The Problem Today

The mentally ill have become a common feature of the social landscape in Micronesia in the last decade. Even short-term visitors encounter them on the road wandering from place to place, often garishly dressed (or undressed), stopping people to beg cigarettes and engaging them in bewildering conversation, usually in fluent English. Sometimes they are zombie-like with unblinking stare and a faraway look that betrays their condition before they ever open their mouth. At other times they are in a frenzy of activity: directing traffic, picking up trash, delivering harangues on religion or politics to anyone within earshot. There are still others, of course, who are far less visible; they skulk in their homes and have dealings with almost no one other than their most intimate relatives. Many of the mentally ill today are relatively young, and their number appears to be legion.

This is not to suggest that psychotics are an entirely new phenomenon in the islands. When I first came to Micronesia in the early 1960s, an elderly and harmless looking woman in the small psychiatric ward of the old hospital was known for her ability to curse passersby in three languages. I also remember how shocked we all were to hear of a homicide committed on a small atoll by a seriously disturbed 40-year old man, whom his neighbors afterwards dropped into a deep wellshaft to prevent further trouble until the next fieldtrip ship could carry him off to the hospital. We had our collection of odd characters, like the man who paraded around town with paper streamers bound around his torso and dangling from the bishop's miter he fabricated for himself of cardboard. Yet, they were relatively few, as I recall, and they seemed to be largely middle-aged or older.

The problem of mental illness, seemingly a growing one, has not gone unnoticed. In 1974, the Trust Territory Headquarters first hired on a staff psychiatrist and clinical psychologist to run its first mental health program and the assist personnel in the districts. In subsequent years, as the Division of Mental Health took shape, the first serious attempt was made to collect data on mental illness in Micronesia. Drawing on the monthly reports submitted to headquarters for the years 1977-1980, the former staff psychiatrist published an article comparing rates of schizophrenia in different parts of Micronesia. In this article, Dale noted the relatively high rates in Yap and Palau and the extremely low rates reported for some of the remote atolls. Meanwhile, a psychiatric resident from Loma Linda Medical School conducted a three-month study of schizophrenia in Palau that showed a heavy preponderance of male victims. In the papers that issued from their study, he and his colleagues attributed the high male rate of illness in Palau to the "relatively recent and rapid disintegration of the traditional culture" and to the rampant drug use among men.

Mental illness has various manifestations and diagnosis is far from a simple matter, as anyone who has picked up a copy of DSM-III knows. In this paper we will be concerned exclusively with what are generally called psychoses: "mental disorders in which impairment of mental function has developed to a degree that interferes grossly with insight, ability to meet some ordinary demands of life or to maintain adequate contact with reality." It is important to recall, however, that the definition of psychosis according to Western psychiatric canons is rather imprecise.

By far the most common form of psychosis found worldwide, according to diagnostic standards used today, is schizophrenia (although most psychiatrists admit that it might more accurately be called a constellation or family of illnesses). An estimated 50 percent of the patients treated in US mental hospitals are diagnosed as having some form of schizophrenia; and our survey indicates an even higher proportion of psychosis in Micronesia ascribed to schizophrenic disorders. The cause of these schizophrenic disorders remains obscure, despite considerable medical research on the question. We know that schizophrenia is essentially a cognitive disorder involving a malfunction of parts of the brain. It is argued that the disease is more than a hand-me-down from parents, and its onset depends, at least to some extent, on other conditions. These conditions may be biochemical, neurological, environmental, or a combination of all three. The importance of social factors in precipitating the disease is suggested by its higher incidence among lower socio-economic groups in Western cities, its apparently greater frequency in industrialized and modernized societies, and conversely the rather low rate of schizophrenia among Norfolk Islanders, who have European genes but a South Seas lifestyle.

If indeed there is an environmental component to schizophrenia–and possibly also to the other major psychoses (bipolar disorder, psychotic depression, and paranoia)–then this topic is of particular pertinence to those studying the effects of social change in Micronesia. The socio-cultural environment of Micronesia, impacted as it has been by modernization and its concomitant changes in recent decades, would appear to be more stressful for many today than ever before. It is conceivable that this could have an effect on the overall rates of psychosis in Micronesia and its distribution among particular segments of these societies.

