WikiJournal Preprints/Mental health in Sri Lanka

Mental health continues to be a critically relevant topic as the island nation has experienced decades of violent ethnic conflict, terrorist attacks, war crimes, and economic disruptions. Sri Lanka has only recently exited the climaxes of a severe economic crisis in from 2019 to 2024, a nearly 30-year civil war ending in 2009, a 2019 terrorist attack, and continues to face the ripple effects of the 2004 Boxing Day tsunami. The exact effect these major events have had on mental health in the country is "unknown", but the statistics remain alarming despite a declining trend.

Suicide rates in the country during the mid-1990s were the second-highest in the world with ingesting toxic products being the main suicide method. Despite the decline in suicide numbers since then—possibly attributed to Sri Lanka's ban on toxic products—evidence from a 2023 study reports an upward trend in suicide through hanging from 2016 to 2021—independent of the COVID-19 pandemic. Several risk factors for suicide, such as poverty and economic instability, are still prevalent and even increasing in the country to this day^[1].

Methods

[source selection process]

Historical Development of Mental Health Services

In the 1800s, established care for mental health began shifting primarily from indigenous practices, mainly derived from Ayurveda medicine, Siddha medicine, and Unani medicine, to a Western model^[2]^[3]. [pull more info from https://www.researchgate.net/publication/342354982_Development_of_civil_commitment_statutes_laws_of_involuntary_detention_and_treatment_in_Sri_Lanka_a_historical_review maybe?]

Adoption of a Western-based mental healthcare model and issuances of ordinances

In 1839, James Alexander Stewart-Mackenzie, the 7th Governor of British Ceylon, released the Lunacy Ordinance, authorizing municipal authorities to create lunatic asylums for the mentally ill in the country^[2]^[4]. The ordinance was concerned with the legal frameworks of detaining individuals considered dangerous to others or individuals falsely presenting themselves as mentally ill, and not on medical treatments to alleviate the conditions of detained individuals. UK psychiatrist Edward Mapother critiqued the ordinance during his 1937 inspection of British Ceylon's mental health institutions in a series of reports titled A Disgrace to a Civilised Community, remarking that the ordinance "[did] not seem to have contemplated treatment as a contingency to be considered"^[5].

In 1840, the 1839 Ordinance was repealed and replaced by the 1840 Ordinance. The 1839 Ordinance was almost identical to the 1840 Ordinance, except the removal of two previous requirements: the requirement for official medical diagnoses of the mentally insane and the mandate to maintain adequate staff-to-patient ratios within lunatic asylums^[6].

In 1873, a third Ordinance was released. It included linguistic changes, where the term, "insane", was replaced with "of unsound mind". The Ordinance also gave more power to medical professionals in determining insanity diagnoses, and more power to detainees in appealing their commitment to the mental asylum. Despite this Ordinance being the most comprehensive outlook on mental healthcare in the country at the time, the legal frameworks behind the detainment of the criminally insane were left identical to previous ordinances^[6].

Development of mental asylums

At the time the 1839 ordinance was released, mentally ill patients were placed either in prisons throughout the country or leprosy hospitals, such as the Hendala Leprosy Hospital in the Gampaha district^[2]^[6]. After the creation of the first mental asylum in Borella in 1846, patients from the Hendala Leprosy Hospital were transferred to the institute in Borella. Overcrowding soon became an issue and patients institutionalized at the Borella mental asylum were sent to prisons across the country.

As medical institutions were being made to house the mentally insane, another mental asylum was created in the Cinnamon Gardens area of Colombo in 1884, though this mental asylum faced overcrowding in just one year^[2]. Treatment in these asylums was limited to occupational and protection therapy, failing to provide treatment for the root causes of the mental disorders.

In 1926, the Angoda Mental Hospital was established, scantily alleviating the severe overcrowding issues that were plaguing the preceding mental asylums. Despite the addition of 1,700 beds to the facility, treatment was still vastly limited and the patients were left in significantly poor conditions.

Edward Mapother's 1937 inspection of British Ceylon

Edward Mapother was born in Dublin, Ireland, on July 12, 1881 and moved to London when he was 7 years old^[7]. Mapother attained his M.D. in 1908. While Mapother was the Medical Superintendent of Maudsley Hospital in London, England, he was invited to inspect British Ceylon's mental health institutions by Dr S. T. Gunasekara, the first Medical Director of British Ceylon^[5].

In Mapother's visit, he commented that the Angoda Mental Hospital had the atmosphere of "a prison that is neglected and dilapidated"^[5]. Overcrowding was still a major issue, with the institute hosting 3,000 patients—more than double the intended capacity. Patients were sleeping on mats and were clearly out of reach of adequate treatment. Mapother also noted that only 4% of public health expenditure in the country was being set for hospitals, drawing a stark comparison to London's 25%^[5]. Mapother offered a vivid and grim account of the hospital in his reports:

The floor, roof and walls of each cell consist alike of drab cement without any attempt at colouring or decoration. High up in one wall is a small window with stout iron bars. In the floor is a large hole into which the patient may pass his motion and urine. These cells are incompletely divided from one another by a partition which does not reach the roof so that the noise and stink from any one cell may reach at least all the others of the same row. Into these empty cells I was informed that the most noisy and troublesome patients in the hospital; were turned at night completely naked. The doors of the cell contain no observation window, and considering the violent character of many of these patients there is every ground for believing that the doors are rarely opened in the night by the solitary attendant on duty. It needs little imagination to picture the suffering of any patient in an early stage of bodily illness passing a night under such conditions, a situation which must frequently arise. I am told that the noise proceeding from this building is like that on a bad night in a menagerie^[2].

