World Alzheimer’s Day

21 Sep 2007, ST

Today is World Alzheimer’s Day. Experts predict a dementia epidemic because the numbers of people with dementia increase with an ageing population. In Singapore, there are about 22,000 affected people, with the number set to increase to 52,600 in 2020 and around 187,000 in 2050.

Are you at risk or do you suspect someone you know of having Alzheimer’s? Early detection is key to treating the condition, so here’s a guide to the main risk factors and signs to watch out for.

Success story: Spot them early

15 Sep 2007, ST

IN MELBOURNE

Here's how the world's most effective clinic does it: Encourage young people to come in; help more, medicate less; perhaps even increase intake of fish oil

AT THIS centre, shocking purple and brilliant green greet you. The garish colours are not most people's idea of a mental facility. But then, Orygen Youth Health in Melbourne, Australia, is not your typical mental health facility.

It is one of the most effective schizophrenia clinics in the world.

The man behind it, Professor Patrick McGorry of Melbourne University, is a passionate believer that early treatment of schizophrenia gives people a chance of a normal life.

He has thought so for 20 years, back when it wasn't a commonly held belief. He managed to convince government and private sector corporations to finance his experimental centre.

Orygen - named for Generation Y - began in 1991 as an early psychosis service, a small outfit with just a handful of doctors.

Today, Orygen is viewed as a cutting-edge mental health centre. Britain and Singapore both adopt its model of early intervention.

It helps 800 new patients a year. Half have what is called a 'social recovery', meaning they can hold down a job or attend school, and have friends, even if some have to remain on medication.

The rest also do better than those treated elsewhere. The key to its success: early identification and aggressive treatment of youth at risk of schizophrenia.

In 1994, Orygen started a mental health clinic specially targeted at young people. Most schizophrenics start showing symptoms in their late teens or early 20s.

To draw in young people, the clinic was set up first at a shopping centre, to 'de-stigmatise' mental illness, said Dr Alison Yung, the psychiatrist in charge of the place.

Today, the clinic has moved to the main Orygen centre which is near both Melbourne and Monash universities. The brightly painted centre caters to all mental health problems among youth such as personality disorders, not just schizophrenia.

'I don't think people feel ashamed of coming here. They talk to their friends about this service.

'It's different from 15 years ago when we had a hospital like Singapore's Woodbridge,' said Prof McGorry, who is one of the external consultants at Singapore's Institute of Mental Health, and who finds Singapore's institutional approach 'bizarre'.

Institutions for mental illness tend to cater to adults and are 'focused on control', Prof McGorry explained. 'It is not geared for teens and young adults in a salvageable situation.'

Staff at the clinic identify youth at high risk of getting schizophrenia - in what doctors call the prodromal phase - and are proactive in trying to prevent the disease from erupting.

Dr Yung has come up with a list of symptoms to look out for. This is derived from extensive interviews with schizophrenia patients on their own early signs and symptoms.

These include: feeling suspicious that other people were out to get them; feeling very self conscious, thinking people are looking at them because they are doing something wrong or look different, and hearing whispers (rather than voices).

Thanks to its proactive approach, Orygen's patients get treated just two months after the first symptoms appear - much lower than the international average of one year.

On average, Orygen patients spent 13 days a year in hospital, against 46 days by non-Orygen patients.

Orygen also boasts a strong applied research unit that has resulted in better outcomes for patients.

It has a research budget of A$8 million (S$10 million) to A$9 million a year and 120 full-time researchers looking into ways to help patients. It also has an annual clinical budget of A$14 million from the state government, and a staff of 140.

Orygen researchers have found that patients will benefit from less medication, since anti-psychotic medicine has side effects.

Long-term use of the older generation of medicines can cause patients to end up with blank-looking faces. Some make involuntary movements like flicking their tongue in and out of their mouth (a symptom referred to as the 'fly-catcher') or repetitively jerking their arms or moving their feet while seated.

Another recent finding that has Prof McGorry excited is the effect fish oil has on preventing psychosis.

A small study in Austria among youth at high risk of getting schizophrenia showed significant protection with fish oil. Eight out of 38 in the control group developed schizophrenia within a year, compared to just one out of 38 in the group taking fish oil.

Prof McGorry will be leading a nine-centre study to verify if the initial findings can stand up to scientific scrutiny. He would love to include Singapore in the study, except doctors here are not yet at the stage where they are picking up prodromal patients, or patients who are at high risk of schizophrenia.

He said: 'If we can show that it's useful, even if it works for only 10 to 20 per cent of patients, we can use it for the whole population as it is such a safe treatment.'

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IN SINGAPORE

Pilot programme to look out for signs of psychosis

IT USED to be that young people who developed mental problems got into difficulties in school or with the police before ending up in the mental hospital.

