PUTTING BACK THE MENTAL IN HEALTH - A PARADIGM SHIFT ?
Next year mental health is due to figure in the Healthy Lifestyle campaign in our country. The Constitution of the WHO that was adopted by the International Health Conference in New York in 1946 , in its very first line states,
" Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity."
WHO constitution ,1946.
Be that as it may, the mental in health has if at all often been an afterthought in the practice of medicine and public health. The reasons for this drop in the position of the mental in health from the position it occupied in the WHO constitution to that in the minds of health administrators, medical teachers and budget planners to the advocates of health promotion programmes , can be found in the way mental health was taught in medical schools. Ignorance, steeped in undue emphasis on the severest of mental diseases and a long entrenched culture of prejudice have contributed in no small way to the neglect of all things mental. To laugh at the mentally ill, those who work in mental health or anything mental, may have been fashionable; but evidence based medicine, public health and psychiatry may yet have the last laugh on the sceptics of all things mental in health.
Despite what many professionals in health and medicine may think, Psychiatry deals with around 500 diseases and not just madness or psychosis. Most of these have nothing to do with psychosis, and are closer to what the general practitioner sees in his daily practice, but often has no label for in his diagnostic list. This has prompted psychiatrists to embark on what has been neglected for long in psychiatry - the development of primary care psychiatry as a branch of psychiatry that covers more than 75% of mental illnesses that are seldom if ever seen by clinical psychiatrists, but are seen by their non psychiatrist medical colleagues. Patients who are anxious, depressed or sleepless are often seen by all doctors but often only investigated and treated for their physical diagnostic possibilities and not mental problems. Primary care studies show unequivocally that although 78% of mental disorders are seen in primary care only about a third of those are recognized and even less treated satisfactorily of those are recognized.
The answer to these low rates of recognition and treatment of common primary care mental disorders lies in the retraining of primary care providers. To this end a primary care version of the ICD-X Chapter V that deals with psychiatry was launched in 1996 and a training kit 2 years later. These offer a modular and simplified way to learn about 24 of the ICD-X diagnosis and for those too busy to do that a simpler 6 common diagnoses version is available in colour coded chart form. Workshops to train primary care providers to recognize common primary care mental disorders and treat them are underway in several countries, including Malaysia.
Clearly the real answer lies in rolling back the institutionalized ignorance and prejudice through the training of the newer generation of medical students and general practitioners as well as primary care nurses and nurse practitioners.
But even when all this is being done there remains a small army of highly placed colleagues in the medical profession who negate progress in mental health care through their refusal to see anything psychological except the psychological barrier in the stock and financial markets. For them working closely with their many patients who never improve because of undiagnosed mental problems, and showing them through successful treatment of depression or anxiety in liaison psychiatry might help.
The changing of public attitudes are best done by example and less so by exhortations as is often unfortunately. Thus the jangan merokok ,and jangan meludah (or jangan tidor sini at one hospitals casualty waiting room notice said) are less than useful when the reasons for these expensive signs are not understood. Thus smoking goes on despite many campaigns laws and threats of jail sentences against smokers; indeed it is growing faster in some countries, DESPITE these campaigns. So is drinking, despite laws, punishments, campaigns, not to mention the million dollar budgets these campaigns involve. There are push factors inside individuals that make them seek out the cigarettes
alcohol or drugs for that matter. The pull factor only relieves the psychological need in most of them where physical addiction is less important. The push factor or the psychological factor, is the last to be emphasized in any campaign against smoking, if ever. Once again the mental in health is marginalized , dissipated and dissolved .
The same is true in multimedia campaigns against that number one killer, of coronary heart disease, where mental stress is seldom if ever given credence over the physical stress test. Has any cardiologist subject ever subjected his patient to mental stress tests ? What exactly is essential hypertension; what is essential about, and why do a fair number of M I patients get their coronaries while NOT doing physical exercise ? If there is such a thing as mental stress, why is it not taught in relation to other stress tests ?
Have doctors ever wondered why patients after being diagnosed to have had myocardial infarcts, sill secretly smoke against the advice of their doctors ?
Have doctors ever wondered why despite all medical advice intelligent and educated patients default their hypotensives, anti-diabetics and antiasthmatics ?
Do they ever wonder ?
The Mental in health goes a much further back than any campaign that is but a public relations exercise. The mental in health was not put in the WHO constitution for the sake of courtesy, so the practice of medicine can do without that mental
component in health. For the mental in health to be effective in improving health, there must be a commitment to change in attitudes, practice and behaviour of all of us doctors.
What is needed in a Mentally Healthy Lifestyle campaign that is something that is truly a Paradigm Shift in archaic attitudes and prejudices in the practice of medicine. That Paradigm shift ,like charity , must begin at home.
Dr. M Parameshvara Deva,
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