A Review of the Perceptions of Mental Illness and Mental Health Literacy in Indonesia

differing in The aims explore the different perceptions towards mental illness and the levels of mental literacy among research By garnering a wider understanding of the aspects that towards the perceptions of mental health, researchers may be better equipped to improve and approaches towards and mental health of the overall Indonesian population.


Introduction
The perceptions of the public about mental illness often develop from one's own knowledge of mental illness, interactions with someone struggling with mental illness as well as culture -specific perceptions or stereotypes (Choudry et al., 2016). These views and beliefs are further shaped by religious, sociopolitical and cultural beliefs, as well as the differing views, values and attitudes towards the medical model of diagnosis, the potential causes of mental health disorders, and the approaches to mental health treatment and management. Communities may possess strong and sometimes skewed perceptions of mental illness, and many of these concepts are based on persistent local systems of belief. These beliefs and attitudes that the public hold on mental illness may further determine the quality of interactions, the types of opportunities, as well the kind of assistance received by those living with mental illness (CDC, 2012). Unfortunately, views and attitudes towards mental illness do not necessarily adhere to scientific findings, and as a result, may lead to unfair and stigmatised treatment of those with mental illness (Ventevogel et al., 2013). Consequences experienced by individuals with mental illness include social avoidance, exclusion from day-to-day activities and worst still, exploitation and discrimination (CDC, 2012). Negative stigma prevents efforts in reducing or delaying the onset of mental illness as well as preventing the awareness regarding the importance of early intervention of treatment (Weiss et al., 2006). Untreated symptoms influenced by negative perceptions may lead to grim consequences for people living with mental illness, and as a result, negatively impact families affected by these disorders (CDC, 2012).

Mental Health in Indonesia
Indonesia, with a population of approximately 270 million people, is the fourth most populated country in the world. From this, sixteen million of the population (6 per cent) aged 15 and older have displayed symptoms of anxiety or depression, and approximately 400,000 individuals struggle with more serious forms of mental illness. Moreover, a suicide occurs every hour, with 3.4 suicides per 100,000 people (Badan Penelitian dan Pengembangan Kesehatan, 2013). The prevalence of mental disorders in the Western Java Province had increased from 296,943 people in 2012 to 465,975 people in 2013 (Pusat Data dan Analisa Pembangunan Jawa Barat, 2014), with the highest incidence of severe mental health problems found in Jakarta (20.3 per mile) (Badan Penelitian dan Pengembangan Kesehatan, 2013). Social factors such as poverty, unemployment, crimes, disasters and political instability play a significant role in the increase of mental health sufferers in Indonesia. The mental health system in Indonesia is further strained with only about 800 psychiatrists (0.3 psychiatrist per 100,000), 450 psychologists and 48 mental health facilities, with almost half of all the psychiatrists located in Jakarta, and with half of all the mental health facilities being located in only four of 34 provinces in Indonesia. (Our Better World, 2019). Further, social barriers resulting from mental health stigma and a lack of knowledge, contact and low mental health literacy levels further complicate help and treatment seeking efforts. Unrelenting mental health stigma and a lack of mental health literacy may affect the treatment given to those who need it, especially to those from the middle and lower class in populations where mental health services is a rarity (Damayanti et al., 2017).

