MENTAL HEALTH

PORTFOLIO

Mental health

NAME : AINA SYAKIRAH BINTI MAHADI
NO.MATRIC :PBA21031
SEMESTER :3 2021/2022

TITLE :MENTAL HEALTH

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TABLE CONTENT

1.Online Article

1.1 What is mental Health?
1.2 The important of Mental Health Awareness
1.3 Mental Health and the Covid-19 Pandemic

2.Online Journal Article

c2.1 Mental Illness Stigma, Help Seeking, and Public Health Programs
2.2 Time And Neuronal Variability in Bipolar Disorder
2.3 The coronavirus (COVID‐19) pandemic's impact on mental health

3.Online newspaper
3.1 Anxiety, depression rampant among children even before the pandemic

3.2 INTERACTIVE: Mental health for all
3.3 Experts: Mental health issues rising with the waters

4.Book
4.1 Anxiety & Depression Workbook for Dummies Charles H.

Elliott, Laura L. Smith
4.2 The Mental Health Clinician’s Workbook: Locking In Your

Professional Skills by James Morrison
4.3 The Therapist's Workbook: Self-Assessment, Self-Care, and Self-

Improvement Exercises for Mental Health Professionals by Jeffrey A. Kottler

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ONLINE
ARTICLE

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1.1 What is mental health?

Medically reviewed by Timothy J. Legg, PhD, PsyD — Written by Adam
Felman on April 13, 2020
https://www.medicalnewstoday.com/articles/154543#definition

Mental health refers to cognitive, behavioral, and emotional well-being. It is all about how
people think, feel, and behave. People sometimes use the term “mental health” to mean the
absence of a mental disorder.
Mental health can affect daily living, relationships, and physical health.
However, this link also works in the other direction. Factors in people’s lives, interpersonal
connections, and physical factors can all contribute to mental health disruptions.
Looking after mental health can preserve a person’s ability to enjoy life. Doing this involves
reaching a balance between life activities, responsibilities, and efforts to achieve
psychological resilience.
Conditions such as stress, depression, and anxiety can all affect mental health and disrupt a
person’s routine.
Although the term mental health is in common use, many conditions that doctors recognize as
psychological disorders have physical roots.
In this article, we explain what people mean by mental health and mental illness. We also
describe the most common types of mental disorders, including their early signs and how to
treat them.

What is mental health?

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Share on PinterestMental health disorders are one of the leading causes of disability in the
U.S.

According to the World Health Organization (WHO)Trusted Source:

“Mental health is a state of well-being in which an individual realizes his or her own abilities,
can cope with the normal stresses of life, can work productively, and is able to make a
contribution to his or her community.”

The WHO stress that mental health is “more than just the absence of mental disorders or
disabilities.” Peak mental health is about not only avoiding active conditions but also looking
after ongoing wellness and happiness.

They also emphasize that preserving and restoring mental health is crucial on an individual
basis, as well as throughout different communities and societies the world over.

In the United States, the National Alliance on Mental Illness estimate that almost 1 in 5
adults experience mental health problems each year.

In 2017, an estimated 11.2 million adultsTrusted Source in the U.S., or about 4.5% of adults,
had a severe psychological condition, according to the National Institute of Mental Health
(NIMH).

Risk factors for mental health conditions

Everyone has some risk of developing a mental health disorder, no matter their age, sex,
income, or ethnicity.

In the U.S. and much of the developed world, mental disorders are one of the leading
causesTrusted Source of disability.

Social and financial circumstances, biological factors, and lifestyle choices can all shape a
person’s mental health.

A large proportion of people with a mental health disorder have more than one condition at a
time.It is important to note that good mental health depends on a delicate balance of factors

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and that several elements of life and the world at large can work together to contribute to
disorders.

The following factors may contribute to mental health disruptions.

Continuous social and economic pressure

Having limited financial means or belonging to a marginalized or persecuted ethnic group
can increase the risk of mental health disorders.

A 2015 studyTrusted Source of 903 families in Iran identified several socioeconomic causes
of mental health conditions, including poverty and living on the outskirts of a large city.

The researchers also explained the difference in the availability and quality of mental health
treatment for certain groups in terms of modifiable factors, which can change over time, and
nonmodifiable factors, which are permanent.

Modifiable factors for mental health disorders include:

 socioeconomic conditions, such whether work is available in the local area
 occupation
 a person’s level of social involvement
 education
 housing quality

Nonmodifiable factors include:

 gender
 age
 ethnicity

The study lists gender as both a modifiable and nonmodifiable factor. The researchers
found that being female increased the risk of low mental health status by 3.96 times.

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People with a “weak economic status” also scored highest for mental health conditions in this
study.

Biological factors

The NIMH suggest that genetic family history can increase the likelihoodTrusted Source of
mental health conditions, as certain genes and gene variants put a person at higher risk.

However, many other factors contribute to the development of these disorders.

Having a gene with links to a mental health disorder, such as depression or schizophrenia,
does not guarantee that a condition will develop. Likewise, people without related genes or a
family history of mental illness can still have mental health issues.

