MEN’S HEALTH

IN SOME CUL­TURES, THE DICTATES OF MASCULINITY MAKE IT HARDER FOR MEN TO ASK FOR HELP WHEN THEY NEED IT.

Southeast Asia Globe - - Feature - BY RITHY ODOM

Sit­ting on a mat­tress on the bare floor of his bed­room, il­lu­mi­nated by a disco ball, a teenage Cam­bo­dian boy who goes by Davith said, “I had no clue what de­pres­sion is, but then I came [across] an ar­ti­cle on the in­ter­net mainly about de­pres­sion, and I di­ag­nosed al­most all of the symp­toms. That’s how I re­alised that’s not only me, there’s ac­tu­ally peo­ple around me that could not [dis­tin­guish] between stress and de­pres­sion.”

Davith’s ex­pe­ri­ence high­lights the dif­fi­cul­ties men­tal health pro­fes­sion­als point to in male men­tal health­care in South­east Asia.

“Although these men­tal health prob­lems af­fect both gen­ders, men­tal health is a silent cri­sis par­tic­u­larly among men,” Wah Yun Low, a pro­fes­sor of psy­chol­ogy at the Univer­sity of Malaya in Malaysia, told South­east Asia

Globe. She spoke of an in­creas­ing need to pay at­ten­tion to the men­tal health of men, who face so­cial pres­sure to avoid seek­ing help in the first place: “The con­cept of masculinity and stig­ma­ti­sa­tion sur­round­ing South­east Asian men are pre­vent­ing them from seek­ing help.”

In May 2016, an 11-year-old boy in Sin­ga­pore, scared to face his par­ents af­ter fail­ing his midterm ex­ams, jumped to his death out of his 17th-floor bed­room win­dow. “I only ask for 70 marks, I don’t ex­pect you to get 80 marks,” his mother wailed in Man­darin, re­peat­edly, next to the body, as re­ported by The Straits Times.

That sense­less tragedy joined the 800,000 deaths by sui­cide each year glob­ally, with South­east Asia alone con­sti­tut­ing 39% of sui­cide deaths, ac­cord­ing to the World Health Or­gan­i­sa­tion (WHO). WHO data for South­east Asia puts the male sui­cide rate at 14.8 per 100,000 peo­ple, com­pared to the global rate of 13.5 per 100,000.

“When a per­son is la­belled by their men­tal ill­ness, they are seen as part of a stereo­typed group which is tra­di­tion­ally as­so­ci­ated with neg­a­tive con­no­ta­tions and as­sump­tions,” wrote CBHS Health Fund, an Aus­tralia-based health in­sur­ance com­pany, on its health blog. “These neg­a­tive at­ti­tudes cre­ate prej­u­dice, which in turn leads to neg­a­tive ac­tions and dis­crim­i­na­tion amongst oth­ers in so­ci­ety.” This can ef­fec­tively si­lence those who need help the most, pres­sur­ing men to down­grade the ur­gency their men­tal well­ness re­quires.

So­ci­ety is par­tic­u­larly good at “pun­ish­ing gen­der be­havioural de­vi­a­tion in men”, Max Birchwood, the clin­i­cal di­rec­tor of Youth Men­tal Health at the Univer­sity of War­wick in Eng­land, told CBHS Health Fund. Men­tal health is­sues can be seen as weak or emas­cu­lat­ing, said Birchwood. Mas­cu­line stereo­types can dis­cour­age men from talk­ing about men­tal health, urg­ing them to mask men­tal ail­ments rather than ac­knowl­edge be­ing vul­ner­a­ble.

The sui­cide rate in Cam­bo­dia was 11.9 per 100,000 in­hab­i­tants in 2015, well below the rate for the re­gion. Twice as many men com­mit

“MEN NEED TO RE­SIST SO­CIAL STIGMA AND UN­DER­STAND THE SYMP­TOMS OF MEN­TAL ILLNESSES. ONLY THEN WILL THEY KNOW WHEN THEY SHOULD GET HELP”

need to re­sist so­cial stigma and un­der­stand the symp­toms of men­tal illnesses. Only then will they know when they should get help.”

Low and Yim agree that many men pri­ori­tise things like work over their health, down­play­ing the signs and symp­toms of ill­ness un­til they fi­nally de­cide to seek help – which can take years of an­guish, and these con­di­tions seem to be on the rise. Ma­jor de­pres­sive dis­or­ders in­creased glob­ally by 37.5% from 1990 to 2010, ac­cord­ing to a pa­per by Al­ize Fer­rari of the Psy­chi­atric Epi­demi­ol­ogy and Bur­den of Dis­ease Re­search Group in Aus­tralia.

