Changing Landscape of Mental Health from Early Career Psychiatrists’ Perspective in Indonesia

Overview of Indonesia’s Mental Health Landscape

Indonesia is a large archipelago country in Southeast Asia, with a population of more than 270 million people spread across 17,508 islands.^1,2 Mental health services using a modern medical model can be traced back to the Dutch Colonial period, where the treatment was mainly provided in asylums.³ In today’s era, despite some important breakthroughs, such as the ratification of the Mental Health Act and the implementation of Universal Health Coverage in 2014, the status of the Indonesian mental health system is still viewed as underdeveloped and falls behind its neighboring countries.^4,5 This perspective is reflected by the facts of low government funding for mental health, the low availability of mental health professionals, and the high treatment gap.^6,7 Indonesia has a mixture of public and private health financing,⁸ with up to 60% private sector contributions from non-governmental organizations (NGOs) and for-profit companies.⁹ The health expenditure, in general, was about 2.8% of the gross domestic product (GDP) before the Covid-19 pandemic, one of the lowest among countries in the region.⁸ Moreover, only 2% of the health expenditure were allocated for mental health, and 66.1% of mental health expenditures were directed to mental hospitals.¹⁰ While national insurance covers routine psychiatric consultation and treatment, paying out-of-pocket for psychotropic medication¹⁰ and psychotherapy is not uncommon for people with mental disorders.

The national basic health survey, or Riskesdas, showed that the proportion of patients with depression who received evidence-based treatment is only 9%. Although the treatment gap for schizophrenia is not as high as for depression, of which 84,9% received treatment, more than half are not on continuous treatment.⁷ Confinement is still occurring in several parts of the country, thus posing a serious human rights challenge.^11–13 Due to a lack of accurate knowledge from the family and society and a lack of access to continuous care, it is sometimes reported that patients released were re-shackled as their condition deteriorates and there are no accessible mental health services.¹⁴ Our experience working with a community health worker in a more rural/peripheral setting has also revealed this phenomenon of re-shackling. It is also common that patients with mental disorders are often stigmatized as lacking faith and not brought to mental health professionals but spiritual leaders instead.¹⁵ In summary, patients with mental disorders often do not receive the care they need and are stigmatized by society due to a lack of accurate knowledge about mental health. The Indonesian mental health system still needs to be continuously refined by improving the political commitment and leadership and increasing participation from various stakeholders to derive the Mental Health Act into a more practical form for optimal implementation.^5,16,17

Pandemic, Young People, and Increasing Awareness of Mental Health

Meanwhile, there is a different side of the story about mental health in Indonesia. While severe mental disorder, such as schizophrenia, is still an important issue to address, there has been a shift in the presentation of a patient coming to psychiatrists’ clinical practice. From our experience, in alignment with Bikker, Tiliopoulos, and Lesmana⁵ findings, the patients are typically younger, have more information (though not necessarily accurate ones), with mood or anxiety or personality-related disorders (“neurotic” disorder). It is not surprising considering the current data about mental health and the pandemic show that young people are at the highest risk for depression, anxiety, and post-traumatic symptoms.^18–21 Faced with these mental health problems in young people, early interventions are invaluable in reducing the mental health burden and improving public health outcomes.²²

Despite the prevalent stigma, there has been an increasing awareness about mental health among young people that drives them to seek professional help. Our observation in the social and mainstream media also reveals that mental health topics are become more frequently mentioned in public discussion, with some popular psychology phrases such as “trauma,” “toxic relationship,” and “narcissistic” pervading. It is also not uncommon to find several live sessions, by experts or patients, on one of the social media platforms addressing such issues during primetime hours. While this development has been generally deemed positive, there are also concerns that inappropriate uses of psychological terms in popular language might mislead and enhance stigma toward mental disorders.^23,24 We support this view by calling for a deeper reflection on the original purpose of psychological terms, which is ultimately for the treatment and benefits of the patients.

