Mental illness is a significant concern for the population of Saint Kitts and Nevis. In 2022, the Federation of St. Kitts and Nevis announced the restructuring of mental health services to refocus on improving service effectiveness and efficiency [1]. The government has been working to better integrate mental health information and education into the primary health care system. There are ongoing attempts to promote education about mental illness and the dangers of suicide by government officials [2]. Mental illness has been called a “disease of pain and exclusion” that is often misunderstood and poorly treated [3]. Research statistics have identified that 60% of mental health patients within the Caribbean islands will not receive psychological assistance or mental health counseling for their mental health issues. Fear of being labelled or discriminated against have contributed to the lack of treatment for mental health issues. Thousands of Caribbean residents endure mental health ailments with no treatment options available. In 2017, the number of individuals having mental illness in the Caribbean was projected to increase by 50% before 2020. The projected increase in 2017 was based upon an increase in the aged population, stress of worry regarding climate change, political environments, and economic and social decline in some countries. The COVID-19 pandemic exacerbated the availability of mental health diagnosis and treatment options. Devastatingly, up to 80% of the individuals living in the Caribbean with mental illness with have no access to mental health treatment. The Caribbean region overall is recognized as being understaffed for treating mental disorders, and is in dismal need of mental health clinicians to treat the mentally ill [3].

The Federation of Saint Christopher and Nevis, commonly known as Saint Kitts and Nevis [4], is comprised of two islands of the Lesser Antilles [5]. The islands are located in the Leeward Islands chain within the eastern part of the Caribbean [6] are approximately two miles apart separated by a strait called The Narrows [5,6]. The islands straddle the Caribbean Sea and the North Atlantic Ocean, and are about 1,200 miles southeast from Florida in the United States [4]. The land mass area of the two islands is approximately 104 square miles [5]. The two islands were once colonies of Great Britain, but gained their freedom from British rule on September 19, 1983 [6]. The Federation continues to remain as a member of the Commonwealth of Nations, while continuing to be heavily influenced by British ideals. The Federation is identified as a Parliamentary democracy and a Commonwealth realm with the legal system being based upon English common law [6]. The capital of the Federation is Basseterre, which is located on Saint Kitts and is the country’s main urban center. Population in 2018 in Basseterre was about 14,000 residents. The only large town on the island of Nevis is Charlestown, which is the second-largest town on the two islands of the country [6].

The majority of the population of both Saint Kitts and Nevis are descendants of enslaved Africans who were brought to the islands by early settling colonial Europeans. There are minority populations of Portuguese, Lebanese, British, and some individuals of mixed African and European ancestry [6]. In addition, there are some smaller groups of individuals who have origins from India and the United States. There is a very small population of South Asian residents [5]. Religious involvement is a significant component in many Caribbean homes, specifically in Black Caribbean households. Research has recognized that participant in organized religion is positively related to self-esteem and coping and negatively correlated to depressive symptoms [7]. Most residents of Saint Kitts and Nevis identify their religious orientation as Christian, with Anglicanism as the primary denomination [6]. Overall, Protestantism is practiced by over 80% of the population [8].

In 1493, Christopher Columbus visited Saint Kitts and found it inhabited by Carib people. At that time, he named the island “Saint Christopher” for his patron saint [5,6]. Columbus also sighted Nevis in 1493. He described the island as having clouds on top of Nevis Peak. He called it las nieves, or “the snows,” which is how the name of Nevis originated. Arriving in 1623, British settlers, under the leadership of Sir Thomas Warner, shortened the name to Saint Kitts. These settlers established the first successful English colony in the West Indies. Following the British settlers, French colonists arrived in 1625 and established their own colony in 1627 under the direction of Pierre Bélain, sieur d’Esnambuc [5]. This was the first French colony established in the Caribbean [4]. On Saint Kitts, in 1626, the last of the Carib peoples were massacred by British and French settlers on Bloody Point [6].

The island of Nevis was settled in 1628 by British colonists arriving from Saint Kitts [4]. During the 17th century, Saint Kitts was divided between warring French and English colonists [5]. In April 1713, Saint Kitts was given to Great Britain by the means of the Treaty of Utrecht and remained under British rule regardless of the capture of Brimstone Hill in 1782 by the French. The Peace of Paris treaty at Versailles restored Saint Kitts back to Great Britain in 1783 [5].

