Deteriorating conditions in Sri Lankan psychiatric hospitals

Under conditions in which the incidence of psychiatric disorders is on the rise in Sri Lanka, there has been a marked deterioration in the state of the country’s major mental institutions. Declining government health funding has resulted in understaffing, poor accommodation and a lack of necessary drugs and equipment.

At Sri Lanka’s main psychiatric hospital—the Mental Hospital Angoda (MHA)—staff have recently protested to the government and health ministry over the failure to provide the anaethetists needed to safely carry out Electro Convulsive Therapy (ECT) or shock treatment.

ECT is a controversial therapy which critics argue has side-effects and is open to abuse. But it is regarded by a significant number of psychiatrists in Sri Lanka and elsewhere as an effective form of treating certain types of disorders, including acute depression, as long as it is properly administered and followed up.

At the Mental Hospital Angoda, patients and their families no longer have any choice. The treatment was halted in May after two patients suffered cardio-respiratory arrests and could have died. The dangerous procedure had been adopted of giving ECT without having anesthetists present or the necessary drugs.

Now the treatment is limited only to those who can be transported to other hospitals. According to doctors at the MHA, an average of 30 patients a day should receive ECT. Lack of access to the treatment is just one symptom of the grossly inadequate character of the country’s psychiatric facilities which, like health services as a whole, have been run down under the Peoples Alliance (PA) government.

A nurse explained: “Here we have a severely depressed patient with suicidal ideas who needs ECT. The consultant psychiatrist has ordered that he receive ECT treatment. But we have been asked to send him to the National Hospital in Colombo, about 15 km away. It will take days to get treatment for this patient, as we have to arrange an ambulance and then the psychiatric unit at the National Hospital only performs the treatment once every two days. If the patient commits suicide who will be responsible for it?”

Consultant psychiatrist Dr Neil Fernando commented: “This is a vital therapy. In some cases it becomes a lifesaving treatment. We use this therapy to treat schizophrenia patients and severely depressed patients. Oral drugs and injections take two weeks to assist a patient suffering from a severe psychiatric illness. Discontinuance of this therapy is a terrible blow to these helpless patients.

“We have been stressing to the government and the health authorities for more than three years the need to appoint anesthetists. We have also told the Health Minister. But all these efforts have come to no avail. There should also exist good resuscitation facilities and intensive care facilities to prevent possible complications after the therapy. Here the qualitative standard of the ECT was poor compared with the other psychiatric units in Sri Lanka in spite of the fact that this is the main psychiatric hospital where more than 10,000 psychiatric patients are being treated per year.

“This year has been named as the ‘World Mental Health Year’. April 7 was the ‘Mental Health Day’ and we have just finished celebrating ‘Mental Health Week’. But, what we see is a deterioration of mental health care in Sri Lanka whilst the psychiatric illnesses are increasing.”

Following talks in the first week of June, the ministry agreed to provide anesthetists on a rotational basis to Angoda. However, the first anesthetist to visit the hospital refused to perform the treatment, saying that facilities were inadequate.

Overstretched services

The Angoda hospital is the most important of four psychiatric institutions in Sri Lanka providing residential care for patients. The facility has 1,215 beds but is badly overcrowded. There are only 185 nurses on the staff—half the number stipulated by the government—and most have no specialised training in caring for psychiatric patients.

A nurse explained: “We have only 48 beds in our ward but we have to accommodate 90 patients. Fifteen beds have no mattresses. Relatives do not visit some patients. These patients do not have even basic necessities such as clothes, soap and toothpaste. The government simply does not supply enough. The meals given to patients are terribly substandard. Even those who want to eat a lot cannot. Very cheap tablets such as Benzhexol Hydrochloride (Artane)—costing only two cents per tablet—are sometimes not available here. Patients are forced to buy injections like Clopixole-Depot for 380 rupees per dose.”

Most of the buildings are becoming dilapidated since there is no proper maintenance. According to hospital workers, the money for repair and building reconstruction has only filled the pockets of the contractors. The hospital also faces the prospect of losing some of its grounds to government deputy ministers. At the end of May, the hospital’s medical superintendent wrote to health authorities complaining that the sale of land would leave the facility even worse off, especially as the government has plans to close the nearby psychiatric hospital at Mulleriyava and transfer patients to Angoda.

Rising levels of psychiatric disorders are also exacerbating the situation in Sri Lanka’s mental institutions.

According to one estimate, an alarming 10-12 percent of the country’s population is suffering from minor psychiatric ailments. One percent of the population is afflicted by serious mental illnesses. The rate of common psychiatric diseases has risen by 14 percent from 225.2 per 100,000 head of population in 1980 to 257.7 per 100,000 in 1999. Suicide and attempted suicide rates are also very high compared to other countries, with 5,800 suicides last year alone.

In his book “Management of Poisoning”, Professor Ravindra Fernando noted: “In Sri Lanka, over 70,000 patients are admitted to state hospitals for poisoning. In 1997, 2,948 patients died of poisoning, and it is the second leading cause of death in state hospitals. Sri Lanka has the highest rate of suicide in the world, as a result of over two thousand deaths caused by ingesting liquid pesticides.”

Psychiatrists have pointed out that the rising rate of mental disorders is linked to the country’s long-running civil war and the growth of unemployment and poverty. Dr Kuruppuarachchi commented: “The war is a contributory factor for the spike of the figures. Displacements, violence, urbanisation, migration, social and economic pressures and trauma are the other problems that have produced mental patients in the country.”

The Sri Lankan government has done nothing to alleviate the growing crisis in the country’s psychiatric institutions. The overall level of public health spending—1.4 percent of GDP—is low compared to other middle-income countries which have an average health budget of 3 percent of GDP. Last year’s Central Bank of Sri Lanka annual report described the level of health expenditure as “highly inadequate”. With military expenditure, debt repayments and concessions to big business swallowing up a large proportion of the budget, the government is under pressure to cut health spending even further.