Methodology of the Study

The data on which most of the earlier studies on mental illness in Micronesia drew is now more than ten years old, and it was probably inadequate even then. The rates of mental illness are almost certainly understated since the data was derived exclusively from reports on patients who sought hospital treatment. In an effort to provide a more up-to-date and comprehensive body of data on serious mental illness, the Micronesian Seminar undertook its own survey beginning in July 1988. Using non-professional researchers, we attempted to draw up a complete list of the seriously mentally ill in the Republic of the Marshalls, the Republic of Palau and the Federated States of Micronesia.

With the kind assistance of mental health personnel in each of these entities, we began to identify and compile records on afflicted individuals. Our field workers interviewed community leaders and canvassed others in each island group to gather information on those who never received hospital treatment and to assemble brief case histories on each individual. Although our researchers did not personally visit each of the smaller islands or even all the sections of the larger islands, they interviewed–sometimes at great length–knowledgeable persons from each of these places. Through dozens of such interviews, they laboriously pieced together the case histories of each of the psychotics. The survey, which was carried on over the course of an 18-month period, was completed in January 1990. Otong Emilio, the principal fieldworker, spent a year of uninterrupted work on the survey prior to its completion.

Although we had access to the formal psychiatric diagnosis for many of the mental patients included in this study, we decided against exclusive reliance on Western medical norms. In determining whether a person for whom we had no formal diagnosis should be regarded as a psychotic, we adopted a loose community-based norm. We asked people in the towns and villages whether the individual had been acting "crazy", at least intermittently, for a period of a year or longer. Through additional questions, we attempted to determine the nature of his symptoms and make a judgment on the severity of his mental illness. Finally, we asked people in the community whether they regarded the individual as seriously ill. This question was used to confirm, or sometimes to revise, the judgment we made from information we had already received.

It should be noted that we excluded from the survey those types of psychoses that were primarily organic in nature: senile dementia, arteriosclerotic dementia, and psychotic conditions attributable exclusively to alcohol or drug abuse. Moreover, in compiling our list of psychotics through interviews, we made every effort to screen out:

• those suffering from personality disorders (brawlers, kleptomaniacs, pathological liars, etc.)
• individuals who were retarded from birth and those whose mental problems stemmed from trauma or physical disabilities such as epilepsy
• persons who suffer from rather severe but temporary problems, such as those who have undergone bouts of depression or those who have experienced the "possession syndrome" that is quite common in the area
• those who display occasional odd behavior, but in the judgment of the community are capable of functioning rather normally.

The data in this study do not include borderline cases–that is, those in which the symptoms are not indisputably psychotic, at least by our definition, or in which the symptoms have not persisted for at least one year. The data, however, do include six psychotic individuals who died during the 18-month period in which this study was conducted and another three who have died since.

This study is not a scientifically rigorous one. Even if the data may not be thoroughly comprehensive, the survey should not be regarded merely as a sample or cross-section of the psychotic population in Micronesia. While the figures in this study may be incomplete, they certainly are an improvement over the 1977-1980 data and can be taken to represent the minimal rates of psychosis in the three nation-states surveyed. Our hope is that the survey, for all its weaknesses, may serve as a baseline against which future data can be compared, even as we hope it might help indicate possible areas of research in years to come.

Psychosis Rates in Micronesia

The survey revealed 445 individuals suffering from psychosis in Micronesia (Palau, Marshalls and FSM). This yields a rate of 54 psychotics per 10,000 adults (ie, 15 years and older). Table 1 shows the 1990 rates for each island group compared with the rates for 1978-1980 that Dale derived from the Trust Territory case registry. It should be noted, however, that the apparent increase in the 1990 rates may reflect incomplete reporting in the earlier data rather than a true increase in the incidence of psychosis in the last decade. If, as is quite possible, there has been a real escalation in serious mental illness, we are unable to measure it accurately with the data available to us.

Table 1: Psychosis Rates by Island Group, 1980 and 1990

1978-1980	Palau	Yap	Chuuk	Pohnpei	Kosrae	Marsahalls	General
Pop (15 yrs +)	8,264	6,009	18,279	13,206	2,568	13,481	61,807
No. of Psychotics	78	50	44	25	4	12	213
Rate/10,000	94	83	24	19	16	9	34
1990
Pop (15 yrs +)	7,666	6,289	24,490	17,476	4,061	21,244	81,224
No. of Psychotics	128	53	92	56	26	90	445
Rate/10,000	167	84	38	32	64	42	54

Micronesia's psychosis rate of 54 can be measured against the norm in other places. H.B.M. Murphy asserts that the average rate of psychosis in the industrialized nations of North America, Europe and Japan is about 90 per 10,000 adults. He found the rates in the Pacific islands he visited much lower and estimates the overall Pacific rate to be about 25. Each of the island groups in Micronesia shows a higher rate than Murphy's average for "traditional" island societies, although all but Palau are lower than the rate for modernized countries. On Murphy's scale, then, the Micronesian psychosis rate is what one might expect to find in a transitional society–that is, one well along the road to modernization.

