Let’s talk about stress | Anton Grech

In an article dated March 2014, you were quoted calling for more awareness and education about depression and other mental health conditions. This week, you raised the alarm about the number of self-harm/attempted suicides at Mater Dei’s Accident and Emergency department. Does this mean that your earlier call went unheeded? Has not enough been done about the issue since 2014?

No: on the contrary, a lot has been done in these past five years. Luckily, mental health is on the agenda at last: both in terms of society at large – as evidenced by how the issue is reported in the media, and so on – but also in terms of government policy.

Recently, we launched a 10-year strategy plan for mental health. The plan will actually cater for all areas of healthcare: but it prioritises mental health to make a point. So a lot has been, and is being done.

But unfortunately, there is an increase in cases presenting themselves [to Accident and Emergency]: not just in Malta, but around the world. It’s a global phenomenon. The main reason is that stress has increased. Stress is one of the biggest causes of mental health conditions worldwide. And our lifestyle has undeniably become more stressful…

Could it also be that the levels of awareness have increased, too?

That is part of it too. Thanks to growing awareness, more people today are seeking help for problems that previously would have been kept hidden. Before, there was the mentality that psychological problems were things that had to be kept out of sight. This is increasingly no longer the case. And there is also more access to services. Today, mental health services are provided in strategic places like University and MCAST, for instance. There are more support services available; and people are using them more.

In the same article you mentioned the substandard conditions of Mount Carmel Hospital. I was under the impression that there were plans for a new psychiatric hospital on the grounds of Mater Dei. Has this plan been put on the backburner?

No. Plans for a new acute psychiatric hospital are still in place. In fact, I am one of the authors of the medical brief. Now we have reached the stage where architects get involved. So things are moving. But the point that perhaps has not come across, is that it makes no sense to wait for the construction of the new hospital, in order the solve the ongoing problems at Mount Carmel. It’s not fair on the patients.

So, apart from building a new hospital, we are also in the process of changing our approach to mental health issues. Before, when people presented themselves with serious mental health conditions, they would be admitted to Mount Carmel…. and in most cases, they would stay there. This is why the patient population there is so high.

It might also explain the traditional reluctance to seek medical help for mental health problems…

Precisely. Even the language we tend to use in such cases is unhelpful: ‘jaqfluk’ [they will lock you up]; ‘jigbruk’ [they will cart you away]… This was the mentality, before. Today, we are trying, as much as possible, to provide support within the community itself: so that the person concerned can receive treatment in his or her own home. First of all, it is a more dignified approach; secondly, even the therapy has a higher rate of success. Because the social aspect of therapy is very important. This is why we are focusing on providing more services within the community.

Unfortunately, however, there will still be cases which are severe enough to require hospitalisation. In such cases, the idea is for the patient to be admitted for as short a time as possible.

But to me, the real success in the mental healthcare sector is not measured in how many state-of-the-art hospitals we build – even though we do need one – but rather, by how few people are actually admitted to hospital. The emphasis in our strategy is that people would not need hospitalisation, even when going through difficult times.

In the meantime, however, we cannot ignore the fact that we have an old hospital – I’ve said it before, and I’ll say it again: Mount Carmel is not fit for purpose. But we’re working on that, too. We have closed down the isolation section completely; and we are in the process of upgrading other wards…

You mentioned, however, that the population at Mount Carmel is high. What about the people who are already committed there?

Many of the long-term patients are people who would have been admitted 40 or 50 years ago, and are today elderly. As such, these people no longer suffer from any mental illness. But they are not capable of living independently, either. So we have accommodated them in nursing homes within the community. There were others who needed supported living; and we have entered into contractual agreements with Suret Il-Bniedem and the Richmond Foundation to accommodate them in hostels. The idea is to reduce the population of Mount Carmel as much as possible.

Let’s turn to the statistics you mentioned last week: between one and three cases of self-harm/attempted suicide daily. First of all, what is the difference between self-harm and attempted suicide?

Put simply, attempted suicide is when someone makes an active effort to put an end to his or her life. The intention would be to kill oneself. With self-harm, the intention is different. In most cases, it will be to send out a message. All the same, however, the danger is still there. For one thing, self-harm attempts can go wrong. Harming oneself can lead to accidental death.

Moreover, research shows that 1% of self-harm cases will go on to seriously attempt suicide the following year. So you can’t say, ‘Oh well, all this person did was swallow four or five tablets’ – because the most common self-harm method is to overdose on tablets. When this happens, you need to take it seriously. It could be an indication of much more serious situations in future.

There is also international research that suggests the majority of suicide cases involve men; whereas with self-harm, the most vulnerable category are young women. Is that true of Malta, too?

Yes, it is. But we have to be cautious how to interpret these statistics. The reason men are more likely to commit suicide is not because they make more attempts than women; but because their attempts are more successful. This is because males tend to use methods which are more lethal.

