Promoted Content

Introduction

Mental health has increasingly become a topic of conversation in Malaysia since the Covid-19 pandemic. Such a conversation often emphasizes on the importance of mental health awareness and education, as well as ways to manage mental health issues. During lockdown periods, some may experience difficulty in adapting to a new routine after a shift to their normal day-to-day activities. The series of lockdowns also impacted many – from students, to workers, to business owners and to many more – that there is an alarming increase in suicide rates of 81% in 2021 compared to the previous year and an overwhelming demand for mental health services.

The General Landscape

Mental health problems know no barriers. Symptoms of mental health problems usually begin in early childhood through adolescence, with some not even identified. In 2019, Malaysia recorded 424,000 children and adolescents experiencing mental health problems.

This shows that the promotion of mental health should be introduced from young to ensure leaders of generations to come are able to effectively manage negative experiences. Thus, Mental health literacy and management is crucial for the development of an accepting and empathetic community that would allow a safe and nurturing space for children to grow.

Malaysia has seen a steady increase in the promotion of mental health awareness over the past two years through efforts ranging from advocacy and literacy programs, to an increase of subsidised and tele-mental health services, and to reviews of mental health-related laws. Awareness on the importance, maintenance and prevention of mental health among the public show a linear growth too.

Challenges and Measures to Mitigate Stigma-Related Pushback

Nonetheless, barriers to mental health awareness in Malaysia remain. The lack of access to practising professionals and services shows a need to increase funding to mental healthcare. For example, many service providers are exhausted with an overflow of demand during the pandemic, particularly those who provide tele-health services.

Just how accessible is mental healthcare to those who have no means to access services? With a 1:100,000 psychiatrist to patient ratio, Malaysia does not meet the World Health Organization’s (WHO) recommended standard of psychiatrist to patient ratio of 1:10,000. The scarcity of practising professionals will largely impact the upkeep of up-to-date data, which ultimately affects the execution of data-driven and informed decisions to further improve mental healthcare in the country.

This lack of manpower may lead to time constraints in developing and executing nationwide efforts. This can, however, be mitigated through a collaborative approach, as mental health is not solely the responsibility of government officials and relevant professionals alone. Educators, policymakers, and members of the various available non-governmental organizations (NGOs) can and should be engaged for the development and execution of nationwide mental health literacy programs to ensure a holistic approach to mental health education.

Apart from that, cultural barriers that arise from the stigma on mental health may lead to a lack of support amongst educational institutions, which includes lobbying of programs and ensuring the buy-ins from staff members as well as recruitment of students. Prolonged stigma will trigger the notion that mental health is a taboo topic, which in turn drives low literacy and awareness, consequently promoting an overall dismissal towards mental health as a whole. 

Interviews conducted by the Green Ribbon Group (GRG) with training providers in the United States and Australia discovered a similar issue in the execution of training programs, particularly with regards to the usage of mental health terms in age-specific programs. Age-friendly terms used in training programs must be suitable to specific age groups to secure buy-ins from relevant authorities, such as caregivers, parents and teachers.

For example, terms such as “burnout” may not be suitable for children aged 15 years and below as it may be too complex for their understanding, while “suicide” or “self-harm” may be deemed as “inappropriate” for younger age groups, which may initiate pushback from concerned parents and teaching staff.

Cultivating Healthy Attitudes to Mental Health

A multi-sectoral effort from relevant ministries – such as the Ministry of Health, Ministry of Education, Ministry of Higher Education and the Ministry of Women, Family, and Community Development – can play a large role in promoting mental health awareness.

This can include: 1) the developing tailored mental health subject in schools according to years of study; 2) developing tailored training for first responders such as parents, teachers and caregivers; 3) delivering said subject and training to different demographics; 4) ensuring the upkeep of knowledge on mental health through annual screenings; 5) reviewing and revising current standard operating procedures (SOPs) that involve managing those with mental health problems to ensure humane responses; 6) execution of annual surveys, and; 7) fostering a system to ensure the upkeep and improvement of mental health subject and training. 

This multi-sectoral effort is not a new request. Former Deputy Prime Minister Datuk Seri Dr. Wan Azizah Wan Ismail, under the Pakatan Harapan (the Alliance of Hope – PH) government in 2018, had set up a robust approach to review Malaysia’s mental health policies in an effort to mitigate mental health challenges faced by youths. She also called for the decriminalization of attempted suicide during the 12^th Malaysia Plan in the Dewan Rakyat in 2021. Outgoing Health Minister Khairy Jamaludin has also launched the National Centre of Excellence for Mental Health (NCEMH), a streamlined platform for mental health services, training and information alongside the National Mental Health Crisis Line in an effort to provide early assistance to those facing mental health problems in October 2022.

What Else Can Malaysia Do? 

Proper training on mental health can and should be incorporated as part of the national school syllabus to promote the development of well-rounded individuals. Ideally, children should be taught what mental health is, how it plays a role in one’s overall health and wellbeing, ways to maintain mental wellbeing, and how it affects each area of life.