These days, the problem signs are more likely to be picked up by teachers and counsellors.

The difference is a pilot programme started by the Institute of Mental Health (IMH) in 2001 to identify early those who show signs of psychosis and treat them.

People with psychosis have a mental illness where they lose touch with reality, becoming, say, suspicious. When it becomes more extreme, it is called schizophrenia.

Under the Early Psychosis Intervention Programme (Epip), hundreds of teachers and counsellors were trained on the symptoms to look out for, such as lack of motivation and apathy or hallucination and delusion.

IMH staff also gave talks to students at universities, polytechnics, junior colleges and institutes of technical studies, and plastered these places with posters of the illness and its symptoms - and the fact that help is at hand.

As a result, teachers, parents and family doctors are able to spot the problem early and get help.

Patients now get spotted about four months after the first symptoms appear - down from an average of one year previously.

So far, 1,100 people have been treated under the programme - without a single one needing long-term hospital care.

The Ministry of Health will expand the programme and gradually raise its funding to $2.5 million a year by 2011.

Once a student with mental problems has been identified, the school can call up a case manager and discuss symptoms.

The student then gets an appointment with an IMH psychiatrist and follows up with treatment. He gets a semester off school to recuperate if necessary.

During that semester off, the student may attend activities like pottery, exercise sessions, social skills training and vocational coaching to keep them active.

Since most are on the verge of entering the job market, they are also taught how to write resumes and do well in interviews.

While schizophrenia cannot be cured, medication can control the symptoms so the patient can continue functioning normally and live in society.

But about 5-10 per cent of patients are drug-resistant and nothing helps. Most of the long-term inmates at IMH suffer from schizophrenia.

Over the years, Epip has become more cost-effective.

In its first year, the disease cost patients $127,602 a year, of which about $4,600 was for medication and treatment and the remaining $123,000 was money lost from not being able to work.

In the second year, the cost fell to $95,856. Money lost from not being to work dropped dramatically to $90,000. The difference is that patients were well enough to return to work.

IMH is also working with the armed forces to identify national servicemen who show early signs of psychosis, since they are at the age when the disease first hits.

IMH research head Associate Professor Chong Siow Ann said the institute is also conducting several large-scale studies on side effects of medication.

Associate Professor Richard Keefe of the Duke University Medical Centre, who works closely with Prof Chong on some of the IMH research projects, said the programmes are 'known throughout the world for its efficiency and patient care'.

A day at IMH: Where the daily routine is everything, otherwise...

15 Sep 2007, ST

IT IS Tuesday morning and Bala is off to visit his older sister and her family. He takes the bus and will arrive at her place before lunch.

He likes McDonald's burgers, so that's what she usually gets for him. He also gets on well with his brother-in-law, who 'jokes with me', he said.

These visits have become almost a ritual, carried out faithfully week after week, for more than 20 years. Sometimes he stops on his way home to do some shopping.

But there is one major difference between Bala and other commuters. The 'home' he returns to is Woodbridge Hospital.

Bala, 43, has been living there for more than two decades. He is one of over 900 schizophrenia patients who have made the mental institution their home.

When The Straits Times team visited the ward, Bala and others in his group were discussing what they had read in the morning papers. The discussion that followed could have taken place in the void deck of any Housing Board block.

At first glance, all seems normal. But the truth is that each person in the ward suffers from severe and chronic schizophrenia. Most have had this mental condition for many years.

In the highly regulated environment of this ward, many of the patients lead nearly normal lives. 'Little things can trigger off an attack,' said psychiatrist Swapna Verma.

If they have to cope with life outside, they would very quickly suffer a relapse and have to be warded again.

She explained: 'They don't react well to surprises or conflicting orders. They need things to be consistent and routine. That's why they have a hard time fitting into society. They cannot handle the unpredictable.'

In his 21 years at Woodbridge, Mr Michael Wee, assistant director of nursing, has seen patients 'do things you'd never imagine'.

Several times a year, Bala would get a relapse and refuse to eat or bathe. He would be unkempt and would wake up screaming and shouting in the middle of the night. Others might shout back, telling him to 'Shut up'.

Staff would talk to Bala gently and encourage him to return to a normal routine. Sometimes, that doesn't work. Then his medication has to be adjusted to treat his changed behaviour.

Said Mr Wee: 'They're unpredictable. When they are well, they are really well. But when they are not, they can do the oddest things.'

'I was a spy in S'pore'

15 Sep 2007, ST

ON THE surface, John appears like a successful young man in his early 30s.

He runs an engineering business, is married, lives in an East Coast condominium and likes fast cars.

There is just one strange thing: He has been hearing voices in his head since he was 18, and living with them. The voices drove him to attempt suicide over 20 times.

