No matter where you are in Armenia, chances are you can-not go long without hearing the familiar refrain, tsaved tanem. A poetic term of endearment, the phrase literally translates to, “let me take your pain.” Often said without a second thought, it betrays a distinctively Armenian expression of empathy, literally taking on the suffering of another as one’s own.
Despite what seems like a recognition that emotional and mental suffering is part of the human condition, Armenia is a country with a long and complicated history of discussing mental health. 2020 was a year that would dramatically shift that conversation: globally, as COVID-19 ground everything to a halt, and nationally, as the autumn war ravaged Artsakh. In Armenia, the toll of a devastating pandemic amplified by a catastrophic war, and the uncertainty left in its wake, has translated to an ongoing national tragedy. While the nation grieves collectively, many have been dealing with the traumas of the recent year individually.
Today, life experiences, along with genetics, brain chemistry, and family history are all understood to impact mental health; mental illnesses, like any other illnesses, are known to often be out of a person’s control. In the face of so much suffering, struggling with mental health is not uncommon, and yet, it continues to be discussed in hushed tones in Armenia, shame often hanging on to every word.
Myths of Madness
The World Health Organization reports that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. This means that approximately 450 million people, living in every country in the world, will likely contend with the stigmas and infrastructural obstacles to accessing mental health care in their communities. That is, if they seek it. Nearly two-thirds of people with a known mental disorder never seek help from a health professional.
“As in many countries in the world, the stigma that surrounds mental health is significant in Armenia,” Dr. Khachatur Gasparyan, Chair of the Medical Psychology Department at the Yerevan State Medical University and Chief Psychologist at the INTRA MH Centre, states. A multitude of diverse factors contribute to dangerous misconceptions about mental illness and those who deal with them.
Notably, mass media, from news reports to popular shows, generally reference mental illness alongside particularly heinous crimes, like homicide. “This creates a false image that all mentally ill patients are dangerous,” Dr. Gasparyan explains. In addition, the singular representation of severe mental illness maintains the inaccurate impression that all mental illnesses are untreatable; as opposed to physical conditions that also lack cures, like diabetes, mental illness carries a marked level of hopelessness.
As treatment options grow and therapy is demystified, an increasing number of people are challenging stigmas, putting their health first, and seeking help.
“When seeking a diagnosis and pursuing treatment is rife with stigma, it becomes more difficult for mental health professionals to build strong, therapeutic relationships with their clients,” Dr. Shakeh Kaftarian, medical psychologist and co-president of the Armenian American Mental Health Association (AAMHA), notes. In Armenian society, a spectrum of conditions that require unique treatments—from depression and anxiety, to schizophrenia and bipolar disorder, and even types of epilepsy, cerebral palsy and dementia—are often dangerously reduced to one word by the public: crazy.
Furthermore, in a country in which ethnic Armenians make up more than 97% of the population, straying from majoritarian mores is still met with condemnation. “There is this dual definition of stigma,” Marianna Pahlevanyan, a practicing psychologist in Yerevan, contends. “On one hand, there is a stigmatization of mental illness and, on the other, there is a rejection of alternative lifestyles and opinions, be they political or cultural.” Conflating dissent with a diagnosis of mental illness creates a lens through which a person is ultimately seen as a pariah.
The myths surrounding mental illness amplify misinformation and obscure nuances. This means that while these illnesses can be as debilitating as some of the worst physical ailments, and there may be resources available, the diagnosis, treatment and management of mental conditions remain missed opportunities.
An Open Mind
Marred by overmedication and institutionalization, the legacy of dealing with mental health in the Soviet Union cannot be overlooked for its influence on how mental illness is still perceived in parts of Armenia. For decades, psychiatry reigned supreme, occasionally used to discredit political opposition, while psychotherapy was banned by Soviet authorities altogether. This meant that the cornerstones of treatment were medication and institutionalization. Often, instead of focusing on ways to integrate those with mental illness into society, the default was to isolate them in institutions; the lines between treatment and punishment were blurred. Both the physical and societal infrastructures created for this approach still prevail.
Tragedy formally introduced psychotherapy into Soviet Armenia. In 1988, when the Spitak Earthquake devastated the country, the influx of humanitarian aid, including mental health professionals from across the spectrum, meant that psychological services and not just psychiatric interventions became more accessible, more broadly understood, and more likely to be sought out. In fact, Armenia was the first country among the former Soviet republics to establish out-patient psychological centers to treat its citizens.
Despite the head start—and the progress throughout almost three decades of independence—Dr. Gasparyan notes that 90% of the resources and budget allotted towards mental health in Armenia today is still committed to in-patient treatment, leaving only 10% to out-patient initiatives, facilities and preventative programs.
In October 2017, when Dr. Dainius Pūras, UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health, toured Armenian healthcare facilities, he noted a “legacy of outdated mental health policies and services reliant on large psychiatric hospitals and long term care institutions.” Currently, there are three main mental health institutions in Armenia—two in Yerevan and one in Sevan—along with smaller institutions in Gyumri, Vanadzor, Kapan and Vardenis. Dr. Pūras warned against the expansion of segregated psychiatric institutions and identified a damning pattern in the Armenian mental health system: “people with mental health conditions are too easily and too often hospitalized in psychiatric hospitals, tend to be overmedicated, and then confined for long periods of time in large institutions, labelled as chronic patients.”
Limitations and Licensure
Official statistics collected by Armenia’s National Institute of Health do not accurately reflect the population’s utilization of mental health services as they only reflect data gathered from public facilities, like those referenced by Dr. Pūras. Information from private facilities, both those providing psychological services and psychiatric services, is not collected. This gap in data is significant when considering the healthcare landscape in the country, especially as more people turn to private facilities for treatment. In order to understand the spectrum of treatment available in Armenia today, understanding the difference between the types of mental healthcare providers and the realities that dictate their work is also paramount.