Stigma and Perceptions of Mental Illness
Stigma plays a significant role in the lives of people with mental illness as well as their families. It impacts the experience of their illness and their access and approach to seeking available health services. In Indonesia, as in many parts of the world, people with mental illness are often viewed and thought upon as aggressive, dangerous, violent, unpredictable, having a lower capacity to handle responsibility, and more likely to commit offenses or crimes. These negative perceptions lead to much fear and social distance from the community (Bennett & Stennett, 2015;Ross & Goldner, 2009). Subu and colleagues (2021), in their qualitative research of interviewing 25 family members of individuals with mental illness, found that that misunderstanding and stigma about mental illness led to the individuals and families of those with mental illness to be rejected or completely separated from their community, suggesting stigma as a true challenge in seeking help for their loved ones and themselves. People with mental illness in Indonesia are often deemed as dangerous, irreligious, difficult to engage with, and are often widely categorised as 'crazy' or 'insane' (Tristiana et al., 2018). Further, Wahyuni and colleagues (2017) in their research found that spirituality plays an influential role in the prevailing stigmas, including the belief that one's struggling mental health condition was a punishment from Allah, or God according to the Muslim faith -the predominant religion in Indonesia. These types of beliefs may continue to reinforce stigmas towards those with mental illnesses, although, it may not necessarily affect help seeking for mental health challenges.
Stigma attached to having a family member with a mental illness seems to be common in the Indonesian community, but the level of stigma may differ between families. While some perceived high levels of stigma and attempted to hide their family member's illness from the community, others reasoned that the mental illness was granted by God and held positive attitudes toward treatment, and therefore, felt less stigmatised (Marthoenis et al., 2016). These experiences of perceive stigma may profoundly affect the patients and their family members. In Indonesia, mental health stigma is perceived not only by members of society, but also among professionals in healthcare (Subu et al., 2017). Subu and colleagues (2017) in their study of exploring mental illness associated stigma in 15 nurses and 15 patients from a psychiatric hospital in Indonesia, found that the stigmatization of mental illness was prevalent in mental health professionals and staff as well as governmental institutions and the media. Health professional workers' attitude towards those with mental illness may have the strongest negative impact, where research findings have shown that a negative experience with a health professional may result in the patient ceasing their current treatment or leading them to choose another mental health service instead (Motjabai et al., 2010).
Demographic factors may also play a substantial role in the perceptions of mental health disorders and illness among Indonesians. Onie and colleagues (2021) investigated whether the prevalence of stigma was influenced by certain demographic characteristics of age, marital status, religion, education, income, and household income. The results revealed that while the prevalence of social stigma (that is, public stereotypes about those with mental illness) did not differ as a function of demographics, the variables of education and household income were negatively correlated with self-stigma (that is, negative self-beliefs about one's own mental illness that impact self-esteem), where individuals who had a higher household income and education were less likely to internalise stigma. Hartini, and colleagues (2018) assessed stigma and mental health knowledge, and reported that younger people had higher stigmas, and individuals were less likely to stigmatize as they got older, presumably because maturity of thought and behaviour is to be gained as one ages (Hsiao, Lu & Tsai, 2015).
A form of discrimination that has resulted from stigma toward people with mental illness in Indonesia is the practice of Pasung [to restrain or confine] (Lestari & Wardhani, 2014). Pasung, which is the practice of confining and restraining the mentally ill, is unfortunately common, with a recorded 1,655 cases of Pasung against people with mental disorders in Indonesia. Pasung appears to be practiced more in rural communities and is often perpetrated by family members from the lower income group (Hartini et al., 2018). A number of antipasung programs have been carried out, such as Indonesia Bebas Pasung [Pasung-free Indonesia] and Jawa Timur Bebas Pasung [Pasung-free East Java]. However, despite efforts to eliminate this practice, repeated delays of the year of completion for these program goals have been pushed from 2015 to 2019, therefore delaying these honourable intentions (Hartini et al., 2018).