After graduation, he began his own business. Then came a major disagreement with his partners and a traumatic parting of ways.

That was when a major depression hit. The voices grew more insistent, driving him to his first suicide attempt.

Once he had decided to kill himself, he planned to do it with style, with his favourite music playing.

He chose a Sunday morning to climb out onto the window ledge of his condominium, ready to fling himself off. He looked down, and saw hundreds of people running on the road below.

'There was a freaking marathon,' he said, recalling the incident. 'I couldn't jump with all those people looking up and pointing at me.'

He decided to try again the next morning but when he woke up and opened the windows, he saw thick ropes and cables - workers were painting the building.

He decided that wasn't the way for him to go.

Next, he tried to gas himself in his car. He put a tube from his exhaust into the car. With his favourite music playing again, he popped two sleeping pills and stretched out on the back seat.

The next thing he knew, there was a loud banging on the door. He found a security guard yelling at him: 'Abang (elder brother), you want to die, don't do it here lah. You die here, I die also!'

John tells the stories of his suicide attempts with a casual self-deprecating humour. Despite the mental anguish he lived through, he can find latent humour in those situations.

He made many other attempts, before finally giving up.

Not all were as comical, he said. The last attempt made him realise that if he didn't succeed in dying, he could end up with more problems than he already had.

He had taken 25 sleeping pills. 'I woke up two days later in hospital with my wife screaming at me. Then I had three days of diarrhoea,' he said, deciding then that enough was enough.

That was when he started treatment with Dr Brian Yeo, a psychiatrist in private practice. John doesn't think the medication is effective, but because 'Dr Yeo is a nice chap', he continued seeing him regularly.

He says the voices no longer plague him. Now, he only hears one voice, that of his guardian angel.

But he still recalls days as a secret agent reporting to several countries about what goes on in Singapore.

'We met at clubs. We'd pass on information with a flicker of our eyelids. I never gave information that is destructive, only good information about Singapore.

'What I did helped Singapore,' he declared.

He has been told that all that spying was a figment of his imagination.

These days, he is busy with his business and his life in the real world - but maintains that his days as a spy remain vivid to him.

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When stress pushed Desiree over the edge

DESIREE, 16, is a pretty, effervescent teen with leadership qualities.

She was thrilled when she became president of the student leaders at her school and was tasked with organising the orientation programme for newbies.

But things did not follow the clockwork precision she expected and last-minute reshuffling of programmes took place.

She said: 'I'm a perfectionist. I felt very stressed. I thought the whole thing was a flop, although the teachers praised the effort.'

Despondent, she felt unable to face her classmates or teachers and started to skip school.

As she isolated herself, her mind and emotions became more disturbed. She started hearing a voice which told her to jump off a building. 'It was a man's voice, and he talked all the time. I suspect it was Satan,' she said.

She attempted suicide by taking an overdose of gastric pills - because that was all she could find at home. Then she panicked and told her mother, who took her to hospital.

Doctors there suggested treatment at the Institute of Mental Health (IMH), but the thought scared her. So she simply went home.

A few days later, she made a second suicide attempt - this time drinking insecticide. Again, she told her mother.

She said she didn't really want to die, but was driven to it by 'the voice'.

This time her elder sister, a biochemist, persuaded her to go to the IMH. She did not admit to her sister that she was hearing voices, for fear of being labelled 'crazy'.

Desiree was admitted to the subsidised ward because it cost less.

'The experience was scary. I didn't feel safe. The people there, they talked to me, but there was no link. I say something and they say something totally different. Or they would hit me.

'It was very scary and I cried and cried. I couldn't stand it.'

Her parents moved her to a private ward. Desiree found this better and quieter. 'Nurses there pay more attention to you. It had facilities like a hotel and I could rest,' she said.

After a month, she was discharged, no longer plagued by 'the voice'.

But recovery was not immediate or smooth sailing. 'I was temperamental and would scold and scream at my family. They didn't know what to do and were fed-up with me. Someone had to be with me 24/7 in case I tried to commit suicide again.'

Her pastor at church and form teacher were also towers of strength. She now appreciates their love and care.

Desiree is slowly putting back together the pieces of her life. Medication keeps her symptoms under control. She's back at school and hopes to graduate this year with enough A grades to qualify for polytechnic.

'I'm happy because nobody's controlling my mind anymore. Before, I would cry every day. Now I feel happier. I play badminton. I'm training to play for the school.

'I want to take up more activities, and I want to lose weight,' said the slightly chubby teenager.

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Learning to live within his limits

WILLIAM has a master's degree in engineering.

He now works as a draftsman, earning about $2,000 a month. He is content with what he's doing and earning.

