32nd Professor J. E. Jayasuriya Memorial Lecture February 10, 2023

By Professor Emeritus Nalaka Mendis
Formerly Professor of Psychiatry, University of Colombo
J. E. JAYASURIYA MEMORIAL FOUNDATION
(ichpl@hotmail.com)

It is a great privilege to deliver this oration in memory of Prof J E Jayasuriya. He was a highly accomplished person, but I shall not dwell on his list of achievements because past orators have referred to these at great length. Instead let me say that he was a highly respected academic, intellectual, psychologist, population educationalist, administrator, and a pioneer in educational development in Sri Lanka. He was a person of international repute. I had the great fortune and privilege of meeting Prof Jayasuriya in Colombo in 1981 and later in Bangkok when he invited me to dine with him. Let me thank the organizers of this event for providing me a platform to speak on mental health, a subject which is central to being human and to the core of life itself.

The topic of mental health was close to the heart of Prof Jayasuriya, who, during his life repeatedly referred to the importance of issues related to mental health either directly or indirectly in his writings and work. He has stated that “third world countries would be well advised to focus their attention on the achievement of a high-quality life through enjoyment of simple and modest standards of material satisfaction and ennobling of the mind by humanistic reflective and spiritual pursuits”. He has been greatly influenced by the philosophy of humanism. He has referred to the importance of the mind, rational thinking, creativity, innovation, and the need for equality in relation to human activity in many of his works.

“Mental health” and “well-being”

Especially in the past, and many, even today consider “mental health” as being synonymous with “mental illness”. The field of mental health, however, embodies far more than illness, and relates to more positive attributes of the state of being human. Mental health is a foundation for “wellbeing” – a concept that is increasingly receiving attention as an indicator of personal, social and economic development.”

Globally, and at national levels there has been increasing reference to “mental health”, “well-being”, “well-being economy”, and “happiness”. Discussions on these topics are currently taking place at political, academic, United Nations and community levels. Increasingly, the term “mental health” is being used to address issues of not only mental illness but of related and wider health issues such as physical, social and psychological wellbeing. This is a continuing discussion on “what is a good life” and “what kind of society do we like to develop” which has been going on for centuries past. I wish to discuss mental health in its broadest context and talk about its implications to individuals, communities and society as a whole.

The present understanding and models of mental health have been developed on the basis of evidence from academic fields including psychology, positive psychology, sociology, economics, neurochemistry, epidemiology and clinical psychiatry. Apart from these, humanistic approaches derived from the philosophy of “humanism” have had a significant influence on thinking about mental health and wellbeing as well as on development .

In this presentation I use the term “mental health” in its broadest meaning to describe two dimensions of health: “wellbeing” and “mental illness”.

The model I use to explain mental health has it’s basis in three factors: One, the innate potential of the individual – meaning desires, aspirations, needs and wants of the individual. Second, the mental attributes of an individual such as cognition, motivations and emotions. And third, “well-being” as a subjective measure of an individual’s experience and assessment of his/her state of being. Mental health and wellbeing are very closely related concepts, and in this presentation, I will use these terms interchangeably.

“Mental health” of an individual is increasingly seen as an asset or a resource also referred to as the “mental capital” which enables one to use his/her abilities to realize the full potential of one’s life. Components or domains of mental health include cognitive, emotional and motivational aspects of a person which enables that person to make decisions, solve problems, develop social interactions and sustain relationships. Attributes such as flexibility, tolerance, empathy, self-control, the ability to compromise, endure stress, being creative and being productive adds to the mental capital of an individual.

The term “well-being” is a very old one, but it is now being taken to mean a person’s subjective assessment of his/her feelings, and functioning in relation to what he/she values. The experience of wellbeing is subjective and is based on the value the person attaches to a particular aspect of life eg. positive emotions, relationships, engagement in certain activities, creativity, generosity, knowledge, health security, spirituality and meaning and purpose of life. It is influenced by culture, and is a dynamic life-long experience.

“Mental illness” on the other hand, is a term used to describe a state of mental dysfunction based on international diagnostic criteria resulting in impaired behavior, and/or disability.