The survey reveals enormous differences in the psychosis rates from one island group to another, even if the variance is not patterned as neatly as Dale's earlier study suggested. (Dale's data for 1978-1980 shows ascending rates from the eastern island groups to the west.) Palau's current rate of 167 is by far the highest in the region. It is twice the rate of Yap, the next highest, and more than four times the rates of Chuuk and Pohnpei; it is well above what Murphy cites as the norm for the industrialized world. Yap (84) and Kosrae (64) approach the rate of Western societies; the Marshalls (42) is considerably lower; and Chuuk and Pohnpei, with rates of 38 and 32 respectively, are at the bottom of the list.

Nearly three-fourths (73%) of all the severe cases treated by Mental Health staff were diagnosed as schizophrenia in one of its many forms. What was diagnosed as bipolar psychosis (manic-depression) accounted for 13 percent of the cases. Acute paranoia comprised five percent of the cases, psychotic depression two percent, and assorted other diagnoses seven percent.

Psychosis as a Male Problem

One of the most startling findings in this survey was the great preponderance of males among the psychotics. For the area as a whole, 77 percent of the seriously mentally ill were males. The overall male/female rate was a striking 3.4: 1.

Although there is considerable variation in the female rates of psychosis for various island groups–the rates range from 0 in Kosrae to 91 in Palau–the female rates appear to be proportional to the total measured rates. Thus, Palau with the highest total rate also shows the highest female rate. On the other hand, Chuuk and Pohnpei, places with low mixed rates, also have very low female rates. Women comprised 17-30 percent of the total of mentally ill in each island group except Kosrae, where no females were recorded. (Even Kosrae, however, has had past cases of psychosis among females, including a woman with schizophrenic symptoms who apparently took her own life ten years ago.)

Everywhere in Micronesia females seem to be at far less risk for mental illness than males. The overall female rate in Micronesia is 24 per 10,000 adults, about the equivalent of the mixed-gender rate that Murphy recorded in his travels around the Pacific more than a decade ago. If the gender-specific rates are low for Micronesian females, they are that much higher for males. In Palau, the male rate is over 200, meaning that about two percent of the adult male population is psychotic, while the male rates in Kosrae and Yap are well over 100. The other three areas–Chuuk, Pohnpei and the Marshalls–have male rates of 50-65.

Table 2: Psychosis Rates by Island Group and Gender

	Palau	Yap	Chuuk	Pohnpei	Kosrae	Marshalls	General
Number Males	89	39	78	42	26	70	344
Females	39	14	14	14	0	20	101
Rate/10,000 Males	207	124	59	50	144	65	83
Females	91	44	11	19	0	19	24

Other Characteristics of the Psychotic Population

Psychosis has always had its folk explanations, and Micronesia is no different in this respect from any other part of the world. Many villagers, when asked about the problem of mental illness, offer a standard explanation for what they regard as a sharp increase in mental illness in the last ten or 15 years. They point to travel abroad and high educational attainments as common characteristics of the psychotic population, implying that either or both may put such pressure on the individual as to cause a breakdown. They also attribute mental illness to the widespread use of alcohol and drugs, particularly marijuana, among the young. Indeed, it is mainly because these factors are singled out so frequently by local people as correlative to mental illness that they were included in the survey and are noted here.

The psychotic population in Micronesia is well-traveled, our recent survey shows; almost half (47%) have lived for more than six months outside their own state or republic, and most of these have resided on Guam or in the US. Unfortunately, there is no data for the general population against which this can be measured.

Micronesian psychotics as a group seem to be above average in their educational attainments, as Table 3 reveals. In the four areas for which there was adequate census data to compare the mentally ill with the general adult population.

Table 3: Average Years of Education for Psychotics and General Adult Population

	Palau	Yap	Kosrae	Marshalls
Adult Population	9.7	7.8	8.8	8.7
Psychotics	10.0	10.1	10.7	9.3

Note: Kosraean adult population figure is for males only. Marshalls figure is for all over the age of 25. Other figures are for total population over the age of 20.

