Mental health is a taboo subject but breakdowns are far more common than you might think.Matthew Taylor takes a closer look in the first article in a Royal Gazette's series highlighting the subject.

Nearly 20 percent of Bermuda's population could be suffering from some form of mental illness say experts.

And they are urging potential sufferers to cast aside their prejudices and seek help because undiagnosed mental issues can destroy the lives of sufferers and their families.

While no official figures exist for the Bermuda population, Mid Atlantic Wellness Institute (MAWI) psychiatrist Chantelle Simmons said large studies in the US estimated somewhere between eight and 17 percent of people suffer depression at one point in their life time. Some get treated by their GP, some never get any help.

Schizophrenia runs at about one percent of the worldwide population meaning nearly one fifth of any population can be suffering from one form of mental illness or another.

Dr. Simmons said: "Those are probably the most accurate results we have because they were based on community researchers going door to door, trying to get the most representative sample."

And untreated mental problems can even harm physical health.

The World Health Organisation (WHO) predicts that by 2030 depression will have become the second leading cause of early death and loss of productive life due to disability.

It's already a risk factor for suicide and many non-communicable diseases such as stroke, coronary heart disease and type 2 diabetes.

Depressed people are more likely to get infected with HIV-1, says WHO, while anti-AIDs drugs are less likely to work if the person is depressed. The same is true for treatment for other conditions such as diabetes and tuberculosis.

MAWI Chief of Psychiatry Dr. Michael Radford believes Bermuda's mental health problems are similar to anywhere else in the world with schizophrenia, manic depression, anxiety disorders and depression all figuring.

He added: "There is a big cost for families from sufferers of manic depressive illness and also alcohol and other addiction problems including gambling and drug addiction. They are all seen in high numbers on this island."

And Bermuda, like so many other countries, has a massive stigma about mental illness, said Dr. Radford.

"In Bermuda we have for a long time made this category mistake people think either you are a St. Brendan's case or you are normal. None of us are either. But there is very much a rigid distinction."

Dr. Radford was involved with a project in Birmingham, England, where it was suspected there was significantly under-diagnosed depression, particularly in men.

So a website was put up which brought in numerous patients who never suspected they were suffering but learned otherwise after submitting a revealing questionnaire.

They were quizzed about behavioural patterns which elicited that they were experiencing depression with all sorts of symptoms far less obvious than simply "feeling down".

Dr. Simmons explained some of the lesser known symptoms of depression.

"There is loss of interest in family, friends and hobbies, changes in sleep pattern, appetite and concentration patterns.

"If you are noticing a change from your normal pattern not accounted by any physical concerns then I would consider coming in for an assessment."

WHO believes that neuro-psychiatric disorders are the most costly of all conditions.

Dr. Simmons said the toll included loss of days from work, costs due to criminal activities and costs associated with substance abuse.

"There are a variety of potential consequences from untreated psychiatric illness.

"A number of clients I work with are lying in their bed all day. They are not interested in anything, are not excited about seeing their children and don't want to visit relatives.

"They are in bed with the covers over their head and missing out on the positive interactions with family members."

But they can be cured and just as with physical illness early treatment is most likely to beat the problem.

The first step for anyone suspecting they had problems is to start with their GP, unless it is an emergency case.

Sometimes the problems can be beaten quickly, said Dr. Simmons, with a combination of medication and practical help.

"Particularly if the problems are the result of a specific stressor maybe the loss of a job contributed to the symptoms.

"Their treatment plan might be starting them on anti-depressant medication and assisting them with finding new employment."

Eventually, once the sufferers get a job, they are normally weaned off the drugs.

While experts don't see any difference in the rates of mental illness in Bermuda compared to the world population they believe there could be some differences in causes for a population severely pressured by money and space constraints.

Dr. Simmons said: "I see a number of clients where the high cost of living in Bermuda is certainly a significant cause of anxiety as well as depressive symptoms."

