Policy Paper on Mental health

Malta Medical Students Association's

Policy Paper on Mental Health

March 2017

Mental Health Malta Medical Students’ Association Policy Paper

Place:

University of Malta

Date of adoption: 28th March 2017 Date of expiry:

March 2020

Background Information The World Health Organisation (WHO) defines health as being “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. In addition to this, mental health is given specific importance when defined by this same organisation as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.

In most parts of the world, however, unfortunately, mental health and mental disorders are not considered as having the same importance as physical health. Indeed, they have been largely ignored or neglected. Reports published by the WHO state that treatment of mental, neurological and substance abuse disorders are unaffordable even in developed countries, and hence only a small minority of persons with mental disorders receive even the most basic treatment.

Mental disorders show a higher prevalence in certain subgroups of people who are more susceptible because of more exposure and vulnerability to unfavourable social, economic and environmental circumstances, with a gender bias of depression and anxiety towards women while men tend toward substance abuse and antisocial disorders.

There is a considerable need to raise the priority given to the prevention of mental disorders and to the promotion of mental health through action on the social

determinants of health. There is a need for mental health to be given greater priority in all countries across the world. Increased awareness and understanding of mental health should also coincide with increased financial, medical, and human resources towards tackling mental disorders and reducing discriminations.

Vulnerable Groups Vulnerable groups, especially those suffering from mental disorders may feel stigmatised and discriminated against and consequently, suffer abuse and violence in different aspects of their lives, be it social, educational as well as employment.

Such groups may include youth and adolescents in which depression is considered to be the predominant mental disorder associated with this age group.

Depression is the most widely reported disorder, with over a quarter of adolescents affected by at least mild depressive symptoms.

In recent years both the prevalence and severity of mental health concerns amongst university students have increased significantly. The nature of the issues brought forward to relevant professionals has changed, with more severe mental health illnesses being addressed as opposed to the previous developmental concerns related to this age bracket.

Unfortunately, the fear of being stigmatized remains a barrier to societal change around mental health, and subsequently only a small percentage of affected adolescents seek treatment.

In addition to this group, people with disabilities and chronic illnesses may also be described as being a susceptible group for mental disorders. While it is recognized that the majority of these people do not suffer from any mental health problems, there is a greater risk of developing some of the aforementioned disorders. This is consistent with frameworks which suggest that the presence of any stressor results in the vulnerability of people to other stressors.

The Lesbian, Gay, Bisexual, Transsexual, Intersex, Queer (LGBTIQ+) community is also one of the most susceptible groups to mental illness, particularly due to fear of stigmatisation. Several studies have shown how LGBTIQ+ individuals suffer from mental health disorders at rates far exceeding heterosexual people. Fortunately,

research in the past decade has identified risk and protective factors for mental health, which point to promising directions for prevention, intervention, and treatment, especially in the mentioned entities.

Treatment of Mental Disorders Tackling issues of stigma and the resulting discrimination against those with existing mental illness could possibly be the first major step in the treatment of these disorders, with more people seeking help and support, such that fewer individuals suffer without help or treatment. Awareness and knowledge in the general population through the media could potentially help reduce associated stigma.

Moreover, on a national level, it is essential that a reassessment of legislation and practices is presented so as to promote protection of human rights, prevent discrimination against people with mental illness and develop initiatives to shed a light on the significance of mental health. Mental health legislation should ensure that people suffering from mental disorders are not isolated and stigmatised.

Additionally, programs may be implemented to provide assistance to people suffering from mental disorders outside of facilities and hospitals, particularly with respect to social and financial support. Such measures need to be prioritised principally because mental health and social care is not given enough importance in the health systems, with only small percentages of people having had contact with health services in previous years.

National-level strategies are likely to have a significant impact on reducing mental health inequalities and have the greatest potential to reach large populations.

Particular emphasis should be given to promoting access to employment, health care, education and treatment, while raising awareness about mental health so as to reduce the stigma surrounding this issue.

Local Statistics Due to a lack of local statistics with regards to the quality of mental health education in Malta, the MMSA has carried out research in the form of distribution of

questionnaires to medical students of each year in Malta. This was focused on medical students as opposed to all students of different courses due to the fact that medical students too, originate from different backgrounds and previous educational institutions.