But it took him many years to accept that he has a serious mental illness and to learn to live with his current level of abilities.

He does not dwell on how he might have turned out, if he had continued with his treatment that started in his second year of university. He doesn't think of how he might be better off today.

'I've learnt to look to the future. Not look back at the past,' he said.

William had all the typical symptoms of schizophrenia 10 years ago during his second year at varsity: he suspected people were talking about him behind his back, so he could not make friends.

He was suspicious of his own family, and would shut himself away from them.

He was irritable and quarrelled incessantly with his father. When his father watched television, he would turn it off because he was sure the people on TV were spying on him and that his father was helping them.

He wouldn't allow his younger sister to turn on the radio, no matter how softly, because it disturbed him.

His schoolwork suffered. From straight As in his first year, he got Bs and Cs.

He started seeing a doctor and taking medication, which controlled his symptoms. His grades improved, allowing him to graduate with a second upper honours degree.

William thought he was well, and stopped seeing the doctor and taking the medicine.

Things remained fine for a while, but he had to struggle to get his master's degree - when study used to be a breeze for him.

Soon, his paranoia returned and he had difficulty sleeping.

Armed with a master's degree, but hampered with his schizophrenia, he took on lowly jobs, as a cook, a cleaner and assistant librarian. He didn't last long in any.

He went back to the doctor and resumed medication. As he got better, and at the urging of his doctor, he took on a job as a draftsman.

He is a trained structural engineer, but has no plans to find a job that matches his qualifications.

He said: 'I'm afraid I can't take the responsibility. An error can lead to very serious consequences.'

He tells himself that he chooses to be a draftsman because it is an easy job he can deal with. 'If I want to, I can do more. It's just that I don't want to,' he said.

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Mum spotted the warning signs in time

KUM Loong had just started his second year at polytechnic.

His grades were good and he looked set to becoming the first graduate in the family. His mother, Madam Tan, was justifiably proud.

But two weeks into the term, her nightmare started. Her son told her he could read people's minds and communicate with some of them through telepathy.

The next day, he warned her that people were observing him. He would laugh uproariously whenever watching television - when there was nothing funny at all. Then he began to see flashing red lights.

Fear gripped her. He wasn't the sort to play practical jokes or fool around, so she knew there was something seriously wrong.

She asked Kum Loong's close friends if they had noticed anything different about him. They had. Instead of being attentive in class, his mind would wander. And once, he stood up in the middle of a lecture and just walked out.

Then, one night, he disappeared.

Hours later, she found him wandering around near their block of flats. When he saw her, he told her that he had called a locksmith to open the door to a flat (that belonged to someone else) because he wanted to live there with his girlfriend (he didn't have one at that time).

The next day, Madam Tan took her son to the Institute of Mental Health. 'He had a mental problem, this is the place that specialises in such illness,' she said in Mandarin of her decision.

He was diagnosed with schizophrenia. His doctor wrote to his polytechnic to let him defer his studies for one semester so he could have time to recover in an unstressed environment.

His medication cost $9 a pill, twice a day. 'It was too expensive, I could not afford it,' recalled Madam Tan, a housewife. She applied for financial help and received it.

Medifund, the Government's health safety net for the poor, pays out more than $10 million a year to needy patients at the Institute of Mental Health.

Said Kum Loong: 'I still don't know what the illness is about. I don't know why it happened.'

But he is one of the lucky ones. Because of his mother's quick action, he received treatment early. Doctors think this makes a huge difference in a person's ability to reintegrate into society.

Madam Tan has a friend whose daughter had similar symptoms. Instead of seeking medical aid, the mother brought in mediums to exorcise the 'evil spirit' that had taken over her child.

It's been a couple of years now, and the girl has stopped schooling. She stays home, helping with housework and talking to herself, says Madam Tan.

Kum Loong, on the other hand, is back to his normal self. But the risk of a relapse stalks him. He is on 'maintenance' medicine, and needs to take it for at least two years before his specialist will consider taking him off.

At that point, he and his family will be counselled to watch out for recurring symptoms. If they occur, he has a hotline to his case manager.

Some patients continue to do well after they have been taken off the medicine. Others relapse, either immediately, or over time.

After a semester off, Kum Loong returned to the course and did well and is now waiting to go to university.

Parents of patients may need as much help

15 Sep 2007, ST

SOMETIMES it is difficult to tell who the patient is: the parent or the child.

Life for parents of a child with schizophrenia can be very trying and tiring, as can be seen in the exchange above between Madam Shankar and Janice.

Parents may be as troubled and suffer as much as their schizophrenic child.

'I've seen some parents who say they can't take it any more,' said Dr Swapna Verma, a psychiatrist at the Institute of Mental Health.

