Friday 10 October is celebrated as World Mental Health Day, but Malta does not have much to celebrate.

Karl Schembri
A year since the National Commission for Mental Health Reform wrote to then health minister Louis Deguara threatening mass resignation unless its proposals were heeded, the commission is today nonexistent and the new ministry has no idea what was going on.
Even worse, 13 years since government launched the mental health reform process, the laws regulating mental health remain those enacted in 1976 as none of the proposed laws have made it to parliament.
The act has been redrafted several times over the years but it has never been presented to Parliament.
Queries made with the office of the health ministry’s parliamentary secretary in charge of mental health, Mario Galea, quickly revealed there was no handing over since the last election. A ministry spokesman said the draft law was still at the Attorney General’s office.
With the legislation clearly outdated and in urgent need of updating, the commission remains unconstituted and the pressing issues facing the former minister remain unsolved.
An urgent problem highlighted by the commission last year, and upon which it had threatened to resign, was the widening of the list mental health conditions to qualify for free medication.
At present, people suffering from mental illnesses are granted free medication only if they are diagnosed with schizophrenia. This excludes people who have a depression or any other condition, but do not suffer from schizophrenia.
The commission had persistently argued that people suffering from depression and other disorders were not getting treatment as they could not afford buying medication which is very expensive.
“Without such medication these people can hardly improve and their illness is likely to prolong and negatively affect their quality of life and the life of their relatives,” the commission had argued.
Last year, it went as far as threatening with its resignation if the situation persisted. The commission, including Director of Psychiatry Joe Saliba, mental health NGOs and users of the mental health services, had slammed Deguara for ignoring its proposals despite it being a constituted body.

False diagnoses
Psychiatrists say that as the present health regulations stand, most of the medication given for free is being prescribed under a false diagnosis – that of schizophrenia – simply to fall under Schedule V, the list of chronic illnesses meriting free medicine.
That means that those suffering from illnesses such as bipolar affective disorder or chronic depression, amongst others, are not eligible for free medicine because the illnesses are not listed under Schedule V.
As a result, most of the medication being given for free is prescribed under the misdiagnosis of schizophrenia or schizo-affective disorder, which are the only two illnesses eligible for free medication under Schedule V.
Although misdiagnosis is ethically wrong in itself, psychiatrists are faced with a dilemma whenever they have patients who do not afford treatment but need it desperately.
“The system is wrong because everyone is virtually classified as a schizophrenic even if they have ‘mere’ chronic depression, challenging behaviour or learning disabilities,” a psychiatrist said. “It is wrong because it’s unfair on the patients to be misdiagnosed, it’s unfair on the system itself because of the chaos it creates in treatment, and it’s unfair on all those who resist being mislabelled as schizophrenics but still require free drugs.”
This means that the health records are largely inaccurate and are also causing chaos in treatment, the commission had maintained.
Then health minister Louis Deguara had shot down the commission’s arguments, claiming it had “a narrow perspective”.
Even when the commission existed, the health minister had belittled it as “just an advisory body”.
“The demands the commission is making are similar to demands made by diabetics, eczema sufferers and all others who want to increase the range of free medicinals available,” Deguara had told MaltaToday.
“It’s a very narrow perspective and whoever has an interest in one illness or another is putting across the same argument.”
And yet, many patients with mental health problems are already being given free medication under the schizo-affective disorder label, irrespective of their condition, so changes to the regulations would not add much to the financial burden, the commission had argued.

Proposals
On the contrary, making medications more accessible would probably decrease admissions to hospital, which are very expensive, and hence decrease costs.
The commission had proposed given free medication to all pink card holders and hospitalised patients immediately. It also proposed cutting abuses through having patients followed up by psychiatrists for six months to ensure that chronic illness is genuine, while the registration of patients would be centralised at the psychiatric outpatients.
According to the commission, Schedule V should include bipolar affective disorder, chronic depression, chronic obsessive compulsive disorder, challenging behaviour in learning disabilities and attention deficit/hyperactive disorder (ADHD).
The commission pleaded with the minister to take on its suggestions as this would lead to better patient care at no extra costs to the services.
According to research carried out by the former commission with the support of the two major mental health NGOs in Malta – the Richmond Foundation and the Mental Health Association – employment and services within the community are among the most pressing needs of people suffering mental health problems.
In the last years, government has instrumentalised mental health at photo opportunities such as next Friday.
Deguara himself had said the people “deserve this commitment from us politicians” when speaking about new medicinals that should be handed for free to mental health patients.
In December 2006, he said mental health “must be a priority” at a conference organised by the same commission that resigned.
“There was a time when mental health was considered to be one of the ‘Cinderella’ areas in the field of medicine and health care. … The challenge we are facing is the prevention of mental illness that can be prevented and the speedy and effective treatment and rehabilitation for those who suffer from some type of mental illness. The spectrum of mental illness and the disability associated is extremely wide and one has to be wary in being too general when discussing mental health as a diversity of approaches need to be taken to ensure that we are catering for all the needs. … We need to make mental health a priority for all other sectors.”
In October 2002, Deguara said: “Mental Health in Malta, as in other countries, has been for a long time the subject of frustrations and hopelessness. …The sad fact is that society generally does not have a clear understanding of the nature of mental illness. … I feel the popular press could do more to alter this perception. … Although mental illness may affect as many as one in six people within western societies, health budget allocations seldom reflect this statistic. Mental health care across countries is often a poor relation of that for physical health.”
Today, Malta is moving towards world mental health day without even a constituted mental health commission.

kschembri@mediatoday.com.mt