With self-harm, the vast majority of cases are female… but there is a big caveat to be made here. All over the world – and we don’t know why – men are ‘catching up’. The statistics for women have remained more or less the same; but self-harm in males is on the increase. There’s a lot of research into this phenomenon going on right now.

One possible explanation concerns the way males and females are viewed by society. The concept of what is ‘male’ is changing…

If I may build on that: from a media perspective, the way men are portrayed – especially in advertising – has also changed. Pressures to have (for example) a ‘perfect body’ are now exerted equally on men and women alike. Do you see a correlative with increase in self-harm among men?

Yes, in fact we’re also seeing an increase in eating disorders among males. In the past, conditions such as anorexia and bulimia overwhelmingly affected women more than men: primarily because the root cause is a concern with physical appearance. But again, men seem to be ‘catching up’. This is happening all over the world, and Malta is no exception.

This leaves us with the question of what can be done to alleviate the problem. Stress is a major cause of mental health disorders… but hospitals and therapy cannot be expected to reduce stress in daily life. What, then, can be done about the phenomenon?

Let me put it this way: many people talk about ‘the need to prevent suicide’… as if suicide were something tangible, floating in the air. But the reality is that nearly all suicide attempts and self-harm cases – with very few exceptions – are the result of psychological problems. So, anything that can be done to decrease psychological problems, and to improve the treatment of such conditions, will help. What we really need to do is provide better mental healthcare, both in prevention and in cure. That is the way to reduce suicide cases.

To give an example, recently we introduced measures to treat post-natal depression in the perinatal clinic. The idea was not specifically to prevent suicide; but post-natal depression is a possible cause of suicide or self-harm; so that would also have the effect of reducing psychological problems that might lead to suicide among women. Basically, any step that improves the level of mental healthcare will have a positive effect.

When it comes to the rest of society, however, there is a lot more that needs to be done. I believe that we need to be able to cope more with stress; but also, that our cultural attitude towards life in general needs to change. We are too involved in the ‘rat-race’, so to speak…

Another point you raised concerns the education system, which is adding to daily stress among young teenagers (a highly vulnerable category). But hasn’t our education system – with its emphasis on competitive examinations – always been stressful?

First of all, I am very aware that the education system is conscious of the problem; and that efforts are being made to reduce stress associated with exams. Recently, the half-yearly examination was removed, for example. But my concern is that even those areas that are supposed to be more relaxed – such as sports – are now also being turned into an exam-based model. You now see small children terrified because they have to pass an exam about football: where before, football in schools was a way to relieve stress, not to add to it.

It’s the same with music, dance… anything that should really be a hobby for one’s own self-development, has turned into a test. What should be a respite from the needed stress of education, has, in itself, become stressful. So yes, I consider this to be a contributing factor.

So far we’ve talked a lot about prevention, but very little about cure. I have noticed an increased tendency for people to resort to anti-depressants, and other equivalent prescription drugs. Am I right in this perception? Do you think that doctors overprescribe anti-depressants, in Malta and elsewhere?

I think there is a tendency to over-utilise medical means to treat psychological situations. Unfortunately, when you use the word ‘treatment’, most people automatically think of ‘medication’: i.e., drugs. But in reality, treatment for mental health should be based on what we call the ‘bio-psycho-social approach’. All three factors – biological, psychological, and social – are equally important.

Let’s just talk about depression, as an example. If the depression occurs in the context of problems at work… and you only use the biological (medication) approach, leaving out the psychological and social dimensions… it would be ineffective. Because the problems at work would still be there.

So ideally, if the condition is not severe, you should start with non-medical treatment. Medication does, however, become essential when the condition is severe, and there is a biological element involved. Then, it becomes not just important, but essential to resort to medical treatment.

In a way, this is why over-prescription worries me. Because if medication is prescribed when there is no real need… it won’t work. So people might get the impression that medication, as a whole, does not work in any circumstance. Then, when drugs are really needed, the patient will be reluctant to take them…

There is also a tendency to think that severe psychological problems only ever develop in people who are genetically re-disposed to such conditions. Is this true… or is it the case that anybody, under certain conditions, can fall prey to mental health disorders?

Like everything else in life, most mental pathologies are the result of genetic predisposition. But there will always be what we call a ‘precipitating factor’. This is true of physical pathologies as well. If someone suffers from diabetes, it means he or she has a predisposition to that illness. But if they then go on to eat a lot of sugary foods… they will precipitate the condition.

It is the same with mental illness. The bigger the genetic predisposition, the smaller the stress needed to precipitate the condition. But there is a breaking point for everyone, regardless of genetics. So yes, everyone can develop a psychological condition, under certain circumstances. But some are more resilient than others.