Positive mental health is a critical requirement for “well-being”. It is also the foundation for wellbeing. Conversely poor mental health impairs well-being. Positive emotion is much more than mere ‘’. Positive emotion includes hope, interest, joy, love, compassion, pride, amusement, and gratitude. Enhanced wellbeing is referred to as “thriving” or “flourishing”.

Health-related quality of life is another closely related concept which came up as many realized that advanced medical technology did not necessarily improve the life of people. WHO defines the quality of life as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”

The link between mental health and development

“Development” is the gradual functional change in skill-sets, behavior, and habits of an individual or society. Development changes the character of a person. And it takes place throughout life. At a personal level development is acquiring new skills, abilities and capabilities to lead a life and to realise one’s potential – for example in learning, being creative, developing and fostering social relationships etc.

At a social level development entails enhancing the social capital and the resourcefulness of the society. Social capital refers to the cohesiveness of society, trust amongst the members, and a sense of belongingness or inclusiveness to the society. Social capital is built on relationships, values, attitudes, and practices of its members and is determined by culture, history and sociopolitical factors. Some elements of social capital promote mental health and wellbeing.

Increasingly the aim of socioeconomic development is seen as to create an environment to promote mental health and wellbeing. Enabling freedom, capabilities and choices in a society promotes realisation of the human potential to lead a life that they value. The term economic development is therefore now being superseded by the term “human development” and “well-being’.

Determinants of mental health

Biological, social and environmental factors are determinants of mental health. Genetically inherited factors determine about 50% mental health attributes. Early childhood and adolescent experiences, including those during pre-natal life also have a significant influence on health and mental health in later life. The rest of mental health components are acquired and develop during one’s lifetime. During this period mental health is influenced by the environment in one’s home by protective factors such as affection, security and love or lack thereof. Adverse childhood experiences such as trauma and abuse may result in long-term mental and physical health problems. Learning and acquiring of skills continues and there is progressive development of mental health influenced by family, school, work place, community and the environment.

Certain elements of social capital are known to facilitate the development of positive mental health. These include caring, fairness, equality, belongingness, peace, security and trust. Conversely neighborhoods of violence, unemployment, drug use and social inequality give rise to poor mental health.

The environment created by government policies such as those which provide access to basic services, health education, housing and promote values such as respect, dignity, human rights, opportunities to make choices are all important in promoting mental health and enhancing the mental capital. Economic policies play a significant part in mental health and wellbeing because material resources are needed for the development of communities and individuals.

Emerging mental health and socioeconomic issues

During the last few decades there have been significant changes in mental health problems as seen in clinical practice, including in my own practice. Addictive behavior, substance-abuse, relationship problems, inflicting self-harm, anti-social behavior, and violence are increasingly seen in clinical practice today. There is also a significant increase in requests by people for psychological services.

Social problems including ethnic divides and conflicts, and insurgencies have greatly contributed to this change, as one often sees in clinical practice. They have given rise to increasing fear, isolation and discrimination amongst people leading to poor mental health. The stigma and low value attached to mental health, and low mental health literacy continues to be a major hindrance to wellbeing.

Lately, unfavorable economic situations giving rise to poverty, inequities, under-employment or dissatisfying employment have aggravated mental health problems.Furthermore, changing demographic and morbidity patterns, increasing urbanization, migration, changing attitudes and values of people are likely to impact mental health in a negative manner.

Studies have shown that the burden of mental health is a major contributor to the global burden of disease as measured by “Disability Adjusted Life Years” or DALYs. As a result of social, environmental and economic problems the burden of mental health ranks third today in the list of health conditions contributing to the Global Burden of Disease, being second only to heart disease and cancer in its contribution to the Global Burden of Disease. Another startling fact is that mental health impairments contribute to as much as a third of all disabilities in the world. The economic loss due to poor mental health is great, with the World Economic Forum estimating that by 2030 the cost of mental health globally would be around sixteen trillion US dollars. Furthermore, poor mental health as reflected in ‘languishing’, undesirable personality attributes and character disorders are increasingly seen as contributing towards the health and socioeconomic burden.

How effective is our response to emerging mental health issues?

