June 26, 2017

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mental health

by George Khoo

I saw the signs a couple of months before my daughter’s wedding. The year running up to this point had been rough. I was feeling upset, tired, irritable and angry almost every day. I teared up easily and was constantly thinking negative thoughts, sometimes even suicidal ones.

Even though I was so tired most days, I wasn’t able to sleep properly, often waking up in the wee hours of the morning. How I felt added to my fatigue, frustration, hopelessness, guilt and feelings of worthlessness.

While the truth that I was clinically depressed started to sink in, I was probably still in denial and hoped that with time, rest and exercise, things would improve. However, it just got worse and the low moods and negative thoughts persisted.

Part of the reason for not seeking help early was because I’m from the medical profession. I felt that admitting that I needed help would not reflect well on me – a healthcare provider who’s not even able to care for himself.

 

How did it get this bad?

It wasn’t the volume of work that affected me most but the issues in my relationships. I have always tried to live peacefully with my fellow man and it’s not in my nature to confront others. However, the leadership roles I’ve taken up at work and in my church have increasingly put me into situations that require confrontation.

I had patients that year that I expected would be grateful to me but turned around to question me on the wisdom of the recommendations I had made with their best interests at heart. I had a colleague who was pushing me to pursue something I was not comfortable with. And I had to confront people who had made wrong choices and required disciplinary action. Meanwhile, in church, a man told me to my face that he wanted me to step down as a church leader.

The worst was when a leader at work, unhappy with a policy I was trying to revise, accused me of being more interested in systems and policies than in caring for patients. I had spent sleepless nights worrying for my patients and trying to get them good healthcare and while what the leader said was absurd, it really hurt to hear him say that to me.

All of this played into my feelings of worthlessness and frustration, causing me to feel even more irritable and upset than I already was.

 

An unusual sense of loss

At some point, however, I realised that these were not the only causes for what I was feeling. It dawned on me that a big factor was the prospect of ‘losing’ my precious daughter once she gets married. That year, we must have attended close to 10 other weddings and I dreaded going to them because they just reminded me that soon, I was to give away my own daughter. Each wedding became more and more difficult to attend and the worst was the one two weeks before her wedding. I teared throughout the wedding thinking of what it was going to be like on that day!

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I was unable to make sense of how depressed this made me feel until I read Unmasking Male Depression by Archibald D. Hart:

“Then there was the time when my first daughter was going to be married. I found myself quite depressed a few months before the wedding. Finally, it dawned on me that my little girl was saying goodbye to me in favour of a young man who was not part of me. Like it or not, being excited for my daughter was not enough to overcome my sense of sadness. I was facing a loss that could never be replaced. There were those who said to me, “You’re not losing a daughter but gaining a son-in-law.” What a ridiculous idea! What I was losing could not be counterbalanced by what I was gaining. Every father of a daughter knows that a son-in-law does not equal a daughter!”

Coming across that passage was like hitting the jackpot (not that I play). Finally, someone understood how I was feeling – he had been through the same thing and knew how I felt.

 

Getting help

I finally plucked up the courage to make an appointment with a psychiatrist to confirm my own suspicion. I needed to know for sure, to be fair to my family and my loved ones. In any case, I had reached a point where not much else mattered and I wasn’t bothered about the stigma associated with taking anti-depressants 

I had reached a point where not much else mattered and I wasn’t bothered about the stigma associated with taking anti-depressants

I was put on Lexapro (escitalopram) and during my review, three and half months after my first appointment, my psychiatrist doubled my dosage. I was definitely feeling better in terms of having less frequent thoughts of hopelessness and a stop to the suicidal thoughts but I was not “walking on clouds”. About a week later, I distinctly remember waking up one morning and thinking: “Oh, this is what it feels to be normal?” That morning, after many months of feeling down, moody and negative, I felt that burden lift. My medication was working well.

The other thing that helped me greatly was reading the Bible and other Christian literature on depression and burnout. I found them to be great in creating self-awareness and for self-therapy.

 

“I believe that I shall look upon the goodness of the Lord in the land of the living! Wait for the Lord; be strong, and let your heart take courage; wait for the Lord!”Psalm 27:13-14

“Despite being a dedicated gospel-hearted Christian who preached grace, the truth is that I was dangerously close to living a gospel of works, not grace.” – Christopher Ash, Zeal without Burnout

“The surprising truth is that the person who pauses long enough to refresh his soul along the way actually becomes more alert, more alive, more efficient.” – W. Phillip Keller, Strength of Soul

 

The other main factor on my road to recovery was the tremendous support given to me by my beloved wife and family. At the end of our family holiday, six weeks before my daughter’s wedding, I decided to be open with them at the airport while waiting for our flight back to Singapore. I am thankful that they took it very well and were very encouraging.

My wife, who knew my struggles all throughout, was a pillar of strength when my whole world was crumbling emotionally. She is not only my best confidante and my best friend, she also makes me laugh and reminded me to rest. She was ever patient with me when I was negative and moody and even scratches my back to help me sleep! God gave her the strength and grace to put up with me.

It’s been a two and a half year journey and while my psychiatrist has encouraged me to try weaning off the Lexapro, I realise that as long as I am in my current role, in church and at work, it would not be possible. I have tried weaning it off but have had to go back on my medication rather quickly. Nonetheless, my dosage has halved and my recovery has been steady.

Having been through the worst periods has helped me to be more disciplined about taking regular breaks. Now, I take a week off every three to four months and am intentional about observing the weekly Sabbath as a time of rest from work. As the writer Christopher Ash puts it in Zeal without Burnout, “God needs no day off. But I am not God, and I do.”

 

Stigma

I have chosen to be open about the fact that I am still on anti-depressants because there is a need to remove the stigma associated with it. In Singapore and in this part of the world, to be on anti-depressants is still very much taboo. Thankfully, I work in a Christian organization that fully understands and supports my stand. However, other employers may not be as understanding and that is probably one of the main reasons why people do not speak up – the fear of losing their jobs or not getting one should they be honest.

