Mental Health

Services in Malaysia &

Globally

Mental illness the result of supernatural forces◦ Gods (communication)◦ Spirit or Demonic

possession No separation

between medicine, religion, & magic

Pre-History

Because mental illness was perceived of as having supernatural origins, treatments for mental illness often involved exorcism (casting out of demons), witchcraft/sorcery, or other “supernatural” cures.

Pre-History

Another very popular method of “curing” mental illness was trepanning (i.e. the surgical boring into the skull) to allow the “spirits” to escape.

Pre-History

The Ebers Papyrus (dated 1550 BC) is believed to be a copy of an even earlier text dated 3400 BC). The Ebers Papyrus contains a wealth of ancient Egyptian medical knowledge including chapters on mental illness (inc. depression and dementia)

Ancient World

Hippocrates claimed that epilepsy was the result of natural causes and not a divine disease

Claimed mental illness was caused by increased humidity in the brain

Also claimed that hysteria was caused by the female womb becoming detached and wondering around the body

Ancient World

Hippocrates460 – 355 BC

Hippocrates recommended treatments for mental illness included:◦ Beatings◦ Confinement◦ Medications

Ancient World

In Ancient Greece, the mentally ill were taken to the Temple of Asclepius (God of Medicine) to be healed.

Along with magical treatments, the mentally ill person would routinely sleep in the temple◦ It was thought that God would

appear to the person in their sleep and cure them

Ancient World

610 AD◦ Beginning of the revelation of the Qur'an

Sura 4:5 states:

“Do not give your property which God assigned you to manage to the insane: but feed and cloth the insane with this property and tell splendid words to him” This gave rise to the first legal protection of persons

with a mental illness, the mentally ill deemed incapable of premeditation in Islamic sharia

Middle Ages

First dedicated psychiatric hospital built in 705 AD in Bagdad (i.e. present-day Iraq)◦ Unlike their European counterparts who still

adhered to the supernatural causation of mental illness, early Islamic doctors relied on clinical observations

Middle Ages

While Islamic rationalism and Muslim physicians held the mental illness was caused by diseases of the brain, animist pre-Islamic based cultures still held that mental illness was caused by djin◦ This gave rise to the fakkir in

North Africa and bomoh in South East Asia as traditional sources of mental health care

Middle Ages

Throughout Europe, the Catholic and Protestant belief in witchcraft led to many oddly behaving people (esp. mentally ill) being accused to witchcraft and subsequently burned at the stake

Middle Ages

Bethlam Royal Hospital (1337) is one of the oldest surviving psychiatric hospitals and one of the first to appear in Europe

Middle Ages

By the of the 17th century, mental illness was increasingly being regarded as an organic disorder “reducing the sufferer to little more than an enraged animal”◦ This let to the treatment

of the mentally ill as animals with whips, chain, and other painful and degrading actions

Modern Period

18th Century:◦ Beginning of the “moral

treatment” movement Combined

psychosocial and religious treatment

Reduced brutalisation of mentally ill inpatients

Became popular after successful treatment of King George III

Modern Period

18th Century:◦ Increasing number of

institutions led to the development of the specialization of Clinical Psychiatry

◦ Rediscovery of hypnotism by Franz Mesmer

Modern Period

First British Lunacy Act introduced in 1808◦ State has legal obligation to provide care for

mentally ill persons◦ Use of restrains, handcuffs, straight jackets, and

chains

Modern Period

Dorothea Dix was a school teacher who, in 1840, became an advocate the improved standards of care for people with a mental illness◦ Advocated that the

government should support people with mental illness financially, with housing, food, etc.

◦ Theorised that many criminals were mentally ill

Modern Period

British Colonial Government established health services focusing on the general health of estate workers and treating tropical and nutritional diseases

No mental health services Development of health services motivated

by need to offset financial losses cause by lost productivity due to malaria and dysentery

Malaysian Perspective

Linda Richards was the first American-trained nurse

Developed the first school of mental health nursing in 1882◦ 8 years later, more than

30 asylums throughout the US had established similar training schools.

Modern Period

In 1896, Emil Kraepelin (German psychiatrist), describes Dementia Praecox (now called “schizophrenia”) and Manic-Depressive Illness (now called “Bipolar Disorder”)

Kraepelin’s descriptions of schizophrenia continued to be highly influential until the late 1990’s

Modern Period

First psychiatric nursing course commenced 1913

Publication of the first textbook for psychiatric nursing:◦ Nursing Mental Diseases

Harriet Bailey (1920)

Modern Period

First mental health service in Malaysia was the “Penang Lunatic Asylum”, used to confine mentally ill sailors of the Colonial Navy

A second asylum operated until 1910 at the site of the current Taiping Hospital (Perak)

First Malaysian Mental Health Service

Established by Dr W.F. Samuels in 1910 at Tanjung Rambutan (Ipoh)◦ Named Rumah Sakit Otak Tanjung Rambutan

Initially built with three male wards and one female ward

1928:  Renamed “Central Mental Hospital” 1970’s: Renamed “Hospital Bahagia Ulu Kinta” Currently:

◦ 54 male wards◦ 25 female wards◦ Over 2,600 beds

Federal Lunatic Asylum

First introduced in 1930’s◦ Administration without

anaesthesia or muscle relaxants Significant physical

injuries to many patients◦ “Modified” ECT with

anaesthesia and muscle relaxants introduced in 1951

Electroconvulsive Therapy

Introduced 1933◦ Did not gain widespread acceptance until 1940’s &

1950’s◦ Involved repeated overdosing of schizophrenic

patients with insulin in order to induce coma◦ At higher doses, comatose patients would

experience seizures which were thought to be helpful in treating psychotic conditions