Mapother proposed a series of reinforcements to the legal, institutional, and medical frameworks of mental health care in British Ceylon. This included the decentralization of the psychiatric services, a reworking of the Lunacy Ordinance to incorporate treatment into the legal framework, and the establishment of a separate service of medical professionals dedicated to psychiatry. Mapother's recommendations led to several of the best local medical professionals to be sent to London for extensive training in psychiatry, while nurses from England were sent to British Ceylon to supervise hospital operations and train local staff^[2]^[5].

On August 25, 1938, the Executive Committee of Health approved the strategies proposed by Mapother, though the Government was unable to fully implement all of Mapother's interventions due to the 'heavy cost'. In fact, the Government decided to forego one of his proposals, which was the suggestion of a "Visiting Committee". This committee was tasked to "meet at the hospital, carry out inspections, and make recommendations" to the Executive Committee of Health^[5]. The Government realized that deficiencies in their mental healthcare system could prove to be "costly" for their reputation. Mapother was reportedly enraged when he found out. Mapother intended to contact the Secretary of State regarding the "distortion" of his plans, but was interrupted by events preluding to World War II^[5]. Mapother passed away on March 20, 1940, without materializing his follow-up plans.

Post-Mapother developments and further innovations

Mapother's insights on the mental healthcare structure in British Ceylon proved to be the catalyst of massive renovations. In 1939, the first outpatient clinic was established in the National Hospital of Sri Lanka in Colombo. The first trained Ceylonese psychiatrists began practice in the 1940s, leading to the establishment of the first neuropsychiatric clinic in Colombo in 1943. Treatments for the mentally ill improved dramatically, as protectional therapy expanded to insulin shock therapy and cardiazol convulsive therapy^[8]. Mapother's advocation for the decentralization of services were further honored through the 1947 establishment of a first child guidance clinic in Colombo General Hospital^[2].

In 1948, British Ceylon was granted independence from the British after the Sri Lankan independence movement. Changes in the mental healthcare structure were not immediate following independence, but rapid expansions of mental healthcare services were still ongoing.

The following decades saw positive institutional developments, such as the creation of a second hospital in Mulleriyawa in 1957, and the creation of a psychiatric inpatient unit in Colombo General Hospital in 1967—effectively granting the city of Colombo the luxury of hosting the top psychiatric care in the country^[9]. The 1950s was also the start of psychopharmacological innovations, with the introduction of lithium and long-acting injectable antipsychotics (depot neuroleptics) in the succeeding years^[8]. Additionally, the number of public psychiatrist positions increased by 400% from 1953 to 1967^[9].

After 1960, mental health services were being established beyond the capital to other cities in the country^[4].

In 1980, the Postgraduate Institute of Medicine began a program where students would enroll in a 5-year medical course and attain an MD in psychiatry, curbing the need for Sri Lankan medical students to be sent abroad to complete their training. Many of the medical students sent abroad for training never returned to Sri Lanka to practice, resulting in a "1:500,000 to 1000,000" ratio of psychiatrists to patients on "most occasions"^[2].

Mental Disease Ordinance of 1956

In 1956, the 1873 Ordinance was revised a second time and renamed the "Mental Disease Ordinance of 1956"^[9]^[10]. Another linguistic development is seen with the new revision as "lunacy" was replaced with "mental disease"^[10]. The Ordinance paved the way for community-based services to be delivered to patients closer to their residences rather than solely allocating services to just hospitals. This led to the creation of a WHO-backed community clinic near the University of Colombo in the 1970s, where the focus was to eventually ease patients in the Angoda Mental Hospital back into the general population^[9].

Developments from the 1990s

The 1990s and onwards saw further positive developments in framing the mental healthcare system, including the establishment of the Directorate of Mental Health in 1998. The Directorate of Mental Health is a part of the Ministry of Health who is responsible for the monitoring and implementation of mental health programs across the country^[11]. As of 2025, the current director of the Directorate of Mental Health is Dr. Chithramalee de Silva^[4].

On November 11, 2005, the Mental Health Policy was approved by the Government of Sri Lanka, advocating for establishments of more de-centralized, community-based mental health services across the country beyond the capital (Colombo). The policy aimed to concisely define the rigorous standards needed to be completed for each respected medical professional, including psychiatrists and clinical psychologists^[12]. The policy also included a new position, the "Medical Officer of Mental Health", who oversees and assists in the implementation of community-based mental health services^[2]. This same year, the Sri Lankan government began implementing psychological services in state institutions, such as the military^[13].

In 2007, the National Mental Health Advisory Council (NMHAC) was created to serve as an 'advisory' board for the Ministry of Health on what actions should be executed by the Directorate of Mental Health^[14].

In 2008, the Angoda Mental Hospital was restructured as the National Institute of Mental Health (NIMH)^[14].

Modern-day Sri Lanka

As of 2025, the Mental Health Act (mental health legislation) has been undergoing development since 2005 and is currently awaiting to be considered for the final stage of approval. This is expected to replace the 1956 Mental Health Ordinance^[14].

Currently, there are 7 tertiary care hospitals, 61 adult patient units, 3 child inpatient units, and 1 forensic unit. The Lady Ridgeway Hospital in Colombo and the Sirimavo Bandaranayke Specialized Children Hospital in Kandy are tailored towards alleviating children with SLD, ADHD, ASD and family support for diagnosed children. As of 2017, 22 rehabilitation centers exist through the country, including 7 alcohol rehab centers^[14]. [expand more on SL Gov't efforts here...]