(the 1989 Chuuk census and the 1985 Pohnpei census do not provide information on education), the level of formal education of the mentally ill is significantly higher than that of the general population. The difference is over two years of schooling in Yap and nearly the same in Kosrae, a half year in the Marshalls, and a fraction of year in Palau. Nearly one-quarter (23 percent) of the subjects surveyed attended college for at least a year, and many spent two or three years there.

The figures on alcohol and drug use in the survey showed a strong differentiation along gender lines. Eighty-eight percent of the males have a history of moderate to heavy drug use, compared with only 36 percent of the females, as Table 4 indicates. This differentiation is not surprising, for nearly everywhere in Micronesia drinking alcohol and use of drugs like marijuana (cannabis) are regarded as predominately male activities. The most commonly used drug, as might be expected, was alcohol; all but a very few of the psychotics of both sexes who had a drug history were at least occasional drinkers. The clear pattern of drug use found among the subjects of this survey is one of accretion rather than substitution. Hence, all but 11 of the males and three of the females who smoked marijuana were also regular users of alcohol, and a much smaller number added other more potent drugs to their personal pharmacopia.

Table 4: Drug Use Among Psychotics by Percentage

Users of:	Males #	Males %	Females #	Females %	Both #	Both %
Any Drug	287	(88%)	31	(36%)	318	(77%)
Alcohol	271	(83%)	28	(33%)	299	(73%)
Cannabis	198	(61%)	12	(14%)	210	(51%)
Other	44	(13%)	1	(1%)	45	(11%)

How does the prevalence of alcohol and drug use among psychotics compare with that in the general population? Statistical data on the latter is lacking for most parts of Micronesia, but a recent survey of a large representative sample of the Chuukese people done by anthropologist Mac Marshall offers some basis for comparison. In the 1985 survey, 86 percent of the general male population in Chuuk were either former or current users of alcohol. This is comparable to the 83 percent figure for male psychotics recorded in this present survey. The rate of marijuana use among male psychotics, however, is more than twice the percentage recorded for all males over the age of 15 in Chuuk–61 percent to 27 percent. Female rates for alcohol and marijuana are much higher among psychotics than in the general Chuukese population, where only 2.3 percent ever drank and 1.2 percent smoked marijuana.

Few of the psychotics studied are known to have used heavier drugs than marijuana and alcohol. Only 44 males and one female, or 11 percent of the total number of psychotics on whom there is any information have a record of heavy drug use (eg, heroin, cocaine, LSD, Speed). The medical histories of these individuals seem to suggest a relationship between their drug abuse and the onset of their mental illness, but their number is too few to be of real statistical significance in the study. Even in Palau, where such drugs were much more easily available than in other parts of Micronesia, only 29 of those afflicted with psychosis were known to have used these drugs.

Psychosis and Suicide

Studies on suicide in Micronesia have insisted repeatedly and emphatically that mental illness is not a major cause of the suicide epidemic since the late 1960s. The rapid increase in suicide, we have steadfastly maintained, must be understood in terms of social forces that are changing the forms and functions of the family, intensifying inter-generational conflict while rendering obsolete some of the traditional structures for dissipating tensions. Suicide has become frighteningly common among young males from every island group and every conceivable background. Individuals with psychotic histories make up no more than five to ten percent of the total number of suicide victims in past years.

If psychosis does not explain the suicide epidemic of the last twenty years, it most certainly does cause suicide on a case-by-case basis. People with mental illness are at far higher risk for suicide than the general population. In the two years after our study of mental illness was begun, nine of the psychotics listed in this survey died; five of them took their own lives. Lacking longitudinal data on mental illness as we do, we cannot tell how truly representative this rate of suicide is among psychotics. We can, however, look at the relationship the other way around. Because our data on suicide extend so much deeper into the past than what we possess on mental illness, we can examine mental illness as a function of suicide.

During the two decades between 1970 and 1990, there have been 616 recorded suicides in Micronesia, 45 of which were by individuals who were clearly psychotic. The rate of psychosis among suicide victims is over seven percent, or 730 per 10,000. When we recall that the rate of psychosis among the general adult population is 54 per 10,000, the enormous over-representation of the mentally ill among suicide victims becomes obvious. Their number is 13 times what we would expect of a group this size. The five psychotics who died at their own hand during the past two years 1988-1989 represent over five percent of the 87 suicides during that period. The psychotic rate, expressed in the usual terms of measurement, would come to 574–over ten times what would be expected.