Mental health conditions such as stress, depression, and anxiety may develop due to
underlying, life-changing physical health problems, such as cancer, diabetes, and chronic
pain.

Common mental health disorders

The most common types of mental illness are as follows:

anxiety disorders

mood disorders

schizophrenia disorders

Anxiety disorders

According to the Anxiety and Depression Association of America, anxiety disorders are the
most common type of mental illness.

People with these conditions have severe fear or anxiety, which relates to certain objects or
situations. Most people with an anxiety disorder will try to avoid exposure to whatever
triggers their anxiety.

Examples of anxiety disorders include:

Generalized anxiety disorder (GAD)

The American Psychiatric Association define GAD as disproportionate worry that disrupts
everyday living.

People might also experience physical symptoms, including
restlessness

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fatigue
tense muscles
interrupted sleep
A bout of anxiety symptoms does not necessarily need a specific trigger in people with GAD.

They may experience excessive anxiety on encountering everyday situations that do not
present a direct danger, such as chores or keeping appointments. A person with GAD may
sometimes feel anxiety with no trigger at all.

Find out more about GAD here.

Panic disorders

People with a panic disorder experience regular panic attacks, which involve sudden,
overwhelming terror or a sense of imminent disaster and death.

Read more about panic attacks here.

Phobias

There are different types of phobia:

Simple phobias: These might involve a disproportionate fear of specific objects,

scenarios, or animals. A fear of spiders is a common example. Learn more about simple
phobias here.

Social phobia: Sometimes known as social anxiety, this is a fear of being subject to the

judgment of others. People with social phobia often restrict their exposure to social
environments. Find out more here.

Agoraphobia: This term refers to a fear of situations in which getting away may be

difficult, such as being in an elevator or moving train. Many people misunderstand this
phobia as a fear of being outside. Read all about agoraphobia here.
Phobias are deeply personal, and doctors do not know every type. There could be thousands
of phobias, and what might seem unusual to one person may be a severe problem that
dominates daily life for another.

Obsessive-compulsive disorder (OCD)

People with OCD have obsessions and compulsions. In other words, they experience
constant, stressful thoughts and a powerful urge to perform repetitive acts, such as hand
washing.

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Find out more about OCD here.

Post-traumatic stress disorder (PTSD)

PTSD can occur after a person experiences or witnesses a deeply stressful or traumatic event.

During this type of event, the person thinks that their life or other people’s lives are in
danger. They may feel afraid or that they have no control over what is happening.

These sensations of trauma and fear may then contribute to PTSD.

Discover how to recognize and treat PTSD.

Mood disorders

People may also refer to mood disorders as affective disorders or depressive disorders.

People with these conditions have significant changes in mood, generally involving either
mania, which is a period of high energy and elation, or depression. Examples of mood
disorders include:

Major depression: An individual with major depression experiences a constant low mood

and loses interest in activities and events that they previously enjoyed. They can feel
prolonged periods of sadness or extreme sadness.

Bipolar disorder: A person with bipolar disorder experiences unusual changesTrusted

Source in their mood, energy levels, levels of activity, and ability to continue with daily life.
Periods of high mood are known as manic phases, while depressive phases bring on low
mood. Read more about the different types of bipolar here.

Seasonal affective disorder (SAD): Reduced daylight triggers during the fall, winter,

and early spring months trigger this type of major depressionTrusted Source. It is most
common in countries far from the equator. Learn more about SAD here.

Schizophrenia disorders

Mental health authorities are still trying to determine whether schizophrenia is a single
disorder or a group of related illnesses. It is a highly complex condition.

Signs of schizophrenia typically develop between the ages of 16 and 30 yearsTrusted Source,
according to the NIMH. The individual will have thoughts that appear fragmented, and they
may also find it hard to process information.

Schizophrenia has negative and positive symptoms. Positive symptoms include delusions,
thought disorders, and hallucinations. Negative symptoms include withdrawal, lack of
motivation, and a flat or inappropriate mood.

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Early signs

There is no physical test or scan that reliably indicates whether a person has developed a
mental illness. However, people should look out for the following as possible signs of a
mental health disorder:

 withdrawing from friends, family, and colleagues
 avoiding activities that they would normally enjoy
 sleeping too much or too little
 eating too much or too little
 feeling hopeless
 having consistently low energy
 using mood-altering substances, including alcohol and nicotine, more frequently
 displaying negative emotions
 being confused
 being unable to complete daily tasks, such as getting to work or cooking a meal
 having persistent thoughts or memories that reappear regularly
 thinking of causing physical harm to themselves or others
 hearing voices
 experiencing delusions

Treatment

There are various methods for managing mental health problems. Treatment is highly
individual, and what works for one person may not work for another.
Some strategies or treatments are more successful in combination with others. A person
living with a chronic mental disorder may choose different options at various stages in their
life.
The individual needs to work closely with a doctor who can help them identify their needs
and provide them with suitable treatment.
Treatments can include:

Psychotherapy, or talking therapies

This type of treatment takes a psychological approach to treating mental illness. Cognitive
behavioral therapy, exposure therapy, and dialectical behavior therapy are examples.
Psychiatrists, psychologists, psychotherapists, and some primary care physicians carry out
this type of treatment.
It can help people understand the root of their mental illness and start to work on more
healthful thought patterns that support everyday living and reduce the risk of isolation and
self-harm.
Read more about psychotherapy here.