Despite the impressive advancements in mental healthcare in the last couple of decades, Sri Lanka still suffers significant mental health issues due to increasing poverty levels in the country. The World Bank reported that the poverty levels in Sri Lanka increased from 11% in 2019 to 26% in 2024, with 60% of Sri Lankan households facing "decreased incomes"^[15]. This was churned by Sri Lanka's excessive foreign debt, economic troubles stemming from Gotabaya Rajapaksa's presidential term, the COVID-19 pandemic, and the ongoing invasion of Ukraine by Russia (2022).

According to New York University graduate student Nadia Augustyniak in her 2025 overview of Sri Lanka's public mental healthcare system, poverty-induced financial precarity remains a major obstacle to receiving access to mental healthcare services. Even though trauma from adverse weather and conflict is deleterious to mental health, issues originating from every-day struggles, especially struggles related to poverty, could arguably play a more significant role^[13].

Impact of Conflicts, Terrorism, Political Instability & Natural Disasters

Sri Lankan Civil War

The Sri Lankan Civil War was a domestic conflict that took place between the Sri Lankan government and the Liberation Tigers of Tamil Eelam (abbreviated as the LTTE), a militant group formed in the 1970s as a result of rising tensions between the majority Sinhalese and minority Tamil population. The group is considered a terrorist organization^[16]^[17]. Through brutal massacres, assassinations, and suicide bombings, the LTTE waged decades of terror which led to civilian displacement, infrastructure collapse, and the reduction of mental health services available in the northern region.

The civil war mainly affected the northeastern portion of the country, including the Vanni region. The conflict caused mass destruction to local mental healthcare facilities. Local residents described the conflict with the phrase varthayal varnicca mudiyathavai, roughly translating into English as 'beyond description by words'^[18]. In 2003, only two psychiatrists were found in the region, operating on extremely limited resources and further deepening long-term trauma and mental health deterioration in the population^[9].

In 2002, the humanitarian organization Médecins Sans Frontières (MSF) performed an investigation of mental health needs in the Vavuniya area, the site of intense conflict during the civil war (including the 1985 Vavuniya massacre), and found that many of the residents suffered from high suicide rates, alcohol abuse, domestic violence, grief, and a "sense of ‘learnt helplessness’"^[9]. A team from the University of Konstanz in Germany found that 92% of grade school children in the region were exposed to "combat, shelling, and witnessing the death of loved ones"^[18].

Accusation of war crimes towards the Sri Lankan government have been documented by various external organizations, despite the government's attempts at removing any mentions or investigations of it^[19]. A 2009 HRW report stated that the Sri Lankan government assumed native Tamil population residing in war zones to be "siding with the LTTE and [therefore, were] treated as combatants", leading to indiscriminate shillings and massacres of civilians^[20]. Alongside the oppression by the Sri Lankan military, the Vanni population also endured the brutal theatrics of the LTTE, which recruited men, women, and even children with minimal training, effectively rendering them cannon fodder.

Over 200,000 Tamil civilians were moved into designated displacement camps during the war, where conditions were abysmal^[21]. The suicide rate in these displacement camps were three times the community-level (2002), with a ratio of 103.5 per 10,000 compared to the Sri Lankan general population's rate of 37.5 per 10,000. Almost all suicide attempts involved poisonous substances. Other forms of violence included domestic violence and child abuse. Local health officials in Vavuniya admitted that mental health concerns were a major problem, but were unable to address these concerns due to a lack of resources and support from the government. During the brief 2002 ceasefire, the MSF implemented a "community-based programme" which included "increasing awareness, community strengthening, reinforcing coping-strategies for long-term war-affected communities, and counselling". The MSF also advocated for restrictions of poisonous substances due to the suicide attempts, and stressed that "much more [than resettlement]" would need to be done to help alleviate the psychological pain the northern population had faced^[22]. The ceasefire ended in 2006 and led to the final phase of the civil war, eventually ending in 2009 with the death of the LTTE's leader.

Post-war

The first district-wide cross-sectional multistage cluster sample survey was conducted in the Jaffna District shortly after the war ended. The study's sample included 1517 households and 2 internally displaced peoples camps. With a response rate of 92%, the study found that symptoms for PTSD were found in 7% of participants, symptoms of anxiety were found in 32.6% of participants, and symptoms of depression were found in 22.2% of participants. 2% of respondents were currently placed in internally displaced peoples camps at the time of the study, 29.5% were freshly resettled from the internally displaced peoples camps, and the rest of the participants (68.5%) were never placed into camps. In comparison to residents who were never placed into camps, participants that were actively held in camps tend to report more symptoms of PTSD, anxiety, and depression. The researchers also found that women were especially vulnerable to deteriorating mental health conditions. This was explained by two factors: women having to assume the roles of both the father and the mother in the family setting after the, either voluntary or forced, departure of the husband to war, and sexist violence^[23]. A 2013 study on adult patients in primary care settings (divisional hospitals, primary medical care units) found major depression to be significantly higher in females (5.1%) than males (3.6%), bolstering the observation seen in the 2009 study^[24].