It is well known that in most countries mental health systems are unable to respond to these emerging mental health needs resulting in a “mental health gap”. This is because they have evolved to respond mostly to the clinical needs of people with mental illness disregarding other mental health needs. In Sri Lanka the mental health services are very much based on a “disease model” with a focus on the clinical state of the individual patient. Similarly, present socioeconomic policy makers and practitioners fail to consider the enhancement of mental health as being important. It is increasingly being realized that present services cannot meet the emerging challenges. A more appropriate model would be one based on a public mental health approach on the basis that mental health is a ” public good”. This would consist of approaches to promote mental health and prevent mental illness. Emphasis on mental health promotion and illness prevention is unfortunately limited in the present service organization in many countries. Interventions that promote mental health empower the person to take control of his/her health and its determinants so that it leads to healthy behavior. Primary illness prevention interventions are effective in preventing mental illness. My own experience is that initiatives to respond to emerging new developments are much welcomed by communities but unfortunately the prevailing public services are unable to sustain and integrate such initiatives into the present system. This is mainly due to the fact that the present system is based on the disease model and evolved to respond to mental disorders of individuals – mainly those with mental illness. Besides, all human service sectors tend to work in compartments. The system also lacks the capacity to take a broader view of promoting good mental health.

A more effective system to respond to the emerging mental health needs

Increasingly there is agreement globally that the aim of development is to enhance wellbeing of people, thereby giving them the opportunity to realize their innate potential. Mental health and wellbeing are considered as having an intrinsic value. Improvement of mental health includes enhancement of wellbeing and reduction of the health burden. In most countries especially in the West the broader model of mental health is being used to improve the mental health of people. This is being done through wider health, social and economic policies which are described as “healthy development policies”. Health, social and economic policies are aimed at creating an environment to promote mental health, prevent mental illness, manage people with mental illness, organize mental health activities based on population approaches and improve the quality of life of people with mental health problems. Promotion of mental health and primary prevention of illness approaches are targeted at the community, while other approaches are focused on the individual. Mental health improvement is also the responsibility of the individual by training and learning mental skills and behavior including practicing meditation, yoga and relaxation exercises. Health services have the responsibility of comprehensively managing the mentally ill while the rest of the services are expected to be provided by range of other services including education, social care, housing and judicial services. Efforts are also being made to improve the quality of life of people with mental impairment and disabilities, using several interventions including those based on the “recovery model”. The “recovery model” is one that has been developed by service users, and is based on learning to live with disabilities and to improve the quality of their lives given the disabilities they have. Increasingly “wellbeing” is being considered as the ultimate goal of social and economic development. For example, “wellbeing economics” has emerged as a new area of thinking with the goal of achieving “wellbeing”.

The aim of policies and focus of service organization in mental health have become population-based rather than focusing only on individual care. This public mental health approach is aimed at minimizing inequalities in health outcomes and increasing equity. This is a deviation from the traditional individual approach to mental health.

This approach has already been undertaken in the United Kingdom, New Zealand, many other western countries, and even in some low- and middle-income countries. Bhutan initiated a new approach by introducing a “Happiness Index” as an indicator of development, and it continues to explore even better, more holistic options to measure “development”. In fact, “wellbeing” is referred to explicitly or implicitly in several of the Sustainable Development Goals of the United Nations.

Improving mental health of the people and communities in Sri Lanka

The challenge in Sri Lanka is to improve mental health in the context of a resource-poor country with declining public services and deteriorating economic conditions amidst increasing needs, aspirations and expectations of its people. The situation is made worse by the fact a large number of people with a range of skills are migrating overseas leaving behind a population of dependent people.

In Sri Lanka there is a growing awareness and demand for including mental health components in all other human and social services. Sri Lanka however, tends to work in centralized and compartmentalized sectors with little coordination and integration between them.

My experience is that although there is a growing demand for mental health services, mental health is marginalized, and discussions on it are stifled. The public mental health approach needs now to be embraced by Sri Lanka, placing individual patient care as one component of the broader goal of improving mental health and well-being of its people. We need fundamentally to value mental health as an asset, and consider it an important component of development. Individuals, communities and the government need to take responsibility for improvement of mental health and wellbeing of individuals and communities. Prof Jayasuriya believed in these concepts and introduced many initiatives during his life time to facilitate individual and social development. Let me thank the family of Prof Jayasuriya, the organizing committee and all of you for giving me an opportunity to present these issues for your consideration, and possibly even encourage further discussion.