Malaysia has too few psychiatrists for its population. What's the solution in a country that sees the profession as 'unglamorous' and 'too difficult'?

By D. KANYAKUMARI

It has been close to 20 years, but Dorothy (not her real name) is still haunted by the memory of her son being admitted to a psychiatric hospital in Malaysia in 2008.

"Mental health awareness back then was far worse (than it is today), and every time we went to the hospital in the city, I would tell the doctor that my son was mentally unwell. Unfortunately, my pleas for help were ignored," she recalls.

According to Dorothy, her son had been diagnosed with bipolar disorder at age 21. Sadly, as her husband had died in 1999 after a long battle with schizophrenia, she could only afford government medical care for her son.

Yet, public facilities were so overwhelmed. And when they did treat Dorothy's son, she claims that he was not well cared for.

"I was helpless for two whole years until a friend of mine directed me to some assistance.

"We worked hard to try and get him treated locally, but clearly, Malaysia was not adequately equipped back then. Thankfully, a well-wisher helped fund a trip to Denmark (where my son could be better cared for)," she explained.

Dorothy says her son now works as an electrician and continues to be treated for his condition. She maintains, however, that he could have been "saved" much sooner had the hospitals in Malaysia been better equipped and had enough psychiatrists.

This isn't a problem felt by Dorothy alone. Malaysia currently has only about 500 psychiatrists nationwide. And that translates to one psychiatrist serving approximately 100,000 persons; a far cry from the World Health Organization's recommended ratio of one psychiatrist to 10,000 persons.

So, what exactly has contributed to the problem and what can be done?

An unglamorous profession

To Malaysian Mental Health Association (MMHA) president Prof Dr Andrew Mohanraj, one of the main reasons for the current predicament is that psychiatry has only become a speciality of choice for medical graduates in recent years.

He explained, "It is often perceived to be unglamorous or too difficult to pursue, as some feel the concepts in psychiatry are too abstract. This suggests that the stigma attached to mental health extends to mental health practitioners.

"Psychiatrists are also referred to as doktor gila (crazy doctors) and are often the butt of jokes among their friends and relatives. It was only during the COVID-19 pandemic that we realised universally that no one is impervious to developing psychiatric conditions."

Notes Dr Andrew further, there is also a preconceived notion that psychiatrists do not make as much money as other medical specialists.

A difficult path

According to a psychiatrist who recently left government practice and who wishes to be known only as Lee, the opinions and opposition of friends and family can also stand in the way of a career in the field.

She said, "My boyfriend and I met in medical school, and we both had considered psychiatry as a specialisation. But while my family supported my choice, his family was opposed. So, I pursued it while he went into orthopaedic care.

"We have been dating for 12 years, seven of which I have been actively either studying or practising psychiatry. Last year, however, after my boyfriend proposed, his family made it a condition for me to leave psychiatry if we wanted their blessings."

Lee said she was told that excessive time spent with "crazy people" in hospitals could affect her prospects of having a healthy child.

"I negotiated with them to allow me to go into practice on a freelance basis and they agreed but said that I could not see patients physically and had to do consultations online," she added.

External pressure aside, clinical psychologist Riithra Vee explains that psychiatry involves a long and taxing academic journey beforehand. And this likely explains the low number of psychiatrists in the country.

"Many people tend to think that psychiatry and psychology are the same thing. Fact is for psychiatry, one needs to become a medical doctor first. That is five years of medical study to earn a medical degree and then another four years of specialisation," she explained.

Conversely, it takes about five years to become a clinical psychologist in Malaysia.

For the record, psychiatrists and psychologists are both mental health professionals. However, only psychiatrists, being medical doctors, can prescribe medication.

Given the dearth of psychiatrists in Malaysia, however, could clinical psychologists help ease the situation?

Divide and conquer

To MMHA's Dr Andrew, the answer is certainly in the affirmative.

Unfortunately, while there are 465 clinical psychologists registered with the Malaysian Society of Clinical Psychology, the services of most of these professionals are beyond the reach of regular Malaysians.

"The sad part is that most psychologists work in the private sector. Additionally, most psychiatrists and clinical psychologists are concentrated in urban enclaves, such as the Klang Valley and Penang. This uneven distribution of human resources contributes to the disparity in access to services between rural and urban areas," he said.

One way forward could be to train doctors to detect, treat and follow up with cases at the primary care level.

"This will free up the bottleneck at specialist psychiatric services, particularly in government facilities, and encourage a seamless collaboration between primary care doctors and specialist services," Dr Andrew said.

This aside, there is also a need to look into more comprehensive insurance coverage for mental health.

Explained clinical psychologist Riithra, private mental healthcare is largely an out-of-pocket expense for many and can be costly. As such, wider insurance coverage would not only mean more people in need being treated, but also less congested government psychiatric facilities.

Importantly, too, it could go a long way in reducing the stigma attached to mental health and increasing awareness of mental health conditions.

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