“These find­ings em­pha­size the im­por­tance of in­clud­ing de­pres­sive dis­or­ders as a pub­lic-health pri­or­ity and im­ple­ment­ing cost­ef­fec­tive in­ter­ven­tions to re­duce its bur­den,” wrote Fer­rari.

Davith, the Cam­bo­dian boy who’d at­tempted to self-di­ag­nose, even­tu­ally sought help, and was pro­fes­sion­ally di­ag­nosed with ex­tremely se­vere de­pres­sion whose symp­toms in­cluded his de­bil­i­tat­ing in­som­nia. “I chose to see a doc­tor be­cause I could not sleep any­more,” he said. When he fi­nally asked for help, it was only af­ter a four-night run of sleep­less nights.

Af­ter get­ting help from the clinic at the Kh­mer-So­viet Friend­ship Hos­pi­tal, Davith re­ported feel­ing much bet­ter – his sleep­ing pat­terns im­proved and he started go­ing out­side and ex­er­cis­ing, which, along with med­i­ca­tions, has helped him re­turn to a more pro­duc­tive life.

“We need more com­mu­nity-based men’s health pro­grammes and more aware­ness and male-friendly health­care ser­vices [that] pro­mote health­ier life­styles among men,” psy­chol­ogy pro­fes­sor Wah Yun Low said. “Men should not sui­cide as women in Cam­bo­dia, and twice as many peo­ple un­der 40 kill them­selves as those over 40, ac­cord­ing to data com­piled by Dr

Keith Har­ris, a re­searcher at the Univer­sity of Queens­land in Aus­tralia.

A month be­fore the boy in Sin­ga­pore jumped to his death, a se­verely de­pressed Cam­bo­dian man jumped off a bridge but lived, and was picked up by a pass­ing fish­ing boat. He later said he couldn't af­ford med­i­ca­tion.

At the men­tal health de­part­ment of Phnom Penh’s Kh­mer-So­viet Friend­ship Hos­pi­tal, men­tal health spe­cial­ist Yim Sobo­tra said this man could have got­ten free or af­ford­able help. He said the hos­pi­tal has an eq­uity fund to help veter­ans, fac­tory work­ers, the dis­abled and those who can­not af­ford pre­scrip­tions.

With its 16 psy­chi­a­trists, the de­part­ment re­ceives between 50 and 60 new pa­tients each day, along with an av­er­age of 500 other ap­point­ments, mostly pa­tients who are di­ag­nosed with de­pres­sion or anx­i­ety. Yim said that “men

was long, she ex­plained, there was of­ten no time to get to the cases at the bot­tom of the pile. These pa­tients would have to be re­ferred to men­tal health NGOs or pri­vate hos­pi­tals.

NGOs like El­lisha’s, which use a slid­ing fee sched­ule, can al­le­vi­ate the pa­tient load at gov­ern­ment fa­cil­i­ties. An­other ex­am­ple is the Malaysian Men­tal Health As­so­ci­a­tion (MMHA), which has qual­i­fied and trainee clin­i­cal psy­chol­o­gists to pro­vide ther­apy ses­sions for as low as $5 for un­der­priv­i­leged clients.

But red tape binds them. MMHA’s sec­re­tary gen­eral, Dr Ang Kim Teng, told South­east Asia Globe that the vol­un­teer out­fit has been strug­gling to ob­tain a li­cense to op­er­ate its Com­mu­nity Men­tal Health Cen­tre.

“The Pri­vate Health­care Fa­cil­i­ties and Ser­vices Act does not al­low [non-govern­men­tal char­i­ta­ble or­gan­i­sa­tions] to op­er­ate health­care fa­cil­i­ties, ex­cept for hos­pices and dial­y­sis cen­tres ,” said the re­tired pub­lic health spe­cial­ist.

She added that the MOH ac­knowl­edged the need to amend the reg­u­la­tions. But un­til to­day, their li­cense ap­proval re­mained up in the air.

An­other chan­nel that can re­di­rect the pa­tient flow from clogged gov­ern- ment hos­pi­tals is pri­vate fa­cil­i­ties. In Malaysia, though, it is dif­fi­cult for pa­tients to sep­a­rate le­git­i­mate clin­i­cal psy­chol­o­gists from hacks. Li­cens­ing and reg­is­tra­tion was not re­quired for pri­vate prac­ti­tion­ers in the field un­til the Al­lied Health Pro­fes­sion­als Act was passed in 2016. Af­ter two years, the reg­istry is still pend­ing.

