Help mentally ill get treatment (Sunday Times 3 Oct 2010)
By Chong Siow Ann & Mythily Subramaniam
Next Sunday is World Mental Health Day. This day is supported by the United Nations to raise public awareness about mental health issues worldwide through open discussions on mental illness and the attendant problems and the measures - or lack of measures - taken to do something about them.
That such a day needs to be commemorated attests to the peculiar status the mentally ill have in society. They constitute a sort of helotry: a sub-class that is often invisible, at times visible for the wrong reason as when some crime or apparently gratuitous act of violence has been committed, and it is deemed notable, newsworthy or explanatory to mention that the alleged perpetrator is mentally ill.
What is less known and less aired is their (and their family's) daily struggle just to get on.
Yet - here are the alarming figures - the number of people with mental illness is sizeable. Up to 30 per cent of the population worldwide is estimated to have clear-cut mental illness each year, and in every country studied at least two-thirds of them receive no treatment. This under-treatment occurs even in rich countries with the best resources. In the world's most powerful economy, 31 per cent of Americans are affected by mental illness every year, but 67 per cent of these individuals are not treated.
Often it is not just their mental illness that is not treated. They are also more likely to be physically unwell and their average expected life span is shorter than in the general population. Mental illness and physical illness often interact: One can be the consequence of the other - as in the case where stress and anxiety can lead to heart disease, which in turn leads to higher rates of depression.
What is particularly disturbing is that people with mental illness often do not receive good physical health care. This may be due to the effects of the mental illness, which leads to patients not seeking care, or adhering to treatment, or assuming unhealthy lifestyles.
However, research has also shown that when they do present themselves, doctors might actually feel ill-equipped, uncomfortable or have a tendency not to engage with them to the same extent as their other patients.
Poverty is another bane of the mentally ill who are often among the poorest in a country. Individuals with disabling mental disorders are less likely to be working and, if employed, tend to be under-employed and underpaid.
Their low rate of employment is due to a number of reasons. Most mental illness occurs early in life (50 per cent of mental illnesses have their onset by the age of 15, 75 per cent by the age of 25).
The emergence of a serious illness at that critical period in the individual's life often disrupts schooling. The consequence is that many lack the necessary education and training required to build careers. A number of the serious mental illnesses tend to be chronic. Persisting in adulthood, these uncontrolled symptoms and impaired intellectual functioning hinder advancement and success at work.
The stigma of mental illness can be as disabling as the illness itself - preventing people from seeking help, eating away at their self-confidence, hampering their re-integration into the community and entrenching them firmly on the fringe of society.
The discrimination may be actual - in surveys done in a number of countries over the past five decades, employers are far more reluctant and negative about hiring people with psychiatric disabilities than almost any other group. In times of economic downturn, the first to be laid off are those with mental illness.
The stigma may also be perceived. This is a sort of debilitating self-consciousness. Those with mental illness are fearful of being found out as mentally ill and therefore do not want to look for a job.
They are often caught in a vicious circle: The illness causes dis-ability and subsequent financial hardships, and these in turn cause or exacerbate emotional and psychological distress. The straitened economic circumstances almost always lead to dependence on others and reliance on public assistance - if available.
In a World Health Organisation survey of 74 countries, more than a quarter do not provide state or public disability benefits for mental illness. Among those where benefits are available, many provide limited assistance in the form of a small monetary amount.
It is a level of assistance that often results in what policy analysts have referred to as a 'poverty trap' where income levels are inadequate to help them meet basic daily needs, let alone for education, job training and job seeking. So mired, they cannot dig themselves out of this hole.
Things are getting better here in Singapore. The first ever National Mental Health Policy and Blueprint was rolled out by the Government with relatively little fanfare in 2007, but it signified a watershed in the perception and commitment of decision-makers on mental health.
The aims of this blueprint are to promote mental health and, where possible, prevent the development of mental health problems and reduce the impact of mental disorders. Among the various values embodied in this policy are that mentally ill individuals should not be discriminated against and that there must be continued efforts to destigmatise and create awareness of mental disorders in the general population.
Improving the lot of those with mental illness will almost certainly need more resources, ideally allocated in a rational, fair and appropriate manner and guided by good quality data and statistics on the state of mental health of the population.
At present, much of this data is still not available but the blueprint has also emphasised enhancing the monitoring of the status of mental health in the population and the quality of services.
The Singapore Mental Health Study, which is a nationwide study that is currently under way, will have, on its completion by early next year, detailed information on the rates of mental disorders and the treatment gaps, on the use of existing services and the barriers to care.
To be sure, it would not have gathered all we need to know but it would have enough to give us a good idea of the lay of the land, and help to formulate and implement better policies to improve not only the lot of the mentally ill, but also the mental health of the populace and their understanding of its importance and commonality. And that is as good a start as any.
Associate Professor Chong Siow Ann is vice-chairman, Medical Board (Research), Institute of Mental Health
Dr Mythily Subramaniam is deputy director of research, Institute of Mental Health