What makes a person mentally healthy? The distinction can depend on many factors. 

JOY* was under tremendous stress, but her friends thought that it was just an adjustment period to her new job after she discontinued her studies due to financial difficulties. 

Her friends and family have always encouraged her to be strong, and “hang in there”. Her mood swings went unnoticed because they thought it was just “the way she is”.  

Two years later, she was hospitalised and diagnosed with bipolar disorder, a mental illness that takes her sky high in ecstasy for one moment, and leaves her debilitated in depression in another.  

Like so many others, Joy is one example of how ignorance have denied thousands of the mentally ill professional help, until it is too late.  

While reports show that an estimated 20% of Malaysians have some form of mental illness, the awareness of mental health is surprisingly low.  

“Malaysia’s mental health awareness is still very poor. Only in the recent three to four years do people realise that there are psychiatric services available in Malaysia,” said Dr Joseph Jacob, a clinical psychiatrist and committee member of the Malaysian Mental Health Association (MMHA).  

The reason for this, Dr Joseph says, may be due to the undetected cases, unwillingness to use these services, or the lack of knowledge about them.  

Stereotyping people with mental illnesses with labels like “psycho”, “mad”, “insane” or “something wrong” may have something to do with it.  

“Society seems to think that whenever you go to see a psychiatrist, you are mad. We want to let people know that this is not true.”  

That is why in conjunction with the World Mental Health Day this year, we want to create awareness within the public, Dr Joseph added.  

Mental health 

What exactly is mental health? There is no official definition, says the World Health Organization (WHO).  

So far, there is no clear separation between the mentally healthy and those who are not because cultural differences, subjective assessments and varying theories in psychology all affect what is “defined” as mental health. 

According to the MMHA, mental health is the feeling of well-being, happiness, the ability to cope with life’s challenges, to accept others and most of all, to have a positive attitude towards oneself.  

“Mental health means being psychologically and mentally healthy, and being able to function within our capabilities and abilities,” said Urmilah Dass, a clinical psychologist based in KL.  

“There are many degrees of mental health. No single characteristic can be taken as evidence of good mental health and nobody has all the traits of good mental health all the time,” wrote the MMHA in their booklet, What is mental health? 

In fact, mental illness can span from depression, anxiety, unwarranted or exaggerated fear, to full-fledged psychosis, schizophrenia, major depression, manic depression and mood disorder.  

Of course, any human being may experience depression, anxiety and fear as part of our natural emotional response, but when those feelings are prolonged and you are unable to control it, that is when you need help.  

Key factors 

What makes a person mentally ill?  

“The predisposing factors of mental illness can be explained using the biopsychosocial model,” Urmilah explained.  

Biologically, some are born with genetic or trauma-induced abnormal changes in the brain, which makes them more prone to develop mental illness.  

Decreased levels of serotonin in the brain have been implicated in depression and functional differences of brain activity in certain parts of the brain have been observed in people with schizophrenia.  

Psychologically, stress affects people with various temperaments differently.  

“Just like how some people see a glass as half-full and others half-empty, some people are strong, and some are weak,” says Urmilah, who further explained that inability to deal with stress and the absence of coping skills to deal with difficulties in life could also contribute to mental illness. 

Socially, the environment we are exposed to greatly affect our mental well-being.  

According to the tabula rasa, “all of us are born with a clean slate,” and it is up to our environment that shapes us into what we are, Urmilah added.  

“Other factors like substance abuse and long-term reaction to certain medications are also factors that could contribute to mental illness.”  

Based on these principles, Dr Joseph describes a typical case of mental illness. 

“Take for example a man who is not happy in his workplace. He is struggling to meet the demands of work, and day-by-day it is eroding into his happiness.”  

Soon, he goes home unhappy and brings his unhappiness to his family. When the family is unhappy, he gets angrier and does not get along with family and friends.  

Wanting a place to vent, he may take it out on his family, resulting in wife battering and child abuse. If this goes untreated, it may develop into more serious issues, such as mental illness.  

Genetics could not be blamed entirely for mental illness. “Without the stress (trigger), the disease may not appear at all,” Dr Joseph said.  

When asked if modernisation was to be blamed for the increased stress in the public, Dr Joseph explained, “There are positive aspects to modernisation on mental health, where people are generally more health conscious, making efforts to exercise and keep fit. However, there are also negative aspects of it, like traffic jams (and other forms of stress).” 

The increased percentage of mentally ill may be due to people being more aware of the disease, rather than an actual increase of the amount of people having mental disease, he added. 

Warning signs 

“It’s natural to be upset,” says Dr Richard Lustberg, a clinical psychologist in his interview with Time Magazine.  

However, when it happens frequently and often without reason, we must be cautious.  

One of the challenges in mental healthcare is the lack of awareness that mental illness is a medical condition, says Dr Joseph, who felt that it is easier to treat patients in the early stage of their disease.  

“Being Asians, most people go for traditional healers, and exhausted all their options before they come to see a psychiatrist. Until then, their mental illness has progressed.”  

