IMAGINE that someone you love is going through a difficult divorce. You notice that she is becoming more withdrawn and listless. One day, she confides in you that she is having difficulty sleeping and has constant thoughts of taking her own life.

Being a concerned friend, you bring her to the nearest primary health clinic to get a professional diagnosis. The GP on duty confirms she is suffering from depression, and writes a referral letter for her to seek help from a psychiatrist.

Your friend is not well off, and since her insurance plan does not cover mental healthcare, you take her to the nearest public hospital to seek outpatient care. However, the psychiatric outpatient department is understaffed and overwhelmed. The registar on duty informs you that your friend will have to wait at least three weeks before her first appointment.

Workforce shortages are barriers to treatment

Last year, in a briefing paper on support for people with mental illness across the Asia-Pacific region, researchers at the Economist Intelligence Unit (EIU) found Malaysia’s mental health workforce to be sorely lacking.

Out of 15 core key performance indicators measuring service provision, Malaysia did particularly poorly on the Workforce indicator, coming in behind even Pakistan and the Philippines, both low income states. Malaysia had approximately a quarter of psychiatrists recommended by the WHO for an upper middle income country, and an even greater paucity of psychologists.

The shortage of qualified mental healthcare workers is not a problem unique to Malaysia. In fact, according to the World Health Organization’s (WHO) Mental Health Atlas 2014, nearly half of the world’s population lives in a country where there is less than one psychiatrist per 100,000 people.

 In 2016, Malaysia had 319 psychiatrists in the public and private sectors (1 per 100,000 population). Of these, 163 were working in government facilities, while the rest were based in universities, Ministry of Defence facilities and private practice.

163 psychiatrists is a minimal figure, considering the high demand for service in government hospitals. In 2016, the psychiatry departments in public hospitals recorded a total of 605,590 outpatient visits (new admissions and follow-up visits). This roughly amounted to 3715 patients per psychiatrist, an overwhelming patient load.

There is an even more critical undersupply of clinical psychologists. Last year, only 12 clinical psychologists were serving in our public hospitals; this despite the fact that we had over 100 clinical psychologists in the country.

These shortages create serious barriers to timely treatment for the mentally ill. In the public healthcare system, patients must present a referral letter from their GP before booking an appointment to meet with a psychiatrist- the typical waiting time is 2 weeks, even longer if manpower is limited.

Over time, patients subjected to long appointment queues are more likely to default from treatment. As it stands, many are already reluctant to seek professional help due to stigma. 

In contrast, accessing treatment in private hospitals and clinics is a relatively quicker process, since one does not need to get referred by a GP. Higher numbers of mental health professionals in the private sector also means that doctor-to-patient ratios are more balanced.

Generally speaking, private hospitals provide a high quality of care that public hospitals struggle to match, owing to over-crowding and understaffing issues.

However, private mental healthcare consultation rates are extremely costly compared to public hospitals, where treatment is heavily subsidized.

Because of this, poorer groups are largely unable to access private services. The socially and financially disadvantaged have no choice but to depend on overburdened public mental health facilities, where the long wait to see a doctor increases the risk of their illness becoming even more chronic.

Give basic treatment at primary care level

One in three Malaysians are already struggling with mental health issues, highlighting the urgent need for universally accessible treatment services in our country.

We require far-sighted planning to address the undersupply of mental health professionals in public service and disproportionate distribution of workers across public and private sectors.

For this, the government must ensure greater provision of psychiatric and psychological training in universities and increase the number of trained personnel positions in hospitals. Yet these are policies which require dedicated funding, commitment and time to roll out. In the interim, to expand the avenues of support for the mentally ill, priority should be given to delivering basic mental health services at community level.

This is not a novel idea. In fact, the move towards community psychiatry has been ongoing in our country since the 1990s, when mental health services were first introduced into primary health care clinics, under the administration of the Health Ministry’s public health division.

Today, a great number of government primary care clinics offer basic mental health diagnostic and treatment services. A recent ASEAN Mental Health Systems report shows that a total of 919 government health clinics, or 89% of all primary health clinics, provide mental health services. The scope of care provided included mental health promotion, early detection and treatment, patient follow up, psychosocial rehabilitation and family intervention.

Increasing mental health expertise in primary healthcare clinics effectively ramps up early detection and intervention of mental health issues, since these clinics are commonly the first point of contact for the sick in both urban and rural communities.

According to the Health Ministry’s 2014 Annual Report, a total of 28,720 mental health cases were treated in primary care clinics. Out of these, 5% were new cases and the remaining were follow-up patients who were given pharmacological treatment, counselling, and in selected health clinics, psychosocial rehabilitation. Moreover, the defaulter rate of treated patients was 8.9%, meeting the WHO target of <10%.

These results suggest that integrating mental health services into primary healthcare settings is an effective way to shift the burden of care away from hospitals. On top of that, it achieves greater service coverage, since these clinics are more widespread in community settings compared to specialist hospitals.

Without undermining the need to address the shortage and maldistribution of psychiatrists and psychologists in the hospitals, community-based services such as those provided in primary care clinics will expand the range of avenues for the mentally ill to seek professional help, and ultimately improve equity in access to treatment for all.

The Health Ministry must closely monitor the mental health services provided in existing primary care clinics, and where necessary, channel greater funding towards increasing the level of expertise and facilities in these units. If quality primary level mental health treatment could be set up in all the states in the country, it would surely go a long way in serving the needs of the mental ill in the community. – September 10, 2017. 

* Lim Su Lin is a Policy Analyst with Penang Institute in Kuala Lumpur. She graduated in 2013 with a degree in History from Cambridge University. Her research interests lie primarily in psychosocial health and wellbeing. She explores these in the context of making recommendations to improve social and development policies. The long-term goals of her work are to advocate for more equitable outcomes and reduced inequalities in society.

* This is the opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insight. Article may be edited for brevity and clarity.