Adding to these concerns is the risk of mental health from social media, such as misinformation and loneliness, which is also quite common in our observation among younger patients, especially during the Covid-19 pandemic.^25,26 However, technology and social media are not necessarily related to negative impacts, as there has been an increased use of such mediums to improve mental health, such as online support groups, chats, and e-mental health consultations during the pandemic situation.^27,28

Moving Forward to Address the Problem

Several recommendations can be made considering this changing landscape. At the policy level, it is important to develop a national strategic plan derived from the Mental Health Act to address the challenge of shackling and re-shackling. The policymakers and related stakeholders can design the development and integration of mental health services into primary care. The integration will be important to ensure continuity of care to prevent unwanted outcomes such as re-confinement of individuals with severe mental disorders. Strengthening primary care is imperative to enable the smooth process of task sharing.²⁹ Earlier studies by Praharso⁴ indicated that the knowledge and attitude of primary care staff are not optimal; however, it should not be an argument to reject the task-sharing strategy and instead be an impetus to invest more in the training of primary care staff.

A strategic plan derived from the Mental Health Act needs to address “common” mental health disorders such as depression and anxiety. The evidence is also compelling that young people, in particular, need to be the target population for early intervention since many mental disorders onset occurs in this period and are most affected by the pandemic.^20,30 A pragmatic trial by Anjara et al.³¹ showed that primary care staff could provide mental health care for common mental disorders with a comparable result with a specialist, given proper training and support. Another interesting trial in Indonesia by Arjadi et al.,³² who used internet intervention (a web-based therapy on the behavioral activation principle) to address depression in the community, also supports the task-sharing approach. This trial recruited trained lay counselors to provide human support in adjunction to the internet intervention under the supervision of mental health professionals.

In conclusion, the findings are consistent with other research on the global scale on the task-sharing issue.³³ Therefore, perhaps it is promising to invest more in the task-sharing approach combined with internet intervention (e.g., internet-based cognitive behavioral therapy, guided or unguided) to address the treatment gap issue faced by the country.³⁴ There has also been a growing discussion of using an “indirect approach” to prevent and treat depression by aiming the intervention on daily problems related to depression, such as insomnia, perfectionism, and procrastination.³⁵ This approach will help overcome the barrier to mental health care access caused by stigma and could be more readily adopted in a task-sharing framework by primary care staff.

This shift of epidemiological burden towards common mental health disorders is also relevant to psychiatry education in medical schools. The teaching focusing more on severe mental disorders, such as psychotic patients in the mental hospital ward, needs to be adjusted to address contextual challenges such as depression and anxiety among urban adolescents.³⁶ The education is obligated to equip aspiring professionals to deal with these issues they will commonly encounter in general medical settings.

Lastly, policymakers and practitioners are encouraged to take a multisectoral view in addressing these issues. Given that more young people are at high risk for developing mental disorders such as depression, it is important to reach out and collaborate with the educational or school sectors for early intervention by using preventive measures and targeting those with early symptoms such as subthreshold depression.³⁷ Available evidence, though not robust in quality, suggests that mindfulness-based intervention effectively improves various psychological outcomes such as cognitive performance, emotional problems, and resilience of students in schools.³⁸ There have also been some trials in a college setting that attempts to address the issue using internet intervention, which suggests that digital innovation is promising.^39,40

Conclusion

From the authors’ contextual perspective, the landscape of mental health in Indonesia is changing. The challenge of severe mental disorder treatment gap, stigma, and lack of knowledge of mental health remains. At the same time, the challenge of common mental disorders is rising, particularly depression and anxiety. Urgent responses at multiple levels are required to address these problems. A practical policy is required, such as integrating mental health into primary care as its core strategy and young people as a vital target population. The changing landscape also has an impact on psychiatry education in medical schools. Lastly, multisectoral approaches, such as involving school stakeholders in early intervention, are required to address the mental health burden in young people. Digital innovation such as internet interventions could also facilitate task-sharing in various settings. These suggestions will also require the stakeholders to reorganize public mental health funding and shift the focus from the hospital toward integrated community-oriented services.