The Ministry of Health department of the government is responsible for the healthcare in the Federation [9]. The islands have government-funded access to health care for children and senior adults. Children under the age of 18 and senior adults over the age of 62 are exempt from public health charges for basic health care [10]. For those who are incapable of paying for health services, there is a “safety net” of social security that provides assistance benefits to ensure health care to citizens, even if they are unable to pay for services [10].

The psychological background for the islands of Saint Kitts and Nevis was significantly impacted by the late Dr. Arthur W. Lake [11]. Dr. Lake was a recipient of the Member of the British Empire (MBE) in 1960, and he was named a member of Order of the British Empire in 1967. These honors were recognition for his years of service to the fields of psychiatry, medicine, surgery, and obstetrics [11]. Dr. Lake was responsible for establishing the first mental health clinics throughout the Federation of Saint Kitts and Nevis. His establishment of clinics occurred during a time in the community when mental illness was “very much frowned upon,” with mentally ill and psychiatric patients often ostracized or hidden from society [12]. Dr. Lake is also recognized as spearheading the establishment of the Saint Kitts Mental Health Association [12]. On February 20, 2018, due to his “long and meritorious service” to pioneering mental health care in Saint Kitts, the island’s first national mental health day treatment center was renamed to the Dr. Arthur Wilfred Lawson Lake Mental Health Day Treatment Centre.

The Saint Kitts Mental Health Association was established in October 2007. The vision of the organization is to decrease the stigma and improve the mental health of the citizens of the twinislands through “cooperation, acceptance research, education, and service” [13]. Members of the mental association are comprised of mental health professionals including psychiatrists, psychologists (PhD level and Masters’ level), social workers, and counselors who offer a diverse range of services to treatment mental illness. There is a more recent organization that has been established for the Federation, the St. Kitts & Nevis Mental Health and Psycho-social Committee [14]. This committee was established with the Ministry of Health to provide mental health and psychosocial support to residents of the two islands. The committee recently embarked on a specific campaign to provide information to community members about the concerns of mental illness, specifically relating to life during the COVID-19 pandemic. The committee team provided short articles online to Federation residents to assist in educating about how to improve mental health and provide self-care during such a stressful life experience. The Mental Health and Psychosocial Committee also partnered with the Pan American Health Organization (PAHO) to provide support networks and mental health initiatives to reduce stress and improve education regarding mental health and coping [14].

Official records cite mental illness affects approximately 1% of adults on the islands of Saint Kitts and Nevis [9]. However, actual records indicate that the true prevalence is likely closer to 5-10% of adults having mental disorders [15]. The most commonly seen mental health issue diagnosed is schizophrenia. Next diagnosed on the twin-islands are mood disorders, which includes depression and bipolar disorders. The PAHO [10] reports that between the years of 2011-2015, the following psychiatric disorders were diagnosed and treated: schizophrenia (793 cases), schizoaffective disorders (297), bipolar disorder (190), depression (120), and cannabis-induced psychosis (54). Adolescents in the Federation have been shown to be susceptible to depression symptomology. In one study, students in grade 10 were identified as having diagnosable depression after taking the Beck Depression Inventory-II (BDI-II) at their high school. The results indicated that 62.1% reported some symptoms of depression. There were 14.8% reporting moderate to severe depressive symptoms, while 9.7% scored reporting severe symptoms of depression. Females reported significantly higher BDI-II scores, with 70% reporting some level of depressive symptoms. Only 52% of males disclosed depressive symptomology [16]. Another study found that 52.1% of surveyed adolescents in the Caribbean, including students from Saint Kitts and Nevis, reported mild to severe depressive symptoms [17]. Of the surveyed adolescents, 29.1% reported moderate to severe depressive symptoms [18,19].

The government of Saint Kitts and Nevis is cognizant that mental health needs require more education and funding for the country. The Ministry of Health is the governing body for mental illness identification and treatment for the islands of Saint Kitts and Nevis [14]. The World Health Organization (WHO) stated in their Mental Health Atlas [20] “There is a paucity of epidemiological data on mental illnesses in Saint Kitts and Nevis in internationally accessible literature.” Nevis Island has one 50-bed hospital, the Alexandra Hospital. At the Alexandra Hospital, when necessary, individuals requiring inpatient mental health treatment are hospitalized. A Saint Kitts psychiatrist conducts outpatient biweekly psychiatric clinic appointments at the hospital. Additionally, there are two psychiatric nurses that see psychiatric patients for necessary triage, make necessary home visits, and are able to see patients in the community mental health clinics [21]. When there are psychiatric emergencies, urgent care is frequently provided by nonpsychiatric primary care providers. This urgent care can include visits and admission into the emergency department, and the preliminary management of psychiatric symptoms for patients. The supervision of the psychiatric patients’ symptoms and behaviors by nonpsychiatric providers typically lasts from one to four days before the patient is seen by a visiting psychiatrist [21].

