Armenia, situated in the South Caucasus, was one of the first states of the former Soviet Union to gain independence. Fifteen years later however, there are still thousands of people with mental health problems in Armenia who live an uncertain life in a society that does not recognise them as equal members. As in many societies, in Armenia the community's rejection is based on myths about people with mental health problems.
‘L’ is a 15-year old girl. She is mentally ill and shows signs of autism. She attended school for 1 year, but is no longer welcomed because the teacher considers her a bad student who cannot be taught anything. Her parents have decided that they do not want to spend any money to buy medication for L or to let her visit a psychiatrist or psychologist. For them, L is a punishment from God. Her future is uncertain as she will not be able to have a job. At the moment her parents still support her, because she is still a minor, but the day she becomes an adult, nobody knows what will become of L.
The case of L is just one example of the way in which stigmatisation affects the lives of people with mental health problems in Armenia every day. Médecins Sans Frontières (MSF) conducted a survey among the general population researching the knowledge, attitudes, and behaviour towards mental health problems.1 It was apparent that the myths about people with mental health problems are very similar to the misconceptions in western Europe.2 Most responders in the survey thought that people with mental health problems should be kept in hospital (56%), that they are usually violent and dangerous (63%), or that they cannot do any work (54%). The majority of the responders said that they would be upset or disturbed about working in the same job as someone with mental health problems (53%), that they would not be able to maintain a friendship with someone with a mental illness (56%), or that they would feel upset or disturbed about sharing a room with him or her (65%).
However, although the myths are similar, their consequences are different from those in western Europe and some consequences are directly influencing the lives of people with mental health problems. They are hidden away by their family members, who are ashamed of them, and parents seldom refer their children to psychological services out of fear of being labelled as ‘mad, crazy people’ for the rest of their lives. For instance, in Armenia one needs the approval of a psychiatrist to receive a driving licence or to work for a government department and, once one has a psychiatric file, it becomes very hard to obtain this approval. Having a family member with mental health problems will also have indirect consequences. Family members of people with mental health problems often encounter problems marrying because mental health problems are considered hereditary. As a result, many people try to hide or deny mental illness and refuse to seek professional help.
However, when people finally decide to look for treatment, they face the reality that treatment hard to find. State funding is insufficient to assure guaranteed free services for vulnerable groups3 and medical staff supplement their meagre wages with ‘under-the-table’ fees before providing services. The financial resources of most hospitals and institutions are not sufficient to provide even the most basic services or to pay qualified personnel.4 Medication, if available, is expensive and self-medication is widespread. As the World Bank has explicitly encouraged the reduction of the state's role in healthcare delivery, with the introduction of user fees for public services in Armenia,5 the medical poverty trap will be exacerbated.6 Additionally, when people from rural areas decide to look for professional support, they often only want to visit professionals from the capital because they are considered to be less involved in the local society; local professionals, if they exist, are too threatening for a person's daily life because of the lack of confidentiality.
Moreover, most psychiatric hospitals and institutions do not have the necessary infrastructure to provide good care. They are often overpopulated and no distinction is made between different disorders. For example, people suffering from autism share the same dormitory as people with schizophrenia. Therapeutic activities for patients are rare and they spend most of the day doing nothing. For children, in particular, specialised care is absent and waiting lists for specialised institutions are long.
In addition to this, many specialists have left the country. Those who stayed were mostly educated during Soviet times and do not have the opportunity to stay in touch with recent advances in psychiatry and psychology. For many of them, most recent developments concerning their profession are out of reach. If this is the situation for mental health specialists, it stands to reason that the situation among first-line caregivers, such as GPs and nurses, is even worse.
The stigma and lack of professional support mean that the demand for mental health care is low. Official statistics are, however, unreliable and often even unavailable.7 The needs, however, are high.
The research conducted by MSF1 showed that one in two responders reported that they knew someone who had been treated for mental health problems; when asked about the number of people who had mental health problems in Armenia, responders's views showed that, on average 38% of Armenians have mental health problems.
The living conditions are such that many people have mental health problems: socioeconomic conditions are poor and unemployment is very high. In addition, it is important to note that lives have been affected by the unresolved conflict with Azerbaijan over the Nagorny Karabakh region and, as a result, there is a high number of refugees (approximately 12 000 in Gegharkunik Marz, which has 200 000 inhabitants7) (P Marzpetarian, 2004, personal communication) who, for the most part, are living in very appalling conditions.
‘A’ is a refugee and lives in a little town in the mountains of Armenia, near the border with Azerbaijan, where almost half of the population are refugees. Winters are cold and last long in the mountains, with temperatures of −30°C, while summers are short, dry, and hot. A is 26 years old and lives with her mother in the refugee hostel where they share a room of 10m2. The only things they posses are two old beds with one blanket each, a small table, an old television, a bookshelf, and a pension of US$8 per month — not much when 1kg of bread costs 50 cents and the poverty level in Armenia is US$20 per month.8 Although A experiences psychotic episodes, she has never visited a psychiatrist; neither has her mother, who also suffers from mental health problems.
For people with mental illness who are hospitalised, the situation is often even worse. Mildly affected or stable patients can often not be discharged from psychiatric hospitals as families do not accept them after hospitalisation, and there are no other places where people with mental health problems can go.
To tackle the needs of people with mental health problems, MSF launched an outpatient project in Gegharkunik Marz, one of the most deprived regions of Armenia and a province with a highly vulnerable population.9,10 MSF tries to find an answer for the scepticism towards professional support and the stigma people with mental health problems face.
In Gegharkunik Marz, people with mental health problems are treated in a newly established mental health centre by a multidisciplinary team and they can participate in ergotherapeutic activities in day centres, which are located in different towns throughout the province. All the services, including the medication, are provided free of charge. Patient rights are acknowledged as human rights and confidentiality is guaranteed.
MSF also tries to tackle the consequences of the stigma on people with mental health problems. However, the goals to decrease stigma and increase awareness in Armenia are different from the goals set abroad. In Europe, the main idea is to encourage people back into meaningful lives, to support employers to hire people with mental health problems, to reintegrate patients into the community via job training and education, and to give them a voice by creating, for example, user groups.2,8 In Armenia, however, the main goals are to encourage people to look for treatment and to inform the general public about mental health. By educating the general population, misconceptions (for example, about marriage and the need to stay in a psychiatric hospital for life) can be eradicated.
In the end, it becomes clear that the combination of appropriate medical support, which is easily accessible for everybody, and a programme to tackle stigma is the only way to convince people, little by little, to approach mental healthcare providers.