While it is probably too idealistic to expect no discrimination at all, I hope that we can help employers be open to accepting applicants with a history of mental illness but are stable on medication. They should be at least considered in the same way as those with other chronic illnesses such as hypertension or diabetes. As long as they are capable of performing the tasks and do not pose a danger to themselves or others, they should be given equal opportunities.

“The lines have fallen for me in pleasant places; 
indeed, I have a beautiful inheritance. – Psalm 16:6

 

Dr George Khoo is a general practitioner in his late 50’s and serves as the Medical Advisor for a Christian organisation. George is married to Mabel and has two grown up children, both happily married. George and Mabel have a newborn grandchild and are expecting a second within the next few weeks.

 

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by Brenda Tan

ON LABOUR Day, I received a WhatsApp message from a friend whose daughter takes the same school bus as my 11-year-old girl. Her daughter had told her that Ah Girl was watching a clip from the Netflix series “13 Reasons Why” – and was concerned.

“13 Reasons Why” is a television series based on a story written by Jay Asher, in which the teen protagonist who commits suicide leaves behind 13 tape recordings on why she ended her life. Each tape implicated a person whom she blamed for her choice to kill herself.

It seems an intriguing and well-constructed piece of fiction, except that when translated into a highly-publicised teen drama series, alarm bells begin ringing for parents and the international mental health community.  They understand how easily a Hollywood treatment of such a complex issue as suicide may glamorise suicide instead.

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A couple of days before receiving that WhatApp message about “13 Reasons Why”, a parent in my 9-year-old son’s class parents’ WhatsApp chat group shared a news article about the “Blue Whale Suicide Challenge”. The report, which was picked up by other major news media, linked the deaths of 130 teenagers in Russia to playing the “Blue Whale Challenge”, in which youths followed the commands of a game-master in ever-escalating acts of danger, culminating in their own suicide. Although fact-checking site Snopes.com said that the claims are unconfirmed, it’s nonetheless of concern that our young people may be susceptible to such sinister suggestions which put so little value on life.

The concerns of parents here were enough for the Education ministry to post a comprehensive advisory on schoolbag.sg regarding suicide games in the online media and how parents should handle it.

Of course, our concerns and fears for our children’s mental health is not new. No one doubts that our high-stress and exam-oriented school culture can easily create a tragic situation where failing to meet parents’ and the school’s expectations may cause yet another student to contemplate suicide. It only remains for parents and school counsellors to be vigilant when dealing with our children, to take note of their behaviour and well-being, and to create an environment where our children can feel safe enough to share their feelings of insecurity with us.

I read the news about the Blue Whale Challenge, I immediately shared the story with the kids and we had a chat about the implications of this challenge. I asked them what they thought of the challenge and how similar or different this challenge was to other internet viral challenges like the ALS ‘Ice Bucket’ Challenge and the more dangerous ‘Cinnamon’ Challenge. We talked about our responses to such challenges and dares, and what separates cowardice and bravery.

For my 18-year-old son, however, I had to be a little more subtle and a whole lot more ‘clueless’. “What’s this Blue Whale Challenge hah?” I asked him – and had him explain it to me. My “Why are they like that?” question encouraged him to give his views on the people who participated in the challenge and the game convener. It’s really good to know that he’s up-to-date with current affairs and, more importantly, to be assured that he places a high value on life.

I had to be a bit careful about talking about “13 Reasons Why” with Ah Girl though, because I didn’t want it to affect her relationship which her friend who had told her mother about her viewing the clip.

It turned out Ah Girl was watching a YouTube video on a friend’s smartphone (because her mobile doesn’t have data roaming), and the Netflix video ad for the series had to play in full before she could watch her TED-Ed video.

I asked her what she knew about “13 Reasons Why” and she shared that she knew it was an M18 show about a girl’s suicide, but she wasn’t interested to watch a show like that. Her younger Di-di, aged 9, chimed in to say that he also saw the ad for the series when he surfed YouTube, but won’t watch it “because it doesn’t have a funny part!”.

“Is there a difference between watching ’13 Reasons Why’ and ‘Star Wars’?” I asked.

“One is real, but the other is not,” the boy replied.

“Actually, both are not real,” I corrected, even though I knew what he meant. “They are both stories written by people and made into movies.”

I felt that it was important for my kids to see the difference between fact and fiction. If they mistook a fantasy for reality, it would create the basis for their behaviours and actions. This is why it is highly unlikely that playing ‘Counterstrike’ would turn Kor Kor into a terrorist, or watching ‘Star Wars’ would turn Di-di into a Sith Lord, even if we did encounter quite a number of these cosplay characters over the Star Wars Weekend at Gardens by the Bay.

However, if my kids believed that Hannah Baker’s suicide story is real, they may just simplify suicide as an option for revenge and justice from beyond the grave, and an action worth carrying out when they encounter difficult times.

Therein lies the true danger of headline news like the unverified ‘Blue Whale Challenge’ and the concerns about ’13 Reasons Why’. Both suicide-focussed stories cut too close to the divide between fact and fiction, reality and fantasy. For vulnerable youths seeking attention or help, these stories may provide an unanticipated call to action that we are not prepared for.

We can’t stop them from watching such videos and clips all the time, but we can start talking to them about the value of life and steer them into healthy pursuits. This is in the hope that the suicide option will never cross their minds as a way to overcome what problems they face. They must know that life is very much worth living whatever the fantasy or fiction might portray.

 

 

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by Mahita Vas

IN OCTOBER 2015, my husband and I contacted one of the participating insurance agencies about signing up for the Integrated Shield Plan (IP). We were keen on a better coverage than what was offered on our MediShield Life plans. Within days, we heard that my husband’s application had been approved. Mine was rejected, but the agent said she would appeal. Less than a week later, I was told the appeal was also rejected. No other option was offered.