Thus, it is important for us to be observant and know the symptoms of mental illness. 

“When we talk about symptoms of mental health, it is important to separate the major mental illness and the minor ones,” Dr Joseph explained.  

“The common symptoms in most major mental illnesses are, sleep difficulties, social difficulties, noticeable behavioural change, and the decline of daily functions, such as the quality of work.”  

“For mild mental illnesses, it depends on the case. For instance, a person who drinks too much alcohol is different from a substance abuser.”  

As violent crime is increasingly being reported in the media, we often equate these crimes with mental illness.  

Surprisingly, violence is not a common symptom in mental disease. In actual fact, violence-prone patients account for less than 5% among those who are mentally ill, and most of them act violently because they are being provoked, a social worker said.  

“This will only deepen the stigma against the mentally ill,” she added.  

The family connection 

It is often intuitional. We knew something had changed in a person, but we did not suspect mental illness to be a medical condition.  

A lot of people may think that mental illness can be overcome by willpower alone, but it is very difficult without therapy, said Urmilah in her talk on psychotherapy.  

“First of all, the family must understand the illness. For instance, in schizophrenia they (patients) may hear voices and have delusions,” said See Cheng Siang, President of the MMHA. 

“They must also encourage their children (with mental illness) to take medications to prevent a relapse.  

“They do not have to be ashamed, or hide their children away. (As it is), the patients often feel inferior and sad. They lose their confidence.”  

Families can help the patients regain their social skills and confidence by taking them out and doing things together, he added.  

However, the family should also balance their own needs and the patient’s needs.  

“When my mother was diagnosed with mental illness, we decided to take care of her. As time goes on, it took a toll on all of us. So, we decided to send her to a good nursing home, to ensure that we can continue to help her,” said May*, who took care of her mother when she was diagnosed with schizophrenia. 

  Treatment and therapy 

Currently, the best treatment for mental illness is still psychopharmacology, which is the use of medications to control the disease.  

Drugs that are used to treat mental illness can be generally categorised according to the disorder which they are primarily prescribed: anti-psychotics (schizophrenia) and anti-depressants (anxiety disorders, mood disorders, panic disorders, phobias).  

Psychotherapy will help patients deal with their disease in their daily life, enabling them to go back into the society.  

“I felt that psychotherapy helped me most after I was stabilised,” said Lina*, who has been taking anti-depressants for three years now.  

“I came to understand that it is alright talking about the disease. Many people have the disease, but they are not willing to be honest with themselves.”  

There are various kinds of psychotherapy, including cognitive behaviour therapy (CBT), group psychotherapy, supportive psychotherapy, interpersonal psychotherapy, cognitive analytic psychotherapy, and psychodynamic psychotherapy, said Urmilah.  

In psychotherapy, the therapist will try to get the person to change his thinking on his own account, she explained.  

While seeking medical help or psychotherapy, it is important to see the correct professional.  

“Do not be afraid of asking for the doctor’s credentials, because it is your right to know.” Urmilah noted.  

“You should be consulting a clinical psychiatrist, clinical psychologist or a clinical social worker,” says Urmilah, who cautioned the public against psychologists who treat patients even when they are not qualified.  

She added that psychologists such as educational psychologists, forensic psychologists, occupational psychologists and sports psychologists can also have a doctorate, but they should not treat mentally ill patients, she added.  

For psychotherapy, it is important for the patient to be comfortable with the person to reveal all problems, because psychotherapy involves cooperation between therapists and patients to work, she explained.  

“That is why people with negative symptoms are harder to treat (with psychotherapy), because they ‘shut down’ and you can’t get through to them.” 

Another treatment that could be considered is electroconvulsive therapy (ECT). This is a controversial therapy as electrical shocks are administered to the patient under anaesthesia.  

It is generally used for patients with severe depression who are not responsive to drugs or psychotherapy. 

Although its effectiveness has been recognised, its side effects, such as some loss of memory, have made physicians very selective in administering this treatment.  

Re-entering society 

The main challenges of mental healthcare in Malaysia are to overcome the stigma attached to mental illness, increasing awareness and making people realise that mental illness is a medical problem, Dr Joseph said. 

“The presence of stigma starts a vicious circle that leads to discrimination in all walks of life, decreasing self-esteem and self-confidence, a low treatment effect or a high probability of relapse for those in remission,” wrote Norman Sartorius in The Lancet. 

Perhaps the stigma of the mentally ill as mentally disabled people could be changed by success stories of those who had overcame their disease and led normal and meaningful lives. 

“After twenty years, my son is now working after getting his schizophrenia under control with medications and psychotherapy. Now he is helping out at the day care centre to help individuals like him overcome their illness,” a proud mother said. 

“Mental disease is just like heart disease and diabetes, although personal actions may contribute to the disease, it is essentially not the choice of the mentally ill to be afflicted with the disease.” 

*Names have been changed. 

References:
1. Treatment of Mental Illness: Overview of Mental Health Care: Merck Manual Home Edition, http://www.merck.com/mmhe/sec07/ch098/ch098d.html