Medication

Some people take prescribed medications, such as antidepressants, antipsychotics, and
anxiolytic drugs.

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Although these cannot cure mental disorders, some medications can improve symptoms and
help a person resume social interaction and a normal routine while they work on their mental
health.
Some of these medications work by boosting the body’s absorption of feel-good chemicals,
such as serotonin, from the brain. Other drugs either boost the overall levels of these
chemicals or prevent their degradation or destruction.
Find out more about antidepressant medications here.

Self-help

A person coping with mental health difficulties will usually need to make changes to their
lifestyle to facilitate wellness.
Such changes might include reducing alcohol intake, sleeping more, and eating a balanced,
nutritious diet. People may need to take time away from work or resolve issues with personal
relationships that may be causing damage to their mental health.
People with conditions such as an anxiety or depressive disorder may benefit from relaxation
techniques, which include deep breathing, meditation, and mindfulness.
Having a support network, whether via self-help groups or close friends and family, can also
be essential to recovery from mental illness.

Suicide prevention

If you know someone at immediate risk of self-harm, suicide, or hurting another person:
 Ask the tough question: “Are you considering suicide?”
 Listen to the person without judgment.
 Call 911 or the local emergency number, or text TALK to 741741 to communicate
with a trained crisis counselor.
 Stay with the person until professional help arrives.
 Try to remove any weapons, medications, or other potentially harmful objects.

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1.2 Mental health awareness

https://crln.acrl.org/index.php/crlnews/article/view/24042/31759

Resources for everyone

Emily Underwood is research and instruction librarian at the Hobart and William
Smith Colleges Warren Hunting Smith Library, email: [email protected]

© 2019 Emily Underwood

Approximately one in five adults (19.1%) experienced mental illness in 2018.1 In my
opinion, one of the reasons that only 43.3% of those individuals received any kind of
treatment or services is the stigma surrounding mental illness.2 As information
professionals, we are uniquely positioned to assist patrons with finding the
information and resources they need in order to learn what mental illness is, what it is
not, discover that they are not alone, and find the best treatment for their situation.
Everyone suffering from mental illness needs to know that there is hope for them and
that they don’t need to suffer alone. When people feel that there is no hope of relief,
their mental illness can become fatal through suicide.

According to the Centers for Disease Control and Prevention (CDC)’s web-based
Injury Statistics Query and Reporting System (WISQARS) Leading Causes of Death
Reports, in 2017 suicide was the second leading cause of death in people ages 10 to
34, and it claimed the lives of more than 6,000 people ages 15 to 24.3 According to
the Spring 2019 Report from the American College Health Association National
College Health Assessment, 13.3% of students surveyed “seriously considered
suicide” sometime in the last 12 months.4 Suicide is preventable. But it’s only
preventable if those who are struggling feel like it is acceptable and safe to share how
they are feeling.

There are many organizations that aim to provide support and relief for mental illness.
The organizations included here (which is far from being an exhaustive list) are doing
what they can to promote awareness of mental illness and to improve the mental
health of people in the United States and throughout the world.

Government organizations

 Centers for Disease Control and Prevention (CDC). CDC has concise explanations
about what mental health is, and why it matters. They collect a variety of data,
especially from a public health viewpoint. CDC also offers a short mental health quiz,
focusing more on demystifying and debunking myths, than on diagnosing potential
illnesses. Access: cdc.gov/mentalhealth.

 MedlinePlus. Sponsored by the National Library of Medicine, MedlinePlus is the
premier resource for consumer-health related information. They have an entire “health
topics” section devoted to mental health and behavior topics. Each of the dozens of
diseases and conditions have a variety of authoritative articles (many articles are also
available in Spanish or other languages, or as easy-to-read
materials). Access: medlineplus.gov/mentalhealthandbehavior.html.

 Mentalhealth.gov. MentalHealth.gov is the U.S. government’s one-stop shop for
information about mental health. Information on the site links to other government-
run sites, including the CDC, NIMH, SAMHSA, and MedlinePlus. It offers great
information to help consumers understand the basics of mental health and mental
illness, as well as offering resources for those supporting people who are struggling

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with mental illness. There are also resources for finding professional help and phone
help lines. Access: mentalhealth.gov.

 National Center for PTSD. The National Center for PTSD operates out of the U.S.
Department of Veterans Affairs. In addition to general PTSD information and
treatment options, the National Center for PTSD is also home to the PTSDpubs article
database (formerly PILOTS), the PTSD Trials Standardized Data Repository of
Clinical Trials, as well as numerous mobile apps to designed assist with treatment and
self-help. Access: ptsd.va.gov.