I tried all the other agencies. At that time there were five – AIA, Aviva, Great Eastern, NTUC Income and Prudential. I was rejected by all of them. Great Eastern told me not to bother applying because my application would definitely be rejected.

Disheartened, I pointed out that I was fit and healthy. I exercised regularly and was careful about what I ate. Neither a smoker nor a drinker. Minimum eight hours sleep. But the answers were all the same – nope. Not approved.

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All because I share one thing in common with these people – Catherine Zeta-Jones, Graham Greene, Winston Churchill, Nina Simone, Lee Joon, Demi Lovato, Carrie Fisher and Eason Chan. The list goes on: Mel Gibson, Stephen Fry, Edgar Allan Poe, Abraham Lincoln, Virginia Woolf, Ernest Hemingway, Amy Winehouse, Vincent Van Gogh, Friedrich Nietzsche, Ludwig van Beethoven, Charles Dickens, Isaac Newton, Florence Nightingale. The list does go on but I’ll stop here.

They are amongst the greatest artists, musicians, performers, writers and thinkers who ever lived. I cannot, dare not, compare myself to any of these leaders in their respective fields, being nowhere nearly as accomplished as any of them. Great as their achievements have been, they are also, first and foremost, people. Just like me. And like about 2 per cent of the world’s population, including Singapore’s.

People with a dreadful illness once known as manic depressive illness, now known as bipolar disorder. An illness marked by extreme mood swings, where patients go from feeling overly happy to feeling empty. Bipolar disorder is indiscriminate, incurable and requires lifelong medication. With diligent medication and visits to the doctor, it is possible for patients to function as normally as anyone.

When I appealed to the insurance companies, I provided them with a doctor’s report from the Institute of Mental Health, which stated that I was compliant with medication and in full remission. Still, my appeals were rejected. I questioned the discrimination – after all, they could simply provide exclusions for any psychiatric treatment or injuries arising from my condition, for instance, injuries sustained in a failed suicide attempt. Some of the agencies raised the issue of two other minor and common ailments but when challenged, agreed that without bipolar disorder, I would get an IP with exclusions for those ailments. The rejection was blamed squarely on bipolar disorder.

Discrimination forces people to keep fighting for equitable treatment. So, on a friend’s advice, I went to see my MP at a Meet-The-People Session armed with an appeal letter, along with all the rejection letters. I didn’t get to meet my MP but his team of volunteers who looked into my case were very helpful. They said it was unlikely that any of the international agencies would bother about a letter from an MP, and advised focusing on NTUC Income as it was my best chance. I left feeling hopeful because my MP was none other than Minister Chan Chun Sing.

Several weeks later, I received a letter which said this, among the usual official phrases:

“We hope you understand that it is our duty to underwrite each case according to our underwriting guidelines consistently so as to be fair to the others who contribute to the risk pool.”

Please help me understand how I could be at a greater risk than someone who drinks and smokes heavily and may even be obese? Risk of what, exactly?

Followed by this:

“Moving forward, we are willing to assess your coverage in future, when you have fully recovered and have been discharged from your follow up for your bipolar disorder condition without the need for medication.”

Brilliant. The day I am discharged from my follow up, when I no longer need medication, will be the day I die. Bipolar disorder is incurable.

Mental illness has no known comorbidity with physical illness. By rejecting my application and appeals, these insurance companies are deliberately denying me coverage for illnesses such as cancer, heart disease and diabetes, all of which have no relation to my mental state.

I made a random check with the overseas offices of two of the international insurance agencies which rejected my application. All offered critical illness plans for psychiatric patients, though with exclusions. Some plans offered supplementary coverage for psychiatric care. So why exclude psychiatric patients in Singapore? Because they can?

If I could bring Isaac Newton, Beethoven or Charles Dickens back to this future, living in Singapore and requiring an IP, I wonder if these companies would deny them coverage.

I also wonder why NTUC Income thought it fit to use me, specifically my condition, on their first Future Peek campaign, and yet think I am unworthy of their insurance policy. Use my condition for marketing but spit me out when I want to buy an IP. Such hypocrisy.

NTUC Income’s website states “Insurance Made Simple, Made Honest, Made Different” and with great emphasis, “People. First”.  I wonder what they really mean by those claims.

 

Mahita Vas is the author of ‘Praying To The Goddess Of Mercy: A Memoir Of Mood Swings’. She spends her time on advocating mental health issues and pursuing personal interests including reading and writing.

 

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by Danielle Lim

‘I look at him sitting at the table, between the certificates on his left and the ashes on his right, between the past on his left and the present on his right, between success on his left and brokenness on his right, between the hope of a bright future, on his left, and the courage to keep going, on his right. My uncle. An ordinary man. Some would say an unsuccessful man. Many would say, a mad man. But for me, I will remember him with his smile and the small, beautiful sounds he has echoed into my life.’
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TWENTY-FOUR years ago, I looked at my uncle as I wrestled with the predicament that his mental illness had put him, and our family, in. The lines above, taken from my memoir, ‘The Sound of SCH’, depict the struggle to make sense of his life after he developed schizophrenia.

When my uncle had a mental breakdown in the 1960s, my grandparents had no idea that he had become unwell. Even when diagnosed much later, treatment at Woodbridge Hospital (the former Institute of Mental Health) was rejected by my grandmother. My mother became his caregiver for the next thirty years, and I spent my growing years watching the loneliness that defined his life, as well as the despair that the circumstances often brought to my mother.

Awareness, treatment and support are better today than during my uncle’s time. Still, the challenges that come when a person crosses from being mentally well to unwell are very daunting. If a word can be associated with this baffling class of illnesses, then that word, to me, is “silence” – the silent onset of illness, the silent suffering of the one afflicted, and the silent despair that family members endure.

