COVID-19 has brought significant change and uncertainty to people’s lives. Family illness and bereavement, unemployment, school closures and lack of physical contact with family and friends can all lead to increased stress and mental health conditions such as depression. At worst, depression can lead to suicide, which tragically takes the lives of more than 700 000 people each year.
Suicide: a significant public health issue
Even before the COVID-19 pandemic, Bhutan, a country in South-East Asia, realized that suicide was becoming a serious public health issue. Despite being renowned for introducing the term “Gross National Happiness” in 1972, suicide is the sixth leading cause of death in Bhutan. Furthermore, for every four suicide deaths in the country, only one attempted suicide is recorded. This is an indication of significant under-reporting, given estimates that, globally, there are more than 20 suicide attempts for every suicide. In 2015, Bhutan’s Ministry of Health established a multi-year National Suicide Prevention Programme to address this significant public health issue. The country’s Suicide Prevention Action Plan (2018-2023) includes strategies to increase detection of suicidal ideation and respond to ideation and suicide attempts.
At the start of the pandemic, Bhutan had few human resources for mental health, with only two practising psychiatrists and a handful of trained psychiatric nurses and clinical counsellors. Anticipating the mental health consequences of the pandemic and the disruption to mental health services, in March 2020, the Ministry of Health set up, with guidance from the WHO team based in the country, a National COVID-19 Mental Health and Psychosocial Response Team to address mental health and psychosocial needs across the country.
Large-scale training: central to scale-up of mental health and suicide prevention services
Training is a core component of scaling-up services for mental health and suicide prevention. During 2020-21, Bhutan’s Mental Health Response Team trained more than 20 000 frontline workers and community volunteers across Bhutan in identification of risk factors for suicide, how to provide basic psychosocial support to community members in distress and how to make referrals. WHO Psychological First Aid+ (PFA+) guide were adapted and used during these training programmes. The Response Team also conducted over 200 webinars on suicide prevention, mental health, and substance abuse management. Participants shared that, following the training, not only were they able to identify risk factors among community members, but they had also learned to recognize signs of stress in themselves and knew when to seek help.
In addition to frontline workers and community volunteers, 140 first responders ̶ district doctors, mental health workers and clinical counsellors ̶ were trained to manage self-harm and suicide effectively. Funded by WHO, the initiatives included a training-of-trainers programme on suicide prevention and management, with a focus on strengthening Bhutan’s national suicide case registry.
The Response Team also organized a training workshop for media representatives in November 2021 to encourage responsible reporting of suicide. The team developed and disseminated ‘Media Guidelines for Responsible Reporting of Mental Health and Suicide’ during the workshop.
These initiatives implemented in Bhutan are in line with WHO’s LIVE LIFE implementation guide for suicide prevention in countries. The guide, released in June 2021, recommends four key strategies for reducing deaths by suicide: limiting access to means; interacting with the media for responsible reporting of suicide; fostering socio-emotional life skills in adolescents; and early identification, assessment, management and follow up of anyone who is affected by suicidal behaviours.
Reviving a crisis helpline
In addition to capacity-building initiatives, Bhutan’s Mental Health Response Team revived a crisis helpline, staffed by trained mental health professionals. More than 1500 people dealing with mental health problems, alcohol and drug use issues, domestic violence and self-harm have already received support through the helpline. The Response Team has also re-established links between services and referral pathways, enabling helpline callers to access clinical treatment and care when needed. In addition to five dedicated counselling helplines at the national level, 22 other helplines are now available in districts and Thromdes (municipalities) across Bhutan.
Reflecting on the Response Team’s activities, Dr Chencho Dorji, a practicing Bhutanese psychiatrist supported by WHO, noted that “the pandemic provided a unique opportunity to adopt new policies and implement mental health programmes that hadn’t been attempted before, enabling mobilization of human resources for mental health. Moreover, increased accessibility, convenience, and the anonymity provided through telephone counselling encouraged many people to seek help and follow up with treatment ̶ opening the door for scaling up online and telepsychiatry services and suicide prevention in the country.”