Not only do victims of mental illness live miserably, but they die miserably as well. Whether because of tension between them and their families that is exacerbated by their illness or out of frustration and despair, the mentally ill commit suicide 10-15 times more frequently than the average Micronesian adult.

Why the Striking Differences by Sex and Place?

Whatever its methodological shortcomings, this survey raises a number of important questions that warrant closer study by psychiatric researchers and psychological anthropologists. It may be useful to review these questions before concluding this paper.

First, why the great disparity between male and female incidence of psychosis? It has sometimes been suggested that this disparity is more apparent than real: that many female psychotics go unrecognized and untreated because their symptomology is muted while that of males is exaggerated for cultural reasons. If we discount this explanation on the grounds that such attenuation of symptoms in a cognitive disorder such as schizophrenia is unlikely, we must somehow account for the great disparity in male and female rates of illnesses that are not usually thought of as gender-linked.

Environmental factors, which play an important although still undetermined role in causing schizophrenia and other psychoses, almost certainly contribute to the onset of these diseases. Just as the stress level in industrialized nations is believed to be responsible for the relatively high rates of psychosis in these countries, the variations in the stress level on particular age or gender groups might similarly affect morbidity rates within a society. The traditional patterns of social organization in Micronesian cultures tend to shelter women, confining them to the home and keeping them from the public roles that bring men both greater satisfaction and greater stress. Anthropologists who studied Micronesian societies soon after World War II noted that the social pressures on men were greater and the supports fewer. This should be all the more true today if, as seems to be the case, men are subject to greater role changes and social dislocation than women.

Moreover, the culturally sanctioned means by which males seek relief from stress, especially alcohol and other drugs, put them at an even greater risk of psychosis. The marked contrast between genders in alcohol and drug use parallels the skewed morbidity rates of psychosis. In their 1981 study of schizophrenia in Palau, Hammond and colleagues suggested that the high morbidity rate among Palauan males was "the result of toxicity from cannabis." Recently a major 14-year study purports to have conclusively linked cannabis use to schizophrenia through its finding that even occasional users are more than twice as likely to develop schizophrenia as non-users. In addition, we might recall that the rate of marijuana use among psychotics in the present survey was twice that reported for the general population of the largest island group in Micronesia. Such studies have their debunkers, of course. Yet, the gender difference in drug and alcohol use is too great to be ignored when we cast about for some explanation of the high rate of male psychosis recorded in this survey.

Another issue raised by the survey is the wide variation in the psychosis rates of different island groups. It is unlikely that the strikingly high rates in Palau and Yap can be explained by better case monitoring and reporting procedures in these two places, however justified these judgments may be. Nowhere in Micronesia was a more exhaustive community survey made than in Chuuk, where each lagoon island was visited and a wide network of community and church leaders mobilized to scrutinize the villages for unreported cases. Yet, for all the effort and time spent there, Chuuk's rate turned out to be very low when compared with Palau and Yap.

It is possible, of course, that social disruption is much greater in Palau and Yap, and the stress levels that might stem from such disruption and precipitate initial psychotic episodes are significantly higher than in other parts of Micronesia. It would be very difficult, however, to establish conclusively such a gratuitous assertion. Another possible explanation is that the alcohol and drug use in these islands, which is said to be particularly high even by island standards, might have a causal relation to the high morbidity rates there. It is no secret that Palau has in the last decade experienced a drug problem–including the use of heroin and cocaine–that is unparalleled in other parts of Micronesia. Although there are no means of gauging the comparative prevalence of drugs in different island groups, there are figures (admittedly incomplete and dated) that furnish a rough index to the relative amount of alcohol consumed in these places. Trust Territory import figures for 1977 showed that the annual expenditure on alcohol in Yap ($66) was about three times as great as in Pohnpei ($21) and the Marshalls ($24). Palau's per capita expenditure ($55), while lower than Yap's, was twice that of Pohnpei and the Marshalls. The figures for Chuuk and Kosrae were unrecorded.

A third major issue is raised by the apparent shift in the age distribution of psychotics between 1980 and 1990. The data show that the bulge in the psychotic population appears to have have moved from the 20s age-group to the 30s. If the data for the earlier period are sound, this is a significant finding. It suggests that the generation which entered its 20s during the 1970s has a higher incidence of psychosis than younger age groups (and, we may assume, older ones as well). It gives reason to hope that psychosis, like suicide, is at least partly epidemic in nature, and the relatively high morbidity rates we see now will pass in time as the stress levels associated with rapid social change decrease.