Schizophrenia - Support, not exclude, mentally ill in NS

Young men with schizophrenia need not be exempted from full-time NS, say a psychiatrist and a young woman who has struggled with schizophrenia

By Chong Siow Ann, Published The Straits Times, 18 Apr 2014

IN 2008, the United States Army woke to an alarming discovery: Its soldiers were killing themselves at a startling rate. The suicide rate in the armed forces used to be well below that of civilians in the US population, but by 2008 the suicide rate in the army had surpassed the rate for civilians, even threatening to overtake the rate of combat deaths.

In response, the Pentagon implemented a raft of measures, including the establishment of a suicide prevention task force. There were also suicide prevention programmes in most army posts, and training in emotional resiliency to cope with the stress of deployment and combat. The Pentagon also initiated the Army Study to Assess Risk and Resilience in Service members (or Army Starrs). It was the largest study of suicide risk and resilience ever conducted among military personnel.

The US Army is also trying to change the culture of soldierly machismo that views psychological problems as indicative of personal weakness. "Getting help for emotional problems should be as natural as seeking help for a sprained ankle," said General Peter Chiarelli, the army vice-chief of staff.

Similar problems have occasionally surfaced in Singapore. In July last year, 23-year-old national serviceman, Private Ganesh Pillay Magindren of the 24th Battalion Singapore Artillery, took his own life.

Unimaginable pain

THE writer William Styron who suffered from depression, once wrote: "Suicide remains a tragic and dreadful act, but its prevention will continue to be hindered, and the age-old stigma against it will remain, unless we can begin to understand that the vast majority of those who do away with themselves - and of those who attempt to do so - do not do it because of any frailty, and rarely out of impulse, but because they are in the grip of an illness that causes almost unimaginable pain."

Pte Ganesh was diagnosed with schizophrenia and was, in all likelihood, in great pain before that final act. We may never know what made him take this extreme action. Was it some symptom of his illness, or was it - as is generally assumed - precipitated by the punishment that was meted out to him for his various infractions? Or was it a combination of these and other factors?

Schizophrenia is a serious mental illness. It occurs roughly in about 1 per cent of the general population. It has often been said that one in 10 of those affected eventually kill themselves. But this figure is lower than that of those with major depressive disorder, another common mental illness.

Straits Times senior writer Andy Ho, in his article on Sunday, suggested that young men with schizophrenia ought to be exempted from national service.

However, one must not make the erroneous assumption that the diagnosis of schizophrenia is synonymous with an inability to cope with stressful or demanding tasks and situations. The truth is that schizophrenia has varying outcomes. Recent studies have suggested that in some cases, long-term medication might not be necessary.

Nor is the illness so bleakly hopeless. People do get better, if not recover. Consider Professor John Nash, the Princeton University mathematician and Nobel Prize laureate. After a stellar early career, he was stricken with schizophrenia and fell precipitously into a state where he was unable to function.

Prof Nash spent his time wandering aimlessly on the Princeton campus grounds - as so dramatically depicted in the book and movie A Beautiful Mind. It was only after he accepted treatment that he regained his mental health and resumed teaching at the university.

I have among my patients a number of young men with schizophrenia who have successfully completed national service and emerged from it stronger and more confident. But they do need close monitoring. They also need - especially when things get tough - that feeling of safety that comes from knowing that there are people who understand them and their illness, and to whom they can turn to for help.

Through the cracks

SOMETIMES, however, some do fall through the cracks.

I have had patients who killed themselves - most times seemingly inexplicably. Often, I would offer to see the family as a way of bringing some "closure", although I must admit that I have difficulty in understanding exactly what that means. Selfishly, these meetings are also a means of seeking some absolution for my own guilt.

I remember one such session with the mother of a patient, an intelligent young man with schizophrenia.

He killed himself in his bedroom using a method he learnt from a suicide site on the Internet. The mother - a middle-aged lady whose face was worn with grief - sat with me while I tried to answer her few questions.

But I couldn't quite answer her most pressing question. That unknowable "why" was like a boundless void and we lapsed into silence. Having nothing more to ask, she left. I don't think I gave her a modicum of solace.

As professional caregivers, we so often do not give enough consideration to those family members who have to deal with the loss. Author Julian Barnes described it in his book Flaubert's Parrot. "You come of it as a gull comes out of an oil slick," he wrote, "you are tarred and feathered for life."