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The Silent Onset of Illness

Unlike many forms of physical illnesses, mental illness cannot be seen. The changes in the brain and mind, while often occurring over a period of time, also often occur insidiously. If cancer is called “the silent killer”, perhaps mental illness can be called “the silent destroyer”.

Diagnosis of mental illnesses can be difficult. Psychiatrists I have spoken to have shared that because the human brain is so complex – with a hundred billion neurons and several hundred thousand synapses per neuron – two people with schizophrenia can present with vastly different behaviours and symptoms. There isn’t a precise “test” that doctors can administer to measure the “level” of mental well-being, unlike how we can take a blood sample to measure levels of cholesterol or haemoglobin.

It is usually through changes in behaviour that family or friends start wondering if something is amiss. Yet the amorphous nature of such illnesses often means that the whole process of ascertaining what exactly is amiss can take a while.

 

The Silent Walk Alone

My uncle’s illness took a long time to be discovered when it struck him in his twenties. His life changed completely – he lost his job and friends, became a sweeper, and spent the next thirty years living a lonely life. Yet, he never complained, and was never violent.

Whilst studies show that around 90 per cent of those with mental illnesses do not become violent, there is a general perception that mental illness is associated with violence. There have been steps forward in how mental illness is viewed and treated, and in how recovering patients are supported in their efforts to reintegrate into society. Even so, it may be difficult for us to imagine what it is like to walk the path of a patient.

A doctor once told me that mental illness is the only illness where suicide rates go up when medication starts becoming effective. Therein lies the irony, that when patients become well enough to realise they have a mental illness, they find it such an unbearable sentence that they would rather end their lives.

Schizophrenia strikes about one in a hundred people. Every day, a child is born in Singapore who will suffer from schizophrenia, and the onset of illness is usually between the ages 15 and 30. In other words, it strikes young. I once had a student who was doing well in her studies but who often missed classes, the reasons for which I was not told. I only found out much later about her struggle with mental illness. She probably did not want the people around her to know of her condition. Sadly, such silence typically surrounds the response to having a mental illness.

I know of many who have recovered and who now lead meaningful lives. Recovery is possible, especially with early treatment, and with support from loved ones and the community. Family members, in turn, need support.

 

The Silent Despair of Loved Ones

As Professor Chong Siow Ann mentions in his article “Mental illness: Caregivers are forgotten collateral damage” (The Straits Times, 29 November 2014), the burden of the illness falls not only on the patient, but also on the caregiver and family members. Treatment and recovery can be a long, difficult and uncertain process. The helplessness, anxiety and caregiver stress of loved ones are often overlooked.

Acceptance of the diagnosis is itself difficult. Perhaps because there is still an entrenched social stigma associated with such illnesses, coming to terms with the diagnosis involves an intense inner struggle. How does one accept that one’s spouse or sibling or child is not “normal” and may be seen as “crazy” or “mad” by people around?

After reading my book, a friend told me that her brother had schizophrenia, and that he took his life years ago. She then said, “Please keep this a secret.”

Organisations such as the Caregivers Alliance have been set up to support caregivers of those with mental illness. Such support can make all the difference in enabling caregivers to push on. Many caregivers themselves become depressed, buckling under the weight they have to carry.

My mother did not have such support as she took care of my uncle for over thirty years. At one point, she had to take anti-depressants. I admire her for what she has done, and I salute all caregivers.

Those with mental illness and their loved ones walk a very difficult path. If we can dispel some of the silence surrounding mental illness, perhaps they can stumble a little less on their journey.

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Danielle Lim is the author of ‘The Sound of SCH: a mental breakdown, a life journey’, a memoir which won the Singapore Literature Prize (non-fiction) 2016.

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This article is part of a series to shed light on mental illnesses. Read the other piece here:

Taking the Myth out of “Mental” Illnesses

 

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by Marcus Tan

“MENTAL” illness, for want of a more accurate and less derogatory adjective that allows us to better conceptualise the nature of these conditions, is as old as mankind.

For much of human history, psychiatric conditions were often considered to have supernatural or paranormal origins. Those afflicted were thought to be under the influence of black magic or possessed by evil spirits. Many treatments before the 17th century were based on occult practices that often led to their recipients in a worse off state. As early as the 8th century, the first psychiatric treatment facilities were set up. However, these institutions served more the purpose of containment or confinement. They offered little more than space to contain persons’ behaviours. Treatment, if any, was empirical by large and seldom based on robust medical evidence.

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Psychiatry, as a discipline in medicine, was proposed in 1808 by Professor Johann Christian Riel, a German physician. The word psychiatry itself derives from the two greek words psyche, meaning soul or mind, and iatros, meaning physician. From then, systematic effort, utilising scientific methods was undertaken to study disorders of human behaviour. This pivotal move heralded the development of modern psychiatry. More humane therapies and focus on public education soon followed.

Despite so, there remains much more to be achieved.

Misconceptions about psychiatric conditions and their treatments continue to abound. These range from notions that people with these conditions are “crazy”, “odd”, “bad” or “weak minded” to them never getting well. Despite advancements in treatment, psychotropic medications and even psychotherapy continue to be very much maligned. Medications do not alter personality or rob a person of his / her identity. Apart from a small handful of situations, one cannot be compelled to receive treatment. Psychotherapy is more than “just talk”. Conversation is but an avenue through which rapport is built so treatment can be effected.


What is Psychiatry?

Psychiatry is one of the most, if not the most, misunderstood fields in Medicine. There are few disciplines that have attracted as much controversy.

Misinformation and the consequent misunderstandings about Psychiatry have resulted in the stigmatisation of its receivers of care, the care providers and its practice. More importantly, this stigma has led to apprehension towards help seeking and delay in treatment. Unnecessary, avoidable prolongation of personal physical and emotional distress aside, the individual’s social and occupational functioning are not spared too. With compromised coping abilities, the person can find him/herself overwhelmed by his/her circumstances. These circumstances can be predisposing, precipitating or perpetuating factors that contribute to the origin(s) of illness, which is often multifactorial.