 National Institute of Health (NIH). NIH is composed of 27 institutes and centers
that each have specific research specialties. While there are several institutes that
focus on mental health specifically, NIH also produces resources to assist people
suffering from mental health issues. They publish a monthly newsletter, NIH News in
Health, that frequently contains mental health-related articles, and they also produce
wellness toolkits that provide practical, concrete strategies for improving one’s well-
being. Access: nih.gov.

 National Institute of Mental Health (NIMH). As the primary federal agency
conducting research on mental disorders, NIMH (part of the NIH), is committed to
improving the understanding and treatment of mental illnesses. Information is
available about research funded by NIMH, obtaining funding for research, as well as
participating in clinical trials. NIMH also is home to numerous fact sheets, topic
summaries, and statistics. Access: nimh.nih.gov.

 Office on Women’s Health. As part of the U.S. Department of Health and Human
Services, the Office on Women’s Health seeks to provide leadership at the national
level to improve the health and lives of women and girls. While their focus is on all
aspects of women’s health, website has robust resources and articles about mental
health issues and how they relate to other women’s health
issues. Access: womenshealth.gov/mental-health.

 Substance Abuse and Mental Health Services Administration (SAMHSA). This
U.S. Department of Health and Human Services agency leads public health efforts to
improve behavioral health in the United States. They administer grants, provide
training for mental health practitioners, and run programs like the evidenced-based
practice resource center. SAMHSA also collects statistics, primarily focusing on the
prevalence of substance abuse and mental illness across the
country. Access: samhsa.gov.

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Nonprofit organizations, general
 Brain and Behavior Research Foundation. According to the Rand Corporation, the

Brain and Behavior Research Foundation is the nation’s top nongovernmental funder
for mental health research. The website features information about the latest
discoveries in research for mental illnesses and hosts a blog with articles about
managing mental illness, stories from supporters, and
more. Access: bbrfoundation.org.
 Child Mind Institute. While the Child Mind Institute focuses primarily on
supporting children with mental illnesses or learning disorders and their families, they
have a wealth of information that is valuable to anyone. These resources include
information about different disorders or concerns, challenges that children and young
people face in the classroom, strategies to help educators, and expert
Q&A. Access: childmind.org.
 Mental Health America. Formerly known as the National Mental Health
Association, Mental Health America runs several different programs (including
#mentalillnessfeelslike) to connect individuals with information about mental
illnesses and to provide hope and support for those suffering from mental illness.
They provide numerous free, confidential, anonymous screening tests, as well as
information for ways people can take back control of their lives, including “DIY
tools” and commonly asked questions. Access: mentalhealthamerica.net.
 Mental Health First Aid USA. One of Mental Health First Aid’s goals is to make
first aid for mental health as common as CPR. It is an eight-hour course that teaches
skills in identifying, understanding, and responding to signs of mental illness or
substance use disorders. This program began in Australia in 2001, and has since
spread to more than 25 countries. In the United States alone, more than 2 million
people have been trained in mental health first aid. Courses are available in both
English and Spanish. Access: mentalhealthfirstaid.org.

 National Alliance on Mental Illness (NAMI). In addition to providing information
about mental conditions and treatments, NAMI has a number of infographics, fact
sheets, and statistics. NAMI publishes two blogs on mental health, one of which
features Q&As with experts. NAMI also provides information for minority
populations, including veterans, law enforcement officers, African Americans,
Latinos, and the LGBTQ community. Access: nami.org.

 National Council for Behavioral Health. This nonprofit organization provides
support for more than 3,000 health care organizations that are providing mental health
and addiction treatment and services. The National Council for Behavioral Health
sponsors the Mental Health First Aid USA program, as well as a major national
conference for behavioral health care. Their policy action center advocates for
improved legislation surrounding mental health care. Access: thenationalcouncil.org.
Nonprofit organizations, specialized

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 Active Minds. Active Minds is a suicide awareness and prevention organization that
was founded by a college student after her brother completed suicide. Their website
explains some of the warning signs that someone may be contemplating suicide and
also provides resources to assist them. Active minds has developed a number of
programs that can be implemented on college campuses to increase awareness about
suicide and prevention. They also have speakers that can speak about mental health
awareness and stigma reduction. Access: activeminds.org.

 Anxiety and Depression Association of America (ADAA). The ADAA provides
resources for both professionals and the public related to anxiety and depression
disorders. Among the resources provided for the public are personal stories, blog
posts from experts, information about commonly co-occurring disorders, and tips for
managing anxiety and stress. They also have information about clinical trials and
finding treatment and support. Access: adaa.org.

 Depression and Bipolar Support Alliance (DBSA). DBSA envisions wellness for
people who are living with mood disorders, including depression and bipolar disorder.
In addition to general education materials about mood disorders, DBSA also shares
myriad stories from people living with mood disorders. They also host online support
groups, podcasts, webinars, and an online course about living successfully with a
mood disorder. Access: dbsalliance.org.

 National Eating Disorders Association (NEDA). NEDA is a major nonprofit
bringing awareness to eating disorders. In fall 2018, NEDA merged with the Binge
Eating Disorders Association in order to provide more comprehensive support for all
eating disorders. As part of that merger, NEDA now sponsors Weight Stigma
Awareness Week each September. NEDA aims to build supportive communities for
recovery by providing resources, including a phone helpline, screening tools,
information about finding treatments options and support groups, research funding,
and awareness events, including the Body
Project. Access: nationaleatingdisorders.org.

