Recently the Menteri Besar of Terengganu, Ahmad Razif Abd Rahman, denied the National Health and Morbidity Survey report that one in four residents of Terengganu are mentally ill. He clarified that mental illness refers to crazy (‘gila’) and that the statistics refers to the prevalence of mental health problem such as stress and worry that stems from stressors such as the high cost of living.
He further elaborated on his understanding of mental illness to mean “by reason of insanity” and gave an example of the stabbing of a man as an individual who is suffering from mental illness.
He is right that the statistics does not refer to insanity. He is right in saying that one in four Malaysians are not crazy, for mental illness does not mean a person is mad. Unfortunately the statement from the menteri besar, who holds an MSc in Counselling from UPM, reveals some common misunderstandings of mental illness.
A diagnosis of mental illness does not indicate the severity of the illness. Briefly, mental illness refers to illness that is of a psychological nature. A person can be severely ill (such as unable to get out of bed for one month due to feelings of depression, having hallucinations and delusions) or mildly ill (such as having meeting the criteria for having a major depressive episode but to a milder degree).
Just as a person can be severely physically ill (eg malignant tumour) or mildly physically ill (eg having the common flu). Both of these physical illnesses are included in the ICD-10 (International Code of Diseases) which is used to classify illnesses. The important point is that the person is ill.
A diagnosis of mental illness does not refer to the cause of the illness. An individual could suffer from a depressive episode as a result of a negative life event such as being put on academic probation, or having a loved one pass away. This is of course a simplification of the cause of the illness.
A mental illness is usually caused by multiple factors including thinking styles, genetic vulnerability and family environment but mental illness is often precipitated by negative life events.
A diagnosis of mental illness does not indicate insanity or risk for violent behavior. Only 3 to 5 percent of violent crimes are committed by individuals with serious mental illness. Out of the 3 to 5 percent of individuals who have been incarcerated, only 7 percent of cases were directly related to symptoms of mental illness.
A diagnosis of mental illness does not need to be treated with medication. Many mental illnesses are successfully treated with psychotherapy. Certainly some mental illnesses are better treated with the medication, however, more often than not, a combination of medication and psychotherapy is recommended.
The menteri besar was right however in saying that the instrument used to measure mental health may not indicate severe mental illness. The National Health and Morbidity Survey (NHMS) which provided the statistics on mental health problems used the General Health Questionnaire GHQ-12 to assess the prevalence of mental illness. It cannot discriminate between different types of illness.
Screener for non-psychotic mental illness
Nonetheless the GHQ-12 has a sensitive rate of 70 to 80 percent as a screener for non-psychotic mental illness. In other words, 70 to 80 percent of individuals who meet the cut-off criteria can be diagnosed as having suffering from a mental illness (eg Makowska et al, 2002; Reuter & Harter, 2001). A similar sensitivity score has been shown using a sample of Malaysian students (Yusoff, Rahim & Yaacob, 2009).
It has been used extensively in general and clinical populations and has been shown to be valid and reliable as a general measure of mental health. For instance, it is used in the annual Health Survey for England (NHS), the Dutch National Survey of General Practice (Hoeymans, Garssen, Westert, Verhaak, 2004), World Health Organisation study of mental illness in 15 different countries (Goldberg et al, 1997).
I am glad that the menteri besar highlighted the fact that the GHQ-12 cannot discriminate between the severely mentally ill and the mild-moderately mentally ill. This only points to the lack of data on the prevalence of the different mental illnesses in Malaysia and the great need for the government to fund more research on the prevalence of mental illness.
The menteri besar however failed to highlight that there has been an increase in prevalence of mental health problems, regardless of what sorts of mental health problems, from 1996 to 2015. Over the past decade, the prevalence of individuals who meet the cut-off score has increased from 10.6 percent in 1996 to 11.2 percent in 2006 and now 29 percent in 2015.
A continued denial of the poor mental health among Malaysians and the perpetuation of myths of mental illness is detrimental to helping the increasing number of Malaysians who are suffering.
DR CHUA SOOK NING is a clinical psychologist.