Muslims in Northern Sri Lanka during the conflict also faced violence and discrimination, most notably the October 1990 expulsion of Muslims from the North to the Puttalam District or Jaffna and the 1990 Kattankudy mosque massacre. The only study testing the displaced Muslim population post-civil war was completed in 2011, where a cross-sectional survey of 450 internally displaced people or people born into displacement (ages 18 - 65) revealed 18.8% of the sample suffering from common mental health disorders (CMD), including somatoform disorder (14%), "other depressive syndromes" (7.3%), major depression (5.1%), and anxiety disorder (2.8%). The percentages found in this study for somatoform disorder and major depression were "considerably higher" than the national percentages, though the researchers noted that the prevalence of CMD was lower in comparison to other countries marred with conflict, including Palestine (40.3%) and Ethiopia (27.8%). The researchers explained that the lower rate of CMD may be attributed to the serenity of the post-settlement destination, as conflict was mainly centered in the North and East. In contrast to earlier findings, this study did not observe a higher prevalence of CMDs among women, although increased rates of somatoform disorders were noted (though the researchers did not show the data behind this)^[25].

Research on the mental state of combatants has been limited, but a post-war 2009 study done between soldiers of the Special Forces and regular soldiers showed higher levels of exposure to traumatic events for units of the Special Forces, yet the former exhibited significantly less symptoms of CMDs compared to the latter. The authors of this study, Raveen Hanwella and Varuni de Silva, offers the camaraderie of the unit as an explanation for the discrepancy^[26]. A follow-up study was completed by the pair (with the addition of former Director-General of the Health Services of the Sri Lanka Navy Nicholas Jayasekera), where the findings were similar, though the statistically significant bridge between the two cohorts in the previous study evaporated in the follow-up study. This may be due to the significant decline in mental health problems observed in the regular unit forces, potentially reflecting resilience in the aftermath of jarring conflict^[27]. Amputees or soldiers with spinal injuries exhibited drastically different numbers, with approximately 40% of nearly 100 male-veterans in a post-war 2009 study displaying PTSD-like symptoms^[28].

About a decade after the conflict ceased, a few notable studies have emerged to help guide understanding on the longer-term mental health effects on victims of the civil war.

From July 2019 to October 2020, a study was conducted on 585 local adolescents (ages 12-19) in the Vavuniya district revealed that despite 15.6% of the statistic having faced one or more war-related events, only 3.9% of the participants had moderate - severe depression. In addition to considerably low depression rates, only 5.7% of participants age 17+ were found to have moderate - severe hopelessness^[29]. The authors referenced a 2010 observation by psychiatrist Daya Somasundaram, who noted that many Tamil IDPs exhibited "remarkable resilience and post-traumatic growth" after the civil war—an outcome he attributed to the close-knit, family-centered nature of Tamil communities^[30]. Findings originating from a 2019 study undertook by several faculty members from the University of Kelaniya, the University of Jaffna, the Gampaha Wickramarachchi University of Indigenous Medicine, and the Office for National Unity and Reconciliation (ONUR) in Jaffna, found contrasting statistics. Out of 336 participants from districts that faced significant ramifications of the conflict (Jaffna, Kilinochchi, Mullaithivu, Vavuniya, and Mannar districts), 50.5% had extreme anxiety symptoms and 36.5% exhibited "extremely severe" symptoms of depression. 92.5% of families in the sample experienced suicidal ideation, with an observed negative correlation between trauma exposure and life satisfaction with families. Drug abuse (86.2%) and alcohol abuse (84.5%) were the two highest problematic behaviors recorded on a community-level, suggesting that the negative consequences of the civil war still persist, possibly on a substantial scale than previously recognized, in Tamil communities in the North^[31]. Further research should be conducted in this field.

In 2019, Dr. R. M. M. Monaragala conducted a study on 1,845 soldiers with combat experience, finding that 3.9% of the sample suffered from PTSD. Dr. Monaragala noted that "probable depression, fatigue, aggression, and family history of mental disorder" were correlative of PTSD presence. He suggested that "screening and psychosocial intervention" were recommended avenues to alleviate CMDs of former combatants^[32].

2004 Boxing Day Tsunami

The 2004 Boxing Day Tsunami was a natural disaster where a tsunami spawned off a 9.2–9.3 magnitude earthquake off the coast of Aceh in Indonesia on December 26. The tsunami greatly affected the coastlines of the country, with the death toll reaching to about 35,000 deaths. In addition, 90,000 houses were destroyed and 516,000 people were forced to migrate due to severe infrastructural damage^[9]. It stands as the worst natural disaster to have ever hit Sri Lanka.

A survey conducted on schoolchildren (ages 8-14) in Manadkadu (Tamil-majority village in the northern coast), Kosgoda (western coast), and Galle (southern coast), just a few weeks after the tsunami hit Sri Lanka, revealed that 33.8%, 13.9%, and 38.8% of children interviewed exhibited signs of PTSD (according to the DSM-IV's criteria), respectively (minus the time criteria, as the DSM-IV does not permit diagnosis of PTSD within 4 weeks of a traumatic incident). The loss of family members and exposure to previously traumatic incidents seem to highly correlate with PTSD development^[33].

Many victims in the Jaffna area suffered with "pathological grief, phobias, depression and PTSD" post-tsunami. Schizophrenia in the Jaffna Tamil community, which had already suffered elevated prevalence of PTSD prior to the tsunami, had worsened—highlighting the need for specialized care in response to cumulative exposures to chronic and acute traumas. In a study published in the journal International Psychiatry (2006), Jaffna-based researchers noted that, contrary to their initial inclinations, there was not a "large[r] (than expected) rise in [the] number of people" seeking mental health support 3 months after the tsunami. However, 10 months after the disaster, the researchers anticipated that "more psychiatric disorders" would emerge due to "very little rebuilding [efforts]" and an apparent "unfairness in the aid system".^[34]^[35]

At the February 2005 After the Tsunami: Mental Health Challenges to the Community for Today and Tomorrow conference in Thailand, Dr. Chandanie Hewage of the University of Ruhuna reported measures taken to assist the affected were "not coordinated" due to poor "communication systems and road [conditions]", which were disrupted by the Boxing Day tsunami. Regardless, efforts were continued by the government and health professionals to alleviate the struggles the victims were facing, including the psychological ramifications of the disaster.

