Accessibility and utilization of mental health care in Bali


Toshiyuki Kurihara, MD, PhD, Komagino Hospital, 273 Uratakao, Hachioji, Tokyo 193–8505, Japan. Email:

Underutilization of psychiatric services is one of the most critical problems in the field of mental health care in developing countries. The authors have recently reported on a community-based, door-to-door survey in the developing country of Bali, and revealed that roughly half of individuals identified as having schizophrenia remained untreated and their clinical condition was poor.1 In this research letter, the authors examined the geographic access to mental health care of community-based, screened individuals with schizophrenia and the association between the access and the individuals' treatment status.

The authors' sample comprised 39 individuals with schizophrenia (revised, 3rd edition, Diagnostic and Statistical Manual), screened from 1966 households with 8546 general residents in Balinese communities. Details of the screening method are described elsewhere.1 In brief, the first author, a psychiatrist who speaks Indonesian and Japanese, conducted a face-to-face interview with one family member as a key informant for each of the 1966 households to obtain information on whether they had persons with schizophrenia among their family members using Family History Research Diagnostic Criteria.2 For the suspected cases, a direct interview was conducted for the diagnosis using Structured Clinical Interview (for revised, 3rd edition, Diagnostic and Statistical Manual)3 non-patient version. Of 39 individuals with schizophrenia, 19 had received psychiatric medical treatment at some point after their onset of illness and 20 had not undergone any psychiatric treatment. The time required to go to Bangli Mental Hospital, the primary mental health facility on the island, was measured for each individual with schizophrenia using a speed of approximately 3 km/h for walking and a speed of approximately 40 km/h for driving.

Mean time required to hospital for all subjects was 107.9 min (standard deviation [SD] 47.3). The travel time was significantly longer in never-treated subjects (mean, 133.9 min; SD 34.2) than in treated subjects (mean, 80.5 min; SD 44.1; two-tailed t-test, P = 0.0001).

The result demonstrated that geographic access to mental health care directly impacted the help-seeking behavior of these individuals with schizophrenia. This was a simple but robust finding which points out the problems associated with the limited mental health-care resources in this developing country. Although it may not be easily implemented, improving physical accessibility to mental health care (e.g. reallocation of psychiatric beds) may lead to an increased opportunity to undergo psychiatric treatment for individuals with schizophrenia in Bali.