Let’s work to reduce stigma about mentally ill
APRIL 17 — The 2006 National Health and Morbidity Survey (NHMS) said that psychiatric morbidity in Malaysia was 11.2 per cent. This year, the Ministry of Health will release the 2011 NHMS, and it will be interesting to see whether the destigmatisation programmes carried out by the government — campaigns I have in the past labelled as “stale” — have had any impact on access to treatment to persons with mental illnesses, or whether statistics may lead to increased attention in this area.
The truth is that I highly doubt it. Funding for mental illness research and legal reforms has always been scant, and it is an area which is underemphasised worldwide. Mental illness is often viewed as something remote, despite clear evidence that depression, for example, is one of the leading causes of disability worldwide. (Okechukwu et al. 2012)
There are several serious issues that require attention with regard to persons with mental illness. Some of them are listed below, but it should be noted that this list is non-exhaustive, and is not arranged in order of urgency of reform.
1. Discrimination in the workplace.
2. Discrimination with regard to insurance policies — mental illness not covered.
3. Third generation drugs (better drugs) are still not available in public hospitals due to limited budget.
4. Gross shortage of clinical psychologists — only two in Ministry of Health hospitals (a couple more are in training), also forensic psychiatrists.
5. No uniform consent forms for treatments such as electroconvulsive therapy (highly effective for depression).
6. Not enough psychiatrists working on the 70 per cent of persons incarcerated for drugs who have psychiatric co-morbidities.
7. Pensions Act does not allow for derivative pensions to be given to mentally ill children.
8. Only relatives can make decisions for involuntary patients.
The enactment and enforcement of evidence-based mental health law and policy can greatly assist in dealing with the above problems. However, discussing all of these problems in one go would require an entire thesis. I hope to address these issues one by one in future articles, but for now, I will address the last one, i.e. that only relatives can make decisions for involuntary patients.
Why is this a bad thing?
Let’s start by looking at the law. Section 77(1) of the Malaysian Mental Health Act states: “Where a mentally disordered person is required to undergo surgery, electroconvulsive therapy or clinical trials, consent for any of them may be given by (a) the patient himself if he is capable of giving consent as assessed by a psychiatrist (b) his guardian in the case of a minor or a relative in the case of an adult, if the patient is incapable of giving consent and (c) two psychiatrists, one of whom shall be the attending psychiatrist, if there is no guardian or relative of the patient available or traceable and the patient himself is incapable of giving consent.
This can be a bad thing in many situations where the relative or spouse believes, for example, that the patient has become a burden. There are many persons who aren’t necessarily emotionally ready to deal with a relative who is mentally ill or mentally disordered, and may not be in the best position to make decisions for the patient. In Malaysia, for example, many families choose not to deal with their relatives’ mental illness, and choose to send them away to a home. This is a clear violation of the patients’ rights.
The state of New South Wales, Australia, chose to remedy this in its Mental Health Act 2007, where it states that the patient can nominate a “primary carer” to make those decisions for him. A primary carer may be someone related to the patient, or non-related, such as a friend. This section was enacted to avoid situations where the patient is subjected to treatments consented to by relatives who simply view him or her as a burden and do not really take into account his or her views or concerns.
Confining our law to only allow relatives to make decisions on behalf of mentally ill adults can and has led to abuse and marginalisation of patients’ rights. Perhaps at some point in the future, our Mental Health Act 2001 can be amended to change this to primary carer. In the meantime, we must focus our efforts on ensuring that stigmatisation is greatly reduced. Stigmatisation is one the main reasons mentally ill persons do not receive treatment they deserve, i.e. treatment that is adequate and humane.
* The views expressed here are the personal opinion of the columnist.
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