Several issues in the delivery of these services were highlighted by Dr. Hewage, including poor maintenance of health records, lack of awareness on drug consumption by the patients themselves, and shortages of health professionals. Dr. Hewage points out that personnel had "little" mental health training prior to the disaster, suggesting increased "research" and adequate "provision[ing] and training of staff" in the long-term^[36]. With inadequate documentation, no systematic procedures in place, and insufficient personnel, tsunami victims with mental health concerns may not receive the services they need, further compacting neuropsychological ailments.

In 2008 (about 3-4 years after the tsunami), researchers in the hard-hit village of Peraliya (Galle District) found that from a sample of approximately 90 adults, 25% suffered from moderate–severe PTSD, with women scoring "above the cut-off for anxiety" and reporting more "somatic symptoms", though researchers inferred that the PTSD rate found in the study may be influenced by war or economic hardship^[37].

2019 Easter Bombings

The 2019 Easter Bombings were a series of coordinated attacks perpetrated by the Islamic extremist group, National Thowheeth Jama'ath, on April 21, 2019. The attack targeted three churches and three hotels in the Colombo area, killing nearly 300 people and injuring over 500. The attack was also attributed to the incompetency of the Sri Lankan government, who ignored multiple warnings regarding the attacks. The attacks negatively affected the Sri Lankan Catholic community and further weakened relations between the major religious groups^[38].

In the aftermath of the attacks, professionals in the Gampaha District resorted to "low-cost methodological" responses to children and adolescents affected by the attack as a "severe shortage" of children and adolescent mental health experts were exposed^[39]. In a qualitative study of 8 survivors of the attacks receiving grief counseling, University of Ruhuna assistant professor Virasha Godakanda observed that 70% of the sample size expressed "doubts" in adequate mental health interventions from the government, reducing the quality of such services. Professor Godakanda strongly endorsed for "culturally-sensitive" programs, a diversity in therapeutic approaches (including nature-based therapy), and "prolonged investigations" to track developments in mental health resources and impacts of implemented interventions^[40].

A few weeks following the attacks, Muslims in Sri Lanka were subjected to violent, coordinated riots masterminded by Sinhalese national forces^[41]. Riots were mainly centered in the Kurunegala, Gampaha, and Kandy Districts. At least one confirmed death was reported. Calls for vague niqab and burqa bans were increasingly prominent, eventually leading to the 2021 burqa ban by the Sri Lankan government. Pakistani and Afghani refugees fleeing religious persecution in Negombo were forced to be "made refugees again" after local protests were orchestrated against their settlement. Islamophobic aroma was "unleashed online, in the law, and on the street"^[42]. Albeit its relevancy to the attacks, no in-depth mental health studies were administered on the minority Muslim population following the Easter bombings. Further research is imperative in exploring the sustained psychological effects of Islamophobia and its effect on the Muslim minority community in the aftermath of the 2019 Easter attacks.

Literature regarding the impact of the 2019 Easter Bombings on mental health are limited and further research should be done in the field.

2019-2024 Economic Crisis

The 2019-2024 Economic Crisis refers to a 5 year period where the Sri Lankan economy experienced massive inflation and an abrupt hike in prices on basic, everyday items. It is the worse economic crisis the country has faced since the Sri Lankans were granted independence in 1948. Schools in Sri Lanka were forced to postpone examinations due to paper shortages. Gas shortages led to long lines at gas stations, some lasting for days, throughout the island. Shortages in electricity, cooking gas, and aviation were additional results of the economic crisis.

Healthcare workers faced a barrage of mental health during the crisis, including a lopsided work-life balance due to unprecedented demand, increased stress and mental fatigue from a lack of resources and personnel, unhealthy coping mechanisms, job dissatisfaction, and a reduction in work quality. Such effects perpetuate a self-enforcing cycle of psychologically distressed mental healthcare workers providing subpar services, affecting patients and amplifying mental health issues experienced by both the workforce and their patients^[43].

Medical students from the Faculty of Medicine at the University of Colombo reported that the economic crisis forced abrupt changes in dietary consumption, increased hopelessness in the future, increased stress and anxiety, and a decrease in interest in pursuing a "clinical post-graduate career"^[44]. 283 government-school teachers completed a web-based cross-sectional survey in April 2024, with majority of the participants reporting a severe reduction in monthly income & 1/3 of participants exhibiting "clinical levels of psychological distress"^[45]. A study published in that same year reported that out of 261 nurses working in teaching hospitals, 91.6% were forced to allocate their finances to strictly "general needs", while more than 50% looked into international opportunism for employment. Notably, the study reported an overall near "twofold greater" rate of depression, anxiety, and stress compared to previously conducted studies on nurses^[46].

The detrimental effects the crisis has had on the mental health sector reveal a concerning area of underappreciation and under compensation by the Sri Lankan government towards a critical sector for the well-being of the country. Comprehensive mental health interventions need to be prepared and ready to implement at times of national emergencies.