Their current level of mental health education provided through the course itself and the MMSA will provide a good baseline for comparison to previous mental health education, allowing them to correctly judge the quality of such education prior to that provided at university level. From this, one can assume that students outside the medical course have received the same secondary school and sixth form level awareness at those stages in their life.

Mental health is not largely addressed in primary to tertiary education, it is normally only briefly mentioned during sessions of Personal and Social Development, or mentioned as an aspect of “Health�. Mental Health is tackled in the form of stress and anxiety normally amongst students, as these are both very likely to be encountered during adolescence; however illnesses of mental health are mentioned in less detail. In primary school and secondary school education, such sessions will often discuss substance abuse and bullying in a great degree of detail, as nowadays these themes are easily encountered by the adolescent, however as previously stated, conditions such as depression and ADHD are described somewhat vaguely. In light of such observations, the MMSA has started to organise Mental Health sessions being held at secondary schools for this sole purpose; to educate students about what they might encounter in themselves or in people around them in the future.

Of course however, services such as counsellors and psychologists are made available for those who wish to seek further information or help involving mental health issues. These services are necessary in every educational and preferably also every working facility, but are individuals aware that such a service is available to them?

From the data collected from the questionnaires, medical students were asked about their knowledge and feelings about such services, firstly asking if they felt that these services were available to them at this point in their life. 51% of the student felt like these were not available to them, while 49% did; this observation is an indication that although these are available, not everyone is aware or considers them easily accessible. The University of Malta offers free counselling services, and a variety of student-based support groups for those in need, and 51% of medical students stated that they would consider making use of such services prior to consulting private clinics

and psychologists.

An interesting observation was that in different educational institutions, students showed a variety of ratings when being asked how much such services were encouraged within the institution. This is significant since although the services are available, informing the students that these services are present is crucial. Students can either be encouraged and shown that it is normal to seek such help, or end up perceiving it as shameful, which causes a major discrepancy in the amount of students that encounter problems in their life, and the amount that actually seek help for them.

How much are mental health services encouraged in schools? (1 - Least 5Most) 9%

17% 1

17%

2 3 22%

4 5

35%

In the case of primary schools, 59% of students do not think these are available at such level, and 89% agree that they should be made available. With regards to secondary and sixth form, 72% and 60% respectively agreed that they felt adequate counselling services were available. However when it came to proper mental health education, 70% agreed that primary and secondary schools did not provide sufficient education on issues about mental health. Therefore as opposed to sexual education, it can be assumed that the majority of mental health education would not arise from school education. This is proven through the survey, where students had to select the

medium through which most of their mental health education was obtained.

The graph below shows that the majority of mental health education was a result of personal research, followed by personal experience with mental health issues, and issues in peers. This statistic interestingly implies that mental health is an integral part of adolescence, as despite not obtaining enough information from school, medical students still learnt about such issues by actively researching information. In addition, mental health was learnt through the students own encounter with mental health, or that of persons close to them, emphasising how mental health affects us all and mental health education is necessary.

Major source of Mental Health Education 22%

Schools

34% NGOs (such as MMSA and IFMSA) 17%

Personal experience and peers

Personal research 27%

From these statistics, the low percentage of education from schools is a clear indication that improving mental health education in such facilities is necessary. A standardised source of education will help in providing students with correct and relevant information, reducing the element of luck and misinformation that comes with searching the internet for information. Better school-sourced mental health education will also allow the education of younger generations, starting from primary schools, which as life becomes increasingly stressful, younger students are being put at risk.

Another striking statistic obtained from the survey was that 85% of medical students agreed that they themselves were not provided with sufficient mental health

education prior to clinical years and experience with psychiatry. This is a worrying value as other than Clinical Medical students and Health Sciences students, the rest may not ever achieve adequate mental health education without seeking it themselves or unfortunately experiencing them. In such cases, besides psychologists and counsellors, individuals may find themselves within mental healthcare facilities such as Mount Carmel Hospital.