With the world moving at an ever-accelerating pace, most of us already struggle to keep up and can ill afford “down time”. The individual with lesser than usual functional capacity to cope can find him/herself stranded and lost. Unhealthy compensatory or self-help behaviours e.g. harmful addictions or recreational drug use can occur. These behaviours, while offering short term escape, certainly do not help improve the situation in the longer term. A sense of loss of control ensues and ultimately worsens the distress experienced.

Despite emphasis on early help seeking, it is not uncommon in day-to-day clinical practice to have persons come forth to seek help only after long periods of being ill. By this time, it is not unusual for the individual to find that his/her work, relationships, and life have suffered appreciably. These individuals let on that they perceive themselves as “weak minded” and feel shame or even become guilt-ridden in their help seeking. It should not have to be so.

Being distressed is not a sign of weakness. As it has been aptly put, distress occurs only when one has been too strong for too long a time. Only when one has put in his/her best effort, can he/her become exhausted.

Occasional media reporting that sensationalises public displays of behavioural aberrations or suggests an association between criminal or offensive acts and psychiatric conditions do not help. While it is convenient to attribute these behaviours or acts to psychiatric conditions, in reality, these are more related to poorly controlled or untreated symptoms, which arise out of delay in seeking treatment, if there indeed is a presence of an illness in these cases. Ironically, it is not the condition, but the lack of treatment that has led to the outcome. Suffice to say, this misinformation that leads to wrongful association must stop.

Modern Psychiatry

With the advent of technological advances in the 20th  and 21st centuries, physicians have been able to achieve a clearer understanding of the disease process behind some psychiatric conditions and the complex interactions between an individual’s environment and innate factors that result in symptom production. These advances, which include higher resolution brain scans and functional imaging, have also aided the development of medical therapies, while far from ideal, that are safer, more targeted and effective.

At present, it is agreed that a combination of medical, psychological and social therapies are indicated for the treatment of most psychiatric conditions to achieve the best outcomes.

Hence, how do we define modern psychiatry?

Psychiatry is the branch of medicine which is concerned with the understanding, assessment, diagnosis, treatment and prevention of disorders of emotions, behaviour, perceptions and thinking. These disorders predominantly present with behavioural symptoms that occur due to a complex interaction of biological, psychological and social factors. It should not be construed simply as a disease of the mind and/or brain. Treatment is tailored and focused on the person, at times the significant others, within the context of their environment.

We hope that through the course of this series, we can help provide insight into the work healthcare workers do for psychiatric conditions, how assessment is carried out and common psychiatric conditions and their treatments. It is hoped that this information will help bring about better understanding of Psychiatry and promote prompt help seeking. Perhaps you will find out too that psychiatric conditions are not so different from other medical conditions managed by our colleagues in other disciplines.

 

Dr Marcus Tan is a psychiatrist with 18 years of experience in clinical practice in both public and private healthcare. Together with his partners, he runs Singapore’s longest standing community private psychiatric clinic in the heartlands. He also volunteers with the Singapore Armed Forces and serves as a medical assessor on the Medical Board of the Civil Aviation Authority of Singapore. He believes strongly in mental health literacy and sees it as key to improving awareness and decreasing stigma towards psychiatric conditions and persons with them. 

 

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by Wan Ting Koh

COULD you forgive a family member who takes the life of another loved one? A son who rapes his own mother? Parents who torture their own children?

With the recent spate of family crimes in the news, we spoke to psychiatrists on how individuals might cope when faced with the traumatic situation of a loved one harming another. They said that there’s a whole web of emotions involved: Guilt, shame and self-blame for failing to protect a loved one or for not sounding the alarm earlier. The road to recovery is long, and talking about it is the first step to feeling better.

The most recent report of such crimes – a three-month-old baby was allegedly smothered by her father during her feeding time in October last year. Mr Mohamed Shiddiq Sazali, 27, was feeding baby Reyhana Qailah with one hand while playing a mobile phone game with another.

He was reportedly so absorbed in the game that he failed to notice Reyhana thrashing about for some two minutes, apparently choking on the milk.

He was reportedly so absorbed in the game that he failed to notice Reyhana thrashing about for some two minutes, apparently choking on the milk.

He only realised that Reyhana’s body was pale and motionless after his father-in-law entered the room and noticed something was wrong. Reyhana’s mother, Madam Nurraishah Mahzan, 31, rushed home after receiving a text from her husband, but she too failed to resuscitate her child. The final cause of death report mentioned smothering or suffocation and choking on milk as possible causes of Reyhana’s death.

When such horrific things happen, how does the family deal with it?

To say that grief would be “normal”, or even the sole emotion would be inaccurate, said Dr Lim Boon Leng, a psychiatrist at Gleneagles Hospital, who added that a family member who is related to both the victim and the perpetrator would feel a more “exaggerated” form of grief.

This may cause an extended period of depression, as compared to when a family member dies of natural causes.

Then, there are the other emotions: Anger, disappointment, and disbelief at the involvement of another loved one. This may make it hard for the individual to reconcile him or her to the incident.

Dr Brian Yeo, a consultant psychiatrist in a private practice at Mount Elizabeth Medical Centre, said that family members of the victim and the perpetrator will feel guilt and self-blame primarily, especially if they see themselves as the supposed protector of the individual.

“[They will ask themselves] ‘How come I didn’t see this coming, and how come I didn’t take action to protect the people I love?'” said Dr Yeo.

“[They will ask themselves] ‘How come I didn’t see this coming, and how come I didn’t take action to protect the people I love?'”

