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Mental Illness


Mental Illness (manosik rog) any disorder that affects the mind or behaviour. In fact mental illness refers to a wide range of behaviour, which is mostly self-defeating and maladaptive in nature, and causes harms to the individual, and to the society. It is associated with some kind of distressing symptoms that may manifest themselves as psychological or physical symptoms or both.

Mental illness is most neglected in Bangladesh, although a large number of people are suffering from different types of mental illness. It is prevalent in Bangladesh probably in the same magnitude as in developed countries. According to WHO, the number of mentally ill people in Bangladesh is about 8.4 million ie, 7% of the population of 120 million. The following Table shows the estimated population of Bangladesh who suffers from different types of mental illness.

The results of small surveys conducted in rural and urban areas, and records from mental hospitals and psychiatric units of general hospitals and private clinic show that mental illness is widely prevalent in Bangladesh both in rural and urban communities. It was noted that about 30% of patients who visit the general practitioners are for psychological problems or problems with a significant psychological component. In a community survey in a rural area it was found that about 15 per thousand people suffered from serious mental disorder and about 50 per thousand have various types of psychoneurotic and psychosomatic disorders. In Bangladesh women suffer more than men do.

Mental illness can affect any or every aspect of an individual's life, it may vary in severity, symptoms, causes, and treatment. Mental illness can be classified in different ways. Some of the important types of mental illness encountered in Bangladesh are described below:

Psychoses Major mental illness in which marked disturbances in thinking, feeling, and behaviour are found. Such illness makes an individual unable to function in society. The psychotic patients lack insight and are unable to evaluate reality objectively. Abnormalities of thought in the form of delusion, which means false beliefs usually involving a misinterpretation of perception or experience, are found in psychotic patients. Hallucination, a sensory perception which is said to occur in the absence of any appropriate external stimulus, is also seen in those patients. The common people of Bangladesh believe that psychosis is caused by supernatural forces or by evil spirits and the person suffering from these disorders is called 'mad' (pagal) or 'insane'.

Psychoses are fundamentally of two types, organic and functional. A person with a psychosis may need to be placed in a mental hospital to obtain proper care.

In organic psychoses there are demonstrable abnormalities in the brain or in other organic systems. Organic psychotic disorder may be acute or chronic, reversible or irreversible. Symptoms of organic brain disorders may include reduced awareness and impaired ability to think, speak or remember. The patient is disoriented in time and place. The incidence of organic brain syndromes is associated with aging. Delirium and Dementia showing memory impairment are the common organic psychoses found in Bangladesh.

In functional psychoses, no demonstrable abnormalities in the brain or in other organs of the body are found, though there may be some form of undetermined biochemical or other abnormalities. Schizophrenia and mood disorders/affective disorders are the two important functional psychoses. The term schizophrenia (from the Greek 'schizen' meaning to split and 'phren' meaning 'mind') refers to the fragmentation or disconnection of the normally integrated psychological functioning. Delusions, hallucinations, disorganised speech, disorganised behaviour and negative symptoms (eg, apathy) are found in schizophrenic patients. About one fifth of all patients in mental health facilities of Bangladesh are schizophrenic. Psychosis is equally common in men and women in Bangladesh.

Neuroses Emotional disorder, primarily characterized by anxiety. Neuroses are less severe than psychoses. They do not involve the major distortion of external reality or marked personality disorganisation but a neurotic person's social relations and work performance are likely to be impaired. Unrealistic and irrational fear or anxiety is the dominant features of the anxiety disorders. Anxiety disorders include phobias, panic disorder, generalized anxiety disorder, obsessive compulsive disorder, and post traumatic stress disorder. The majority of the neurotic patients in Bangladesh seek help at the general health service, which often leads to prolonged distress and unnecessary prescriptions and investigations.

Personality disorders Long standing inflexible, maladaptive inner experience and behaviours that impair social or occupational functioning. They deviate significantly from the expectation of the person's cultural norms and cause distress both for the individual, his family and the society. Personality disorders differ in form and severity. Like other countries personality disorders are also found in Bangladesh mostly in males and they occur in adolescence or earlier.

Substance related disorders 'Maladaptive behaviour associated with the prolonged and the recurrent use of some substances such as drinking heavily and taking drugs. They are detrimental to individual and to the society and give rise to legal, social or occupational problems. Study conducted on trends in substance abuse in Bangladesh reveals that majority of drug abusers are unmarried and unemployed, and majority (79.5%) of the abusers are between 20-34 years. Trends of primary drug abuse have shown that heroine is consumed by the majority (54.06%) of patients and that of alcohol by the lowest number (1.39%) of patients. The number of drug abusers is increasing in Bangladesh, therefore, proper care and management of this problem is necessary.

