Mental health: the ‘Cinderella’ of medicine | Sasha Taylor-East and Nigel Camilleri

Awareness of mental health issues has undeniably increased over the years. More people (or families) are seeking help for conditions such as depression, bipolar disorder, ADHD, etc., than ever before. At the risk of a facile question: does this reflect an actual increase in the incidence of mental disorders? Are more people developing mental conditions… or were we always prone to the same issues, but never recognised them as ‘health concerns’ in the past?

Nigel Camilleri: There isn’t a straightforward answer. I think we are becoming a lot more aware of mental health disorders; but there has also been an increased level of stress in our lifestyle. There are a number of studies linking life in an urban area – and Malta can be considered urban – to increased stress levels. And according to the stress vulnerability model, the more stress you are exposed to, the greater the chance of developing illnesses such as psychosis. There are also societal issues: you mentioned ADHD, for example. A hundred years ago, if there was a boy in class who was very hyperactive, the teacher would send him out into the fields to run around a bit, and calm down. Or he wouldn’t go to school at all, and would do physical work instead. There was never any talk of ‘medical issues’, still less ‘seeing a psychiatrist’…

Sasha Taylor-East: Another consideration is that there has been an increase in general expectations.  People tend to compare themselves to other people these days: especially on the social media. This may create a certain pressure to live up to ‘what we should be like’, or ‘how we should be feeling’; inevitably, there will be a difference between people’s realities, and what they might be seeing around them. That may add to stress and anxiety...

Speaking of social media: another effect is that people now ‘socialise’ 24 hours a day… where, in the recent past, social interaction was limited to specific occasions here and there. Does this constant exposure to other people also have an effect?

STE: This is something I was discussing with a schoolteacher quite recently. Take online bullying, for example: where before, bullying used to take place only at school, nowadays children can’t escape from it just by ‘going home’. Bullying continues to take place on their tablets, and on their computers. But it’s not just about bullying or children. In general, the idea of ‘taking a rest’ – giving yourself a breather, spending time alone to recharge your batteries, and so on – is something we might not be doing enough anymore. It may partly be the pace of modern life, which doesn’t allow as much time for oneself…

At the same time, greater awareness has also brought about a certain level of scepticism. Sticking to the example of ADHD: some among the older generation might look at that, and say: ‘in our days, we used to call them ‘naughty kids’.” Is it possible that they might have a point… that medical science tends to over-pathologise certain issues?

NC: One of the issues we touched upon in our report concerns standards for the assessment of mental health in Malta. There are a number of psychiatrists/psychologists trained in different ways, and assessments are carried out differently. As a result, interpretations of the diagnosis may vary. So yes, I think there is an element where we may be over-pathologising, in certain cases. However, this is not to say that the conditions don’t exist…

STE: In fact, by over-pathologising certain cases, we run the risk of minimising the severity of what it truly means to have ADHD. Because ADHD is a real condition; and there is a lot of pain and suffering that goes with it. It’s not just about a child being hyperactive…

Nigel Camilleri

NC: One other important consideration is that the reason why conditions such as ADHD – or schizophrenia, or psychosis – still exist, is because there is a genetic component which has survived. Genes generally survive because there is an evolutionary benefit to having those genes. If you go back to hunter-gatherer societies: someone with ADHD, back then, would probably have been an extremely successful hunter, because he was impulsive; had a lot of energy; he would go out there, survive, kill, and get the kill back. It’s the same with psychosis: the psychotic person who didn’t trust anyone, and stayed in the cave… he or she had a higher survival chance. So this is not something we have invented nowadays. Historically, these conditions have always existed…

Would you say the reason they are now considered problematic, is that there is no longer any benefit to having those conditions… because our lifestyle has changed, perhaps, and the survival modalities are different?

NC:  Not necessarily. There are still certain benefits to certain conditions. People with autism, for instance, tend to be highly focused on one area of interest: today, they might become the next Steve Jobs. Likewise, people with ADHD tend to be highly creative. So there are ‘positives’… but naturally, this has to be balanced with the ‘negatives’: the suffering associated with the same conditions. Nonetheless, I believe we should also look at the positives. Children or adults with ADHD can lead ordinary, productive lives… if given something they are interested in. It’s the same for bipolar disorder: people in a hypo-manic, or mild hypo-manic phase, have been known to create great works of art, or composed great pieces of music. Again, however, the illness does come with a lot of suffering. It would be a mistake to minimise the seriousness of such conditions, but I do believe we also need to be aware of the full complexity of mental health issues…

Could another reason for the increased awareness be that the social stigma traditionally associated with mental illness has lessened, leading to more people stepping forward for treatment?

STE: Definitely, there has been a movement to talk about mental illness more. Not just in Malta; I think this is an area where we are feeding off a growing global awareness. There is also more organisation than ever before: more mental health charities, NGOs, support groups, etc. Having said this: when it comes to stigma, it is still a battle we face on a day-to-day basis. It may not take the same form as it used to in the past, but it still exists… in the form of minimising the severity of certain conditions, for instance. The way we flippantly use terms such as ‘OCD’ (Obsessive Compulsive Disorder)… as though it’s ‘cool’ to have OCD, when it very emphatically is not. OCD can be a very debilitating illness. But there is also stigma in other areas: how people perceive Mount Carmel Hospital, for instance...

NC: There is a world-wide stigma, but in Malta – while there is definitely still a lot of stigma associated with the place where we work – there is also a level of professional stigma. Even the way psychiatrists are looked at: we don’t work within a medical service; we work alone, on the outside… in an outdated hospital in Attard. The fact that mental health has been ignored for so many years, by so many different administrations, indicates that mental health is still something we don’t really want to talk about.