Mental Health in Indonesia
One way to challenge and reduce negative stigmatic attitudes and practices towards mental illness is through education (Corrigan & Shapiro, 2010). Knowledge is important for changing stigmatic beliefs against people with mental illness by reducing prejudice, creating and increasing awareness of mental disorders, as well as in reducing and eliminating stigmatizing labels (Corrigan & Shapiro, 2010). Conversely, poor mental health literacy may result in delays of help seeking behaviours in patients, which in turn prevents proper care and increases incidence of treatment omission (Henderson et al., 2013). Kristina, and colleagues (2020) carried out a survey-based cross-sectional study, that aimed to measure the mental health literacy among university students in Yogyakarta. 650 health and non-health related field students participated in the study, and researchers found that mental health literacy among university students in Yogyakarta was relatively poor. Another study that echoed these findings explored 130 adolescent students' general knowledge of mental disorders in Surakarta, Indonesia through open ended questions, and results revealed that students' mental health literacy was inadequate (Asyanti & Karyani, 2018). Their recognition of symptoms were limited to behavioural symptoms of mental disorders and not emotional or cognitive symptoms, and participants mistakenly claimed that experiences of stress, a lack of self-confidence and a lack of problems solving skills as mental disorders rather that psychological symptoms or experiences. Research by Willenberg and colleagues (2020) found similar findings, and concerning evidence found that adolescents believed that poor mental health would not impact or would 'exempt' them from a mental disorder, where stigmatized views dominated. The participants did not explore the common symptoms of poor mental health, and did not possess information of common mental disorders, nor the notion of the how struggles of mental health are very much relevant to a normal human experience. This lack of mental health literacy in Indonesian students is worrying as it may result in an increased risk of developing moderate to severe depression, and thus, a call for a universal mental health literacy program is crucial in lowering this risk (Lam, 2014;Jorm, 2007).
Among family members, a delay in seeking assistance from mental health services was substantially influenced by the lack of knowledge and low literacy with regards to an understanding of mental health disorders (Marthoenis et al., 2016). Supernatural beliefs were attributed as the cause of mental illness, with many believing that ghosts, black magic, being possessed, sorcery, or the casting of spells on one, as some possible reasons underlying the mental health illness of their family member. These supernatural causes of mental illness were often referred to as sakit kampung [sakit = sick, kampung = village] which led family members to berobat kampung [berobat = to seek medication], which is to seek care and help from traditional healers. Using traditional healers as a first point of contact for assistance often led them to be misinformed, where healers provided inappropriate information about mental disorders and occasionally prevented families from getting help from a healthcare professional. Families only reached out to mental health professionals once the repeated treatments from traditional healers failed and did not show to help the person with mental illness's condition (Marthoenis et al., 2016). Perceived and experienced stigma and a lack of mental health knowledge or literacy may play a significant role in determining the degree to which one seeks help and treatment and in turn determine a possible prognosis of an individual with a mental illness (Langholz, 2014;Braun, 2013;Shidhayea & Kermodeb, 2012).
The involvement of the family member in help seeking is persistent among Asian cultures, and is similarly reflected in Indonesia. Families, as discussed earlier, continue to play an active role in deciding the form of treatment, and provide financial support and care treatment (Scheppers et al., 2006), and therefore are to be considered in matters of treatment planning (Marthoenis et al., 2016). In addition, School-based psycho-educational interventions have been found to be successful in reducing stigma, promoting young peoples' mental health literacy, and increasing mental health literacy in higher and lower income countries (Weare & Nind, 2011). Besides education, contact is another approach to reducing stigma associated with more positive attitudes towards mental illness (Penn& Couture, 2002). Research findings showed that knowing or having direct contact with individuals with mental disorders was associated with more positive attitudes toward mental illness (Henderson et al., 2013;Kelly, 2014;Radhakanth et al., 2016), and interventions may truly benefit by including a component of creating opportunities for direct contact between the public community and those with mental disorders. The Indonesian government has also put forth various interventions in dealing with issues pertaining to mental disorder treatments, namely through continuing to provide an all-inclusive and sustainable mental health service, supplying the needed resources to support mental health services in all regions of Indonesia (including drugs, medical devices, health professional and health workers) and advocating community efforts to implement preventive and promotive interventions, and to increase the early detection of mental disorders as well as to implement rehabilitation efforts of individuals with mental illness (Tristiana et al., 2018).

Conclusion
While the Indonesian government continues to work towards improving the mental healthcare system in its developing nation (Tristiana et al., 2018), much work still needs to be done in order to transform the largely negative perceptions towards individuals with mental illness. Anti-stigma campaigns and interventions, along with education and contact-based approaches may provide positive changes in mental health perceptions and knowledge, and in the long term, a sense of hope that those with mental illness receive the support, care and understanding that they need in order to improve their sense of well-being and belongingness within their communities.