By Dr. Chua Sook Ning
Recently the Chief Minister of Terengganu, Ahmad Razif Abd Rahman, denied the National Health and Morbidity Survey report that 1 in 4 residents of Terengganu are mentally ill. He claimed that mental illness refers to crazy (“gila”) and that the statistics refers to the prevalence of mental health problem such as stress and worry which are caused by 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 1 in 4 Malaysians are not crazy, for mental illness does not mean a person is mad. Unfortunately the statement from the Chief Minister, who holds a M.Sc 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 1 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 (e.g. Malignant tumour) or mildly physically ill (e.g. having the common flu). Both of these physical illnesses are included in the ICD-10 (International Code of Diseases) which 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 passed away. This is of course a simplication 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 – 5 % of violent crimes are committed by individuals with serious mental illness. Out of the 3 – 5 % of individuals who have been incarcerated, only 7 % 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 Chief Minister 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 -12 to assess the prevalence of mental illness. It cannot discriminate between different types of illness. Nonetheless the GHQ-12 has a sensitive rate of 70-80% as a screener for non-psychotic mental illness. In other words, 70-80% of individuals who meet the cut-off criteria can be diagnosed as having suffering from a mental illness (e.g. 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 (Hankins, 2008). 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 Organization study of mental illness in 15 different countries (Goldberg et al., 1997).
I am glad that the Chief Minister 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 Chief Minister, 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% in 1996 to 11.2 % in 2006 and now 29% 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.
Goldberg, D. P., Gater, R., Sartorius, N., Ustun, T., Piccinelli, M., Gureje, O., & Rutter, C. (1997). The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological medicine,27(01), 191-197.
Hankins, M. (2008). The factor structure of the twelve item General Health Questionnaire (GHQ-12): the result of negative phrasing?. Clinical Practice and Epidemiology in Mental Health, 4(1), 1.
Hoeymans, N., Garssen, A. A., Westert, G. P., & Verhaak, P. F. (2004). Measuring mental health of the Dutch population: a comparison of the GHQ-12 and the MHI-5. Health and quality of life outcomes, 2(1), 1.
Makowska, Z., Merecz, D., Moscicka, A., & Kolasa, W. (2002). The validity of general health questionnaires, GHQ-12 and GHQ-28, in mental health studies of working people. International journal of occupational medicine and environmental health, 15(4), 353-362.
Reuter, K., & Härter, M. (2001). Screening for mental disorders in cancer patients–discriminant validity of HADS and GHQ‐12 assessed by standardized clinical interview. International Journal of Methods in Psychiatric Research, 10(2), 86-96.
Yusoff, M. S. B., Rahim, A. F. A., & Yaacob, M. J. (2010). The sensitivity, specificity and reliability of the Malay version 12-items General Health Questionnaire (GHQ-12) in detecting distressed medical students. ASEAN J Psychiatry, 11(1), 36-43.