Both Saint Kitts and Nevis would benefit from additional staff in the mental health field. One research article [21] stated that there is a “paucity” of mental health workers on the island of Nevis. However, there are shortages in mental health-qualified staff in Saint Kitts as well. In 2017, a mental health center was delayed in opening because of the lack of mental health-certified nurses. Specifically, there were only four nurses with training in mental health available, and these nurses would have to collaborate their working schedules with the psychiatric units elsewhere on the islands [22].

In 2007, the World Health Organization Assessment Instrument for Mental Health (WHO/AIMS) was used to collect data regarding the mental health structures available in Saint Kitts and Nevis [23]. According to the report, approximately 1% of current and nonrecurrent expenditures was allotted for mental health services for the islands. WHO reported in 2011 that the majority of primary health care doctors and nurses in Nevis and Saint Kitts have not received official in-service trainings in the past five years for mental health treatment for disorders. There have been seven outpatient mental health facilities available on the two islands. There were 12 psychiatric beds available in general hospitals for inpatient stays for mental illness [24]. In 2012-2013, there was only one psychiatric inpatient unit, having 14-beds, in the Federation that is located on Saint Kitts [21]. In 2011, there were 1172.47 individuals treated (per 100,000 population) in mental health outpatient facilities. Females comprised 41% of the total treated. There were approximately 2% of children under the age of 18 treated [24].

The primary delivery service for mental health care has been the community-based approach for treatment. In the Federation, mental health treatment is provided by several options. The first opportunity is weekly-scheduled clinics in 3 of the 11 primary health care centers. The second option is provided through bimonthly clinics provided at Her Majesty’s Prison for mental health treatment. The third opportunity is at the counseling center. And the fourth option is treatment at the outpatient counseling clinic at the Joseph N. France hospital. At specific nursing homes, CARDIN house in Saint Kitts and the Flamboyant Nursing Home in Nevis, inpatient care is provided to some mental health patients. Government mental health officers occasionally make home visits for treatment and are sometimes accompanied by psychiatrists [24]. There are potential cultural considerations that likely contribute to mental illness on Saint Kitts and Nevis. The first consideration is that marijuana is often not viewed as a drug on the islands. The Rastafarian religion incorporates the usage of marijuana into their religious rituals [25]. This usage of marijuana for religious purposes reduces the taboo factor of marijuana as a psychoactive drug [21].

The next concern that impacts mental health treatment is the lack of psychiatric medication available for patients. Specifically, occasional financial concerns at the Nevis hospital create inconsistent availability for treatment with modern antipsychotic medications [21]. According to the WHO, there is significant scarcity of psychotropic medications for neurological and mental health illness in the Federation [24]. If medication is available, it is provided for free through the government pharmacies from the Ministry of Health [21]. However, sometimes the medications which are available are expensive and are only available from private businesses [24]. The third cultural consideration is the stigma of mental illness. In larger cities and urban environments, the stigma attached to mental illness is often buffered by larger populations and more options for treatment. On Nevis, one researcher noted that with only approximately 12,000 in population, it is more difficult to ensure anonymity because it is a smaller community [21]. Difficulties in retaining patient anonymity in small island populations, such as Saint Kitts and Nevis, can create ethical dilemmas similar to ones noted in rural communities [26]. The final cultural consideration is that of hurricane trauma and its impact on mental health [21]. The islands have significant hurricane activity, which can be traumatic and life-threatening. This should be a consideration in the diagnosis of such disorders as Post-Traumatic Stress Disorder or Acute Stress Disorder. Researchers have suggested that local health-care providers should be competently trained for post-disaster mental health issues [27].

The Federation of St. Kitts and Nevis has identified that more organized and efficient distribution of mental health services are necessary to improve competency and treatment [1]. There are several opportunities for growth for the twin-islands to provide more mental health services and allocate more resources to the treatment of mental illness. The Ministry of Health has identified their need to improve education about mental health illness, and are working to provide informative training to destigmatize the myths surrounding mental disorders. There is a significant need for more highly trained professionals in the field of psychology, psychiatry, social work, and counseling on the islands. These professionals would enhance the existing mental health network, and would allow for more citizens to receive the necessary mental health treatment for their mental illness.

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