Dr Yeo noted that such an incident in the family would also call into question the parents’ parenting capabilities if they had other children: “Parents would question whether they are competent and able to take on the responsibility of looking after the surviving children.” In Reyhana’s case, it wasn’t reported whether she had siblings.

The fact that the identities of Reyhana’s parents were disclosed to the public may well worsen situation at home. According to Dr Yeo, family members would have to deal with the stigma on several levels. “All your relatives will be talking about it. It affects how society sees you, your colleagues, your extended family and how you see yourself,” said Mr Yeo.

Not to mention the legal intervention, such as police investigations and social workers who are involved. However, it is the exposure to the public that is “more devastating”, said Dr Yeo. It is this disclosure that allows “the public, neighbours, family members to effectively know and pass judgement”, he added.

 

Other factors to consider

Age was another factor when assessing the extent of the impact on other children in the family.

Children, said Dr Lim, tend to be “more egocentric”, so they blame themselves more. Adults on the other hand, have a “better understanding of the attribution of guilt”, he said.

And then there are the children who grow up in an abusive environment, such as in the case of two-year-old Mohamad Daniel Mohamad Nasser, who was repeatedly kicked, slapped and pinched by his biological mother and her boyfriend for 25 days over a 35-day period.

That wasn’t the only thing that his mother, Zaidah, 41, who goes by one name, and her boyfriend, Zaini Jamari, 46, did. They also made Daniel stand with his hands on his head while wearing only a nappy and forced him to eat spoonfuls of dried chilli.

Their abuse finally culminated in little Daniel’s death, on Nov 23, last year. The morning after a horrific day of torture inflicted by Zaidah and Zaini, Daniel remained motionless. He never woke up.

An autopsy later found a total of 41 external injuries on Daniel’s small body. The duo responsible for the act were charged earlier this month, with Zaidah given 11 years’ jail, and Zaini ten years’ jail and 12 strokes of the cane on July 5.

But Daniel wasn’t Zaidah’s only child. The cleaner, who was pregnant at the time of her abuse, has five other children. All of whom might potentially be more vulnerable to anxiety, depression or feelings of trauma if they grew up in the same environment Daniel, or if they witness the incident, said Dr Lim.

Daniel’s biological father, Mr Mohamad Nasser Abdul Gani, 42, had lost contact with his son and his ex-wife, Zaidah, after a prison stint for drug offences. The heartbroken father said in an interview with The New Paper that he blamed himself for not protecting his son. Said Mr Nasser, who works as a cleaner: “If I could turn back time, I would stay away from drugs, then maybe Daniel would still be here.”

“Instead, I was not there when he was born. I could not be the father he needed to protect him.”

Another case involving a young victim at the hands of her parents made the papers at the end of last month. The perpetrator was a 43-year-old security guard, and the victim? His 12-year-old daughter, whom he molested over a period of ten months in 2014.

The father would wait till his family was asleep or the house was empty before sending text messages to his daughter to go to his room, where he would grope her. After her mother, who was living apart from the family, found out, she confronted her estranged husband. On June 30 this year, the guilty father was sentenced to four years and three months in jail and five strokes of the cane.

Dr Yeo pointed out that for such cases in general, the question is whether the mother believes the child or the husband’s version of events. Either choice would have its own set of consequences. If the mother chose to believe her child, she would have to file a police report which would not only destroy the family, but affect the family finances, especially if the father is the main or sole breadwinner, said Dr Yeo. “Once you start it is not easy to turn back.”

 

No one saw it coming

As to how other family members can cope with the incident, Dr Yeo said that one of the factors is the “intent” of the perpetrator. The main thing would be to subject the perpetrator to a psychiatric evaluation to find a possible motive behind the crime. For the case of a son, who went on trial earlier this month for allegedly raping his mother for example, assessing the son will be a priority.

The 33-year-old man was accused of raping and molesting his biological mother, 56, at their home, where he allegedly restrained her while kissing her breast and forced her to touch him sexually. The incident occurred at the victim’s one-room flat in October 2013, while she was sleeping. Her son returned in the wee hours of the morning and, according to the prosecution, “molested and raped his own mother despite her pleas for him to stop” while her husband, the man’s stepfather, was out.

Said Dr Yeo of the possible impact on the father: “If it is due to a mental disorder, it’s easier for the father to see that… there is an explanation and there is some sort of redress physically and psychologically.”

He added: “If on the other hand the son has always harbored such lustful intent towards the mother, then the father may suffer a bigger portion of the guilt because it’s something that he had some sort of inkling may happen, and he did nothing to prevent it.” If his son had been “plotting or planning” the act for a while, then the father would have a “higher moral duty to act”, said Dr Yeo.

“If on the other hand the son has always harbored such lustful intent towards the mother, then the father may suffer a bigger portion of the guilt because it’s something that he had some sort of inkling may happen, and he did nothing to prevent it.”

Same goes to the son who allegedly caused the death of his father after putting him in a fatal headlock and causing him to suffer a cardiac arrest in February last year. Mark Tan Peng Liat, originally charged with murder, is currently on trial for culpable homicide not amounting to murder. The victim’s elder sister, Madam Tan Hoon Choo, 72, took the stand on the first day of the trial (July 7) to testify that she was at home when her brother’s maid, Ms Sumarti Dwi Ambarwati, came to her house in tears, saying that the Mark and his father, Mr Tan Kok Keng, 67, were fighting.

By the time she reached the semi-detached house at West Coast Rise, which was two minutes away from her own, it was too late. Her nephew, a 30-year-old businessman, was standing outside, looking unlike his usual self. Madam Tan said: “His face was pale. He looked very bewildered and lost. I gave him a hug… I had a grim feeling.” She entered the house and found her brother lying on the floor of the second-storey master bedroom. The elder Tan was later taken to the hospital where he was pronounced dead.

No one saw the incident coming. Not the aunt, who described father and son as having “a very good relationship”. Not Mark’s mother, who reportedly broke down in court after her son was charged and said: “What do you expect me to do? Kill my son?”