 National Suicide Prevention Lifeline. This nationwide network of crisis centers
offers free, confidential support to people in suicidal crisis or emotional distress 24
hours a day, 7 days a week. The lifeline is available both by phone and by chat and in
English and Spanish and for the deaf or hard of hearing. They offer resources for a
variety of communities, including veterans, LGBTQ+, attempt survivors, loss
survivors, Native Americans, deaf or hard of hearing, and
youth. Access: suicidepreventionlifeline.org or 1-800-273-TALK (8255).

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 The Trevor Project. The Trevor Project provides crisis intervention and suicide
prevention services to LGBTQ+ young people (particularly those under 25 years of
age). Their resources include information about the warning signs of suicide and a
support center with information and FAQs specifically geared toward the LGBTQ+
community. They also run a lifeline available by phone, chat, and text 24 hours a day,
7 days a week. Access: thetrevorproject.org.
Professional organizations

 American Psychiatric Association (APA). While many of the resources available
through APA are geared toward psychiatry professionals, they do have a series of
webpages devoted to “patients and families.” These resources include topic pages for
many illnesses complete with patient stories, topic summaries, Expert Q&A, and
relevant blog or news articles. Access: psychiatry.org.

 American Psychological Association (APA). In addition to being the organization
responsible for the popular citation style, APA’s website offers a wealth of
information for those interested in psychology-related topics. Available topics expand
beyond typical mental illnesses and include issues like shyness, trauma, learning and
memory, and even parenting. Each topic includes not only related articles and
resources, but also includes a scrolling display of related APA publications.
Recommended books range from those with a professional audience to children’s
picture books. Access: apa.org.
International organizations

 World Health Organization (WHO). WHO maintains information about mental
disorders across the world. WHO has several projects they are currently working on to
expand access to mental health care across the globe. The have a variety of fact sheets
and data available on a number of mental disorders, including suicide. Their website
is available in Arabic, Chinese, English, French, Russian, and
Spanish. Access: who.int/mental_health.

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1.3 Mental Health and the Covid-19 Pandemic

List of authors.
Betty Pfefferbaum, M.D., J.D., and Carol S. North, M.D., M.P.E.
August 6, 2020
N Engl J Med 2020; 383:510-512
DOI: 10.1056/NEJMp2008017
Uncertain prognoses, looming severe shortages of resources for testing and treatment and for
protecting responders and health care providers from infection, imposition of unfamiliar
public health measures that infringe on personal freedoms, large and growing financial losses,
and conflicting messages from authorities are among the major stressors that undoubtedly
will contribute to widespread emotional distress and increased risk for psychiatric illness
associated with Covid-19. Health care providers have an important role in addressing these
emotional outcomes as part of the pandemic response.

Public health emergencies may affect the health, safety, and well-being of both individuals
(causing, for example, insecurity, confusion, emotional isolation, and stigma) and
communities (owing to economic loss, work and school closures, inadequate resources for
medical response, and deficient distribution of necessities). These effects may translate into a
range of emotional reactions (such as distress or psychiatric conditions), unhealthy behaviors
(such as excessive substance use), and noncompliance with public health directives (such as
home confinement and vaccination) in people who contract the disease and in the general
population. Extensive research in disaster mental health has established that emotional
distress is ubiquitous in affected populations — a finding certain to be echoed in populations
affected by the Covid-19 pandemic.

After disasters, most people are resilient and do not succumb to psychopathology. Indeed,
some people find new strengths. Nevertheless, in “conventional” natural disasters,
technological accidents, and intentional acts of mass destruction, a primary concern is post-
traumatic stress disorder (PTSD) arising from exposure to trauma. Medical conditions from
natural causes such as life-threatening viral infection do not meet the current criteria for
trauma required for a diagnosis of PTSD,1 but other psychopathology, such as depressive and
anxiety disorders, may ensue.

Some groups may be more vulnerable than others to the psychosocial effects of pandemics.
In particular, people who contract the disease, those at heightened risk for it (including the
elderly, people with compromised immune function, and those living or receiving care in
congregate settings), and people with preexisting medical, psychiatric, or substance use
problems are at increased risk for adverse psychosocial outcomes. Health care providers are
also particularly vulnerable to emotional distress in the current pandemic, given their risk of
exposure to the virus, concern about infecting and caring for their loved ones, shortages of
personal protective equipment (PPE), longer work hours, and involvement in emotionally and
ethically fraught resource-allocation decisions. Prevention efforts such as screening for
mental health problems, psychoeducation, and psychosocial support should focus on these
and other groups at risk for adverse psychosocial outcomes.

