The realities of mental illness

MENTAL illness, just like any other disease or condition, affects millions of people across the world.

Malaysia’s National Health and Morbidity Survey ( NHMS) 2015 found that 29.2% of Malaysian adults suffer from a mental illness.

According to the survey, there is an increasing trend in the prevalence of mental health problems among Malaysian adults, especially among females and younger adults.

Gender plays a critical role in mental health and mental illness. For example, all over the world, more women than men are diagnosed with depression and anxiety. Certain other mental illnesses are more prevalent among men than women, such as antisocial personality disorder.

Furthermore, according to the World Health Organization ( WHO), gender is a significant determinant in the difference of power and control men and women have over the socioeconomic factors that affect their mental health and lives, their social position, status and treatment in society, and their susceptibility to specific mental health risks.

The risk factors that disproportionately affect women include gender- based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status, and unremitting responsibility for the care of others.

These factors undoubtedly affect Malaysian women just as they do women all over the world.

The spectre of ‘ madness’

Though the increase in the numbers of people with mental health problems in the NHMS can be partly attributed to better reporting – Malaysians nowadays are more aware of their mental health and relatively less reticent about reporting it – social stigma and cultural misconceptions about mental illness still exist.

A study by International Medical University ( IMU) published in the Singapore Medical Journal in 2009 found that while the younger people surveyed during the study had a better attitude towards mental health and were more willing to seek help, a combination of ethnic background, religion, education level and residential location influenced their knowledge and attitudes towards mental health issues.

Though the study took place seven years ago, awareness and understanding of mental health in Malaysia have not changed sufficiently.

“While perceptions of mental illness may have changed for the better over the years due to increased awareness as well as advancements in the treatment of mental illness, the Malaysian society, like most Asian societies, still holds erroneous cultural perceptions and belief systems with regard to mental illness,” says psychiatrist Datuk Dr Andrew Mohanraj, who is also the deputy president of the Malaysian Mental Health Association ( MMHA).

In such instances, chronic mental illnesses such as schizophrenia are attributed to being possessed by spirits or “charm” put on a person, he explains.

“Depression is still not regarded as a clinical condition that needs medical intervention. Instead, many people view it as a defect of personality or being unduly sensitive or fussy, and expect the person to just ‘ snap out of it’.”

It is clear that people diagnosed with mental illnesses inhabit a different space in public perception from those hospitalised for physical conditions such as cancer or heart disease.

The latter are seen as health crises that are, to a certain extent, beyond your control while mental illness is seen as a condition that can and should be dealt with on a personal level.

British television personality Trisha Goddard illustrated this in a 2010 interview about her battles with breast cancer and mental illness, saying, “With breast cancer, people ran towards me with open arms... with depression, people ran away.”

Breaching the wall

In the interview, Goddard revealed that people’s reactions to her mental illness affected her recovery, explaining that when she tried to talk about her depression, she was made to feel embarrassed, ashamed and guilty.

A recent University of Cambridge study on mental illness in Malaysia found that stigma is a significant barrier to seeking help and care for mental health, and most often manifests in the form of labelling, rejection and social exclusion by family, friends and workplace staff.

The study, published last year, states that this stigma leads to “patients being trapped in a vicious cycle of discrimination leading to detrimental consequences for the individual, their families, communities and society as a whole.”

“We need to have better awareness about mental illness and understand that it is like any other illness that affects the brain. Its causes are multifactorial and much is still unknown about mental illness, not unlike cancers,” says Datin Dr Ang Kim Teng, secretary- general of MMHA.

While knowledge can certainly lead to greater understanding and tolerance about mental illness in general, women have one extra wall barring them from seeking treatment – gender discrimination.

WHO reports that gender stereotypes about the proneness to emotional problems in women appear to reinforce social stigma and lead to constraints in people seeking help as well as accurate identification and treatment of psychological disorders.

According to WHO, communication between health workers and female patients in many developing countries is extremely authoritarian, making women’s disclosure of psychological or emotional problems difficult.