“It is a confusing and frustrating event, generally you don’t think such things will happen. It is not as if this is a drug user and you fear he will go back to drugs again. These things are much rarer, you wont expect it to happen unless he has prior knowledge that it has happened before,” said Dr Yeo.

“It is a confusing and frustrating event, generally you don’t think such things will happen… These things are much rarer, you wont expect it to happen unless he has prior knowledge that it has happened before.”

The fact that it happened within a close-knit family also makes it difficult to talk about. Said Dr Yeo: “You cannot really talk to other family members because this is going to be so shameful.”

 

The road to recovery

But talking also happens to be the first step towards recovery.

When asked how family members may cope with traumatising events, Dr Lim said that one of the best ways best ways to get over it is “really to talk about it”.

“A lot of people will try to deny this has happened…sometimes in their grief their first stage is denial, so the best thing is to keep talking about it so that the brain can process the whole event,” said Dr Lim. He added that the afflicted individual needs to talk to someone who can not only assess the grief but guide him along on the process.

“A lot of people will try to deny this has happened…sometimes in their grief their first stage is denial, so the best thing is to keep talking about it so that the brain can process the whole event.”

This was how Ms Leela Jesudason coped after the death of her sister at the hands of her nephew in a 2012 case which made the papers last July. Her nephew, Sujay Solomon Sutherson, who was diagnosed with paranoia schizophrenia, had brutally attacked his mother, Ms Jesudason’s sister, with knives, then hid her body under his bed.

“For me the way I cope is to be active. And to do something positive. I started a charity called PSALT Care, with the intention of giving support to families of those who have mentally ill at home, and also support groups for the mentally ill as well. For me, coping is to go round doing these kinds of things,” said Ms Jesudason.

Her first reaction, when she got the phone call in London from her sister-in-law about the incident, was incredulity. Then came the uncontrollable crying. Learning that her nephew was the one who did the deed only intensified her grief. However Ms Jesudason, 50, said that she felt no anger or resentment at her nephew. Only pity.

“I was sad not just for her but for him too because I knew that this is not going to go well for him either. His life is also over in that sense,” said Ms Jesudason. The first thing she did upon returning to Singapore was to engage a lawyer for her 35-year-old nephew, who was later sentenced to life imprisonment.

Said Ms Jesudason: “I don’t blame him. I blame a system that doesn’t enforce medication, because we had spoken to several doctors about him being off his meds, but there didn’t seem to be much concern on their part…he was throwing the tablets away.”

However Ms Jesudason cannot come to terms with her sister’s sudden departure. Nor did knowing that her nephew suffered from a mental disorder make the incident any more acceptable. “I think the sudden departure of somebody that you are close to, it’s very hard to say this could have lessened it, I don’t think so,” said the director of a public relations firm.

When asked whether she blamed herself in any way for the incident, Ms Jesudason said that she felt she “should have pushed a bit harder.”

“My sister was not the sort who would pick up the battle cry. She was a much more placid person than me, I feel like I should have taken up the mantle and gone to see the doctors,” said Ms Jesudason.

“I feel like I should have done more. I don’t know what more is, or could have been. But I should have done more.”

“I feel like I should have done more. I don’t know what more is, or could have been. But I should have done more.”

 

Featured Image by Natassya Diana Siregar

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Watch, 08:30

GOOD morning! News from the Singapore society and its people make the headlines this morning.

Singapore is the OCD – or obsessive compulsive disorders – capital of the world, according to the first and only Mental Health Study released in 2011 by the Institute of Mental Health (IMH), which found that one in 33 people in this country are suffering from it. And these comparatively higher rates of the mental illness have continued to rise, even if the numbers are not necessarily complete, because many remain undiagnosed or do not seek treatment. ST added that as of November last year, 850 adults were treated at the IMH, an increase from the 640 adults in 2010.

Through anecdotes, the report further stressed the roles of IMH psychologists and charity counsellors – as well as family members – when helping patients with OCD.

Help is also given to youth volunteers in the community, who come from households with a per capita income of less than $2,000. Sovereign wealth fund GIC, through its GIC Sparks and Smiles scheme, is offering cash grants of $3,000 to $5,000 to these youths for 25 hours of community service, with 48 university students benefiting thus far. Mr. Gerald Ee – executive director of Beyond Social Services, one of the charities hosting these student-volunteers – said: “What’s special about this programme is that it bridges these young people … to contacts at GIC and people who will be useful for them in their careers going forward, but … also bridges them to parts of society that they will generally not have much contact with.”

In addition, along this tangent of charities and charitable giving, the National Volunteer and Philanthropy Centre (NVPC) announced that its “Giving Week” initiative in the first week of December 2015 – which aims to motivate Singaporeans to give back to the community – raised 24 per cent more money, with a sum of $751,822, compared to the same period in 2014. Money was raised through the new NVPC Giving.sg portal, which is expected to benefit more than 350 charities in Singapore.

And moving to public housing, two-thirds of singles now make successful applications for Build-To-Order (BTO) flats. Zaobao reported that after the Housing and Development Board (HDB) relaxed restrictions for singles in July 2013, 7,700 of the 11,600 invited to book new flats have done so, and 700 have already collected their keys to their new homes. ST added that while 57.5 singles applied for each BTO unit in July 2013, the number has fallen to 7.5 in November last year. It “will continue to monitor this group of homebuyers and calibrate its supply of two-rooms flats,” the HDB said.

Finally, those wishing for a nostalgic blast from the past should look out for the “Be My Movie Kaki” bus by the People’s Association, which will travel around the island for outdoor movie screenings. Both ST and Zaobao made reference to the kampung spirit of the past, further alluding to the Jurong open-air movie experience and gatherings at community centres to watch television shows. Hundreds of residents turned up in Ang Mo Kio for a screening last evening.

