illustration of a person sitting on a pillar while the next pillar over starts to crumble with the backdrop of Mount Ararat, as a metaphor for mental health in Armenia

Of Two Minds

Armenia’s ambivalence towards mental health

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.”

People gather day and night to mourn fallen soldiers at the Yerablur Military Memorial Cemetery in Yerevan.
People gather day and night to mourn fallen soldiers at the Yerablur Military Memorial Cemetery in Yerevan.
People gather day and night to mourn fallen soldiers at the Yerablur Military Memorial Cemetery in Yerevan. Photo by ITAR-TASS News Agency / Alamy 

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.

Law and Order 

In May 2004, the definitive Law of the Republic of Armenia About Psychiatric Assistance and Service was ratified. From provisions detailing how many hours a patient can legally be restrained to information on psychiatric evaluations, the law has grown more robust, encompassing civil rights for patients and protections for psychiatric facilities. Despite 10 amendments over the last 17 years, the last ratified in June 2020, it is far from a panacea.

“One law is not enough,” Dr. Soghoyan explains, “there needs to be an ambitious mental health plan, and an implementation plan for it.” Because mental health is relevant to so many facets of civic life—from education to health, social welfare to prisons—it cannot exist on the agenda of just one governmental entity. It must live in the intersections of multiple ministries, among them the Ministry of Health, the Ministry of Social Affairs, and the Ministry of Education, Science, Culture and Sport.

COVID-19 Effect

As all ministries in the Armenian government shifted their attention to containing COVID-19, many projects that were in development were halted. However, the sudden global awareness of anxiety and depression in a moment of collective trauma catapulted the conversation around mental health into the spotlight. No longer the neglected child in the scope of healthcare, mental health is being centered in conversations about staying healthy in such challenging times.

Though ambivalence still seems to characterize the perceptions of mental illness in Armenia today, in the three decades since independence, new legacies have already begun forming. As treatment options grow and therapy is demystified, an increasing number of people are challenging stigmas, putting their health first, and seeking help.

Wartime Aftershocks

September 27 will forever mark a clear before and after in Armenia. The torment of 44 days of war and the uncertainty in its aftermath have amplified the importance of mental health in a nation facing tragedy. A vast majority of people in the country either know someone or has been personally affected directly by the war in Artsakh. As military personnel return to civilian life, many carry the traumas of the battlefield home with them. Due to unprecedented access to the frontline through social media and the onslaught of graphic videos released by Azerbaijan’s soldiers, even those who have not seen the devastation first hand, have been steeped in the visual vocabulary of the war: the faces of the tortured, executed, and disappeared, the drone strikes and burning homes.

The prevalence of complex mental health conditions as a result of heavy psychological traumas has exacerbated the need for trained mental health professionals. Establishing a standard of care in order to diagnose and treat patients effectively continues to depend on licensure and access to quality medication, especially as the number of people presenting with symptoms of PTSD, anxiety, and depression increases.

At the American University of Armenia, Yelena Sardaryan continues to organize workshops, but these days, many more center on managing grief and loss. The majority of the lives claimed by the war were young men, conscript age, often university age; among the fallen, AUA students. University staff is being more proactive in student outreach, reminding faculty to remain mindful and empowering them to engage. Yet, other universities are not as quick to follow suit.

Sardaryan has also noticed that television and radio programs in the country have attempted to integrate mental health topics, normalizing efforts to seek help. Invited to speak on one such program, she was asked to explain how best to approach a loved one who has returned from the front and likely experienced a traumatic event.

“Cultivating a culture in which people accept mental health as health remains our goal, even more so now,” Sardaryan says. With the barrage of troubling news, many in Armenia feel apprehensive about the future, doubting the November ceasefire will translate to sustainable peace. Amplified by the mounting geopolitical hostility regionally and political turmoil domestically, uncertainty has characterized daily life. With it, comes an acknowledgement of the physical and emotional toll of such stress. And yet, only time will tell how much of this current climate translates to the prioritization of access to mental health and its full integration into comprehensive healthcare in the country.

As uncertainty looms, so too does resilience. Where the government has been unable to facilitate access to treatment or provide support, organizations and private individuals have been embracing the challenge. “We remind ourselves that we have seen darker days,” Sardaryan says. “We will continue on, because we are a courageous people, because there is no option not to.”

*Name changed to protect identity. Banner illustration by Peter Ryan

Originally published in the March 2021 ​issue of AGBU Magazine. end character

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