This is because poor mental health will largely affect a child’s academic, personal and social development. Unattended mental health problems – as simple as stress – may snowball into a much larger issue such as mental illness and suicide. These can be prevented with literacy to mental health. 

The request to include mental health as part of the official education syllabus is not foreign to Malaysia alone. In 1986, the WHO has identified children’s and adolescent’s mental health as an essential area for public concern.

WHO has also recommended for schools to function as one of the key support systems for students. This is done through the implementation of mental health awareness, intervention, prevention and rehabilitation as well as the fostering of a healthy psychosocial environment.

These practices have since been executed in various countries. For example, in July 2018, the Department of Education in New York became the first state in its nation to make mental health education mandatory for all its students. Similarly, Singapore’s Ministry of Education  has been rolling out mental health lessons in stages in the primary, secondary and pre-university levels since December 2021 and will continue to do so. Efforts like these should be replicated in the Malaysian context too.

GRG aims to do exactly just that. GRG, which was established in January 2021, is a local mental health NGO consisting of a small team of non-mental health professionals and led by HRH Princess Iman Afzan. GRG believes that mental health is not solely the responsibility of government or medical professionals and that the community is an untapped resource to mental healthcare.

Initial data from the programs GRG executed in 2021 in collaboration with the Malaysian Mental Health Association (MMHA) indicate that the public is interested to participate in efforts to improve mental health. A total of 100 individuals undertook the GRG-sponsored Mental Health First Aid training course with over 79% success rate. Furthermore, over 108 individuals undertook the suicide prevention training programme called A Conversation on Suicide. Moreover, a total of 200 counselling and psychotherapy sessions were sponsored across 44 callers, with 16-year-olds being the youngest callers.

Despite these encouraging statistics, a question remains. How soon can we introduce mental health literacy to the community?

To replicate these efforts into the Malaysian context, GRG has placed a focus on piloting mental health literacy programs in secondary schools and universities in 2022. To ensure the needs of students are met, GRG works alongside counsellors and teaching staff in both universities as well as high schools to empower a collaborative and holistic approach.

This model proved to be successful in GRG’s activities in 2021 with the MMHA and the same model has been replicated throughout 2022.

The secondary school programme is executed under GRG’s partnership with Telekom Malaysia (TM) Foundation and Creative Minds under the Foundation’s education arm called TM Future Skills. TM Future Skills: Mental Health Literacy is a two-hour programme for 15–17-year-olds encompassing an introduction to mental health, ways to self-cope and manage, and ways to encourage support amongst peers. The Green Ribbon Effective Agent Training (GREAT) Project is a 1.5-day programme that focuses on an introduction to mental health and empathy training. It aims to create a network of student advocates of mental health. 

As of November 2022, GRG has conducted programmes for students across 10 public and private universities and eight public secondary schools, upscaling the mental health awareness of a total number of 495 students. It is hoped that this community approach will create a trickle-down effect, whereby the knowledge learned from these programs is introduced into and practised within the student’s respective communities.

Conclusion

Given these analyses, mental health should be included as part of the national school syllabus. The lack of manpower shows that there is a need for an increase in the mental health resource pool to cater to the needs of the increasing demands of the community. We can only do so with proper education and training. A small step now would leave a lasting impact in the future. However, the challenges discussed must be mitigated to secure a complete buy-in from relevant authorities. Without these interventions, we can foresee mental health problems among students to continue in prevalence in the future.

Introduction

While struggling to contain COVID-19 infections, Indonesia like many in the world is facing a “second pandemic.” As a consequence of the pandemic, many Indonesians are suffering from various forms of psychological issues such as anxiety, depression and trauma. Confounding this is the implementation of social distancing measures, a response to the virus’ quick transmission, that impacts access to health services. It is, thus, important to evaluate the impacts of the COVID-19 pandemic on mental health services in Indonesia and measures to address this issue.

Limited Mental Health Services in Indonesia even Prior to COVID-19

Indonesia possesses 9,831 community health centres, locally known as Puskesmas, spread across 34 provinces. Of which, 92.4% administer mental health programmes. This indicates the Indonesian government’s reliance on them to provide mental health services to the community. Though some form of assistance are rendered to them by the Ministry of Health such as service guidelines and Mental Health and Psychological Support (MHPSS) during the pandemic, it is uncertain how many of these programmes are still running and how effective they are to reach the community. Unfortunately, there is also a lack of in-depth research that evaluates the sustainability of these mental health programmes, especially in areas that are remote and with limited resources.

Key to ensuring the sustainability of such programmes in these community health centres is the availability of resources, namely financial and health personnel. When conducting research in Lombok after it encountered a disaster in 2019, the author found that mental health programmes were not administered in several community health centres because of limited funds. To confound matters, available funds were also redirected to other programmes as mental health was not deemed to be an urgent issue. This was despite the discovery that around 60% of the elderly had developed PTSD; none were treated.