When someone has schizophrenia, the stress on the family can be severe. Uncertain and fearful, some family members may react by being controlling, hostile and critical.

'Sometimes, they think their child is making it all up, that he can pull himself out of it if he would only just try,' she said.

Parents may also feel guilty that they did not pay enough attention to the child and caused the child to fall ill. Or they may think they did something to contribute to the problem, and become over-protective.

Dr Swapna has seen some families break up because of the schizophrenic child, when parents take to blaming each other for the child's condition.

Because schizophrenia may have a genetic link, the parents themselves may also be mentally unwell.

The IMH is aware of the anguish that families often go through, since schizophrenia is a long-drawnout illness and not something that can be fixed in a matter of weeks, or even months.

'Case managers not only help patients, but also call the parents to give them support. We also run workshops for parents,' Dr Swapna said.

At Orygen Youth Health in Melbourne, which deals primarily with youth suffering from schizophrenia, there are special case managers to look after families of patients.

One case manager, who himself has a son with schizophrenia, told The Straits Times that many parents feel guilt, especially if the child's illness happened shortly after an 'incident'.

This could be the parents getting a divorce, a parent losing his job or finding out that he has a serious illness like cancer.

'We keep telling them it's not their fault. If that incident didn't happen, something else would have triggered off the problem,' he said.

'Some parents worry about the genetic link. We tell them, if that's the case, you could as easily blame your parents or grandparents.'

Experts say it is important to help families cope, since they are the greatest influence on a patient's recovery. In Singapore, almost all patients live with their families, so tending to family concerns is important.

Ideally, said Dr Swapna, family members should be there to lend support when needed, and be caring, attentive and encouraging. This helps patients recover faster.

'But it is very tiring for them,' she admits.

Family strain: A mum and her daughter's illness

15 Sep 2007, ST

MADAM Shankar, a bank clerk in her 40s, and her two children, 24 and 17, live in an old three-room Housing Board flat. Her husband, a doctor, is an Indian citizen who comes only occasionally to visit his Singaporean wife and children.

Madam Shankar has been struggling as a single parent for more than two decades, with just a little financial help from her husband.

She is feeling the stress of working, being a mother and giving continuous emotional support to her older child, Janice, who has schizophrenia.

Madam Shankar: The first time I noticed Janice behaving extraordinarily was after her Primary School Leaving Examination. 'She did well in all subjects except for Maths where she got a C grade. She was so upset, in tears, as though she had failed.

'She was posted to a neighbourhood school. After orientation, I found her downstairs sweeping the playground. I knew immediately that something was wrong.

I took her to a doctor, and she was treated at the child guidance clinic. For four years, she was on and off her medicine. Her O-level results were good and she went on to junior college.

She was very confident she was well and refused to continue with the medicine. She would be tense during exams, but she took part in active sports. So I thought it was all right.

But when she couldn't get into the law course at university, she started getting upset again.

Janice: My grades were good enough for university, but not law. So I went for a private law course instead. There was a lot to memorise, and I was not able to cope. I knew within the month that I couldn't make it.

I was very stressed with law school. I felt that the lecturer was repeating whatever I had read, that somebody was tape recording whatever I was reading or saying. They knew what I was thinking about. So I quit the school although I had already paid $7,000.

One day, I suddenly told myself, it was like a prophecy, that a road would collapse. And Nicoll Highway collapsed. I really thought it was me, because I said it and it happened.

'I then found that whatever I said would come to pass. One time, I predicted that a $10 note I would give to a shopkeeper would turn into a $2 note.

'That afternoon, my mother gave me $10 to buy bread, but the shopkeeper told me it was only $2. I told my mother what happened, but she said she gave me only $2. I was very sure it was $10 - I saw it was a $10 note.'

Madam Shankar: Janice would cry and cry for no reason. I wanted her to see a doctor but she refused, saying there was nothing wrong. I finally got her to the Institute of Mental Health. I thought it was depression. I didn't know anything about psychosis.

The doctor wanted to observe her, and had her admitted for two days. But she didn't even stay a day.

Janice: Everyone in the ward was making noise. They're really mad people. At least I am aware of my surroundings. Those people really had mental problems. I couldn't stay there.

Madam Shankar: The doctor gave her anti-depressant medicine. But getting her to take her medicine became a real struggle for me. She became violent.

Janice: I believed I was okay. I didn't want to be addicted to the medicine. I preferred to be counselled.

Madam Shankar: I pressed her to get a job. She didn't want to study or work. If she wanted to stay home, at least she should do some housework.

Janice: She didn't want me to stay at home. She wanted me to go to a care centre. I don't give her any problems.

Madam Shankar: She would sleep all the time, doing nothing.