Childhood behaviour disorders/problems Deviant or irregular patterns of behaviour that vary widely in type and severity. Hyperactivity, conduct disorder, aggressiveness, delinquency, depression, schizoid anxiousness, social withdrawal, nervousness, inattentiveness, self-destructiveness, sex problems etc, are some of the common behaviour problem in children. Study on behavioural problems in children in Dhaka, Bangladesh revealed that mothers reported 11.8% of boys and 10.7% of girls, and teachers reported 12.8% of boys and 11.2% of girls to have behaviour problem in the clinical range. Boys scored significantly higher than girls, and children from lower socio-economic status obtained higher problem score than children from upper and middle socio-economic status. Slum dwelling children have higher problems than those of the non-slum areas.

Mental health problems in elderly Mental health problems in the aged persons are increasing in Bangladesh due to weakening of the traditional family structure and the family support system. It was found that anxiety, loneliness, insomnia, memory loss and inattentiveness were the important psychological problems faced by the old people of Bangladesh.

Mental health service in Bangladesh is poor compared to other neighbouring countries. Here formal care and treatment of mentally ill persons started only in 1957 with the establishment of mental hospital at Pabna with 60 bed facilities, which were later increased to 400. Outpatients' services for the mentally ill patients and a few in-patients beds were available in the psychiatric units of general hospitals since the early seventies. In 1975 post-graduate course in psychiatry was started in IPGM&R (now Bangabandhu Sheikh Mujib Medical University). For the extension of mental health services to the rural areas of Bangladesh, training for upazila medical officers and health assistants in mental health was organised in Dhaka. Recently a National Institute of Mental Health has been established at Sher-e-Banglanagar, Dhaka. Some private clinics/hospitals/institutes are also offering valuable services to mentally ill patients.

Bangladesh for its present population of over 130 million, have only about 70 psychiatrists. In 1995 a three-year postgraduate training course in clinical psychology was introduced in the Department of Psychology, the University of Dhaka, linking with the University College, London, under the financial assistance of the British Government. In 1997 the Department of Clinical Psychology of Dhaka University was established with the objectives of promoting the psychological health of the people of Bangladesh.

Drugs are commonly used in Bangladesh for the treatment of mental illness. Electroconvulsive therapy is also used for rapid and effective treatment for severe depressive patients. In order to help the distressed individual with emotional and psychological problems different types of psychotherapy are currently being used by the clinical psychologists and the trainee clinical psychologists.

Although mental health services are available in Dhaka and some other cities, vast majority of the population living in rural areas in Bangladesh receive little service facilities. Prejudice, superstition, and ignorance about mental illness exist in this country among different sections of people. It is a common belief that mental illness is caused by supernatural forces or by evil spirits, and most of them are not curable. Many mentally ill persons of Bangladesh seek help of religious and traditional healers, fakirs, kabiraj and magicians etc, who usually maltreat, and exploit them.

Knowledge and awareness about mental illness are still in the very early stage in Bangladesh. Organising seminars, symposia and workshops may create awareness among general people. There is no developed rehabilitation centre for mentally ill people in Bangladesh; hence, a planned rehabilitation service is urgently needed. [Roquia Begum]

Mental depression Disorder of mood and emotion characterized by sadness, inactivity, and a reduced ability to enjoy life. Simple grief or sadness in mild form is a part of human life and they are expressed as appropriate emotional responses to the loss of loved persons or objects. Depression is considered to be present when the depressed mood is disproportionately prolonged or extreme that disrupts the normal life or activities of the person.

The depressive disorder may vary in severity; it may be acute or chronic, and unipoplar or bipolar in nature. In unipolar depression the patient experiences one or more major depressive episodes without a history of either a manic episode or a hypomanic episode. Patients with bipolar depression also experience depressive episodes but this period alternates with episodes of mania. These two categories are also called endogenous depression and both of them are recurrent disorder.

Mental depression is very common in Bangladesh. In a survey of a village near Dhaka City it was found that 2.9% of the people were suffering from depression. Another study revealed that about one third of the patients attending psychiatric outdoor of a hospital in Dhaka City, and in general practice were diagnosed as depressive. The rate of depression is found to be the highest in the ages between 50 and 59 years and the widowed, divorced or separated persons have highest incidence of depressive illness. In Bangladesh women suffer three times more than men and most of the women are housewives.

In depressive illness the individuals suffer not only from mood but also from motivation, thinking, and physical and motor functioning. A depressed person usually experiences one or more of the following symptoms: feeling of sadness, hopelessness or feeling of worthlessness and guilt, loss of pleasure or interest in usual activities, disturbance of appetite and signs of loss of weight, sleep disturbance or insomnia, psychomotor retardation or agitation, loss of energy and vitality, slowness of thought or action and a preoccupation with death and suicide. In Bangladesh, symptoms of depression are somewhat different compared to western countries. They are often expressed as somatic complains rather than the feelings of sadness and guilt. Due to cultural factors, prejudice and lack of acceptance of psychological symptoms, physical symptoms are overemphasized. Burning all over the body, pain and other sensations which include numbness and tickling etc, heat in the head and headache, palpitation, sleep disturbance, loss of libido, and gastrointestinal problems are the common physical symptoms expressed by a depressive patient in Bangladesh.