At the national level, the budget for mental health is also insignificant. However, from this meagre sum, 90% of it is allocated for psychiatric hospitals. Additionally, the human resources for mental healthcare are still far from ideal. For every 100,000 citizens, Indonesia only has 0.31 psychiatrists, 0.17 clinical psychologists, and 2.52 trained mental health nurses. Similarly, these numbers are insufficient to serve more than 260 million Indonesians. Furthermore, these specialists are not evenly distributed; most are largely concentrated in Java. With such limited resources, mental health programmes may only be present in name at these community health centres as they lack impactful activities.

With the onset of COVID-19, Indonesia was reported to have experienced a disruption in its mental health services. Globally, disruptions occurred due to reasons including 1) outpatients could not come for their appointments, 2) social restrictions, and 3) a decrease in the number of inpatients due to the cancellation of elective services. Although the types of services that were disrupted and the scale of disruption were not specified, any disruptions could further burden Indonesia’s already fragile mental healthcare system, potentially leading to its breakdown. As an example, the author discovered a psychiatric hospital in a major city in Indonesia was forced to discharge their inpatients earlier due to disruptions. Unfortunately, such disruptions can lead to a knock-on effect of overwhelming Indonesia’s primary healthcare due to a surge in patients. If the primary healthcare was to fail, patients can be left untreated, thus widening the mental health treatment gap in the community.

Tele-psychiatry: An Ideal Replacement of Conventional Mental Health Services Model

Despite the grim mental healthcare situation in Indonesia, there were several innovative strategies to respond to the people’s mental health needs during the pandemic.  First, the Indonesian government launched a psychological service programme called Sejiwa, abbreviated from Sehat Jiwa (literally Mentally Healthy) at the end of April 2020, in collaboration with the Indonesian Psychological Association (HIMPSI). This service entails providing psychological assistance via the telephone, thus improving accessibility. A month into its launch, this programme has received nearly 15,000 calls from all over Indonesia, or an average of about 500 callers per day. Some local governments have also provided online-based mental health services. For example in Jakarta through a programme called Mental Health Friend (Sahabat Jiwa) and in West Java with Online Mental Health Consultation (KJOL).

Second, many mental health practitioners have themselves taken the initiative to provide their services via online communication platforms such as WhatsApp, Zoom, and Meets. These individual initiatives help overcome the absence of such services that are supposed to be integrated into healthcare facilities. The community also benefits from the presence of various psychological consulting applications, for example: Getbetter.Id, Riliv, Kalm, Klee and Kariib. These proliferation of online-based service innovations can further reduce the gap in mental health services.

Demonstrating the potential of such innovations, tele- medicine as well as mental and psychosocial helplines were the two most widely used strategies to manage psychiatric issues during the COVID-19 pandemic. Tele-medicine (or tele-psychiatry specifically for mental health) and the helplines were used in about 70% and 67.7% of respondent countries, respectively. This approach is beneficial for the continued provision of healthcare services in this pandemic, considering the highly-contagious nature of the virus. The conventional mental health services model which emphasizes three factors (i.e. providing face-to-face consultations between therapists and patients, conducting consultations in a healthcare faculty, and is provided by specialists) is, thus, becoming less relevant. Continued emphasis on these three factors will only widen the service gap.

Innovations such as tele-psychiatry that were developed in the midst of the COVID-19 pandemic were found to possess  three characteristics: 1) offering spatial flexibility, 2) entailing health and social aspects, and 3) leveraging on technology. Therefore, it can be argued that this pandemic is a catalyst for the development of tele-psychiatry in Indonesia. In just one year, many have switched from conventional services to adopting this innovation; a feat difficult to achieve under normal conditions.

Towards Sustainability and Scaling up of Tele-psychiatry

However, it should be noted that this innovation is only at its infancy because of the current pandemic. Also known as imposed service innovation, such innovations are not triggered due to the strength or development of services, otherwise known as extant service innovation. Unfortunately, such innovations can end abruptly if the compelling circumstances no longer exists and / or if there is no further effort for development. Moreover, many tele-psychiatric services are currently provided as a private initiative with minimal facilities. Even though such services are beneficial, they will encounter issues in sustainability and scaling up.

Sustainability and scaling up are important due to two reasons. First, regardless of the pandemic, tele-psychiatry is considered a strategy that has the potential to reduce inequalities in mental health services. It is important to highlight that while developing countries such as Indonesia require such innovations, many have yet to implement it on a large-scale. Second, sustainability would be dependent on factors such as relevance of the innovation. Tele-psychiatry’s relevance can be ensured by using the behaviour of current users during the pandemic as a reference to envision the future market. Such massive developments would thus require political will from the government and support by its stakeholders.

Noteworthily, tele-psychiatry is not a strategy that can be applied in all situations, considering the socio-demographics of Indonesia. However, it is an effective stopgap measure to reduce the gap in mental health services that have been disrupted due to the pandemic. Moreover, with the limitations of mental health specialists, tele-psychiatry can be used to reduce spatial and temporal needs of service delivery. What the provincial governments of Jakarta and West Java are implementing should be adopted by other regions, although ideally this service should be meted out in every district / city while working closely with the community health centres to reach the community at the grassroots. Investment in this field will greatly impact everyone as they can access mental health services wherever they are, even after the pandemic.