Pte Ganesh's father said that the family is "all broken up". Research has shown that suicide-bereaved parents and family members report eddying feelings of shame, anguish and disbelief as they struggle to make sense of the suicide. They also experience a wall of silence: Being stonewalled by others and silencing themselves as they are afraid of being judged - a sense of uneasiness which accentuates their sense of isolation and abandonment.

Demystifying suicide

"EVERY suicide is as different and as unique as the people themselves," said Gen Chiarelli in testimony in the US Senate. "And the reality is there is no one reason a person decides to commit suicide. That decision reflects a complex combination of factors and events."

While that is true, we cannot afford to mystify suicide as something beyond our comprehension and control.

Following the few cases of sudden death in otherwise fit young servicemen while training, the Singapore Armed Forces has put in place a more vigorous system for the pre-enlistment screening for any potentially risky heart problems. The challenge now might be how to minimise, if not prevent, potential suicides in an inclusive, non-discriminatory and non-stigmatising way.

Thousands of young men are enlisted every year to serve the country. They will be the ones who - should it become necessary - will put themselves in harm's way to defend the rest of us. So we do owe them something.

The writer is the vice-chairman on the medical board (research) at the Institute of Mental Health.

Don't deny mental health patients the chance to live normally
By Chan Lishan, Published The Straits Times, 18 Apr 2014

I READ with some dismay, Dr Andy Ho's article, "Exempt these young men from NS" in The Sunday Times, Think section on April 13. He said that a key question raised by the death of Private Ganesh Pillay Magindren was whether individuals with schizophrenia should be enlisted for national service. He went on to argue that the answer was "no".

The young man, diagnosed with schizophrenia, was found dead at the foot of his Sengkang condominium last July. Schizophrenia is a mental condition which distorts a person's thoughts and emotions, causing the sufferer to lose touch with reality.

To me, the key question should be how we can better accommodate and support people with mental health problems who are enlisted for national service.

By denying them the chance to serve NS, it prevents them from experiencing something that all our fathers and brothers go through, including personal growth, and the formation of deep friendships.

For, at risk of romanticising the NS experience, denying them the opportunity to serve NS is to exclude them from a chance to contribute to and serve their country.

Dr Ho stated that people with schizophrenia should not do NS because they are on lifelong medication that can have severe side effects. If they stop taking their medication, they are likely to suffer a relapse. And the NS environment is just the place where someone would be likely to stop taking medication, due to stigma or self-stigma.

But it is not clear that the NS setting is exceptional in its stigmatisation of mental illness. Other environments, such as educational and workplace settings, are similarly stressful and unforgiving. But do we wish to exclude people with schizophrenia from all such settings? The answer must necessarily be "no".

Dr Ho said that in addition to lifelong medication, the person with schizophrenia needs lifelong family support and psychosocial support in order to function minimally. In other words, people with schizophrenia cannot live independently or function effectively without plenty of help.

This is not always the case. People with schizophrenia can recover and cope and, in some cases, with advice from their psychiatrist, reduce and even stop taking medication without relapse.

People with schizophrenia can also live independently without constant reminders from family members to take their medication. They can find meaningful work as professionals in full-time jobs. I say this from my understanding of the experiences of people with schizophrenia, including my own.

Dr Ho rightly suggests that society needs to understand and be more accepting of those with schizophrenia. Additionally, society needs to consider how to best include and support those with schizophrenia. What resources can be provided to ensure that those who need help, get help?

While I believe that Dr Ho's intentions are to ensure the safety of people with schizophrenia, removing these individuals from society, whether by exemption from NS or by not giving them a chance to resume or return to their studies or work, is not the solution.

How, then, can we help such people? Here are some ideas that can be put to immediate practice.

If an employee discloses that he has a mental health problem, the employer should discuss with the employee any necessary adjustments, including workload management, and the importance of having access to a quiet spot in order to relieve stress. There may also be a need to take time off work for therapy or treatment. As schizophrenia is episodic, these accommodations need not be permanent.

The recruitment process should also be fair to potential employees who have disclosed their mental illness. Bosses should develop a work culture of open and honest communication, where people know that it is perfectly fine to talk about mental health. One way of being supportive is to have informal chats to track the progress of someone who has recently returned to work after hospitalisation.

There is no need for everyone to become an expert on mental health. However, it would be good to develop a sense for when someone needs professional or clinical help. Fellow workers should also make it a point not to treat affected colleagues as special or different from anyone else.

Don't ask "How many mg of what drug are you taking?" or "Why do you think you have a mental illness?". Instead, ask "How can we support you to do your work better?".