 

Featured image by Chong Yew. 

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by Wan Ting Koh

HAVE you ever accused a fussy person of being “OCD”? To most of us, the term “Obsessive-compulsive disorder” (OCD) is one that we simply throw at that friend who straightens his books obsessively or the colleague who scrubs at her table religiously everyday. You might want to be more judicious about the term because OCD can actually be a serious psychiatry condition that requires treatment.

It’s an anxiety disorder characterized by uncontrollable, unwanted thoughts which may sometimes result in repetitive, ritualized behaviors the person feels compelled to perform. Plagued by distressing images, the person might create “rituals”, such as counting backwards, to distract them from the images. Somehow, the rituals make them feel calmer.

According to a 2010 study done by the Institute of Mental Health (IMH), OCD emerged as one of the top three most common disorders in Singapore together with major depressive disorder and alcohol abuse. The Singapore Mental Health Study showed that one in 32 people suffered from OCD at some point in their lifetime.

However, a more recent study done on 3,000 people and released by the IMH in October this year showed that OCD was relatively less well-recognised as compared to other mental illnesses in Singapore. The study, called The Mind Matters: A Study of Mental Health Literacy, obtained information on people’s recognition and beliefs about five common mental disorders – alcohol abuse, dementia, major depressive disorder, OCD and schizophrenia – and found that across the five disorders, recognition was relatively poorer for OCD, at 28.7 per cent. Recognition was highest for dementia (66.3 per cent), followed by alcohol abuse (57.1 per cent) and major depressive disorder (55.2 per cent). Schizophrenia was at the bottom of the list at 11.5 per cent.

In the recent case of the allegedly mistreated maid, Ms Thelma Oyasan Gawidan, 40, the court was told that her employer Chong Sui Foon was suffering from OCD, hence Thelma would be asked to shower in a public toilet since it would take ages for Chong to clean the toilet every time she showered.

Such cases are the more common forms of OCD, according to three psychiatrists we spoke to. In addition to obsessive cleaning, checking and re-checking and collecting or hoarding are two of the other most common symptoms of OCD encountered.

So how do you differentiate a true sufferer from one who is merely a perfectionist at heart?

According to psychiatrist Lim Boon Leng, who owns a private practice Dr BL Lim Centre for Psychological Wellness, the line between a perfectionist and a person suffering from OCD is “not difficult to draw”. OCD is a condition acquired over time and is “episodic in nature” as it affects patients who were originally fine. On the other hand, perfectionists are born.

A perfectionist might even enjoy washing his hands or tidying his room everyday as the ritual would award him satisfaction, whereas the same behaviour would be distressing to an OCD patient. “A person suffering from OCD finds his thoughts intrusive and feels distressed by them,” said Dr Lim.

OCD could be caused by multiple factors, he added. There could be a combination of biological causes – a lack of seratonin in the brain or a dysfunctional neuro-transmitter – and external factors such as stress from the environment. In some cases, OCD is also hereditary.

Many of the patients he has encountered developed the condition when they were around nine or 10 years old. And though the condition could be a passing phase, more often than not, it would last for years, becoming a chronic condition that worsens without treatment.

Unlike Dr Lim, Dr Brian Yeo, a consultant psychiatrist at Brian Yeo Clinic Psychiatric Consultancy, doesn’t think it is as easy to draw the line between a perfectionist and someone with OCD. In fact, Dr Yeo thinks that perfectionists are more prone to tipping over to OCD behaviour. The main difference: For someone to suffer from OCD, there “must be a disturbance in his everyday life”.

He described the recurring images in an OCD patient’s mind as akin to a “brain full of spam messages”.  “It interferes with daily functions and thoughts to the extent that they cannot meet appointments, they lose out in their jobs, and their families are affected,” he said.

One of the more serious cases Dr Lim Boon Leng has encountered was a patient who became mostly bed-bound due to his fear of contamination. Getting out of bed was a problem as he could only climb out in a particular manner, so he would just remain in bed. But even in bed, the patient refused to turn left or right for fear of coming into contact with contaminated areas. Showering was also a painful process for the patient who would scrub his skin raw and use a copious amount of soap.

Dr Lionel Lim, a psychiatrist at his own practice L.P. Clinic, said that one way to identify whether an action is compulsive is through social norms. For example, a “normal” person would take less than a minute to wash their hands after going to the toilet. So if you take up to 10 minutes to wash your hands each time, there’s a likelier chance that you’re suffering from OCD. One patient he treated even chalked up a monthly water bill of $100 to $200 in a household of two, simply because he washed so much.

“People do not recognise the importance of getting help…your marital, interpersonal and familial relationships can all be affected. I have known those that have their marriages broken up or their family structures destroyed,” he said.

He recalled meeting a man whose wife had OCD just two days ago. Working from 9am to 9pm daily, his wife would be “the first to arrive and last to leave office” due to her compulsion to check through her work multiple times. Apart from making her inefficient at her work, it took away precious time that could have been spent with the family. Even upon reaching home, the wife would start cleaning the house till the moment she fell asleep, leaving no time for her husband and child – and the cycle would be repeated the following day.

“I’ve met a young lady who doesn’t want to go home because of her mother’s OCD. The moment she steps into the house, her mother would ask her to change clothes and bathe. Once she enters her room, she cannot come out anymore, as her mother would keep cleaning after her. Now she just stays out until night after her mother is in bed or one, two hours before her mother goes back to sleep so as to minimize contact.” – Dr Lionel Lim.

Because OCD is a biological as well as a behavioral condition, psychiatrists said that it can be treated by a combination of medication, such as anti-depressants, and cognitive behavioral therapy or exposure therapy, where the patient is gradually exposed to his object of fear, in order to desensitize him.

So next time, when you feel compelled to level the OCD label on someone, don’t.

*Coming up next on The Middle Ground – How much does a mental illness help your case in court?