Furthermore, when women do disclose mental health problems, stigma and gender bias means that health workers either over treat or under treat women – WHO statistics show that women are prescribed more mood- altering psychotropic drugs than men.

On top of that are factors such as continuous day- to- day responsibility for the care of others that prevents women from having the opportunity, time or energy to identify mental health issues in themselves and seek treatment, and fear of humiliation or retaliation for seeking help.

“For many women, domestic violence or other forms of gender- based violence may be precipitating factors to developing psychological conditions such as depression and anxiety but they are often reluctant to seek help for fear of disclosing their victimisation,” says Dr Andrew, citing this as a possible factor for the difference in help- seeking behaviour between men and women.

This cycle of stigma and gender discrimination must be stopped if women are to be able to seek and obtain appropriate and successful treatment.

The IMU study found that there is a big gap when it comes to understanding general mental well- being and the importance of seeking mental health care, which should be filled through dissemination of accurate information by the mass media as the primary source of information on mental health.

This position is shared by Dr Ang, who says that the Government can use the mass media to educate the public and create better awareness about the early manifestations of mental illness for early treatment and to destigmatise mental illness.

“MMHA is doing its part by using social media to reach out to more people, but we ourselves have not yet maximised its use,” she says, adding that educational programmes for caregivers and the public, such as those that MMHA organises, also bring more awareness to mental illness and better access to treatment.

Treatment and access

In 2013, WHO described deficiency of mental health provision and access all over the world as a “long- neglected problem” and called for international attention to change attitudes towards mental illness and an expansion of services to treat it.

To aid in this, WHO devised the Mental Health Action Plan 2013- 2020 and is using the latest Mental Health Atlas 2014.

The Mental Health Atlas 2014 reports that the rate of service coverage for severe mental disorders remains low.

It states that levels of public expenditure on mental health are very low in middle- income countries – of which Malaysia is one – and there is a very large disparity between the number of mental health workers and mental health beds in hospitals in middle- income and high- income countries.

Malaysia’s country profile in the publication reveals that in 2014, there were four mental health hospitals, 48 psychiatric units in general hospitals ( there are 139 government hospitals in the Health Ministry’s list) and 27 residential care facilities.

That year, Malaysia reported 0.8 psychiatrist and 0.9 psychologist per 100,000 people. Malaysia certainly needs more mental health services and those available to be more accessible.

Though Malaysia is part of the 68% of WHO member states that have a standalone policy or plan for mental health ( it was implemented in 2013) and part of the 51% that has a standalone mental health law ( enacted in 2002), it is also one of the countries where, as the Mental

Health Atlas 2014 states, “implementation is weak and persons with mental disorders and family members are only partially involved”.

Unfortunately, even when and where treatment is available, WHO reports that nearly twothirds of people with a known mental disorder never seek help from a health professional, mostly due to stigma, discrimination and lack of understanding – the cycle rears its ugly head again.

Seeing the light

WHO reports that reducing the overrepresentation of women with depression should “contribute significantly to lessening the global burden of disability caused by psychological disorders”.

In fact, the United Nations has recognised that investing in mental health services brings health, social and economic returns to a country, which is why it has included mental health in the UN Sustainable Development Goals ( SGDs) and WHO has made mental health a global development priority.

WHO director- general Dr Margaret Chan has said that the SGDs “seek to move the world towards greater fairness that leaves no one behind”, something that will benefit women in terms of mental healthcare.

As a WHO member state, Malaysia should do whatever it can to meet the health SGD goal for the benefit of the rakyat as well as for economic development gains.

The 10th Malaysia Plan states the country’s readiness to use “aggressive efforts” to increase awareness and the practice of healthy living, including through campaigns on mental health. One of the groups singled out for improved health outcomes through these efforts is women.

It remains to be seen if implementation and uptake is successful. Efficient and successful mental healthcare, not just for women but everyone, can be achieved with more effort and political will.

WHO reports that reducing the overrepresentation of women with depression should ‘ contribute signi cantl to lessening the global burden of disabilit caused b ps chological disorders’.