A Better Mental Health for All

MJP Online Early 01-04-17

BRIEF COMMUNICATION

Jasraj S1, Viknesh N2

Hospital Permai, Persiaran Kempas Baru, Johor Bahru, Malaysia

Abstract

Psychiatric services have progressed well throughout history, marked by a shift from heavily inpatient asylums to outpatient management via deinstitutionalization, and advances in psychopharmacology. An overview of important themes is discussed at public mental health level. Firstly, differences between sexes are touched upon from theoretical and societal perspectives. Next, among the disabled, the phenomenon of diagnostic overshadowing, attributing apparent mental health problems to learning disability, contributes to their overall poorer quality of life. Mental health at both extremes of age is another important theme, whereby dementia and depression are keenly observed in the older age group, while maternal risk factors and parenting play a role in the mental well-being of the younger age group. Fourthly, inequalities, stigma and discrimination, are rife among people living with mental illness, and thereby detrimental in their road to recovery. Deinstitutionalization is explained as being more than just downsizing the inpatient load, gaining prominence with the emergence of community psychiatry services, and found to be helpful in overcoming stigma. Demographically, it was demonstrated that developing countries, as opposed to developed countries, have advantages in their approaches to psychiatric services, including better integration of people living with mental illness into society. Lastly, the psychological well-being of mental health workers should not be discounted, with measures such as stress management and resilience training proving to be key in combating burnout.

Keywords: Psychiatric Services, Mental Health, Public Mental Health, Stigma, Deinstitutionalization