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Beyond stresses inherent in the illness itself, mass home-confinement directives (including
stay-at-home orders, quarantine, and isolation) are new to Americans and raise concern about
how people will react individually and collectively. A recent review of psychological
sequelae in samples of quarantined people and of health care providers may be instructive; it
revealed numerous emotional outcomes, including stress, depression, irritability, insomnia,
fear, confusion, anger, frustration, boredom, and stigma associated with quarantine, some of
which persisted after the quarantine was lifted. Specific stressors included greater duration of
confinement, having inadequate supplies, difficulty securing medical care and medications,
and resulting financial losses.2 In the current pandemic, the home confinement of large
swaths of the population for indefinite periods, differences among the stay-at-home orders
issued by various jurisdictions, and conflicting messages from government and public health
authorities will most likely intensify distress. A study conducted in communities affected by
severe acute respiratory syndrome (SARS) in the early 2000s revealed that although
community members, affected individuals, and health care workers were motivated to
comply with quarantine to reduce the risk of infecting others and to protect the community’s
health, emotional distress tempted some to consider violating their orders.3

Opportunities to monitor psychosocial needs and deliver support during direct patient
encounters in clinical practice are greatly curtailed in this crisis by large-scale home
confinement. Psychosocial services, which are increasingly delivered in primary care
settings, are being offered by means of telemedicine. In the context of Covid-19,
psychosocial assessment and monitoring should include queries about Covid-19–related
stressors (such as exposures to infected sources, infected family members, loss of loved ones,
and physical distancing), secondary adversities (economic loss, for example), psychosocial
effects (such as depression, anxiety, psychosomatic preoccupations, insomnia, increased
substance use, and domestic violence), and indicators of vulnerability (such as preexisting
physical or psychological conditions). Some patients will need referral for formal mental
health evaluation and care, while others may benefit from supportive interventions designed
to promote wellness and enhance coping (such as psychoeducation or cognitive behavioral
techniques). In light of the widening economic crisis and numerous uncertainties surrounding
this pandemic, suicidal ideation may emerge and necessitate immediate consultation with a
mental health professional or referral for possible emergency psychiatric hospitalization.

On the milder end of the psychosocial spectrum, many of the experiences of patients, family
members, and the public can be appropriately normalized by providing information about
usual reactions to this kind of stress and by pointing out that people can and do manage even
in the midst of dire circumstances. Health care providers can offer suggestions for stress
management and coping (such as structuring activities and maintaining routines), link
patients to social and mental health services, and counsel patients to seek professional mental
health assistance when needed. Since media reports can be emotionally disturbing, contact
with pandemic-related news should be monitored and limited. Because parents commonly
underestimate their children’s distress, open discussions should be encouraged to address
children’s reactions and concerns.

As for health care providers themselves, the novel nature of SARS-CoV-2, inadequate
testing, limited treatment options, insufficient PPE and other medical supplies, extended
workloads, and other emerging concerns are sources of stress and have the potential to
overwhelm systems. Self-care for providers, including mental health care providers, involves

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being informed about the illness and risks, monitoring one’s own stress reactions, and
seeking appropriate assistance with personal and professional responsibilities and concerns
— including professional mental health intervention if indicated. Health care systems will
need to address the stress on individual providers and on general operations by monitoring
reactions and performance, altering assignments and schedules, modifying expectations, and
creating mechanisms to offer psychosocial support as needed.

Given that most Covid-19 cases will be identified and treated in health care settings by
workers with little to no mental health training, it is imperative that assessment and
intervention for psychosocial concerns be administered in those settings. Ideally, the
integration of mental health considerations into Covid-19 care will be addressed at the
organizational level through state and local planning; mechanisms for identifying, referring,
and treating severe psychosocial consequences; and ensuring the capacity for consulting with
specialists.4

Education and training regarding psychosocial issues should be provided to health system
leaders, first responders, and health care professionals. The mental health and emergency
management communities should work together to identify, develop, and disseminate
evidence-based resources related to disaster mental health, mental health triage and referral,
needs of special populations, and death notification and bereavement care. Risk-
communication efforts should anticipate the complexities of emerging issues such as
prevention directives, vaccine availability and acceptability, and needed evidence-based
interventions relevant to pandemics and should address a range of psychosocial concerns.
Mental health professionals can help craft messages to be delivered by trusted leaders.4

The Covid-19 pandemic has alarming implications for individual and collective health and
emotional and social functioning. In addition to providing medical care, already stretched
health care providers have an important role in monitoring psychosocial needs and delivering
psychosocial support to their patients, health care providers, and the public — activities that
should be integrated into general pandemic health care.

19

ONLINE
JOURNAL
ARTICLE

20

1.3 Mental Illness Stigma, Help Seeking, and Public Health
Programs
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698814/
Am J Public Health. 2013 May; 103(5): 777–780.
Published online 2013 May. doi: 10.2105/AJPH.2012.301056
PMCID: PMC3698814
PMID: 23488489
Claire Henderson, PhD,corresponding author Sara Evans-Lacko, PhD,
and Graham Thornicroft, PhD

Author information Article notes Copyright and License information Disclaimer
Abstract
Globally, more than 70% of people with mental illness receive no treatment from health care
staff. Evidence suggests that factors increasing the likelihood of treatment avoidance or delay
before presenting for care include (1) lack of knowledge to identify features of mental
illnesses, (2) ignorance about how to access treatment, (3) prejudice against people who have
mental illness, and (4) expectation of discrimination against people diagnosed with mental
illness. In this article, we reviewed the evidence on whether large-scale anti-stigma
campaigns could lead to increased levels of help seeking.

