Health, we are trying to do a decentralisation of services. For example, you don't need to travel from St Thomas from the countryside to come to Kingston to see a psychiatrist. We try to come closer to you, meaning that we are trying to expand the community mental health services. In the south east region for example, we have psychiatrists in St Thomas, in Kingston & St Andrew and we have psychiatrists in St Catherine running the community clinics in the government health centres."
He admits however, that things aren't nearly close to perfect given a string of challenges, including a lack of ambulances, the unavailability of certain drugs, and a lack of community support arising from the stigma associated with mental illness.
"Between 1996 and 2011 there has been significant improvement in community mental health services even though the level of services we have is not to our satisfaction or standards," Dr Oo said.
There is also a shortage of other professionals in the field of mental health.
"There's always need for more in terms of the psychiatric nursing aides, as well as other rehabilitative interventions that are necessary. We have an occupational therapist (at the UHWI) but there is only one for all these patients, and sometimes it requires more individual attention. We also need more social workers to maintain contact with the patients and the families after the patient is discharged," said Dr Sewell.
The inadequate number of qualified personnel aside, the deficiencies plaguing the country's formal mental health system are many and varied.
In our next installment of Matters of the Mind, the Sunday Observer looks at the physical infrastructure in place for specialised groups of mentally ill persons.