Dr Alvin Ng, head of the De­part­ment of Psy­chol­ogy at Sun­way Univer­sity in Malaysia, wel­comes the manda­tory reg­is­tra­tion be­cause he sees it as rein­ing in mal­prac­tice and re­in­forc­ing clin­i­cal psy­chol­o­gists’ role in the men­tal health­care sys­tem.

But en­force­ment could be com­pli­cated, said Ng. The act covers a wide range of al­lied health pro­fes­sions work­ing in clin­i­cal, non-clin­i­cal and tech­ni­cal set­tings. The vice pres­i­dent for the Malaysian So­ci­ety of Clin­i­cal Psy­chol­ogy would have pre­ferred stand­alone leg­is­la­tion for clin­i­cal psy­chol­ogy alone.

De­spite its short­com­ings, Ng said this leg­is­la­tion rep­re­sents hope for a more reg­u­lated pro­fes­sion, given the tepid gov­ern­ment sup­port for a stand­alone law and the lack of qual­i­fied clin­i­cal psy­chol­o­gists in the coun­try to draw it up.

Un­reg­u­lated prac­tice is just one is­sue in the pri­vate sec­tor. The other is the steep price. As long as most med­i­cal in­sur­ance in Malaysia ex­cludes cov­er­age of men­tal illnesses, treat­ment at pri­vate health­care fa­cil­i­ties will be in­ac­ces­si­ble to the ma­jor­ity. Mean­while, the queue at gov­ern­ment hos­pi­tals gets longer.

Lim Su Lin, a re­search an­a­lyst at the Pe­nang In­sti­tute and au­thor of the Bridg­ing Bar­ri­ers re­port, pointed out that coun­tries with pri­vate in­sur­ance cov­er­age for men­tal health treat­ment like the US tend to have strong sup­port for re­search into lo­cal men­tal health data. Her re­search in Malaysia, by con­trast, was a bu­reau­cratic maze. Track­ing down the lat­est fig­ures from Malaysian gov­ern­ment hos­pi­tals re­quired her to snail-mail of­fi­cial let­ters, reg­is­ter her re­search and ap­ply for ap­proval. And af­ter she jumped through the hoops, she never did re­ceive those data.

The big­gest chal­lenge for re­searchers, to Lim, is the “dis­persed na­ture” of pub­lic men­tal health data that is not com­piled into a sin­gle “store­house”.

On top of that, both Lim and Ng said that sci­en­tific re­search into men­tal health in Malaysia is not as ro­bust as in other med­i­cal spe­cial­i­sa­tions. This im­pedes un­der­stand­ing of men­tal dis­or­ders.

“The deficiencies of data on men­tal health ex­plain why pri­vate in­sur­ance underwriters are so guarded against in­tro­duc­ing poli­cies for men­tal health cov­er­age,” Lim wrote in her re­port. “With­out solid ev­i­dence-backed data on men­tal health con­di­tions in our coun­try, it is hard for them to act [since] they would not be able to per­form cal­cu­la­tions of men­tal health risk, let alone gauge po­ten­tial pre­mium rates for men­tal health treat­ment.”

Pal­try re­search and the lack of med­i­cal in­sur­ance cov­er­age may have writ­ten the fates of Visha­latchi and Mala. For the past seven years, Visha­latchi bounced from one con­fus­ing di­ag­no­sis to an­other. Ev­ery di­ag­no­sis came with a new cock­tail of medicines, with one doc­tor re­fut­ing an­other’s pre­scrip­tions. Some sta­bilised her con­di­tions. Some did not. But all of them had to be paid for with Mala’s ir­reg­u­lar earn­ings.

Visha­latchi be­lieves that stronger re­search would have im­proved the field’s un­der­stand­ing of com­plex cases like hers, and bet­ter sup­ported her re­cov­ery.

“But the whole men­tal health­care sys­tem in Malaysia seems to be be­hind the times,” she said.

And be­cause of that, she is kept be­hind, too.

“THE DEFICIENCIES OF DATA ON MEN­TAL HEALTH EX­PLAIN WHY PRI­VATE IN­SUR­ANCE UNDERWRITERS ARE SO GUARDED AGAINST IN­TRO­DUC­ING POLI­CIES FOR MEN­TAL HEALTH COV­ER­AGE”

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