Sometimes combined with ECT to produce even great seizure effects

Insulin Coma Therapy

Lobotomy procedure first introduced in 1935

“Ice-pick” lobotomy method made popular throughout the US by Dr Walter Freeman

Procedure involved hammering a small ice-pick through the orbits of the eye, into the brain to sever the connections to and from the prefrontal cortex

Psychosurgery

Rumah Sakit Otak Tampoi established 1936◦ Renamed Permai Hospital, Johor◦ Catchment:

Johor Melaka Negeri Sembilan Kelantan Terangganu Pahang

Malaysia’s Second Psychiatric Hospital

Publication of DSM-I in 1952 by the American Psychiatric Association (APA) to standardise the use of diagnoses used by psychiatrists and the US Dept. Veteran Affairs for pension payments

DSM became the standard reference due to its adoption by the Health Insurance industry and the ability of the five axis diagnostic system to identify social and preventable causes of mental disorders

Currently DSM-IV-TR

Diagnostic and Statistical Manual of Mental Disorders – I (1952)

Publication of Interpersonal Relations in Nursing by Peplau (1952)◦ Amalgamated theories from

psychiatry, nursing, and communications

With no medications available, psychiatric nurses were often the pioneers of psychosocial treatments

“Which is more important, what nurses do with patients or what they do to patients”?

Hildegard Peplau

1952 – Governor of the East India Company in Malaya pressured the Rulers of the Malay Federated States accept the Mental Disorders Ordinance “to regulate proceedings in cases of mental disorders”◦ Note the language used at the time. The concept of

caring was distinctly absent! Relates to “reception and detention of

persons of unsound mind in mental hospitals”◦ Again, note the language used. There is no mandate

for treatment or rehabilitation.

Mental Disorders Ordinance

Introduction of phenothiazine psychotropic's in 1955◦ Resulted in a substantial reduction in the

severity of psychiatric symptoms for most patients

Most countries which introduced the use of psychotropics reported 50% reduction in number of patients needing to be hospitalized◦ Increasing optimism of psychiatrists and nurses

that patients can “get better”◦ Beginning of “deinstitutionalization” movement

Psychotropic Medications

Established 1967 Community based NGO dependant on public

donations and a grant from the Department of Social Welfare

Objectives:◦ to advocate for positive attitudes towards mental

health; ◦ to plan and implement mental health

programmes; ◦ to provide rehabilitation services.

Malaysian Mental Heath Association

1976: 25 Psychiatrists in Malaysia (50% of which planned to leave Malaysia and migrate elsewhere)

1977: MPA inaugurated by the Honourable Minister of Health Tan Sri Lee Siok Yew on 19th March 1977 at Hospital Bahagia

Dato Seri M. Mahadevan was elected as the MPA’s First President

Malaysian Psychiatric Association

Government move to have General Hospitals and District Hospitals establish psychiatric units and clinics◦ Currently 12 units attached to General Hospitals◦ Provides continuity of care and follow-up after

discharge from main psychiatric hospitals◦ Function as short-stay and assessment units

Example: Jalan Perak, Penang

Decentralization Policy- Ministry of Health, Malaysia

Early Psychosis Prevention and Intervention Centre (EPPIC) began operations to detect early signs of potential schizophrenia◦ Discovery of prodromal phase

Period of approx. 2 years in which minor psychotic symptoms, behavioural symptoms, or cognitive deficits may emerge but do not meet criteria for actual schizophrenia diagnosis

Diathesis-stress model used, symptoms may disappear in the absence of the stressor (e.g. academic stress, drug abuse, etc.)

Early Intervention (1996)

Malaysian Act of Parliament introduced for the care and protection of people with mental disorders

Relates to:◦ Hospital admissions◦ Involuntary detention◦ Lodging◦ Care◦ Treatment◦ Rehabilitation◦ Control & protection

Mental Health Act 2001

Established 2003 Purpose:

◦ to determine the disease burden attributable to mental disorders;

◦ to identify subgroups in the population at high risk of mental disorders to whom prevention effort should be targeted;

◦ to identify potential risk factors involved in mental disorders;

◦ to evaluate the treatment, control and prevention of mental disorders;

◦ to facilitate epidemiological research on mental disorder

National Mental Health Registry

Established 2005 for the purposes of collecting data regarding suicide in Malaysia

Database is updated daily by Dept. Forensic Medicine upon receipt of Death Certificate acknowledging suicide as cause of death◦ Difficulties collecting accurate data due to false reporting

of “sudden death” to cover-up actual suicides Data used to inform government and social policies

National Suicide Registry Malaysia (NSRM)

Key Points

In prehistoric times mental illness was thought to be caused by supernatural forces, gods, spirits, or demons

In ancient times, mental illness was thought to be caused by various bodily diseases (real or imagined) which would be treated in temples

Middle Eastern and Asian schools of medicine held that mental illness was caused by medical conditions; while Western schools of thought regarded mental illness still has largely supernatural and spiritual in origins

Key Points

Advent of moral treatment brought more humane care and compassion to the mentally ill and triggered the birth of psychiatry as a specialization

Beginnings of the Biological Psychiatry movement with the success of psychosurgery, ECT and pharmacological agents

Hildegarde Peplau is regarded as the founder of modern psychiatric mental health nursing

Mental health services, both in Malaysia and Internationally, continue to evolve stressing the importance of human rights for people with mental illness

Key Points