Indonesia struggles to care for mentally ill (Feature)

By Ahmad Pathoni Feb 10, 2010, 3:04 GMT

Jakarta - Siti Maemunah says her son has been delusional for more than seven years, often talking to himself and sometimes becoming angry for no apparent reason.

But instead of taking him to a psychiatric hospital, she consulted a traditional healer, or dukun in Indonesian, who advised her that the 36-year-old Agus was a victim of black magic.

'I don't know if people with illness like his can be cured. I just hope that he doesn't attack people and destroy things,' she said. Maemunah, 57, is not alone in her ignorance of mental health problems.

Belief in black magic is widespread in Indonesia, and people often take family members who are mentally ill to those who are believed to be able heal patients through magical powers, experts said.

In many cases mentally ill people are restrained for years in shackles, or stocks, in a practice known locally as pasung.

Basic mental health services are not available in many parts of the world's fourth most populous nation, leaving many mentally ill people without access to treatment, experts and officials said.

'In a country of 230 million people, there are no more than 700 psychiatrists, half of them working on Java island, including about 200 in Jakarta,' said Prijanto Djatmiko, head of the Jakarta branch of the Indonesian Psychiatric Association.

According to a 2007 Health Ministry survey, 4.6 per cent of Indonesians suffered serious mental disorders, including schizophrenia.

The plight of mentally ill in Indonesia came into the spotlight in 2003 when the US news magazine Time published photographs showing patients in a mental institution being chained and held in terrible conditions.

A restructuring plan at the Health Ministry that may see the disbanding of a directorate in charge of mental health has sparked fears that mental health care is being further sidelined.

'If that happens, we expect cases of mental problems such as depression and suicide will increase because we don't have a system to address these,' said Pandu Setiawan, chairman of the Mental Health Communication Network, a non-governmental organization.

Health Minister Endang Rahayu Sedyaningsih insisted that the ministry was not putting mental health care on the back burner.

'We are in the process of restructuring but we have not made a decision on what to do with the directorate,' she told parliament last month. 'We are open to suggestions.'

She said there was a plan to set up a centre within the ministry to deal with mental health and substance abuse.

Sedyaningsih said community health clinics, known as puskesmas, and public hospitals were ill-equipped to handle patients with mental health problems.

'Very few puskesmas have psychologists or psychiatrists. Even in hospitals, psychiatrists only work in provincial capitals,' Sedyaningsih said.

She said a total of 48 psychiatric hospitals in a far-flung archipelago comprising 33 provinces was simply not enough. 'In some communities, mentally ill people are confined and restrained,' she said.

According to the World Health Organisation's Mental Health Atlas published in 2005, Indonesia's ratio of psychiatric beds per 10,000 people was 0.4 while the number of psychiatrists per 100,000 people was 0.21.

A paper last year by the Advocacy and Human Rights Working Group of the National Taskforce for Mental Health System Development in Indonesia said hospitals and clinics did not prioritize mental health care, and the skills of clinicians were inadequate to detect illness and treat patients.

It also said the quality of mental health services in hospitals was generally poor and human rights protection for patients was weak.

'Custodial treatments dominate in psychiatric hospitals. Involuntary treatment is common, even though there is no legal basis for involuntary admission,' the paper said.

But at the state-run Soeharto Heerdjan psychiatric hospital in Jakarta, there are no such images.

Patients can be seen sitting in the hallway, chatting with each other; the wards are clean and the lawns well-manicured.

Muhammad Reza Syah, the hospital's head of medical services, said the quality of health care had improved markedly over the past few years and patients were being treated humanely.

'This hospital used to be known as a place for crazy people. But there's been a lot of progress in therapy techniques,' he said.

'With the shift in paradigm, we try to make sure patients don't stay here too long. As a result, more people are served as outpatients,' he said.

Of the hospital's 300 beds, only 200 were occupied, Reza Syah said.

But despite the needs, mental health programmes still do not receive the budgets they need. With only 1 per cent of the total health budget going to mental health, the sector is to receive about 22 million dollars this year.

Djatmiko of the Jakarta Psychiatric Association acknowledged that the government was not treating mental health as a priority.

'Research is scarce because of the lack of political will,' he said. 'It's partly because the government is preoccupied with other health issues such as malnutrition, TB, HIV/AIDS and other communicable diseases.'