Lost pa­tience

Southeast Asia Globe - - Contents - Bridg­ing Bar­ri­ers: A Re­port on Im­prov­ing Ac­cess to Men­tal Health­care

How Malaysians strug­gling with men­tal health is­sues are get­ting caught up in end­less red tape

On her good days, Visha­latchi Aruna­giri went for flower ar­range­ment classes, wrote, and gave speeches and me­dia in­ter­views as a men­tal health ad­vo­cate. On her bad days, the 26-year-old could do none of that. Se­vere anx­i­ety and a di­ag­no­sis of schizo-af­fec­tive dis­or­der crip­pled Visha­latchi, leav­ing her un­able to feed, clean or take care of her­self. Delu­sions filled her head. So did the voices – which at­tacked her mum and sib­lings while push­ing her to kill her­self.

As Visha­latchi teetered on the tightrope between pro­duc­tiv­ity and paral­y­sis, she was sup­ported by her 61-year-old sin­gle mother, Mala Davi N Than­jap­pan.

“Visha is very at­tached to me. I can­not leave her and go to work for too many hours; she of­ten has anx­i­ety at­tacks when alone,” said the Montes­sori ed­u­ca­tion con­sul­tant. Mala’s free­lance ca­reer al­lows her to pro­vide this care, but the down­side is ir­reg­u­lar projects and pay.

Ap­prox­i­mately one in three Malaysian adults suf­fers from a men­tal health con­di­tion or is at risk of de­vel­op­ing a di­ag­nos­able men­tal ill­ness, ac­cord­ing to the coun­try’s last Na­tional Health and Mor­bid­ity Sur­vey (NHMS), in 2015.

Men­tal health fig­ures into the vast ma­jor­ity of sui­cides, with 90% of cases as­so­ci­ated with men­tal health dis­or­ders, ac­cord­ing to the World Health Or­gan­i­sa­tion (WHO). WHO re­ports an av­er­age of 2,000 sui­cides a year in Malaysia, or more than five a day.

A WHO study in 2016 found that two dis­or­ders alone – anx­i­ety and de­pres­sion – knock $1 tril­lion off the global econ­omy each year. Many of those liv­ing with these af­flic­tions strug­gle with pro­duc­tiv­ity at work or can’t hold down a job. This squeezes their earn­ings, which means less abil­ity to pay for men­tal health treat­ment. Thus a vi­cious cy­cle is born.

Cheaper treat­ment can flip the script. It cer­tainly did for Visha­latchi, who gets free care at a pub­lic hos­pi­tal as a holder of an OKU card un­der the gov­ern­ment’s So­cial Wel­fare De­part­ment – OKU stands for “orang ku­rang up­aya”, which means “dis­abled per­son” in Malay. This saves Mala an av­er­age $247 that she used to cough up ev­ery month for her daugh­ter’s treat­ment at pri­vate fa­cil­i­ties since men­tal health treat­ment is not cov­ered by most med­i­cal in­sur­ance in Malaysia.

Even pay­ing pa­tients at pub­lic men­tal health­care fa­cil­i­ties save sub­stan­tially, ac­cord­ing to

“VISHA IS VERY AT­TACHED TO ME. I CAN­NOT LEAVE HER AND GO TO WORK FOR TOO MANY HOURS; SHE OF­TEN HAS ANX­I­ETY AT­TACKS WHEN ALONE”

pub­lished by the Malaysian think tank Pe­nang In­sti­tute ear­lier this year.

Take the treat­ment charges for de­pres­sion, for ex­am­ple. The re­port cal­cu­lated that the to­tal price for psy­chi­atric con­sul­ta­tion, psy­chother­apy and med­i­ca­tion is at most $55 a year in pub­lic health­care sec­tors. In pri­vate hos­pi­tals, the amount bal­loons to $2,016.

In its pre-elec­tion man­i­festo, the newly elected gov­ern­ment of Malaysia promised to chan­nel more re­sources to men­tal health­care through gov­ern­ment hos­pi­tals.

More money would be nice. Since 2012, the Malaysian Min­istry of Health (MOH) has spent less than 1.5% of its an­nual op­er­at­ing bud­get on men­tal health­care.

But money may not be able to fully patch the gaps – not when much of it is caused by a bro­ken sys­tem, as laid bare by the dearth of clin­i­cal psy­chol­o­gists in pub­lic ser­vice.

To be fair, the men­tal health­care work­force is short­handed all around. It’s just not a pop­u­lar ca­reer choice in Malaysia. Yet the short­age of clin­i­cal psy­chol­o­gists in gov­ern­ment-run fa­cil­i­ties seems self-in­flicted. The MOH has capped its po­si­tions for clin­i­cal psy­chol­o­gists at 15, even though there are 45 hos­pi­tals un­der the min­istry of­fer­ing psy­chi­atric ser­vices through­out the coun­try, ac­cord­ing to the Bridg­ing Bar­ri­ers re­port.

In other words, more clin­i­cal psy­chol­o­gists could not en­ter the pub­lic ser­vice even if they wanted to. Here’s why that mat­ters.

Clin­i­cal psy­chol­o­gists are in­stru­men­tal in psy­chi­atric de­part­ments. They per­form dif­fer­ent func­tions from psy­chi­a­trists, but both com­ple­ment each other in sta­bil­is­ing a pa­tient’s con­di­tion. Psy­chi­a­trists di­ag­nose men­tal dis­or­ders and of­fer bio­med­i­cal treat­ment, of­ten with med­i­ca­tion, but pop­ping pills alone can­not cure un­der­ly­ing is­sues that lead to a dis­or­der.

Clin­i­cal psy­chol­o­gists can­not pre­scribe medicine, but they are trained to do psy­cho­log­i­cal as­sess­ments, cru­cial for ac­cu­rate di­ag­no­sis of some dis­or­ders. They also ad­min­is­ter clin­i­cal in­ter­ven­tions to as­sist in emo­tional and men­tal re­cov­ery, as well as long-term be­havioural change.

In many cases, clin­i­cal psy­chol­o­gists help treat­ments stick – but there were only 14 clin­i­cal psy­chol­o­gists em­ployed in Malaysian gov­ern­ment health­care fa­cil­i­ties as of Jan­uary 2017, com­pared with 114 psy­chi­a­trists. This is ac­tu­ally a step up from 2016, when 12 clin­i­cal psy­chol­o­gists were work­ing in these fa­cil­i­ties. In con­trast, there were 188 coun­sel­lors, who deal with less se­vere emo­tional dis­tress com­pared with clin­i­cal psy­chol­o­gists within a non-psy­chi­atric set­ting.

The pre­vail­ing sen­ti­ment among clin­i­cal psy­chol­o­gists is that the gov­ern­ment has mixed up its role with that of coun­sel­lors.

The re­cruit­ment sys­tem could be part of the prob­lem. Un­der the civil ser­vice, clin­i­cal psy­chol­o­gists are

SA staffer for Malaysia's SOLS Health, an NGO of­fer­ing com­mu­nity psy­cho­log­i­cal health­care, leads in­dige­nous chil­dren at a sum­mer camp

SClock­wise from top left: Dr. Alvin Ng, El­lisha Oth­man, Lim Su Lin and Dr. Ang Kim Teng

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