Present-Day Challenges

Ethnic tension

Despite the end of the Sri Lankan civil war and the introduction of pluralist policies, such as the 2017 National Policy on Reconciliation and Coexistence under the Sirisena administration, tensions amongst members of the ethnic groups still persist in the country. Evidence of these tensions was found through a 2022 study conducted in the Ratnapura district, where religious leaders expressed skepticisms, through semi-structured interviews, for "conflict transformation". A Tamil citizen of the Ratnapura community recounted that they were forced to "hide in jungles" and consume "dirty water in drainage[s]" due to scarcity of food and drinkable water as a result of the conflict. In certain personal accounts, ethnic conflicts appear to affect the social behavior and identity of the majority ethnic group. One Sinhala participant recounted his objection to the war-time retaliatory destruction of a shop run by a Tamil shopkeeper was met with interrogative questions about "whether [he was] Sinhalese or not". Both accounts convey interethnic tensions stemming from decade-long conflicts^[47].

Beyond individual accounts and the official end of the civil war, the minority groups in the country continue to feel ostracized. The Sri Lankan Tamil population remains dissatisfied with the Sri Lankan government and their accountability of perpetrators of war crimes and information on the whereabouts of thousands of enforced disappearances that took place from the 1980s. Additionally, rising anti-Muslim sentiment in recent years contribute to increased ethnic tensions, a stark contrast to the previous centuries of peaceful co-existence between the groups.

Laws passed by the Sri Lankan government, such as the Prevention of Terrorism Act and anti-conversion laws, have forced the United States Commission on International Religious Freedom to label Sri Lanka as a nation that "[engages] or [tolerates] severe violations of religious freedom" in their 2024 report. The government has been criticized by human rights organizations for "disproportionately targeting religious minorities"^[48]. Additionally, the implementation of the three dominant languages, English, Sinhala, and Tamil, across formal education and government services have been lackadaisical, narrowing opportunities of foundational social interactions between the groups. Persistent discrimination and prejudice towards minority groups can lead to an array of complex and self-deprecating mental health issues.

Effort to mitigate ethnic tensions include strategies like community-based participatory research (CBPR), task-sharing, and securing online mental health services in order to expand mental health services. However, the implementation of evidence-based plans has been met with difficulty due to inaccessibility, high costs, and shortages of adequately-trained personnel.

Movements aiming for improved intra group and inter group coexistences, such as the Jaffna People’s Forum for Coexistence developed in the wake of the 2019 Easter bombings, should be emphasized on a systematic and multi-level basis, including but not limited to education, public sectors, and within communities. Pluralistic values should be stressed across both private and public schools to foster cultural sensitivity and tolerance. Measures should be taken against threatening extremist groups promoting sectarian hostility, such as the Bodu Bala Sena.

Poverty

It has been proven that poverty significantly increases the chances of developing mental illnesses. This is further amplified by possible discrimination^[49]. Poverty also affects the ability for individuals with mental health concerns to receive the treatment they need. Due to the repercussions of the economic crisis, clients in Sri Lanka could not attend further counseling sessions^[13]. Poverty from 2021 to 2022 reportedly doubled, with future forecasts predicting the poverty line to "remain above 25 percent". Suicide has been empirically linked to economic hardships in previous studies^[50]. A 2013 study done on suicidal patients in Batticaloa Teaching Hospital revealed 76% of patients who attempted suicide were from rural areas while 15% were from urban areas^[51]. The Sri Lankan government should consider the economical impacts that poverty has on mental health and implement ways to aid poverty-stricken individuals with mental health concerns.

Stigmas

Stigma consists of the "combined effect of prejudice, ignorance and discrimination."^[52].

A 2012 interview consisting of nine participants (two doctors, three nurses, one occupational therapist, one development worker, and two volunteers) revealed a number of concerning societal viewpoints on individuals with mental health concerns. The interviews revealed that negative judgements were not only levied against the individual with the mental illness, but also the family. Families hid mentally ill family members from the public to avoid "shame" and possible hinderances in marriage proposals. Views that mentally ill individuals were "violent" served as the motivating factor behind socially isolating those with mental illness from their communities. Interviewees mentioned that individuals dealing with mental health challenges would have stones and "derogatory names" launched at them. A lack of community awareness regarding mental health and negative portrayals of mentally ill individuals in media exacerbates stigmatization, though the researchers commented that the media was "improving" in their depiction of mental illness. Beliefs that illnesses are caused by "spirits" can be problematic for individuals dealing with mental health issues and serves as evidence to poor mental health awareness in the country. Mental health workers themselves believed that they were being stigmatized, as mental health is reportedly not taken as seriously as physical health. Despite the intriguing perspectives provided, the small sample size and usage of snow sampling raise questionable concerns regarding the contextualization of the results^[52].

Improving media portrayal of subjects concerning mental health and involving community members in interventions dealing with mental health issues are ways that could destigmatize mental health amongst communities in Sri Lanka. Tying collaborations between allopathic services and traditional healers instead of having these two services work individually could enhance engagement between traditional medicine and Western medicine.

Suicide Trends & Risk Factors

Suicide is defined as "the act of killing oneself deliberately, initiated and performed by the person concerned in the full knowledge or expectation of its fatal outcome"^[53]. Although Sri Lanka has seen a significant reduction in suicide rates from the mid 1990s due to its banning of extremely toxic pesticide products, suicide and self harm remains a significant issue. The suicide rate per 100,000 people increased from 14.0 in 2019 to 15.0 in 2022 (according to WHO). On average, 27 males per 100,000 males and 5 females per 100,000 females committed suicide in 2022^[54]. Hanging appears to be the most used method for suicide for both males and females, with studies revealing a steady increase in recent years^[55].

