The cleaving of the mind, indeed, a fearful thought. How would it feel if once there was unison and integration and now there is only confusion and fear from an overwhelming flood of stimuli? Thought then emerges as sound-like balls upon a floor, bouncing, endlessly, in a manner that carries no coherent meaning. Fearful, indeed.
Mental illness collectively pertains to a group of disorders that arise from the brain and are expressed through the mind. The mystery associated with mental illness is attributable to several factors.
Firstly, the presenting symptoms of most mental illnesses are not concrete manifestations of traditional illness. In most instances there are no observable bodily changes. There is nothing to palpate or auscultate. There are no laboratory tests to affirm the diagnosis. Psychiatrists are expected to make a diagnosis based on a thorough history, observation of behavior, and conduct of a mental status examination. While this is possible in the context of a dyadic doctor-patient relationship, the acuity of the diagnosis is further enhanced in the doctor-patient-caregiver triad. Psychiatrists, therefore, diagnose mental illness best by looking at a patient's life, their relationships, and their motivations from a triadic and longitudinal perspective.
Secondly, mental illness affects a person's thoughts and feelings. These are the core factors that define a person's capacity to negotiate life and relationships. The symptoms are observed as changes in behavior relative to patterns established prior to the illness. These changes can be acute or episodic, associated with definite stressors or may be ill-defined and gradual in development. Psychiatric diagnosis is therefore borne out of knowing the person of the patient and interpreting the observable symptoms within their specific context.
Based on these premises, all mental illnesses affect the very essence of being human and are thus potentially devastating. Yet none is more feared than the psychotic disorders, specifically schizophrenia.
Schizophrenia, tagged as the "cancer of psychiatry," is probably the most puzzling of all the mental illnesses. The estimated prevalence rate worldwide is one percent. In the epidemiologic survey conducted by Perlas et al. in Western Visayas, the estimated local prevalence rate of psychotic illness among adults was 4.3 percent. If this were applied to our population, approximately two million Filipinos are afflicted with the illness.
The symptoms of schizophrenia probably best represent mental illness to most laymen. It is characterized by marked behavior changes. The spectrum of psychotic behavior can extend from quiet, social withdrawal to aggressive, assaultive behavior. There can be paucity of speech, or incoherence, as thought processes become more disorganized. Poor hygiene and self-care may also be observed, and can certainly be disconcerting to those who relate with the person with schizophrenia.
Local interpretations of psychotic symptoms extend from
sumpong, which pertains to the phase of quiet, social withdrawal, and may even include the irritability, which some patients manifest in the early phase of the illness. Using the paradigm of
sumpong, the prodromal symptoms of schizophrenia are understood as slight deviations from the patient's normal behavior, but are still acceptable. The fearful and aggressive symptoms that later develop are commonly described as
praning, a local slang for paranoid. Most people will attribute this to illicit drug use or recidivist behavior, but may not directly relate it to mental illness all at once. The terms
buwang, luko-luko, or sira actually refer to the florid psychotic symptoms of disorganized speech and behavior. At the other extreme, totally bizarre and unexplained behavior changes may be termed as
nasasapian or a state of being possessed. All of these words translate to one syndrome-schizophrenia.
The varieties of terms, which have evolved, reflect the local explanatory models used to understand mental illness. These have direct implications on the management of the illness and how patients and their families eventually choose among available therapeutic options.
The global trend in schizophrenia management espouses the illness model. As such, pharmacologic agents serve as the cornerstone of treatment. The market is deluged with antipsychotics that are of comparable efficacy but differ widely in safety, tolerability, and affordability. Discussions with patients and relatives must include an explanation of the effects of these medications and the side effects they eventually cause. The newer antipsychotics, collectively called atypical antipsychotics, are generally more expensive but boast of significantly less extrapyramidal symptoms and better cognitive function. While they do elicit other side effects, the atypicals give patients new hope. This has also resulted in improved adjustments and quality of life both for patients and caregivers.