Err on the side of not being too intrusive or personal, just as you would with any other colleague.

Be aware that an employee with a mental health problem is not more vulnerable than any other employee to workplace stress.

Chan Lishan's struggle with schizophrenia in 2008 is recounted in her book A Philosopher's Madness (Ethos Books), published in 2012. She is now a freelance writer with a passion for raising awareness about mental health.

Exempt these young men from NS
Suicide of NSF with schizophrenia raises question of whether those with this serious affliction should enlist
By Andy Ho, The Sunday Times, 13 Apr 2014

Schizophrenia used to be thought of as a psychological disorder brought on by cold, uncaring mothers. But that was a terrible misconception because it is really an organic neurological disorder with psychological symptoms.

Because some brain circuitry is improperly tuned, the individual's thoughts are disconnected from reality. His inner world is altered, which is why his behaviour changes, depending on whether the disease is in a passive or acute phase.

During the passive stage, he may be socially withdrawn. He can't say how he feels, and fails to take care of himself. He may be anxious, depressed, even suicidal. At this stage, he may be easily misunderstood, appearing to others as a dishevelled, lazy good-for-nothing.

During an acute bout of schizophrenia, however, his bizarre behaviour will be unmistakable and may alarm those around him.

He may ramble illogically, become angry or violent over an imagined threat because he may be deluded, suspecting that others are conspiring against him or controlling him. Or he may believe he has super powers. He may also hallucinate - hearing voices or, more rarely, seeing things. His thinking becomes disordered, he jumps from one thing to another. His speech may become disorganised, his reasoning muddled.

These symptoms may frighten others, not just strangers but even family members and co-workers.

The Institute of Mental Health, as the national centre, sees cases of depression, schizophrenia and anxiety the most frequently, in that order.

Last week brought tragic news from a coroner's inquest into the death of a full-time national serviceman (NSF) who had schizophrenia. Private Ganesh Pillay Magindren's camp supervisor had been informed about his condition, but she never tried to find out what it was or how to manage him. Instead, the coroner heard, she was consistently strict and harsh towards him, aiming to make a better soldier of him.

Last July 4, she punished him for tardiness by giving him 14 extra weekend duties. Pte Ganesh, 23, killed himself the next day.

The key question this death raises is whether a youth with schizophrenia ought to be enlisted at all.

Writing on his Facebook page, Dr Ang Yong Guan, a psychiatrist in private practice who headed the Psychological Care Centre at the Military Medicine Institute up to 2003, says a male with schizophrenia is exempted from NS if he has "symptoms of the illness at the time of his medical check-up at the Medical Classification Centre of the Central Manpower Base". But if he is symptom-free, he may be enlisted "as a non-combatant... on a case-by-case basis".

Pte Ganesh's sad end suggests that known schizophrenics should be exempted from NS regardless of whether or not they display symptoms at the check-up. Here's why.

A person with this brain disorder needs powerful drugs, which have severe side effects, to keep his condition in check. He requires medication for life and is never cured as drugs don't rewire the brain. Acute bouts recur if he stops taking his medication when he feels better, not least to avoid the side effects.

One reason patients stop taking their drugs is "treatment stigma" or the shame associated with seeing a psychiatrist or seeking help for a mental illness. An NSF wouldn't like his buddies to know he is popping "crazy" pills.

There is another kind of stigma - "internalised stigma", or the embarrassment of being known as someone with a serious mental illness. No NSF would want his camp mates to call him "mental".

A new paper published in Psychological Medicine, a journal in the Cambridge University Press stable, reviewed 144 studies covering 90,000 participants worldwide and found that both forms of stigma hinder patients from being treated.

Among specific groups particularly affected were the young, males, minorities and those in the military - all of which apply to Pte Ganesh.

All this suggests that NS is not the ideal environment for those who must comply with drug treatment for schizophrenia.

Here's another reason: The patient also needs lifelong support from family members who ensure, among other things, that he sticks with his drug regimen. But NS removes him from his family.

There is no evidence that workplace stress, family tension or social pressures can trigger a schizophrenic relapse.

Stressful episodes are known to occur before symptoms recur, but this may be because once the person stops taking his medicines, he may begin losing his temper, lacking focus, becoming anxious, neglecting himself and so on. In a military setting, this cannot but trigger disciplinary action.

It therefore seems to make good sense to exempt a youth with schizophrenia from NS, irrespective of whether or not he displays symptoms on the day of his pre-enlistment medical check-up. Better to let him remain in the care of his family and doctors, and in the community at large. That brings us to the other issue this sad case highlights: how society needs to do more.