By way of example Dr. Simmons, who worked in the States until recently returning to Bermuda, said her electricity bill was just $40 a month in Atlanta whereas families here were paying hundreds of dollars.

"Not to mention the cost of food and health care etc. that contributes to anxiety rates here in Bermuda and depression symptoms.

"And, because we are such a small island, it can place clients at increased risk for paranoia.

"I have had clients say they wondered if their boss was coming past their house because the boss knows where they live. Because we are a small community it is very difficult to retain anonymity.

"Then there is youth cannabis use, we know there is a high prevalence and the evidence clearly shows it increases the risk of development of schizophrenia and other psychotic disorders."

Dr. Simmons provides integrated treatment for clients who carry dual diagnoses, such as psychiatric and substance use disorders.

While experts can only guess at the numbers of undiagnosed mental conditions, there are more than 1,200 people getting help.

Currently there are about 400 people in the community rehab area dealing with long-term mental illness and about the same number in acute area i.e lower disability out-patients and short term in-patients.

And there are about 400 in Turning Point which deals with addiction problems.

Mental health problems used to be dealt with by keeping people locked away.

Dr. Radford said: "That's what helped increase the stigma and increase the illness. Recently there have been more active treatments, most of the conditions people were locked up for can be treated.

"There are residual symptoms, with a third of these people needing continuing support."

Too often the support has either meant going to hospital or prison. It's often a revolving door for those who can't cope on the outside and who sometimes end up homeless.

Dr. Radford believes there are about 30 people with major psychotic illness in prison, while about 30 percent of inmates are trying to cope with some form of mental problem.

Government is looking at creating a new plan to meet mental health sufferers in their own environment and Dr. Radford believes many MAWI staff are keen to improve services.

"We need to help people become empowered, rather than looked after and go and meet people where they are rather than people have to come to hospital for help."

So why do some people succumb to mental problems and others not? That is not easy to answer, the factors are often a combination of nature and nurture.

So is there anything anyone can do to stave off mental trouble?

Avoid drink and drugs for a start. "Alcohol in the short term can make you feel good, it is a depressant, it slows down the brain," said Dr. Simmons. "Attend to your medical conditions as well."

Hypothyroidism, if left untreated, can actually cause depression as can anaemia.

And all the general advice for a healthy lifestyle can also help such with mental wellbeing such as a healthy diet and plenty of exercise.

In the long run it will need society to take the issue more seriously. MAWI is trying to break down some of the stigma via Mental Health Week and the recent Mind Frame exhibition which showed the artistic work of some of the MAWI's patients.

Often problems start at a young age. Worldwide about half of mental disorders begin before the age of 14. Around 20 percent of the world's children and adolescents are estimated to have mental disorders or problems, with similar types of disorders being reported across cultures.

But far too often mental health problems are ignored and it can then become too late to help people.

Maj. Doug Lewis of the Salvation Army has said his staff had seen plenty of cases of people struggling to cope with mental problems.

He believes the majority of Salvation Army clients are suffering from a combination of addiction and mental health problems.

It means staff have to tread carefully and the ratio of staff to clients had to be kept high to cope when things threaten to get out of hand.

Maj. Lewis said: "People joke about the full moon but that does have an effect. There are days and nights when everybody seems strange.

"We have some who come who seem great, happy to chat to you but the next day you just look at them and they lose it.

"You have to know how to handle them, let them know you are a friend. You have to develop a relationship so you can help them."

He wishes the public were more aware and sympathetic to the plight of the mentally challenged as shunning them did no good. Sometimes those having seizures were dismissed as being drugged up or on drugs.

"People need to be more tolerant and understanding," said Maj. Lewis.

Sometimes when clients get to the Salvation Army they are beyond help and beyond reason – some of them don't know how to help themselves.

Indeed some can't even comprehend that they are homeless said Maj. Lewis

"We can book them a doctor's appointment at Wednesday at 10 o'clock but they have no clue about when Wednesday at 10 a.m. is.

"Perhaps if their problems had been caught earlier before they got into the drugs perhaps they could have been salvageable."