Psychiatry and its services has come a long or mystical origin, and sufferers were treated way since the beginning of time. It took in barbaric ways. Asylums were built in the birth way back in the 3rd century BCE [1], 13th century, and patients were referred to with roots in ancient India, and 4th to 5th as inmates. Those who were aggressive and centuries amongst the Greeks and Romans thought to be dangerous were chained; no [2]. Avicenna was the first to classify real treatment was available then. At the neurotic disorders [3], in the 9th century. Age of Enlightenment, the 18th century, Psychoses were regarded as of supernatural perspectives had changed; patients were MJP Online Early 01-04-17 treated compassionately and provided with Differences between the sexes basic daily needs, moving away from inhumane practices [4]. The 19th century Statistics show that Major Depression is was when asylums took credence, inpatients twice as common in women whereas rose to hundreds of thousands, and within a Alcohol Dependence and Antisocial century, these figures would be reversed personality disorder are 5 times more with deinstitutionalization. common in men [5]. It is also well known amongst mental health practitioners that The 20th century proved revolutionary, with men present to our services with a Emil Kraepelin bringing a paradigm shift in significant delay compared to women; men the perspectives of viewing psychiatry. are thought to have more illness of the Sigmund Freud came along and pioneered psychotic spectrum and women of the Psychoanalysis. The mid-1900s introduced neurotic spectrum. This was posited by to us Psychopharmacology with the likes of Sigmund Freud, suggesting women Chlorpromazine - essentially a ‘psychiatric experienced aggression towards the self, Penicillin’, Lithium - the work of John Cade which arose from developmental issues [6]. in 1948, and Prozac. These days, Sarah Rosenfield utilizes the Object psychotherapy and psychopharmacology Relations Theory, suggesting that mothers form the ‘bread and butter’ of psychiatry; stress upon relationships with their however, these form just the tip of the daughters, pushing their sons to seeable, tangible iceberg. Psychiatry still independence, and hence causing men to deals with the not-so-tangible like biological have more externalising mechanisms and socioeconomic subject matter. Despite manifesting as substance abuse and the advances, there is still much that needs personality disorders, whereas women to be addressed and done, as the end result internalize causing more anxiety and mood isn’t remission - the absence of symptoms; symptoms [7]. Two main causative factors instead, recovery, improvements in quality for these are gender roles - societal of life, and return to function are expectations of behaviour which are quintessential. considered appropriate, acceptable or desired, based on conceptions regarding Here, we would like to outline what we their masculinity or femininity. Men are think are the themes of paramount expected to not show their emotions; importance that when tackled, could prove toughen up and be an ‘alpha male’. to be significant in a community and public Controlling certain external factors mental health level. associated with gender roles, shows an equal or even lower rate of mental illness amongst • Differences between the sexes women [8]. Coupled with the second factor, • Amongst those with disabilities or are societal patriarchy, it could lead to a disabled dangerous misrepresentation statistically and • Extremes of ages hence give birth to stereotypes. • Inequality, discrimination, stigma • Deinstitutionalization Amongst the disabled or with disabilities • Developed vs developing countries • Psychological well-being among health Compared to the general population, it has workers/ mental health workers been shown that people with learning disabilities (LD) die prematurely and have MJP Online Early 01-04-17 notably higher comorbidities of medical creating of opportunities to take on valued origin, alongside a poorer quality of life [9]. social roles, such as an employee or a family Men and women with LD died on average member. This would help society see people 13 and 20 years respectively earlier than the with LD as valued individuals of a general population, succumbing to heart community. SRV includes opportunity, problems and complications of chest respect, competence development, infections [10]. These inequalities arise from independent living and individual choice. hurdles in assessing health care timely, This encourages acceptance and appropriately and effectively. Diagnostic coexistence, further dissolving stigma. overshadowing is partly a cause for this. Diagnostic overshadowing is the Inequality, stigma and discrimination overlooking of mental illness in those with LD, and the attribution of a physical health In healthcare settings, mental illnesses may problem to a pre-existing one. Despite that, not receive the same attention afforded to by there are many factors; namely patient, physical ailments. Even though clinician, and disorder-related. Improvement approximately 8% of the world’s population comes in areas of apt and early diagnosis live with a form of mental disability, this with a higher index of suspicion, health issue has often been side-lined in involvement of caregivers and adequate conversations surrounding human rights and support. In addition, patient-held health equality [12]. Individuals living with mental records should be introduced and given to illness, from a human rights perspective, are all patients with learning disabilities who just as entitled to agency, freedom of choice have multiple health conditions. Finally, and inherent dignity, as any other human there is a need for standardization of being. A significant breakthrough was investigations and treatments as is done for achieved on October 3rd, 2008, in the form the general population. of The Paul Wellstone and Pete Domenici Mental Health Parity Act. The law, signed in Apart from the health aspect, the overall the United States, was intended to bring quality of life could be improved for the LD about parity for mental health in insurance population. Bengt Nirje introduced the plans, thereby making it more affordable for theory of Normalization, which entails a those with mental illness. While it was able social principle, enabling the intellectually to provide equality of access, this legislation disabled to experience normal patterns of did not take into account differences in type everyday life. This includes living in their and severity of mental illness, each of which own homes, having a job, taking part in could incur extra costs, such as supported normal day to day activities, the freedom to employment in Schizophrenia [13]. Social, make their own choices, their desires be economic and political factors invariably respected, and access to all the standards of play a part in determining the course of a the general population [11]. Normalization mental illness; therefore, it is difficult to would help improve understanding and estimate the total cost that an individual with relationships, promoting self-efficacy and mental illness would face. Moreover, a building of confidence, bringing to an end mental disorder, coupled with underlying discrimination and prejudice. The concept of medical illness such as HIV or Tuberculosis Normalization was expanded by Wolf would certainly increase inequalities. Wolfensberger, bringing into light ‘Social Role Valorization’ (SRV), by inclusion and The Cambridge Dictionary defines stigma as MJP Online Early 01-04-17