The other cornerstone in schizophrenia management is psychosocial rehabilitation. With the improvement in general brain function, patients now need assistance to reintegrate to society. This may include occupational rehabilitation and practical support in conducting their day-to-day lives. The effective control of symptoms refocuses attention to the concomitant disability from the illness.
It is unfortunate, however, that the illness model is not a prominent concept in the local explanatory models of schizophrenia. If schizophrenia is not commonly perceived as an illness, then medication and hospitalization are irrelevant treatment options.
Bakit gagamutin ang isang taong wala namang sakit? It is not surprising then that patients are brought to traditional healers and herbolarios before they are brought to psychiatrists.
The treatment-seeking behavior for mentally ill patients have a lag time of at least two years between the onset of symptoms and the actual consultation with a health-care worker. The local concept of
sumpong can partially explain why families are able to tolerate the early behavior changes. Help is generally not sought until the bizarre and assaultive behavior is manifested. When this happens, the concept of
nasasapian becomes more prominent. Thus the traditional healer and the herbolarios are first on call. There are instances, however, when the paradigm of hopelessness comes in-the
luko-luko or the buwang model is used to explain the persistence or symptoms and its unexplained fluctuations through the years. At this point, caregivers may feel a sense of helplessness and start searching for better answers. A common knee-jerk reaction at the point of desperation is to bring the patient to a mental institution where treatment can be had in the safety of an enclosed environment. The illness model is therefore thought of at a later stage of the illness. And the question families ask is "where can they bring the patient for treatment?"
In a nation of 79 million, there are 355 registered psychiatrists mostly clustered in Metro Manila. Of the 16 regional hospitals, only 10 have inpatient psychiatric
beds. None of the 12 city hospitals around the country offer any form of mental health service. Of the total hospital beds in the country, only one percent is available for the mentally ill and this is dismally distributed-the Metro Manila-based National Center for Mental Health provides 67 percent of this total capacity.
The current challenge is in bridging the gap between demand and supply. Introducing the illness model as a paradigm for understanding schizophrenia and the other mental illnesses will create a demand for mental health resources. These resources are generally inaccessible because they are few and are clustered in metropolitan areas. The quality of services also varies widely. Improving the infrastructure for mental health services is probably a more prudent first step. Considering the budget-strapped economy and the low priority given to health in the political and financial agenda, the solutions must therefore be creative and practical.
One, existing health-care facilities must be developed to include mental health care in their available services. Case finding and early detection should be part of the mandate of local chief executives who have the responsibility and authority over municipal health units.
Two, training of nonmedical health workers and nonpsychiatrist physicians must include the promotion of mental health, early diagnosis, and emergency measures that they themselves can undertake in the absence of a psychiatrist.
Three, existing health infrastructure must allot a reasonable percentage of its resources for the care of the mentally ill with acute symptoms. Emphasis is placed on inpatient care only for those who are acutely ill because this is the phase in the illness where structure and limit setting are essential to prevent further morbidity. After the acute and agitated phase, patients can be brought home to initiate the process of social reintegration. Establishing a network of facilities where patients can be treated appropriately at various stages of the illness is necessary to ensure efficient community based mental health care.
Four, psychiatrists need to rethink their own roles in a nation such as ours. Where the illness model is not widely accepted, a clinical solution is an inappropriate first step. Psychiatrists must be advocates for mental health; teachers to nonmedical health workers and nonpsychiatrist physicians; researchers who will provide more answers to a long list of questions; leaders who will beat the drums for the cause of stakeholders handicapped by the scourge of mental illness-all these more than being clinicians.
Five, the caretakers of our nation must take the issue of health to heart. No nation will ever achieve economic development if half its population are young, four percent of its adults are potentially mentally ill, with another four percent saddled with taking care of those who are sick. Add to this the 1.6 percent who may have bipolar illness and 14.3 percent who suffer from many forms of anxiety and 5.6 percent who are debilitated by panic disorder. While these figures are based on the Western Visayas epidemiologic study and may be argued as not applicable to the nation, they are the only figures we have that hit closest to home. The numbers speak for themselves. It is not a mystery then that our nation's trek to development is cleaved.