Depression may be caused by many factors, such as loss of one's beloved one, childhood trauma and stressful life events. Biological research in different countries has shown that the major mood disorder is sometimes genetically transmitted, especially in bipolar depression. Among biochemical causes, low level of norepinephrine leads to depression and a low level of serotonin allows wild fluctuations in the activity of other neurotransmitters and produces depression and mania.

In Bangladesh antidepressant drugs are commonly used in the treatment of depression. The clinical psychologists and trainee clinical psychologists are using different types of psychotherapy to resolve underlying psychic conflicts that may be causing depressive state. For mild form of depression supportive psychotherapy and counselling are also found to be very beneficial. Like other western countries electro-convulsive therapy is used in Bangladesh as a last resort for severely depressed people who fail to respond to other treatments and who need quick therapeutic results. [Roquia Begum]

'Mental retardation (manoshik pratibandhi) Subnormal intelligence defective brain development. The consequence is the impairment in intelligence from early life, inadequate and slow mental development during the growth period, reduced learning ability, and poor behavioural and social adjustment. It is a permanent disability but not a disease. Mentally retarded children have reduced language capacity, deficiencies in different types of skills and reduced cognitive abilities.

According to the severity of their intellectual deficit, mentally retarded children are divided into four groups such as mild, moderate, severe, and profound. One type of mental retardation differs from other types in presentation, etiology, associated features, prevalence, management, and outcome. Intellectual capacity is generally measured by a standardized intelligence test. For a diagnosis of mental retardation the child's intelligence quotient (IQ) should be less than 70, and he should be functionally impaired in his every day life. Mildly retarded individuals have an IQ in the range of 50-70. They are not always distinguishable from the normal children until they enter school. The moderately and severely retarded persons have IQ in the range of 30-49 and 20-30, respectively. Profoundly retarded persons have IQ below 20. Many severely and profoundly retarded children have serious motor and sensory impairment.

In Bangladesh interest in mental retardation is relatively recent. An organisation of the parents of the mentally retarded children was formed in 24 December 1967. In 22 June 1980 the first National Conference on Mental Retardation was held in Dhaka.

The number of retarded person in Bangladesh is more or less the same as in other developing countries. A nationwide epidemiological study of childhood disability in Bangladesh showed the prevalence rate per 1000 children for severe mental retardation (SMR) and mild mental retardation (MMR) were 5.93 and 4.45, respectively. The prevalence rate of SMR was higher for girls' (6.94) than boys' (5.08). All types of mental retardation and disabilities were found more prevalent in urban area (6.03) compared to rural area (5.84). Lower socio-economic status was associated with the occurrence of MMR but not with SMR. The mildly retarded persons are difficult to be identified as they can adjust in a simple society like Bangladesh and moreover, the education standard in Bangladesh is lower compared to western countries.

Diagnosis of mental retardation is difficult in Bangladesh as birth register is not strictly maintained and correct record of health information does not exist. However, Weschler Intelligence Scale for Children (WISC) and Denver Developmental Screening Test (DDST) have been translated and standardized for diagnosis of mental retardation in Bangladesh.

Mental retardation may be caused by a number of factors that may occur before, during or after birth. In one study with urban children in Bangladesh it was observed that the genetic factors, Down syndrome, cerebral palsy, and prolonged labour were among the main causes of mental retardation. In another study in a rural area of Bangladesh it was found that the severity of retardation among children increased with the increase of malnutrition. Prenatal threat, low birth size, and postnatal hazards were found to be related with the occurrence of serious mental retardation. In Bangladesh, anoxia and birth trauma during delivery have been found to cause damage to the brain leading to both mentally and physically handicapped children.

There are a few voluntary organisations that run training programme for the retarded persons. The Society for the Care and Education of Mentally Retarded Children of Bangladesh (SCEMRCB) run 11 education classes for the retarded children in regular schools in the Dhaka city. SCEMRCB has at present 21 branches all over the country. Bangladesh Institute for the Mentally Retarded (BIMR), established in 1982 provides vocational training course and training in basic skills of behavioural development. Bangladesh Protibondhi Foundation (BPF) which was formed in May 1994 also provides services, training and counselling for the retarded children and their parents. [Roquia Begum]

Schizophrenia Psychosis marked by withdrawn, bizarre, and sometimes delusional behaviour and by intellectual and emotional deterioration. Schizophrenia is the single largest cause of admission to mental hospitals and private clinics in Bangladesh. It is estimated that about 1.3 million people (1% of the population) of Bangladesh suffer from schizophrenia. The illness usually appears in adolescence and early adulthood and in most of the cases the onset is between 17 and 25 years of age but it can occur at any age. Antipsychotic drugs are mainly used by the psychiatrists and various forms of psychotherapy are used by the clinical psychologists for the treatment. [Roquia Begum]

See also mental hospital.