“a strong feeling of disapproval that most replacement of long-stay psychiatric people in a society have about something, hospitals with smaller, community-based especially when this is unfair.” alternatives, it is not limited to downsizing Discrimination, on the other hand, refers to the patient load in hospitals. The three treating an individual or group of people essential components of differently, notably in a negative way, deinstitutionalization are the discharge of because of a significant characteristic they inhabitants from psychiatric hospitals to possess [14]. In a similar vein to people alternative community facilities, redirecting living with debilitating disease such as HIV, potential new admissions to these facilities, stigma and discrimination are rife among as well as the development of special people living with mental illness. People services for a mentally ill population who living with mental illness have to cope with are non-institutionalized [18]. stigma and discrimination from their family Deinstitutionalization is notably met with its members, healthcare personnel or at work, own unique challenges, including a lack of as illustrated by a London study which states funding and the assumption that that nine out of ten people experience this comprehensive community care is cost- phenomenon [15]. The different effective [18]. For some individuals, there is characteristics that could add to stigma and an apparent dearth of social support, which discrimination, include gender, race, may in turn lead to homelessness and a advanced age or presence of a disability, as strong likelihood of frequent readmissions. well as differences in sexual orientation. A Ideally, the promotion of better mental 2012 report by Stonewall and The health for all would require a clear University of Cambridge showed that 55% deinstitutionalization plan and careful of Britain’s youth from the gay, lesbian and consideration of its associated challenges. bisexual community faced homophobic bullying in schools, which in turn, was To use Malaysia as an example of linked with depressive symptoms [16]. From deinstitutionalization measures implemented a global perspective, WHO indicates that the in a developing country, a gradual process of stigma of mental illness is present in both downsizing was seen over decades. By the Western and Eastern contexts. This was late 1990s, a series of policy changes and solidified by studies in India, China and legislative measures culminated in a growth Malaysia [17]. Mental health professionals of community psychiatric services. 40% of from Malaysia concluded that stigma is all hospitals in Malaysia, be it general or damaging to people living with mental district, provide basic psychiatric services, illness, producing a cycle of discrimination while 15% provide community psychiatric permeating family life, communities and the services [19]. Depending upon the severity wider society. of mental illness or a potential crisis, the latter services are divided into acute home Deinstitutionalization care and assertive care. These services have done well to reduce the number of The humane practice of managing admissions to hospitals, thereby promoting individuals with mental illness outside the deinstitutionalization. The proof lies in the confines of an institution is a crucial step in number of occupied beds in a mental battling stigma and discrimination in institution; for instance, in Hospital Permai, psychiatry, as described previously. While Johor Bahru, a decrease of occupied beds deinstitutionalization refers to the from 1400 to 900 was noted between the MJP Online Early 01-04-17 years 2006 to 2011 [19]. At present, this networks [20]. The latter promotes a shared figure is estimated to be approximately 650. responsibility among a wider community, Apart from community psychiatry services thereby reducing the burden from a nuclear which cater to the different needs of service family as well as serving to ameliorate users; the outpatient department plays an ‘expressed emotions’; a considerable risk important role as well in factor. Considering these, and strengthened deinstitutionalization. Factors such as good by follow-up studies, more positive long- social support and closer proximity to the term outcomes for Schizophrenia in hospital contribute to individuals with developing countries should come as no mental illness opting for outpatient surprise. Stigma, too, is notably less in appointments as an alternative to receiving developing countries, as evidenced by community care. Furthermore, the outpatient feedback from psychiatrists working in rural department also works as a filter, referring settings. Some villages in Nigeria and suitable cases for community care, hence Malaysia tend to label people with decreasing admissions. underlying mental illness as ‘crazy’ only if they are overtly violent; meanwhile in Sri Developed vs Developing countries Lanka, more stigma is afforded to tuberculosis [20]. It is inevitable that there would be differences in how psychiatry or mental Psychological well-being among health health is viewed amongst communities in workers/ mental health workers developed countries as opposed to developing ones. Although major advances Psychological well-being is a triad of have been made in the field of psychiatry evaluative well-being (life satisfaction or thanks to individuals from the former fulfillment), hedonistic well-being regions, the psychiatric model in developed (subjective feelings of happiness), and countries is not without its drawbacks. With eudaimonic well-being (sense of purpose, a an abundance of knowledge available, an life of meaning) [21]. Ideally,everyone emphasis on pharmacological measures should have high levels of positive feelings, arises, feeding into stigma and eventually little to none negative feelings, a purpose in leading to segregation. T.M. Luhrmann life and a resultant sense of fulfillment. argues that Western psychiatrists miss the Psychological well-being has a reciprocal chance to engage with affected individuals relationship with physical health, and is on a personal level, by focusing on the found to be health protective and boosts “medical” nature of mental illness and the longevity [22]. It is quintessential