Landscape of Psychiatry in Malaysia

I thought a fitting first post for this website would be an exploration of what psychiatry seems to look like in Malaysia. This is also an accumulation of my research into trying to understand the landscape of the field of psychiatry in my home country.

No. of psychiatrists in Malaysia

Recently, the Malaysian Health Minister made a comment that the health ministry does not need to employ any more doctors because they have enough, and that after they have trained all the current doctors in their employ, Malaysia would have enough specialists.

I think this statement is unfair because of many reasons, but let’s specifically look into the field of psychiatry.

I was on a 2-week quarantine due to COVID-19, so I had some time to go on the National Specialist Registrar (in which all specialist have to register on before they’re legally allowed to practice as a specialist in Malaysia), go through all 414 psychiatrists currently in Malaysia (Yes, you saw that right, we only have 414 psychiatrists in Malaysia, and yes, they can probably all fit in a ballroom for dinner).

In 2016, a comprehensive mental health report was published by the health ministry reporting that we have 0.52 psychiatrists per 100,000 people.

Based on current estimation by the Department of Statistics of Malaysia - in July 2020, the population stands at 32,657,300 (both citizens and non citizens). So the current ratio is 1.268 per 100k people.

What does 1.27 per 100k population mean? Is that enough?

Psychiatric patients in Malaysia

With my assumption that 414 psychiatrists in a country of 32.7 million is low, I decided to look into how many patients are there that are seeking care. We know that there is a huge population of patients that do not seek care, there are multiple studies quoting a wide range (and I will not quote them because their range is too big, which means it’s inaccurate, likely due to self reporting and therefore some people hiding if they need help anyway).

According to that 2016 report, the prevalence (amount of people who are suffering from mental illness at that time) is about 29.2% of adults.

With the current population - we have about 6.68 million people suffering from mental health illness.

6.68 million patients for 414 psychiatrists.

Psychiatrists in Malaysia are not yet overwhelmed by the amount of patients that might require help because, I think -

1. The stigma is so strong, a large population do not seek care anyway

2. Mental health knowledge is so low, some people who are suffering from Major Depression or Generalized Anxiety do not realize why they are feeling that way

3. GPs and FM, or other specialists are caring for a large number of psychiatric patients that they do not refer to psychiatry because of the stigma anyway.

But if we were to plan ahead, and if our goal were to create a healthy and strong Malaysia, we need to plan for and work towards a future where patients with mental health issues can address them and that there will be enough resources for them because the numbers above are too scary.

For patients with schizophrenia, arguably one of the more debilitating mental illnesses, a Malaysian study in 2011 states that only 28% of patients with “first break” (their first episode of psychosis) seeked help directly.

In that 2016 report, there were only 445,000 outpatient governmental clinic visits.

What’s actually happening right now for mental health?

Is the government invested in mental health?

I was curious about the low number of psychiatrists. Is it because of the same stigma among Malaysians that doctors don’t want to specialize in it?

Malaysia’s health budget allocates only 1.2% of its budget into mental health. In comparison, the average percentage allocated by “upper middle income” countries to their mental health field is about 2.4%, double what Malaysia is investing.

Malaysia is essentially practicing only tertiary prevention and a little of secondary prevention. There isn’t enough healthcare staff in the field of mental health to work on primary prevention.

Mental healthcare facilities

There’s 4 dedicated psychiatric hospitals in Malaysia

34 hospitals that have a psychiatric unit within their hospital

22 MENTARI clinics - community mental health clinics

I don’t have too much data other than what’s reported in the papers published by the Health Ministry.

Pathways to become a psychiatrist in Malaysia

Based on the NSR data, there are 5 universities that train doctors to be psychiatrists.

They undergo a “Masters” program - in which doctors will apply for after they have completed 2 years of “housemanship”/internship (right after medical school), and they sometimes wait for 2-3 years after the housemanship before getting accepted to a program.

The program then trains them for 4 years.

During a conversation with a psychiatrist trained in Malaysia, because of the lack of training spots, the Health Ministry is allowing trainees to take the MRCPsych (an examination paper in the UK taken by UK trainees upon entrance into training) as a form of specialization.

Conclusion

Well, the Health Minister might be right

1. If the mental health stigma continues to be a problem and therefore only <1% of people suffering from mental health illness seek care

2. If the Malaysian population slows down in it’s growth

3. If there’s suddenly a bunch of psychiatrists who have trained overseas who would suddenly want to come home or move to Malaysia

4. If psychiatrists in Malaysia never retire

Otherwise, as a realist, even if we were to look at just one specific field in Malaysia, I do not believe we have enough specialists, and that waiting for the current medical officers to slowly be trained through the current programs or hoping that they will pay their own way for MRCPsych or to go overseas and then come back to serve Malaysians out of altruism is a weak plan, and I think the Health Ministry can do better.