INCREASING EVIDENCE suggests that significantly greater barriers exist to receipt of
mental health care in comparison with physical health care. Worldwide, more than 70% of
young people and adults with mental illness do not receive any mental health treatment from
health care staff.1 The difference between true prevalence and treated prevalence can be
called the treatment gap.2 This article describes the roles that stigma and discrimination
contribute to the treatment gap3,4 and assesses the evidence that public health approaches to
stigma and discrimination can facilitate access to mental health care. We present new data
from the evaluation of Time to Change, England’s largest ever program to reduce mental
illness stigma and discrimination.5

Go to:
DISCRIMINATION, STIGMA, AND MENTAL HEALTH CARE ACCESS
The relationship between stigma and discrimination and access to care is multifaceted; stigma
and discrimination can impede access at institutional (legislation, funding, and availability of
services),6–8 community (public attitudes and behaviors),9 and individual levels.10a
Descriptive studies and epidemiological surveys suggest potent factors that increase the
likelihood of treatment avoidance, delays to care, and discontinuation of service use include
(1) lack of knowledge about the features and treatability of mental illnesses, (2) ignorance
about how to access assessment and treatment, (3) prejudice against people who have mental
illness, and (4) expectations of discrimination against people who have a diagnosis of mental
illness.

21

Addressing public stigma might reduce experienced and anticipated stigma among services
users and facilitate help seeking and engagement with mental health care. For example,
individual service users living in countries with higher rates of help seeking and treatment
utilization, in addition to better perceived access to information about how to deal with
mental health problems and less stigmatizing attitudes, tended to have lower rates of self-
stigma and perceived discrimination.10b Globally, however, stigmatizing attitudes persist
among the public and have been shown to be prevalent11–13 and associated with a reluctance
to seek help.14–16 Specifically, beliefs about effectiveness of treatment and services at the
start of treatment have been shown to influence subsequent treatment behavior.17–19 This is
significant because currently individuals often only access services once they have already
experienced significant impairment, clinical symptoms, and stigma, and these effects may be
difficult to reverse.

Stigma and discrimination and their influence on access to care may vary based on
experience of mental distress or other sociodemographic factors. For instance, psychotic
disorders are highly stigmatizing, and people with psychosis are more likely to be perceived
as violent and unpredictable relative to people with other mental health problems. This can
lead to high levels of experienced and anticipated discrimination in health care settings.20,21
Moreover, substance abuse is consistently associated with high rates of public stigma and
institutional discrimination that may discourage individuals with substance abuse problems
from getting health care; these individuals fear poor treatment by health care providers or
trouble with the authorities.22 Multiple stigma among specific subpopulations may also
exacerbate barriers to care. Different ethnic groups may have different histories and
experiences with the health care system, and therefore, certain barriers may be more

prevalent among individuals of different ethnic groups.23–25 For example, negative

experiences of coercion in mental health care may be more prevalent among ethnic
minorities.26 As a result, it has been suggested that future research should investigate
subgroups and potential interactions between subgroups and on help-seeking attitudes and
behavior.

IMPACT OF PUBLIC HEALTH PROGRAMS ON HELP SEEKING

Because of the complex multifaceted nature of stigma and discrimination and the subsequent
barriers associated with accessing care, the solutions for reducing stigma and discrimination
and facilitating access to care will need to be equally diverse.27 In the United Kingdom, there
are related but separate national programs to reduce stigma and discrimination in Scotland,
England, and Wales. Each of these anti-stigma programs consists of multiple components
aimed at specific target groups (e.g., the media, young people) and at the general public, and
operates at multiple levels (i.e., national social marketing campaigns and regional activities,
such as those based on support from stakeholders), and at the level of small community
groups funded to carry out local anti-discrimination work. Similar programs are also running
in New Zealand (Like Minds Like Mine), Canada (Opening Minds), and Denmark (One of
Us). No data are available regarding any increase in access to mental health care over the
course of these programs, although it should be noted that an increase was observed over the
course of a smaller scale mental health awareness program carried out in Nigeria.28 The lack
of a control group makes it difficult to interpret the extent of any change as being the result of
such programs,29 especially if there are contemporaneous policy and service developments.
In Australia, however, there was variation among states and territories in the utilization of the
depression program Beyondblue, allowing comparison of knowledge and attitudes toward
treatment of depression to be compared across these areas.29 Although these data suggested a

22

positive impact of Beyondblue on attitudes toward help seeking and treatment, no data from
Australia are available on whether help seeking itself increased.

In England, the Time to Change program began in 2007, and the social marketing campaign
started in January 2009.5 The second phase of Time to Change began in October 2011, and
will run until March 2015. The evaluation of Time to Change is carried out by the United
Kingdom's Institute of Psychiatry at King’s College London. Again, the lack of a control
group did not allow us to determine whether help seeking increased as a result of Time to
Change. However, questions about intended help seeking were included before the start of
Time to Change in the Department of Health Attitudes to Mental Illness Survey, a nationally
representative survey which has been ongoing since 1994.30 This survey thus provides a tool
to evaluate the Time to Change campaign.