Janice: So what if I sleep all the time? Did I give her any problems? I was minding my own business. I never trouble her in any way. And she couldn't take it. She must get rid of me.

The Hougang Care Centre run by the Anglican Society is a step-down care facility for psychiatric patients. Janice spent three months there following her discharge from IMH in 2005. She has lived at home since.

Madam Shankar: I thought if she was there, she would be engaged in activities instead of sleeping all the time.

Janice: At the care centre, the people are really mental. What they do are sewing and other menial jobs. I find that meaningless. I can't do that. I didn't like the food as well.

Madam Shankar: She was so stubborn and rebellious. I wanted to admit her to hospital.

Janice now works at a busy hospital clinic, preparing case notes for doctors, and appointments for patients. Her employer does not know of her mental illness.

Janice: I'm working and I'm having a really hard time. Every day I struggle. When I come home, I cry to God: Please help me. I don't know how I'm going to face tomorrow.

I find my job very difficult, though it is a simple job. I just need to stick the label on the form, chop the doctor's stamp and get the case sheet.

Sometimes the case sheets are not given to us and we have to trace the case sheets all over the hospital. Doctors get upset when there are no case sheets.

My probation report was not good. It said I'm slow and not capable of running a heavy clinic. They want us to multi-task. There are lots of calls coming in and that's very distracting. Other girls can pick up the calls and continue doing their work. I can't do that.

Madam Shankar: Every day she comes home and cries. She tells me that after her one-year bond is over, she's going to stay home and not work any more.

Janice: I now have this wish, to get married so I don't have to work any more.

Madam Shankar: Getting married is not so easy. It will not solve all the problems.

Janice: A few days ago, my job was just too much for me. I came home and told my mother and she said: 'I cannot live like this, you know. My life is going to be shortened because of you.'

If I had a choice, I would not have come into this world. Even now, I pray to God, can you please take my life, I find it too difficult. But I can't take my own life. That's a sin.

Madam Shankar: It's very difficult bringing up two children without my husband here.

When she comes home and says she cannot cope, it makes me feel very stressed. Because I worry for her, I'm also very stressed. I want her to settle down in her job and get better.

But she is getting better. Before this, she had suicidal thoughts. She refused to understand what was happening. Now when I tell her something, she understands. She takes her medicine and she can sleep.

Breaking out of the mental prison

15 Sep 2007, ST

SCHIZOPHRENIA

One in 100 people suffers from this mental condition. Over 16,000 people with this condition cope with it daily, holding down a job or going to school.

Health Correspondent SALMA KHALIK looks at those with schizophrenia, who face a lifelong struggle to get out of their mental prison to lead near-normal lives

DESIREE is a student leader with everything going for her. Her bubbly personality makes her a favourite with teachers and fellow students.

Then schizophrenia hit.

It sapped her confidence. She got depressed, saw herself as a failure and tried to kill herself.

JOHN is a successful, inventive businessman with an engineering firm. He is married, lives in a condominium and owns a couple of nice cars. He has lived with voices in his head for over 15 years. Many times, those voices told him to kill himself. He has survived those attempts.

ENTER the world of schizophrenia. A world of mental anguish and darkness, where one hears voices others cannot hear, sees things invisible to others, thinks thoughts others do not understand, and starts to be suspicious of everyone, even one's closest family.

Locked in the mental prison caused by the disease, people with schizophrenia feel estranged from society.

In Singapore, there is not much awareness of this condition.

In fact, it is a common mental illness, affecting one in 100 people. Half the 32,000 outpatients treated at the Institute of Mental Health (IMH) suffer from this, which means there are over 16,000 Singaporeans living a relatively normal life, coping with schizophrenia.

Eighty per cent of the 6,600 - or 5,280 - of the patients warded at IMH each year suffer from schizophrenia.

Every day, a child is born in Singapore who will suffer from schizophrenia.

Far from the stereotype of violent lunatics foaming at the mouth, many people with schizophrenia in fact are able to lead a relatively stable, normal life. Like John, the businessman. Or William, the draughtsman.

Fearsome disease

SCHIZOPHRENIA remains one of the most feared and least understood of mental illnesses. Dr Swapna Verma, a psychiatrist with IMH, explains: 'Schizophrenia is a syndrome, and no two patients behave the same way.'

A medical condition is referred to as a 'syndrome' when no one knows its exact cause and so defines it by a collection of symptoms.

Even symptoms vary: many schizophrenia patients will hear voices or see things that don't exist. Some believe they have super powers. Others become suspicious of people around them, to the point of paranoia.

In its mild form, this mental illness that causes people to lose touch with reality is called psychosis.

One in 40 people here will suffer from a psychotic episode some time in their lives. If a psychosis persists for six months or longer, or is a recurring problem, it is called schizophrenia.