These are issues that were highlighted – albeit indirectly – in the MAP report, which pinpoints staff shortages and a general state of neglect in the mental health sector. For example, Malta currently has 26 psychiatrists; your report suggests there should be a minimum of 50…

NC: There are 26 qualified psychiatrists, but only 15 of them are consultants. The rest have not been given a post. So in practical terms, we are working with 15…

Does this reflect a poor uptake of psychiatry students, though?  Is it because not enough people choose to specialise in psychiatry in the first place?

NC: No. There are 26 qualified psychiatrists, and another 20 trainees… so within five years, we will have the numbers. And there are several Maltese psychiatrists working abroad: when I worked in the north-east of England, there were more Maltese child psychiatrists working at the hospital than there are in Malta right now. But it’s not just about psychiatrists. Each psychiatrist also needs a multidisciplinary team: occupational therapists; social workers; nurses and so on…

If I’m understanding correctly, then, it is our general approach to the mental health sector that is the problem…

STE: To be fair, psychiatry has always been the Cinderella of medicine: not just in Malta, but everywhere in the world. And there is no such thing as a ‘perfect’ department: all departments at Mater Dei have their own issues and shortcomings. But it remains a fact that mental healthcare in Malta, is nowhere near the same level as physical healthcare…

NC: If you compare the number of physical health consultants at Mater Dei to the rest of Europe, you’ll find that the numbers are the same. Proportionally, there are as many cardiologists – to mention one example – as the rest of Europe. The same cannot be said for psychiatry. We’re at a much lower level. After this report, we can thank the Health Ministry for creating one new consultancy post in child psychiatry. We welcome that reaction, but we also need to be clear that one post is not going to make a difference. To make a difference, we need to have a significant increase in numbers. Also, the 26 existing consultancy posts are only available for two days a week… when there should be availability all week round.

The same report also indicates that, while psychiatrists and psychologists are in short supply, the number of nurses at Mount Carmel is on a par with European levels. Are these nurses specially trained to deal with mental health issues?

STE: Not all nurses who work at Mount Carmel are psychiatric nurses. A few are trained therapists, but many receive no specific training in psychiatry. Unfortunately, we also have trained psychiatric nurses who, for whatever reason, work in other health departments, not in psychiatry. Having said that: there are some very good general nurses who work in mental health.

NC: One must also point out that the Malta Association of Psychiatric Nurses does an excellent job, too. However, the general role of nurses in mental health is something that needs to worked on. The fact remains that many nurses at Mount Carmel do clerical work… that is not going to help.

It has been argued (internationally, at least) that even the idea of having a ‘mental hospital’ – isolated from other health sectors – is itself old-fashioned. Should we be moving to a situation where mental issues are treated at Mater Dei hospital, like any other health issue?

STE: The government has already approached us to discuss a National Mental Health Strategy, and I believe the first draft will be launched at the beginning of December. Obviously, we look forward to seeing what it proposes. What we do know, however, is that government has talked about the development of a new Acute Psychiatric Hospital: which we welcome, because we believe that Mount Carmel has gone far beyond what it can realistically do, and needs to be changed. We also believe that psychiatry should be linked to physical illness; that it should be on the same footprint as physical healthcare. In the same way as the new oncology hospital was built on the premises of Mater Dei, the new psychiatric hospital should also be physically connected to the general hospital.

NC: But it is important to stress that an Acute Psychiatric Hospital, while needed, is only a ‘full-stop’ in the sentence of mental health; it is the end phase of a process. So yes, we welcome the initiative to build a new hospital… but what we need before that, is to build up and strengthen a community care system. Malta is divided into nine regions; currently, only five are covered. The available manpower is already severely stretched. So we need to have a community service that meets people’s needs within the community itself; that acts as a gate-keeper, to prevent illness from becoming serious enough to require treatment at a hospital. As things stand, a significant percentage of admissions to Mount Carmel – I don’t have actual figures, but I would guess maybe 30-50% – are not because of mental health issues. They are inappropriate admissions. So, we clearly don’t have a proper gatekeeping system in place.

Given that people are generally more aware of mental health issues, and might be able to recognise symptoms of dementia, depression, and other widespread conditions… what proportion of mental illness can realistically be treated ‘at home’, so to speak, without referring to a psychiatric hospital?

STE: I can’t put a precise number to that, if that’s what you mean; but I would say the answer is ‘almost all’…

NC: [nodding] Nearly all cases can effectively be treated within the community. To give an example: in Malta, the national mental health budget works out at 95% inpatients, 5% outpatients. In the UK, it is 97% outpatients, 3% inpatients… in other words, 97% of the investment in mental health goes towards services provided within the community, not at psychiatric hospitals. So yes, most mental illness can be – and already is, in other countries – treated at home. In Malta, however, it is the other way round….

Last question: what are your expectations, in the wake of this report? What sort of response are you hoping to see?

STE: We hope to be active participants in the discussion on a new National Mental Health Strategy; and it would be good to also see the development of a patient lobby-group, and for patients to be more actively involved in the any mental health service development. We would also like to see the active creation of more consultant posts that are necessary within the existing service; and also, while we’re already discussing a new hospital, we need to start preparing the spade-work and lay the foundations for a proper community service that supports the new hospital.

NC: Ultimately, we feel that the mental health sector is not advancing at the pace it should, given the way physical wealth and social wellbeing are on the increase in our country. At the moment, Malta is doing well economically. We need to match that progress with advances in our mental health systems.