Because of the ban on psychotherapy, psychiatrists—medical doctors with a specialty in psychiatry, who can prescribe medication to patients as part of their treatment—represented mental health in Armenia for almost three generations during the Soviet era. Today, there is a profound lack of psychiatrists throughout the country, even in Yerevan. “In some provinces, we have only one or two psychiatrists,” Dr. Armen Soghoyan, President of the Armenian Psychiatric Association and Editor in Chief of the Armenian Journal of Mental Health, explains. More stark is the lack of child psychiatrists, of which there are only 10 in the whole of Armenia.
This shortage means that while public hospitals throughout the country provide psychiatric care free of charge, and the doctors working in these facilities are skilled professionals, they will see 20-30 patients a day and only be able to dedicate a maximum of 30 minutes to each consultation. In contrast, psychiatrists working in private facilities will be able to take up to an hour with each patient and generally see only five patients a day. Not only does this lead to the exhaustion of individual doctors, it can compromise diagnosis and treatment.
In the last thirty years, with the integration of psychotherapy into mental healthcare, there has been an increase of psychologists in Armenia. Unlike psychiatrists, psychologists—who treat the emotional and mental suffering in patients with behavioral intervention, like talk therapy—are not medical doctors and so, a gamut of academic and professional experience, or lack thereof, could describe their qualifications in Armenia. Currently, there is no institution of licensure that regulates practicing psychologists so someone with an undergraduate degree who studied psychology, with little to no practical training, could begin treating clients as a “psychologist.” Licensure, or becoming licensed to practice with patients, would set a national standard of care, providing guidelines for formal education, supervised field exposure, and continuing education for mental health professionals.
Cultivating a culture in which people accept mental health as health remains our goal, even more so now.
“No one ministry or government entity yet oversees a psychologist’s work, which creates a serious threat to quality assurance,”Yelena Sardaryan, senior counselor and coordinator of Counseling Services and Disability Support Services at American University of Armenia, observes. In her role at AUA, the only higher education institution in the country that provides counseling services to students, Sardaryan is keenly aware of how this lack of standardization impacts both patient and provider. Mental health professionals are not mandated to go through evaluation and so there is often little attention paid to the management of their own mental health. “If you don’t have your therapy, you will not be able to properly support a person who needs therapy.”
The Drug Dilemma
Engaged to be married, Aram* was 23 years-old when he was officially diagnosed with schizophrenia. On average, 50% of mental illness begins by age 14, and three-quarters begins by age 24. Though he had often struggled with concentration, when Aram started experiencing bouts of crippling paranoia and sudden mood swings, his father convinced him to see a doctor. As soon as he was diagnosed, his fiancée’s family found out, the wedding was called off, and Aram’s journey through Armenia’s mental healthcare system began.
After an episode brought on by the stress of the diagnosis, Aram was admitted to an in-patient psychiatric facility in Yerevan, where he was soon prescribed the generic form of the antipsychotic medication Olanzapine. Though his family’s support meant he could continue managing his symptoms at home, Aram began feeling weak, too tired to walk but unable to sleep. Going without the medication meant the return of his most severe symptoms, but taking it meant an agonizing deterioration of his physical health.
“While there are common symptoms associated with different types of mental illness, each patient has a unique experience managing the illness—and that includes medication.” Dr. Soghoyan maintains. A 2014 study on the side effects of Olanzapine prescriptions, published in the Armenian Journal of Mental Health, found that the drug in its generic form leads to increased disability in younger patients, calling for the usage of the safer, brand-name Zyprexa.
Not only is overmedication when treating mental illness in Armenia notable, so too is the lack of access to safe, quality medications when it is essential, like in Aram’s case. In fact, in his official 2019 Report on the State of Protection of Human Rights and Freedoms, RA Ombudsman Arman Tatoyan references the dangerous case of generic Olanzapine prescriptions when urging the Armenian government to reconsider the procurement process for all medications, not just those associated with mental illness, approved in the country. Changes to the official medication list have been made in the last two years but the government’s procurement process for all medications generally prioritizes price over quality.
Beacons of Light
The alternative to overmedication and institutionalization Dr. Pūras suggested, which some in Armenia had already embraced, was providing diverse treatment options through community-based services. Instead of a singular approach to mental health, professionals trained in a variety of methods, operating outside of institutions and in the community, would not only make treatment less daunting, but more accessible.
“More training translates to more effective treatment,” Izabella Ghazaryan, psychologist and lecturer at Yerevan State University explains, noting the increase of services available through both governmental and non-governmental bodies, and private practices.
“The goal is to move away from long term facilities and invest in community care homes,” Dr. Gasparyan explains, praising the Spitak Care Centre. Integrated into the community, the facility champions the autonomy of the 16 individuals currently living and receiving treatment there.
At AUA, Sardaryan is doing her part to provide alternatives to silence and suffering. Though the university began offering counseling services in order to receive its international accreditation status, it has since invested in the initiatives she has piloted: organizing workshops on soft skills and self-care, providing materials on various disorders, and training faculty to understand student mental health. Met with a range of often undiagnosed conditions, from eating disorders to autism, there is a growing number of counselors at AUA working towards dismantling stigma one student at a time.
“We try to communicate that seeking help is a sign of strength,” Sardaryan explains. “There has been a 600% increase in the number of students who use our services from just five years ago, when we started.” The goal is to make therapy a given, something that is a part of maintaining good health and is available at all educational institutions, especially those of higher learning. This way, students will grow to accept and expect certain services well after graduation.