Up to October 10 every year, local and international media will often mention mental health and well-being in the run-up to World Mental Health Day. From October 11, 2016, attention to mental health issues will dwindle but mental ill-health will not go away. Mental health challenges are real and here to stay.

A society that respects itself should be ‘thinking’ mental health daily. Investing in mental health provides a guaranteed return on investment. OECD states that direct and indirect costs of mental ill-health may exceed four per cent of GDP.

Apart from healthcare costs and social costs, mental ill-health pushes up the cost of treating other health problems. Indirect costs include: lack of employability, absenteeism and presenteeism (going to work and doing nothing); the substantial cost of informal care delivered by parents, spouses and partners; and the immeasurable intangible costs of emotional distress, pain, and stigma to patients, carers and families.

Beyond economic arguments, social solidarity and human decency oblige society to act. Society should be taking concrete, timely and effective action to translate the age-old Roman maxim Orandum est ut sit mens sana in corpore sano, which is the same concept behind the buzz-phrase used by WHO “there is no health without mental health”.

Initiatives need to be guided by scientific knowledge. Available local research compares with international evidence and compels Maltese society to act.

The first priority area is child, adolescent and youth mental health. International literature reveals that neuropsychiatric conditions are the leading cause of disability in young people: 80 per cent of lifetime mental illness begins by the mid-20s, half of that starts before the age of 14.

Between 16 and 30 years of age, for each newly diagnosed diabetic or asthmatic, four youngsters develop a mental disorder that will scar their entire life. Untreated mental disorder in youth severely influences physical and mental development, impairs educational attainment and diminishes the potential of a fulfilling productive life.

Other challenges include stigma, isolation and discrimination. The benefits of early identification are often jeopardised by delayed or lack of access to health care and education facilities.

Early detection and intervention involves parents, educators, youth workers and front-line health staff particularly in primary care, paediatrics and A&E services. Screening for mental disorders must be part of regular primary school medical examinations. New services should be set at definite age points in secondary, upper secondary and tertiary education settings.

Youngsters at risk or in trouble need help to improve coping skills and build personal resilience. Health, education and social services must be synchronised not duplicated. Transition from adolescent and youth services to adult services must be seamless and not based on the attainment of the 18th birthday. Many Maltese youngsters in trouble are being lost due to this artificial bureaucratic barrier.

A second area where concerted intervention reaps immediate results is better mental health at the workplace.

Mental ill-health affects 20 per cent of the working-age population at any given moment. Half of the employed persons will suffer a period of poor mental health during their working lifetime. Employees who seek help or treatment take more days of absence from work.

Average OECD countries have 16 psychiatrists and 50 mental health nurses per 100,000 population. Malta has roughly a third of that

Studies looking at white collar workers suggest a return on investment of up to €9 for every €1 spent. Mental health at the workplace must become a priority among policymakers. Examples of good practice locally are the employee support programme for public officers and specific support programmes for some businesses run by the Richmond Foundation.

Employers and employees must widen the agenda for better mental health at the workplace. Mental ill-health must be de-stigmatised. Employers and employees should be empowered and enabled to detect stress and mental health problems through appropriate risk assessment at the workplace.

Analysis of absenteeism or presenteeism at individual level and focused assessments of those work practices that are characterised by high staff turnover should be ongoing. The workplace should provide non-penalising and anonymous individual support. Unions and employers must engage in positive dialogue if staff mental health in this country is to move a step higher.

Poor mental health literacy has been quantified at 45.7 per cent of the adult population in Malta Health Literacy Survey 2014. Poor awareness to mental health issues and failure of early identification and treatment of disorders is the third challenge that needs to be tackled locally.

In Malta in 2015, 400 individuals required involuntary admission for acute mental health problems. Furthermore in the local context, up to four times as many individuals seek voluntary admission in psychiatric institutions. In 2015, 2,000 individuals had serious mental ill-health problems requiring acute hospital care, mostly for brief spells lasting less than 15 days.

This does not include those who suffer in silence and the real picture is definitely much worse.

The EU estimates that only 50 per cent of Europeans actively seek help for mental health disorders. In western societies, the lag-time between first symptoms and first help sought was estimated at 64 weeks for psychosis and at 6.5 years for depression.

This calls for intensive promotion of positive mental health and well-being at individual level and within families, organisations and communities. This means learning to relax and unwind; taking up more and regular leisure and pleasure activities; managing stress and not stressing others by our behaviour.

Heightened awareness and early detection is a paramount responsibility for all staff in health, education and welfare. Mental health literacy improvements must target groups known to be at higher risk as well as the general public.

The fourth challenge focuses on reforms in the health care system. More community clinics supported by community-based psychiatrists and specialised teams, consisting of nurse, social worker, psychologist, etc., are needed to provide an appropriate national network.

These clinics allow earlier discharge and closer follow-up of acute patients. Chronic care can be delivered in the community. GPs, health centres and NGOs can safely provide care for persons with mental ill-health within the family environment. A possible fast track is the gradual closure of the hospital psychiatric out-patient service as more community clinics are opened and staffed. Data sharing between service providers is critical to effective community services.

Children with psychiatric emergencies should be admitted in acute paediatric wards, following appropriate measures to ensure safety and availability of trained staff. All adult acute psychiatric care must move towards the acute general hospital setting with progressive grafting of more psychiatric beds within the Mater Dei building itself rather than by accommodating psychiatry in a discrete ad-hoc facility on or close to the Mater Dei site.

Emergency services require a 24/7 crisis intervention team that can deal promptly with hospital and community psychiatric emergencies.

Specialised community rehabilitation facilities for specific disorders should follow the standards set by Dar Kenn għal Saħħtek for eating disorders. A totally refurbished Mount Carmel Hospital should become a dignified residential facility for its institutionalised residents who will not cope in the community and whose care needs are geriatric and medical rather than psychiatric.

These four action priorities require significant financial outlay and human resource investment together with bold service re-engineering in health, education and social welfare systems. There are insufficient complements of psychologists, social workers and allied health care professionals.

Average OECD countries have 16 psychiatrists and 50 mental health nurses per 100,000 population. Malta has roughly a third of that: six psychiatrists and 50 nurses (of whom only 16 mental health nurses) per 100,000 population. An interministerial holistic plan is necessary. This must be appropriately resourced, tightly managed and take a mental-health-in-all-policies approach.

Our economy today relies mainly if not solely on human brain capital. The sustainability of our existence as a successful nation depends on human brain capital. We will be foolish not to invest now in our biggest and only real national asset. Mainstreaming mental health and ‘thinking’ mental health daily is not an option.

It is a national policy priority.

John Cachia is Commissioner for Mental Health.

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