Saturday, February 21, 2009

Dealing with devils in the mind

Dealing with devils in the mind
Fri, Feb 20, 2009

By Radha Basu, Senior Correspondent

PSYCHIATRIST Ang Yong Guan (top) despairs when he bumps into patients in the street and they act like total strangers.

But he understands all too well that they are not being shy or rude. It is the stigma of mental illness that stops them from exchanging a greeting.

He is determined to work to overcome the deep-seated prejudice that leaves patients feeling so ashamed.

'Seeing a psychiatrist should be as readily accepted as seeing a doctor for fever,' says the talkative 54-year-old who has been soothing frayed minds for over two decades.

'It's slowly happening in many countries in the West. So why not here?'

He hopes to see the day when patients who see him in public will introduce him to their companions.

People with mental illness are simply people who are unwell. Yet their journeys to fight illness are shrouded in shame, secrecy and often, solitude.

'We cannot help the mentally ill without fighting stigma,' says Dr Ang.

It is stigma that prevents many from seeking help early and thereby improving their chances of a complete recovery.

It is stigma that compels some to undertake the tough journey to recovery all alone.

And it is stigma that blocks those who have recovered or whose symptoms are under control from finding work or love.

Ironically, the recession has helped some overcome at least the first barrier - reaching out for help.

The doctor, who spent nearly 17 years with the Singapore Armed Forces, is now back on another front line, dealing with the walking wounded from the recession.

He sees at least one patient complaining of work-related anxiety or depression every three or four days, a dramatic rise from one every three or four months a couple of years ago.

Not surprisingly, his patients still want their conditions hidden from their employers. 'They fear that even acknowledging they are seeing a psychiatrist will cost them their job.'

This was not always so.

Singapore's fourth president, the late Mr Wee Kim Wee, for example, wrote in his autobiography of being given three months off to cope with job stress in 1937 as a 22-year-old journalist with The Straits Times, notes Dr Ang.

He had been sent to Ipoh to reorganise a local paper which The Straits Times had bought and had to work 16 hours a day as the staff there were uncooperative.

'He couldn't sleep well. He couldn't eat. He lost weight. He could not relax. His mind kept racing to the workplace.

'Finally, he went to see the company doctor who told him that he must go home immediately to rest. He returned to Singapore and rested three months before returning to the job.'

But 70 years on, such examples of enlightened corporate conduct are still rare here. Even those who get treatment and learn to control their symptoms sometimes fall prey to prejudice.

A patient of Dr Ang's recovered from schizophrenia and was working as a tutor. But when he spoke about his battle with the condition on television, a number of his students pulled out.

Another patient, with the same condition well under control, has been married for eight years. But she still keeps her medical past secret from her husband and in-laws, fearing rejection and divorce.

'In these cases, the patients had their symptoms well under control, but were discriminated against, or were worried about discrimination anyway,' he says.

Those seeking jobs have it harder. 'That's because many employers falsely believe that mental patients are naturally violent,' he says.

Yet many studies have shown that most mentally ill folk who are receiving appropriate treatment are at no greater risk of committing violent acts than anyone in the general population.

But stigma is not the only big stumbling block to better mental health care. Many others, says Dr Ang, also fall between the cracks of a system under strain from too few staff, too many patients and not enough follow-up.

About one in six here - about 750,000 people - are believed to suffer from some form of mental illness.

They range from those with niggling anxieties to people with depression, dementia or schizophrenia, who are held prisoner by tormented minds, having lost the ability to reason, to remember or even to love.

About 135,000 people - about 3 per cent of the population - are believed to have clinical depression. About 45,000 - 1 per cent - may have schizophrenia.

And now the system of care has a potent new trigger in the form of recession to deal with. Work woes are common during downturns, says Dr Ang, but most people can bounce back without seeking professional help.

Those who cannot usually have anxious personalities and low self-esteem. 'They get trapped in a vicious circle of worry about losing their jobs, being laughed at by friends and neighbours and about having to lower their standard of living.'

If they seek help, psychiatrists may help them to reframe their outlook on life by teaching them to focus on the positive.

So yes, there is a way out and things are looking up for the mentally ill, particularly in light of recent government moves to pump in more funds and help chronically ill patients financially.

Last week, for instance, the Government announced that chronically ill patients suffering from depression or schizophrenia will soon be allowed to use their Medisave money for outpatient treatment. About 20,000 people are expected to benefit.

The move will lighten the financial burden for many, says Dr Ang, who heads the Action Group for Mental Illness, an advocacy group for the mentally ill.

Yet, problems remain. A big stumbling block is that follow-ups are often not rigorous enough. What is needed, he thinks, is a blueprint for the minimum standard of care every patient is entitled to.

'Currently, there are guidelines on the clinical aspects of care, but we need to pin down issues like who tracks progress after a patient's discharge from hospital, and who ensures that patients really take their medication and come for follow-up treatment,' he says.

'The procedures for follow-up treatment must be watertight. If a patient defaults on treatment, for example, there must be a system to ensure caregivers are notified. If the patient still continues to miss his appointment, home visits must be made.'

Some of these steps are already being taken. The Institute of Mental Health (IMH), for instance, has a community psychiatric programme, where frail and elderly patients receive follow-up treatment at home.

But while 33,000 people sought treatment at IMH last year, only about 160 patients were on its roster for follow-up home visits as of late last year.

One key difficulty is the shortage of trained staff. There are only about 120 practising psychiatrists here, he says, or about 2.6 per 100,000 people.

It is a low ratio compared to other developed countries like the United States (13.7), Britain (11) and Australia (14).

Dr Ang himself sees about 500 new patients a year. Countries like the US, however, have a higher prevalence of mental illness than Singapore.

He also laments the shortage of other mental health professionals like nurses, psychologists, social workers and therapists.

The Government has responded by pumping in $123 million to strengthen mental health services. Dr Ang applauds the use of some of this money for training more staff and to ensure the early detection of illness.

But he wishes more could be spent on integrating separate services now provided by private practitioners, public hospitals and voluntary welfare organisations.

He points to another difficulty: Some mental illnesses such as stress-related disorders are often vague and ill-defined so defining standard procedures for care may be difficult. 'Perhaps we should start with illnesses like clinical depression and schizophrenia, which are relatively more clear-cut and well-defined.'

Access to better and modern drugs could also be improved, he suggests.

Recently, he saw a schizophrenia patient suffering from drug side effects such as drooling and eye-rolling.

'There are newer, more expensive drugs that completely do away with the side effects and allow patients to hold down jobs,' he said.

'Her caregiver said that though she would have happily paid for it, she never knew that there was an option for better drugs.'

Older medicines with obvious side effects reinforce the stigma that distresses so many patients, while good drugs and rigorous follow-up care can allow many to get a fresh start in life.

In 2007, US professor of law and psychiatry Elyn Saks wrote a memoir chronicling how daily medication and therapy helped her defeat schizophrenia.

Dr Saks, who was first diagnosed at age eight and suffered severe breakdowns as a student at Oxford University and later at Yale University, is now happily married and a successful professor at the University of Southern California.

Dr Ang says the road is difficult but Dr Saks' experience shows that with the right doctors and drugs, it is possible for the mentally ill to lead successful and fulfilling lives.

'Such stories may one day go from being the exception to becoming the golden rule,' he says. 'We just need to work towards that goal.'

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