Issue link: https://maltatoday.uberflip.com/i/1055420
17 maltatoday | SUNDAY • 25 NOVEMBER 2018 INTERVIEW a growing global awareness. There is also more organisation than ever before: more mental health charities, NGOs, sup- port groups, etc. Having said this: when it comes to stigma, it is still a battle we face on a day-to-day basis. It may not take the same form as it used to in the past, but it still exists… in the form of minimising the severity of certain conditions, for instance. The way we flip- pantly use terms such as 'OCD' (Obsessive Compulsive Disor- der)… as though it's 'cool' to have OCD, when it very em- phatically is not. OCD can be a very debilitating illness. But there is also stigma in other areas: how people perceive Mount Carmel Hospital, for instance... NC: There is a world-wide stigma, but in Malta – while there is definitely still a lot of stigma associated with the place where we work – there is also a level of professional stig- ma. Even the way psychiatrists are looked at: we don't work within a medical service; we work alone, on the outside… in an outdated hospital in Attard. The fact that mental health has been ignored for so many years, by so many different adminis- trations, indicates that mental health is still something we don't really want to talk about. These are issues that were highlighted – albeit indirectly – in the MAP report, which pinpoints staff shortages and a general state of neglect in the mental health sector. For example, Malta currently has 26 psychiatrists; your report suggests there should be a minimum of 50… NC: There are 26 qualified psychiatrists, but only 15 of them are consultants. The rest have not been given a post. So in practical terms, we are work- ing with 15… Does this reflect a poor uptake of psychiatry students, though? Is it because not enough people choose to specialise in psychiatry in the first place? NC: No. There are 26 quali- fied psychiatrists, and another 20 trainees… so within five years, we will have the num- bers. And there are several Maltese psychiatrists working abroad: when I worked in the north-east of England, there were more Maltese child psy- chiatrists working at the hospi- tal than there are in Malta right now. But it's not just about psychiatrists. Each psychiatrist also needs a multidisciplinary team: occupational therapists; social workers; nurses and so on… If I'm understanding correctly, then, it is our general approach to the mental health sector that is the problem… STE: To be fair, psychiatry has always been the Cinderella of medicine: not just in Malta, but everywhere in the world. And there is no such thing as a 'perfect' department: all de- partments at Mater Dei have their own issues and shortcom- ings. But it remains a fact that mental healthcare in Malta, is nowhere near the same level as physical healthcare… NC: If you compare the num- ber of physical health consult- ants at Mater Dei to the rest of Europe, you'll find that the numbers are the same. Pro- portionally, there are as many cardiologists – to mention one example – as the rest of Europe. The same cannot be said for psychiatry. We're at a much lower level. After this re- port, we can thank the Health Ministry for creating one new consultancy post in child psy- chiatry. We welcome that re- action, but we also need to be clear that one post is not going to make a difference. To make a difference, we need to have a significant increase in num- bers. Also, the 26 existing con- sultancy posts are only availa- ble for two days a week… when there should be availability all week round. The same report also indicates that, while psychiatrists and psychologists are in short supply, the number of nurses at Mount Carmel is on a par with European levels. Are these nurses specially trained to deal with mental health issues? STE: Not all nurses who work at Mount Carmel are psychi- atric nurses. A few are trained therapists, but many receive no specific training in psychiatry. Unfortunately, we also have trained psychiatric nurses who, for whatever reason, work in other health departments, not in psychiatry. Having said that: there are some very good gen- eral nurses who work in mental health. NC: One must also point out that the Malta Association of Psychiatric Nurses does an ex- cellent job, too. However, the general role of nurses in mental health is something that needs to worked on. The fact remains that many nurses at Mount Carmel do clerical work… that is not going to help. It has been argued (internationally, at least) that even the idea of having a 'mental hospital' – isolated from other health sectors – is itself old-fashioned. Should we be moving to a situation where mental issues are treated at Mater Dei hospital, like any other health issue? STE: The government has already approached us to dis- cuss a National Mental Health Strategy, and I believe the first draft will be launched at the beginning of December. Obvi- ously, we look forward to see- ing what it proposes. What we do know, however, is that gov- ernment has talked about the development of a new Acute Psychiatric Hospital: which we welcome, because we be- lieve that Mount Carmel has gone far beyond what it can realistically do, and needs to be changed. We also believe that psychiatry should be linked to physical illness; that it should be on the same footprint as physical healthcare. In the same way as the new oncol- ogy hospital was built on the premises of Mater Dei, the new psychiatric hospital should also be physically connected to the general hospital. NC: But it is important to stress that an Acute Psychiat- ric Hospital, while needed, is only a 'full-stop' in the sentence of mental health; it is the end phase of a process. So yes, we welcome the initiative to build a new hospital… but what we need before that, is to build up and strengthen a community care system. Malta is divided into nine regions; currently, only five are covered. The available manpower is already severely stretched. So we need to have a community service that meets people's needs with- in the community itself; that acts as a gate-keeper, to pre- vent illness from becoming se- rious enough to require treat- ment at a hospital. As things stand, a significant percentage of admissions to Mount Car- mel – I don't have actual fig- ures, but I would guess maybe 30-50% – are not because of mental health issues. They are inappropriate admissions. So, we clearly don't have a proper gatekeeping system in place. Given that people are generally more aware of mental health issues, and might be able to recognise symptoms of dementia, depression, and other widespread conditions… what proportion of mental illness can realistically be treated 'at home', so to speak, without referring to a psychiatric hospital? STE: I can't put a precise number to that, if that's what you mean; but I would say the answer is 'almost all'… NC: [nodding] Nearly all cases can effectively be treat- ed within the community. To give an example: in Malta, the national mental health budget works out at 95% inpatients, 5% outpatients. In the UK, it is 97% outpatients, 3% inpa- tients… in other words, 97% of the investment in mental health goes towards services provided within the commu- nity, not at psychiatric hospi- tals. So yes, most mental illness can be – and already is, in other countries – treated at home. In Malta, however, it is the other way round…. Last question: what are your expectations, in the wake of this report? What sort of response are you hoping to see? STE: We hope to be active participants in the discussion on a new National Mental Health Strategy; and it would be good to also see the develop- ment of a patient lobby-group, and for patients to be more ac- tively involved in the any men- tal health service development. We would also like to see the active creation of more con- sultant posts that are necessary within the existing service; and also, while we're already dis- cussing a new hospital, we need to start preparing the spade- work and lay the foundations for a proper community service that supports the new hospital. NC: Ultimately, we feel that the mental health sector is not advancing at the pace it should, given the way physical wealth and social wellbeing are on the increase in our country. At the moment, Malta is doing well economically. We need to match that progress with advances in our mental health systems. Sasha Taylor East (below) photographed by James Bianchi, and (inset) Nigel Camilleri