About a third of schizophrenia patients recover after treatment.

Another third would appear to recover and may be fine for some years, before relapsing.

The rest are chronic sufferers, who need to manage the disease throughout their lives.

The latter two categories need medication all their lives.

Catch it early

RECENT research has been promising in pinpointing several facts about schizophrenia.

First, it is now accepted that schizophrenia often shows up first in the young adult years - late teens to 20s - at a time when the brain is still growing.

The brain does not mature fully till about 25. Schizophrenia occurs when something goes wrong during this developmental stage.

Doctors consider the teen years 'the most mentally unhealthy' time in a person's life.

That's when a lot of mental disorders appear - depression, anorexia, substance abuse, personality disorders, and schizophrenia.

These are the years when the brain's frontal lobe is developing. This part of the brain deals with how a person plans, organises and strategises - in other words, all the high-level processing.

The temporal lobe, which deals with emotions, is also changing during these years, causing the emotional see-saws of adolescent years.

Some doctors speculate that it takes both a predisposition and a trigger to set off the chain of chemical reactions in the brain that leads to schizophrenia. Others think that either factor - a genetic link, or a traumatic event - is enough.

Dr Alison Yung, who runs a state clinic for young people with mental problems in Melbourne, said a child has a 12 per cent risk of getting schizophrenia if one parent has the disease, and 40 per cent if both parents suffer from it. For those with no family history, the risk is 1 per cent.

Dr Tan Hao Yang, of the National University of Singapore (NUS), who is doing research into what happens to the brain of someone with a mental disorder, described schizophrenia as 'a terrible chronic disease starting early in life that lasts a lifetime'.

The second promising development is that early treatment appears to make a real difference to patients' lives. So the trick is in identifying patients early, as soon as symptoms appear.

A pilot project in Melbourne University is doing precisely that. Scientists there have come up with a list of things to look out for to identify those who are at risk of developing schizophrenia, before full-blown symptoms appear.

For example, teachers and counsellors are trained to identify young people who start becoming suspicious of others or talk of hearing 'whispers'. This is the stage before they become fully paranoid or start hearing voices.

At this Melbourne centre, schizophrenia patients are picked up two months after symptoms appear, compared to a year in other programmes. Many are young people seeking treatment on their own.

Professor Patrick McGorry, a world expert in schizophrenia based in Melbourne, said that if a patient goes without treatment for a couple of years, the disease becomes relatively permanent and 'treatment at that point is largely ineffective'.

Singapore has started an early psychosis intervention programme at IMH, modelled on the Melbourne experience. So far, the results have been positive. Of the 1,100 people identified and helped in the last six years, none has required long-term treatment. The Ministry of Health is pumping more resources into this programme.

Enigma in the brain

SCHIZOPHRENIA spares no one and has a wide spectrum of victims - from brilliant students and sports enthusiasts to the less successful. It affects the rich and poor like.

Specialists are still fumbling around for an explanation of what causes schizophrenia.

NUS' Dr Tan said: 'There's a great deal of research on schizophrenia in the world. But we still know relatively little because the brain is such a complex organ, locked in the skull, making it very difficult to study.'

One theory is that the hallucinations and other symptoms of schizophrenia are caused by high levels of dopamine. This is a neurotransmitter - or chemical messenger - which controls the flow of information in the brain.

Many anti-psychotic drugs reduce the supply of dopamine, thus reducing or shutting off these problems. Unfortunately, a shortage of dopamine affects a person's development of cognitive behaviour.

This means that the medicine needed to suppress the symptoms may also cause his intelligence level to go down.

But Professor Kua Ee Heok, a senior psychiatrist at NUS, said there are indications that this drop in ability is caused by the illness itself, and not just the medicine.

One of the first signs that something is wrong with the youth is often his falling grades, Prof Kua said. Almost invariably, it is mathematics that suffers first. And this comes before he is even diagnosed and given medicine.

Anti-psychotic medicine works by altering the brain chemistry. Medication can remove the irrational fears, voices and delusions that plague patients, so they can behave more 'normally'.

But there are side effects, ranging from weight gain or diabetes to muscular spasms and blank-looking faces.

So, when a patient appears to be doing well, doctors will want to take them off the medicine.

If they stop medication too suddenly, symptoms may flare up again. Hence, doctors often phase in the withdrawal from medication and seek the support of family members to make sure the patient remains stable while medication is being reduced.

The mental anguish

PEOPLE with schizophrenia may lose touch with reality but retain enough self-awareness to know their mental faculties are impaired.

Dr Tan said: 'Many will unfortunately suffer long-lasting cognitive deficits that make it difficult for them to work as well as before. Many will have difficulty with social relationships, in thinking or reacting as fast as before.'

