Mental illnesses and mental health have, out of ignorance and fear, evoked a low priority in healthcare systems the world over. The concept that all mental illnesses were synonymous with madness has its origins in the beginnings of ignorance and fear. To a large extent, these have contributed to the marginalization of psychiatry and neglect of the mentally ill. The kings of old, seeing the ill-treatment of the mentally ill, built asylums for them, but again, the prejudice soon was overwhelming and care of the mentally ill was often given to those who were not the best administrators and carers. The long and controversial tradition of mental asylum care for the mentally ill was also brought about by the lack of specific treatments for mental illnesses. With the advent of chlorpromazine in the 1950s and other psychotropics afterwards, the need for incarceration in asylums became largely redundant. However, what also became obvious soon after was the fact that the psychotropics only helped to control symptoms and not to cure diseases of the mind. Although considerable research has gone into attempts at correcting supposed defects in neurotransmission, the cure of mental illness seems some way off. The need for rehabilitating or re-housing those with mental illnesses especially those needing long-term care and those whose cure seems difficult has been recognized for a long time. It was Phillipe Pinel who almost 200 years ago unchained the mental patients at an asylum in Paris and proposed work therapy and humane care. Psychosocial rehabilitation of the mentally ill is not, therefore, a new concept. The need for methods of changing the behavior, thinking and functioning of those with severe mental illnesses using psychological, social, occupational, behavioral and medical methods is called psychosocial rehabilitation. This method, although developed in stages over the past two centuries, has undergone changes and deterioration and development in different parts of the world with different priorities and emphasis.
Recent innovations in the treatment of schizophrenia reflect a growing trend towards community-based care. Malaysia had in the past few years attempted to deinstitutionalise mental patients in the mental hospitals. Therefore it is important to conduct research to compare the two groups of schizophrenia patients (community-based patients against chronic hospitalised patients) to ascertain if deinstitutionalisation has been beneficial. The main objective of the study was to compare levels of depression and function in community-based patients against chronic hospitalised patients as depression is prevalent among schizophrenia patients. This study was cross sectional in nature where data was collected from 51 inpatients in Hospital Bahagia Ulu Kinta (HBUK) and 23 community-based patients. Calgary Depression Scale for Schizophrenia (CDSS) and Global Assessment of Functioning scale (GAF) were the assessment tools used. Community-based patients were found to have significantly lower scores in the CDSS scale (1.96) as compared to chronic hospitalised patients (4.04); p < 0.01). They also showed higher functional capability between community-based and hospitalised patients respectively (74.04 vs 57.92) respectively. (p < 0.001). Community services appeared to be more effective than long stay in-patient services in preventing depression and promoting better functional levels.
Since the Government was implementing the policy of decentralization of psychiatric services, a large number of chronic schizophrenic patients failed community management because of the breakdown of family support. The rejected patients were admitted to the Old Persons' Home for protection because no other suitable places were available for them. In a follow-up study in one of the Homes, the one-year prevalence rate of treated psychiatric illness and schizophrenia was found to be 27.5% and 15.3% respectively. Lack of rehabilitation and community care facilities and inadequate staff in all categories were the root of the problem. The author foresees that the Government will face a serious problem in future to cater for the increasing number of chronic schizophrenic patients in the community if it does not take immediate action to improve mental health services in the country.
Psychiatric services have progressed well throughout history, marked by a shift from heavily inpatient asylums to outpatient management via deinstitutionalization, and advances in psychopharmacology. An overview of important themes is discussed at public mental health level. Firstly, differences between sexes are touched upon from theoretical and societal perspectives. Next, among the disabled, the phenomenon of diagnostic overshadowing, attributing apparent mental health problems to learning disability, contributes to their overall poorer quality of life. Mental health at both extremes of age is another important theme, whereby dementia and depression are keenly observed in the older age group, while maternal risk factors and parenting play a role in the mental well-being of the younger age group. Fourthly, inequalities, stigma and discrimination, are rife among people living with mental illness, and thereby detrimental in their road to recovery. Deinstitutionalization is explained as being more than just downsizing the inpatient load, gaining prominence with the emergence of community psychiatry services, and found to be helpful in overcoming stigma. Demographically, it was demonstrated that developing countries, as opposed to developed countries, have advantages in their approaches to psychiatric services, including better integration of people living with mental illness into society. Lastly, the psychological well-being of mental health workers should not be discounted, with measures such as stress management and resilience training proving to be key in combating burnout.
Deinstitutionalization has shifted much of the burden of care of chronic schizophrenia from mental institutions to the family. The aim of this study is to asses the prevalence of mental disorders among 210 primary carers of Malay schizophrenic patients, explored the burden and hardship experienced by them. This is a two-stage psychiatric screening procedure. All the cases suspected from initial screening with WHO Self-Reporting Questionnaires (SRQ-20) were called for clinical interview. Patients' behavioural problems and the burden of relatives were assessed by the Social Behaviour Schedule and the Interview Schedule respectively. It was found that about 23% of the carers developed neurotic disorders resulting from the stress; nearly half of them had neurotic depression. Despite their burden, they do not complaint about it. Neurotic carers compared with non-neurotic carers had significantly more subjective burden and distress related to the product of active psychosis. The carers were generally able to tolerate the negative symptoms of schizophrenia. The number of problem behaviours and previous admissions were significantly correlated with the severity of burden.