From 2023 to 2024, a group of researchers from the Eastern University in Sri Lanka assessed 828 patients admitted to the Teaching Hospital in Batticaloa, Sri Lanka for attempted suicide. They concluded that suicide prevention programs should be attuned to younger people (ages 15 to 35 in the study), emphasize the importance of education and reducing unemployment, and increase social support in the Tamil community. Despite the relevant insights into certain aspects of an average Sri Lankan's life that could lead to suicidal ideation (ie, poverty), the results from this study suffer in external validity as 90% of the patients were Tamil and over 50% were between 16 and 25 years. In addition, correlations between suicide and unemployment rates have been questioned, with austerity being a more reliable indicator of suicide rates than unemployment rates^[53]. Further comprehensive studies on risk factors relating to suicide should be studied to assess correlations between unemployment rates and austerity measures.

The WHO suggests implementing evidence-based suicide prevention programs, such as LIVE LIFE, to reduce the national suicide rate^[56]. Media potrayals of suicidal methods, such as hanging, can lead to sensationalism and the media should be cautious of such displays in movies and TV shows^[55]. Awareness of depression and other mental health issues can serve as a safeguard against suicidal ideation in Sri Lankan men and women.

Role of Religion

According to the last demographic report (2012), 70.2% of Sri Lankans are Buddhist, 12.6% are Hindus, 9.7% are Muslims, and 7.4% are Christians. The Theravada Buddhist community makes up the majority in several provinces throughout the country^[57]. Religion, especially Theravada Buddhism, has had a significant influence on not only the historical treatment of mental health in the country, but also everyday life^[3]. The Mahāvaṃsa affirms hospitals treating patients suffering from mental health issues as early as the 4th century BC. Additionally, the 1700s Nayaka king Kirthi Sri Rajasinghe detailed the implementation of Buddhist philosophy in psychiatry^[8]^[58].

Modern-day empirical studies have attested to the usefulness of religion in mitigating stress and elevating mental health^[59]. Religion has been found to be positively correlated with improved mental health, and more religious patients were concluded to have "better mental health and adapt[ed] more quickly to health problems" versus patients who weren't religious^[60]. Dr. Wickramarathna of the University Psychiatry Unit (UPU) at the National Hospital of Sri Lanka (NHSL) argues that psychiatrists must strive for a balance in their approach to patients and "make positive use of religion in [their] practice[s]"^[61].

Buddhism

27 Sinhalese Buddhists from four Buddhist temples were selected for a series of 70-minute interviews and focus group discussions with the aim of learning the Sinhala Buddhist understanding and experience of spiritual well-being and psychological well-being. The interviewees held spiritual wellness to be the "center" of overall wellness, the "precondition for a successful life"^[62]. Sinhala Buddhists believe that wellness cannot be achieved without spiritual tranquility. The report states that participants emphasized that spirituality "cannot be directly intervened" and can only be seen through "[interactions] with society"^[62]. Despite the athmaya (soul) being "unreachable", it can be "intervened", or treated, through the actions of the mind and body with society^[62]. One being "psychologically ill" can affect one's spiritual being, as the participants reported in their interviews, and can be affected through "lifestyle stressors, environmental and socio-cultural causes, non-human related causes and bad-karma in the past lives"^[62].

The researchers concluded that despite Sinhala Buddhists not being able to articulately decipher the discrepancies between psychological well-being and spiritual well-being, they are able to conceptualize and maintain a culturally embedded understanding between the two, serving as reputable evidence of the integration of mental health in Sinhala Buddhist practices. However, it is important to note that these results come from a very small sample size and cannot be generalized to all Sri Lankan Buddhists.

In addition, a 2009 study found that a belief in karma was correlated with poor health. However, an earlier study found a positive correlation between the reliance on the Buddhist concept of karma and trauma, inferencing Buddhist karma being a prevalent response to trauma^[63]. Overall, the effectiveness of karma as a coping mechanism appears to be conflicted.

Studies indicate that other practices of Buddhism seem to be utilized by individuals affected by the war. 40% of Sri Lankan Buddhists affected by the 2004 tsunami found the Buddhist ritual Bodhipuja to be helpful in dealing with traumatic experiences^[64].

Catholicism

Catholic counseling refers to "a nuanced and holistic mental health care paradigm that intricately weaves together psychological science with the moral, spiritual, and pastoral traditions of the Catholic Church"^[65] and aims to assimilate Catholic theology and evidence-based psychological treatment while including Sri Lankan cultural elements. This is achieved through emphasis on community cohesion and a locally-based understanding of "personhood"^[65].

The origins of Catholic counseling trace back to the introduction of Roman Catholicism to the island in the 1600s, with the focus of the early Sri Lankan Catholic community being on "evangelization, education, and sacramental formation". Demand for counseling services in general increased due to the impacts of the Sri Lankan Civil War, where Catholic organizations (Caritas Sri Lanka, Seth Sarana, Subodhi Integral Centre (Piliyandala), etc.) established several Catholic-based trauma-informed programmes for victims of the Civil War. Programmes use group therapy, forgiveness rituals, and narrative repairs to alleviate war trauma.

Examples of integration of Catholic virtues and counseling can be seen in Cognitive Behavioral Therapy (CBT), where "hope" and "humility" are used as the frameworks for creating spiritual resilience^[65]. The general Christian call of "agape love and acceptance" is echoed by the concept of unconditional positive regard. Lectio Divina (Catholic prayer and meditation) and Marian devotions are integrated into therapeutic practices to achieve emotional regulation and mindfulness.