Medical clinical students expressed concerns about such facilities through the questionnaire, 70% stating that they were not enough to cater for the mental healthcare demands of Malta. However the question stands as to whether this inability to keep up with the demands is due to the weakness in mental health education or the lack of promotion of free services such as counselling, prior to one seeking a psychologist or psychiatrist. A discrepancy between the quality of medical care and mental health care in Malta was noted in the questionnaire, indicating that many students did not agree that mental healthcare was up to standard in both keeping up with demand and promoting recovery; would this imply that there are too few persons who understand the importance of mental health, is there a large number of cases of mental health problems, due to lifestyle or lack of mental “primary care�? Clinical students therefore took to recommending certain improvements in areas that they deemed to have potential to grow in the mental healthcare system.

Recommendations 1. Create guidelines for standardised mental health education for educational institutions to follow. a. Educate students and primary, secondary and sixth form levels, especially when there is suspicion of risk or vulnerability. b. Educate against stigmatisation of mental health from an early age.

2. Provide awareness of the provision of counselling in primary, secondary and sixth form education. a. Encourage students to seek out such help without fear of judgement. b. Encourage students to seek help even when people close to them are experiencing problems. c. Inform students that they are able to encourage other students to make use of such services. d. Inform teachers and other staff members to look out for any signs of

3.

4.

5.

6.

mental health issues in students and encourage them to seek help. e. Ensure Promote the University counselling services to each faculty to ensure all students are made aware of it. f. Introduce awareness talks from patients who have suffered with mental health issues, emphasising how they sought help and how it brought about change to their situation.

Provide adequate mental health education to medical students, especially prior to clinical years, as the stress of the course may harm vulnerable students. a. That the students are made aware of counselling services and support, even from graduates which have completed the course. b. Promote Mental Health First Aid campaigns which are provided by the MMSA. Introduce the notion of “Mental Health Primary Care� which is making use of counselling and support groups prior to seeking psychiatrists and immediate medical help. a. Promote such systems in the work-place, ensuring that such services are not only available to students. b. Encourage staff members to routinely have mental health check-ups with occupational therapists and psychologists, especially in stressful work places. c. Emphasise the importance of rest and leisure in every work-place.

Improve mental healthcare services in Mount Carmel Hospital in Malta. a. Recommend refurbishment of the facilities to ensure the building is of adequate safety and comfort for the patients and staff. b. Ensure specialist and staff training at the healthcare facilities are up-todate. c. Ensure that patients are placed in a well-kept environment promoting physical and psychological recovery. d. Provide assistance to patients’ rehabilitation into the community and ensuring they manage to integrate. e. Facilitate the employment of sufferers of mental health issues, during (if employment is desired) and after the duration of their treatment and recovery.

Integrate mental health services with the services provided by the General Hospital to function as a more singular entity as opposed to isolating mental

health services. a. Improve mental health services to reach the standard of medical services that are provided by the hospital.

7. Encourage the community to facilitate the integration of mental health patients following their recovery. a. This will in turn reduce the stigma against mental health. b. Encourage recovered or recovering mental health issue sufferers to share their experience within the community of patients and the general public.

References: World Health Organization (2001) World health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization.

World Health Organization (2001) Atlas: mental health resources in the world 2001.

Geneva: World Health Organization, Department of Mental Health and Substance Dependence.

Patton G, Sawyer S, Santelli J, Ross D, Afifi R et al. (2016). “Our future: a Lancet commission on adolescent health and wellbeing”. The Lancet 387.10036: 2423– 2478 Brooks, T. L., Harris, S. K., Thrall, J. S., et al. (2002). Association of adolescent risk behaviour with mental health symptoms in high school students. Journal of Adolescent Health, 31, 240-246.

Kessler, R. C., & Walters, E. E. (1998). The epidemiology of DSMIII-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression and Anxiety, 7, 3-14.

Emerson E, Madden R, Robertson J, Graham H, Hatton C, Llewellyn G. (2009).

Intellectual and Physical Disability, Social Mobility, Social Inclusion and Health.

Lancaster: Centre for Disability Research, Lancaster University.

Meyer, I,. Northridge, M. (2007). “The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay, Bisexual and Transgender Populations”.

Robinson JP, Espelage DL, Rivers I. (2013). Developmental trends in peer victimization and emotional distress in LGB and heterosexual youth. Paediatrics: 131:423–30.