as it also quest for the “fixable perfect brain” [20]. affects the quality of performance and care delivered, alongside absenteeism and Several factors lie in favour of a better presenteeism. Psychological well-being prognosis of mental illness such as amongst healthcare especially mental health Schizophrenia in developing countries, workers are often under-recognised and not based on comparative studies by WHO. given sufficient importance. Occupational These include retained integration in society stresses can prelude to burnout - a mixture including individuals living with mental of emotional exhaustion, low self fulfillment illness, availability of menial jobs so that and disillusionment. Amongst the causatives there is some form of contribution from to these are an increased work demand, lack them, and the tight-knit nature of communal of affirmation for a valued contribution, MJP Online Early 01-04-17 long work hours and restrictions in decision- an exponential increase in dementia among making freedom. the ‘oldest old’ (after the age of 90), highlighting the issue as a public health Mental health workers and professionals concern [26]. Meanwhile, depression is not a have recorded higher than average scores in component of the aging process. Major burnout and emotional exhaustion [23]. depression among the elderly is estimated to Multiple treatments have been proven have an incidence of up to 5%; and there is a effective to improve well-being at the higher risk when a chronic illness is also workplace such as Interpersonal and present [27]. As individuals with psychiatric Cognitive Behavioral Therapy, mindfulness- illness approach their twilight years, some based stress reduction and meditation [24, may eventually find themselves in nursing 25]. Taking it a step further would be apt homes. The elderly require more attention as prevention; and there are many things that they tend to depend on others to care for can be done to improve workplace their personal hygiene, and cater to basic psychological well-being, and these can be needs such as food. However, the placement implemented in multiple domains. The work of the elderly with psychiatric illness in context and content may be elusive whereas nursing homes bring about the question of the individual remains of utmost importance. its effect on their perceived quality of life. A A repeating and ever important theme in 2006 study by Scocco et al. assessed 68 psychological well-being is resilience, subjects at entry to a nursing home and 6 which is the ability to retain and recover months later, using the Geriatric Depression well-being in testing times. Training in Scale (GDS) and Brief Symptom Inventory resilience, stress management and (BSI). The subjects initially reported psychological flexibility could be offered. psychiatric symptoms, cognitive decline, Talking about their hardships should be and feelings of loneliness; which after 6 encouraged, a listening ear offered, bringing months worsened, indicating a poor into mind a mental health first aid approach. perceived quality of life and hence, Furthermore, this could be an area of interest emphasising that nursing homes may be in the field of Occupational Psychologists to detrimental to their overall well-being [28]. develop upon. Rehabilitation, advice and support on returning to work, and a graded At the opposite end of the spectrum, integration into tasks could prove beneficial newborns coming into this world are in situations post-crisis. welcomed with risk factors interplaying even before they were conceived; the Extremes of Age environment they are born into and raised in. A mother’s health is particularly crucial; At an advanced age, people are at risk of poor nutrition, health, environment, living various ailments, including mental illness conditions, also alcohol and drug abuse can such as dementia and major depression. be detrimental on a fetus. A lower Prior to the age of 65, there is no increased socioeconomic status would worsen the risk of dementia; therefore, any symptoms above situations, causing further harm. An of dementia should be addressed with a high in-depth systematic review found that index of suspicion. Between 65 and 90, the maternal depression is linked with low birth risk of dementia rises every 5 years. A weight and stunted growth; this itself leads population-based study of aging, known as to development of depression in the later life ‘The 90+ study’, concluded that there was of the fetus. It has been shown that children MJP Online Early 01-04-17 of mothers with mental illness are 5 times Mental illness and an approach towards more likely to develop mental illness mental health itself, needs to be rethought. themselves [29]. Additionally, a lack in One way is to adopt a life course maternal education has been demonstrated perspective, focusing on every stage of to be associated with increased infant development in a person’s growth that may mortality, malnutrition or obesity, poorer influence mental well-being, in addition to vocabulary and cognitive skills, conduct, tackling potential risk factors. Above that, of emotional and mental health problems utmost importance is the creation of [30,31]. Infants of depressed mothers have awareness regarding mental illness among attachment issues; they are withdrawn and society, combating stigma and passive, with problematic sequelae in social discrimination, as well as the help available. development, relationships and behaviour Hope should be inspired and the journey to [32]. Children from lower socioeconomic recovery should not be a lonesome, long and strata will more likely experience a arduous one. Service users should be suboptimal development [29]. Furthermore, empowered, and mental health professionals quality of parenting, conflict between should rally for the rights and equal parents, dynamics and conditions of treatment of service users. families, lack or absence of stimulation all could compound the inadequacies in a We hope that this article stimulates some child’s mental well-being. 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Corresponding Author Jasraj Singh Hospital Permai, Persiaran Kempas Baru, 81200 Johor Bahru, Malaysia Tel: +6016-7608545 / +6072311000

Email: [email protected]