Senior Lecturer Udeshini Perera of the University of Colombo articulates a critical role of Catholic counseling. She claims that secular counseling fails to address the "spiritual roots of distress and moral confusion". Catholic counseling fills in this gap by integrating "psychological insights with a transcendent orientation, supporting lasting transformation and integrity"^[65].

As of 2025, no formal accreditation or standardized training exists for pastoral counselors in Sri Lanka, hampering the legitimacy of Catholic counseling. Udeshini Perera remarks that mental health stigma, lack of standardized training, research regarding Catholic counseling effectiveness, and acceptance of the combination of religion and science in a professional setting present challenges for Catholic pastoral counseling in the country. Additionally, Catholic psychiatry in Sri Lanka appears to be under-researched, and evidence of its empirical effects on followers appears sparse. Further research is needed in assessing the empirical effects of Catholic counseling in Sri Lanka.

Islam

The literature on the empirical effects of Islamic-based psychotherapy in Sri Lanka is limited. Research has revealed a 2012 case study where a 21-year-old Muslim woman was experiencing episodic possession states. The patient ceased attending psychiatric services and opted for religious rituals. The patient reported, in a follow-up visit, that the possession states had been absent for 3 months since her switch to religious rituals. The woman and her family attributed the apparent improvement of her condition to religious rituals^[66].

Future recommendations would be to employ resources to research the foundations of Islamic psychiatry in the country, and to observe the rituals employed and their effects on patients. Studies have found that Islamic prayer can be an effective means of "support and coping"^[3]. Seven world-wide case studies using Islamic-based psychotherapy on patients, consisting of religious rituals such as scriptural reading from the Quran, teaching of fundamental Islamic concepts (such as tawakkul), and active implementation of contemplation (tadabbur), have reported positive effects in decreasing cognitive and emotional symptoms associated with "religious, obsessive-compulsive disorder, depression, agoraphobia, generalized anxiety disorder, grief, and substance use disorder.”^[67] Additionally, a community-based study of elderly patients in Bangalore, India receiving Islamic-based psychotherapy observed decreased exhibitions of sleep disorders, eating disorders, and emotional distress^[68].

Hinduism

Despite Hindus being 12.6% of the population of Sri Lanka, the research on Hinduism-based therapy in the country is limited. Ayurvedic medicine, a form of medicine originating from ancient India, predominated the Sri Lankan medical landscape for over 2,000 years and even had a symbiotic relationship with Sinhalese medicine, which also played a significant and influential role in the country's medical framework^[2]^[69]. Despite its historical dominance, Ayurvedic medicine has been challenged against modern evidence-based medical standards^[70].

Comparative synthesis

Taking an overarching review of the role of religion in Sri Lanka, methods to improve mental well-being are practiced by adherents of Buddhism, Hinduism, Islam, and Christianity. These methods are practiced through karma, tawakkul, hope, and humility. Additionally, these practices are implemented in traditionally-oriented mental health care, which has been reported to be preferred over psychiatric care at times. These rituals practiced across these religions indicate a common theme of psychologically integrated aspects of well-being. Interpretation of trauma is a central use in religion, with religious principles, such as karma and tawakkul, serving as psychologically analogous mechanisms during times of distress.

In terms of methodological comparisons to the studies described, qualitative interviews have documented Buddhist practices and principles, like Bodhipuja and the belief in karma, in response to traumatic events, while case studies found religious practices by other religious groups, such as a Muslim patient reading Islamic scripture and observing prayer to reduce emotional distress. Peer-reviewed sources have documented Catholic practices and principles, such as Lectio Divina and unconditional positive regard, in improving mindfulness and emotional regulation. The paper acknowledges limitations in the evaluation of certain findings, such as in Islam and Hinduism. These shortcomings, however, are a reflection of the existing literature and its deficiencies. Empirical findings indicate mental health practices are complex and are multifaceted in their effects.

Evidently, religion serves a parallel role to psychiatric services in improving mental health. Despite its perceived benefits, the findings surrounding religions' role in mental health suffer from conflicting, and sometimes contradictory, results. Additionally, a disproportionate amount of empirical findings seem to be Buddhist-predominant, while other religions are underrepresented in the research. Regarding research barriers, the methodological approaches implemented to study the practices of religious followers vary, though much of the research was brought from qualitative or case-based studies, impeding generalizability. Another noteworthy issue is that many studies do not utilize standardized, psychiatric measures.

Future Outlook

Criticism of the Mental Disease Ordinance of 1956

^[10]^[71]

Expansion of services for women facing domestic violence

^[13] (last paragraph before 4.2; see discussion + conclusion as well)

Conclusion

Additional information

Acknowledgements

Any people, organisations, or funding sources that you would like to thank.

Competing interests

No competing interests.

Ethics statement

An ethics statement, if appropriate, on any animal or human research performed should be included here or in the methods section.

References

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[Azeez-1] Old Dominion University

[2] yonikmalik@gmail.com

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[:15-5] 3.0 ^3.1 ^3.2 Baminiwatta, Anuradha; Williams, Shehan (2025). Arafat, S. M. Yasir. ed. Social Psychiatry in Sri Lanka (in en). Singapore: Springer Nature. pp. 141–158. doi:10.1007/978-981-96-8078-8_7. ISBN 978-981-96-8078-8. https://doi.org/10.1007/978-981-96-8078-8_7.

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