Aside from lifelong medication and family support, the patient also needs lifelong psychosocial support as his greatest problem is difficulty in socialising, cultivating and maintaining meaningful relationships.

While drugs control the delusions and hallucinations, they cannot improve the person's ability to communicate, get along with others, get a job and live well.

He needs training in social skills, as such training has been found to help reduce relapses by half. Such patients also have trouble finding and keeping a job. They need help to learn skills such as how to work in a team, manage stress and handle job interviews - and even then, many won't be able to hold down a job or care for themselves sufficiently. The reality is that most will have to rely on family members, the usual caregivers. They, too, need to be educated about the illness.

Out in the world, the patient has major social problems. Whether in the military or in civilian life, if his condition is known, he can expect to be stigmatised and discriminated against.

There is no solution other than to raise awareness and educate family members, bosses, co-workers and others to understand and be more accepting of those with this brain disorder. And unconditionally exempt young men with schizophrenia from NS too.

Pte Ganesh's suicide also raises the question of how young men diagnosed with other psychoses should be viewed regarding NS. That is a policy question deserving close and urgent scrutiny.

Hard to integrate mentally ill soldiers into active SAF units

WHILE pundits debate the merits of integrating persons with mental conditions into the Singapore Armed Forces ("Support, not exclude, mentally ill in NS", last Friday; and "Exempt these young men from NS", April 13), the SAF must remember that it also has a responsibility towards the majority of its personnel, who do not have such problems.

As a reservist sergeant major in charge of camp procedures and discipline during the 1980s, I witnessed at first hand how mentally ill staff endangered safety and lowered morale.

Each year, as I took over equipment and personnel from the camp's permanent staff, I was usually advised by the person doing the handing over that one or two of his clerical and store personnel, who would be reporting to me for the duration of the in-camp training, had been medically downgraded because of "issues". They were to be assigned only light duties.

Like the captain in charge of Private Ganesh Pillay Magindren, I was not privy to the "issues".

I learnt very early that those personnel could not be trusted to do even simple, non-strenuous jobs such as directing traffic, which was necessary when the men exercised on public roads.

Soldiers running to beat the clock to pass their physical fitness tests do not look out for oncoming cars; they expect staff to stop traffic for them.

After some near-accidents, I ceased assigning medically downgraded personnel to any role where safety was important. But even routine work proved difficult for them.

The majority of my men were reservists who served, if not willingly, at least out of a sense of duty to the nation. They carried out assigned work, if not happily, at least responsibly.

How would they have felt if I had not taken action against the medically downgraded personnel for sloppy clerical errors and careless stock-keeping? Outwardly, they looked no different from the hundreds of other men in the camp, who expected the same rules to apply to all.

The fastest way to destroy morale is to create the impression that there is favouritism.

While I fully sympathise with those who have medically recognised mental ailments, their attempted integration into active SAF units creates more problems than it solves.

Lee Chiu San
ST Forum, 22 Apr 2014

Reflect on attitudes towards those with mental health issues

WHILE I respect Mr Lee Chiu San's views, I suggest that one should avoid making hasty generalisations based on only personal experience ("Hard to integrate mentally ill soldiers into active SAF units"; Tuesday).

The essence of stigma is a negative and prejudicial attitude towards someone with a mental illness.

Discrimination occurs when people with mental illnesses are treated unfairly or denied their rights because of their conditions.

In ancient Greece, stigma was used to describe the mark branded onto someone to indicate his social undesirability. People with mental health issues were seen as having less social value then.

These attitudes continue today and are expressed in different ways in different cultures. They create a vicious circle of alienation and discrimination, and can become the main impediment to recovery, causing social isolation, unemployment, homelessness and institutionalisation.

With appropriate treatment and support from family and friends, people with mental health issues can live quality lives just like anyone.

Despite their conditions, famous people such as mathematician John Nash, authors Charles Dickens and Ernest Hemingway, and the late American president Abraham Lincoln made important contributions to society.

The recognition of the importance of mental health and the consequences of stigma and discrimination should help free us from an "us and them" attitude.

It is time to reflect on our attitudes towards people with mental health issues and join hands in making Singapore a gracious country.

Porsche Poh (Ms)
Executive Director
Silver Ribbon (Singapore)
[Silver Ribbon is a non-profit organisation that fights the stigma of mental illness and encourages early treatment]
ST Forum, 24 Apr 2014