Issue link: https://maltatoday.uberflip.com/i/1185664
17 maltatoday | SUNDAY • 17 NOVEMBER 2019 INTERVIEW 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 complete- ly; 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 pa- tients 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 liv- ing 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 con- tractual 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 pos- sible. 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 ac- tive 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, howev- er, 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 sui- cide the following year. So you can't say, 'Oh well, all this per- son 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 in- dication 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 be- cause their attempts are more successful. This is because males tend to use methods which are more lethal. With self-harm, the vast ma- jority 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 phe- nomenon 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, con- ditions such as anorexia and bulimia overwhelmingly affect- ed women more than men: pri- marily because the root cause is a concern with physical appear- ance. 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, float- ing 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 prob- lems, and to improve the treat- ment of such conditions, will help. What we really need to do is provide better mental health- care, 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 sui- cide; but post-natal depression is a possible cause of suicide or self-harm; so that would also have the effect of reducing psy- chological 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-year- ly examination was removed, for example. But my concern is that even those areas that are supposed to be more re- laxed – such as sports – are now also being turned into an exam-based model. You now see small children terrified be- cause 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, be- come stressful. So yes, I con- sider 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 depres- sion, as an example. If the de- pression occurs in the context of problems at work… and you only use the biological (medi- cation) approach, leaving out the psychological and social dimensions… it would be inef- fective. 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, be- come essential when the condi- tion is severe, and there is a bio- logical element involved. Then, it becomes not just important, but essential to resort to medi- cal treatment. In a way, this is why over-pre- scription 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 pa- tient 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 patholo- gies 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 ill- ness. 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 psycho- logical condition, under certain circumstances. But some are more resilient than others. PHOTOGRAPHY JAMES BIANCHI