Some attempt suicide when they realise they can no longer reach the intellectual and performance levels they used to take for granted.

Some learn to accept their limits, like William, who has a master's degree and chose a simpler job as a draughtsman. Some are unable to cope with the loss.

In Singapore, as with the rest of the developed world, one in three schizophrenia patients attempts suicide. In spite of all that the doctors, case managers and their families can do, one in three attempts succeeds.

In other words, nearly one in 10 schizophrenia patients dies at his own hands - with more than half of them doing so within the first five years of being diagnosed.

For someone diagnosed with schizophrenia, the journey is lifelong.

They have to accept that they suffer from a mental illness and need medication when symptoms flare up.

As Dr Swapna said: 'It's hard to tell a 19- or 20-year-old, when they feel better, that they will need the medicine for a long time, maybe even all their lives.'

Next, if they are taken off medicine, they have to be self-vigilant, and be proactive in seeking help or taking medication at the first sign of symptoms. If put back on medication immediately, symptoms like hearing voices usually subside.

If symptoms persist and a patient loses touch with reality, he may end up in hospital. Others may become irrational, or lose control and do things like strip in public.

In the past, when less was known about the disease, it was often left untreated till symptoms got so bad that the patient was sent to Woodbridge Hospital.

As a result, more than 900 patients, or three in four of the long-term stayers at IMH, are there because of severe schizophrenia. But even at IMH, some patients are well enough to go back on home visits occasionally.

These days, the promise of early treatment holds hope that many schizophrenia patients can lead relatively stable lives with medication.

With over 16,000 people seeking outpatient treatment for schizophrenia, the chances are good that someone you know or come across, is a silent sufferer.

With greater awareness of this condition, each person can help create a climate that is accepting of people with this condition, so they are not more isolated than the illness already makes them.

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When and where to get help

What is schizophrenia?

It is an illness affecting the mind. Doctors think it is caused by changes in the structure and chemistry of the brain.

Who gets it?

It could happen to anyone, although people with a family history of schizophrenia are at higher risk. People tend to get it in their late teens or early 20s.

How common is it?

One in 40 young people could have some symptoms that flare up and then never recur. This is called a psychotic episode.

One in 100 will get the more severe form called schizophrenia and may need long-term medication.

How do I know if I have schizophrenia?

The illness can come on gradually or quickly. There are two types of symptoms.

Positive symptoms: Hearing voices or seeing things that are not there. Belief that one has the ability to read minds or to make things happen. Feeling of persecution and paranoia.

Negative symptoms: Lack of motivation, social isolation, apathy and difficulty with abstract problems.

Parents should take note if a teenager who used to be outgoing starts shutting himself up in his room and avoids the social interaction he used to enjoy.

What can I do if I have or someone I know has such symptoms?

Speak to your parents, school counsellor or family doctor. You can call the IMH helpline on 9017-8212 during office hours to talk to a counsellor about your symptoms. Mental health information is also found at www.imh.com.sg

Don't be too harsh on families who abandon kin

23 June 2007, ST Forum

THE article, 'Long-stay mental patients strain IMH' (ST, June 11), highlighting the plight of patients at the Institute of Mental Health who have been abandoned by their family, paints a sad story, placing the blame on irresponsible relatives and society in general.

Little does the reporter or the lay public know the burden of looking after a patient with chronic mental illness.

Mr Raymond Anthony Fernando's letter, 'Govt support needed to care for the mentally ill' (ST, June 22), is atypical only because he has chosen to shoulder his burden instead of dumping his wife at IMH.

By doing so, he sacrificed a significant portion of his life. His is not the worst-case scenario because his wife has recovered. For the families of mentally-ill patients who do not achieve a remission, the burden can be overwhelming.

While I do not condone the families abandoning their relatives at IMH, I can understand why they do so.

I would like to praise IMH for doing a great job in keeping these mentally-ill patients off the streets and giving them a decent quality of life. The alternative would be to deinstitutionalise these patients, as is the politically-correct policy in Western countries. This would result in many of the patients ending up as vagrants or bag-people, with maybe a few ending up in prison.

We need more chronic stay facilities, not just for chronic psychiatric patients but also adult patients with mental retardation and other handicaps who are now physically too big for their elderly parents to look after; likewise for demented patients who may be difficult to nurse at home.

While we would like the families to take on the care-giving responsibility, as a neurologist I have seen the lives of all the family members ruined by one ill relative, through no fault of their own.

Let's be realistic: If we find ourselves in the situation of these families, what would we do? If I were a patient, I would certainly not wish to burden my family or society. But as a 'First World' society, we owe our less-fortunate members a minimum quality of life with dignity.

Assoc Prof Lee Wei Ling