Using data from the survey, we found that mental health knowledge predicted intentions to
seek help for a mental illness and to disclose such an illness to family and friends, which
underlines the importance of mental health literacy.31 This applied to two types of
knowledge measured by the Mental Health Knowledge Schedule.32 The first was knowledge
that might influence subsequent mental health-related attitudes and behaviors. This type of
knowledge was found to predict help seeking and disclosure more strongly than either
attitude factor present in this survey. The second was whether major psychiatric disorders
(depression, schizophrenia, and bipolar disorder) were considered mental illnesses, which
was associated with help-seeking intentions from a primary care physician.33

Attitudes toward mental illness showed a more mixed pattern with respect to help seeking
and disclosure intentions. A factor analysis of the shortened version of the Community
Attitudes Toward the Mentally Ill scale,34 used in the Department of Health Attitudes to
Mental Illness Survey, suggested that intentions to seek help for a mental health problem
were associated with attitudes of tolerance and support for community care, but not with
stigmatizing attitudes of prejudice and exclusion. These findings suggested that the presence
of strong positive attitudes might be more relevant to help seeking and disclosure than the
absence of negative attitudes.

The preceding findings suggested that if social marketing campaigns were effective at
improving knowledge and positive attitudes, they would result in increased intentions toward
help seeking. However, it was also possible that awareness of the campaign affected help-
seeking intentions through some other mechanism. For the 2012 Attitudes To Mental Illness
Survey, we included questions to assess awareness of the Time to Change social marketing
campaign so that we could directly examine the relationship between campaign awareness
and intended help seeking and disclosure to friends or family. Table 1 describes the
prevalence of intended help seeking by sample characteristics. Prevalence of intended help
seeking ranged from 79% to 89% regardless of sociodemographic characteristics, campaign
awareness, or familiarity with mental health problems through knowing someone.

Table 2 shows the results of multivariable logistic regression that examined the relationship
between campaign awareness and help seeking and disclosure, controlling for
sociodemographic characteristics and familiarity with mental health problems. We found no
relationship between campaign awareness and intended help seeking. For disclosure to family
and friends, the unadjusted results suggested a marginally negative relationship; however,
there was no relationship after adjustment. It was possible that those who were uncomfortable
with discussing a mental health problem with friends and family were more likely to
remember the campaign, which in 2012 emphasized the need to be more open in discussing
mental health problems (It’s Time to Talk). For both items, we found positive relationships

23

with being female; for the help-seeking item, we also found a negative relationship for the
age category 25 to 34 years, which included some of Time to Change’s campaign target
group of those aged 25 to 45 years with middle incomes.

Thus far, we considered initial help seeking; however, examination of the relationship
between anti-stigma programs and help seeking should investigate initial and subsequent
actions. Negative experiences with mental health professionals perceived to be discriminatory
and discrimination experienced at the hands of others because of having a mental illness
might deter individuals from seeking treatment. Therefore, it is hoped that programs such as
Time to Change will lead to reductions in unfair treatment by both health professionals and
others. Interim data from the Viewpoint survey35 suggested that between 2008 and 2009,
after the Time to Change social marketing campaign began in January 2009, the overall level
of discrimination fell. This was accounted for by reduced discrimination from a number of
sources, including friends, family, dates, neighbors, employers, and education professionals.
However, there was no reduction in reports of discrimination from either mental health
professionals or physical health care professionals. This suggested that even if Time to
Change were to increase initial treatment seeking, that is, if public knowledge, attitudes, and
behaviors improved, a lack of reduction in the risk of negative experiences with health
professionals would continue to deter people from seeking further help.

Acknowledgments

Data collection for this article was funded by the Big Lottery Fund; Comic Relief and SHiFT
(Shifting attitudes to mental illness), UK Government Department of Health, through their
funding of the Time to Change program. G. Thornicroft and C. Henderson were funded in
relation to a National Institute for Health Research (NIHR) Programme Grant for Applied
Research awarded to the South London and Maudsley NHS Foundation Trust, and G.
Thornicroft was funded in relation to the NIHR Specialist Mental Health Biomedical
Research Centre at the Institute of Psychiatry, King’s College London and the South London
and Maudsley NHS Foundation Trust. C. Henderson was also funded by a grant from Guy’s
and St Thomas Charity, a grant from the Maudsley Charity, and a NIHR Programme Grant
for Applied Research awarded to Camden and Islington NHS Foundation Trust. G.
Thornicroft received grants for stigma-related research in the past 5 years from Lundbeck
UK, and from the National Institute for Health Research, and has acted as a consultant to the
UK Office of the Chief Scientist.

We thank Sue Baker, Maggie Gibbons, and Paul Farmer, from Mind, Paul Corry and Mark
Davies from Rethink Mental Illness, and Gillian Taylor from TNS BMRB, for their
collaboration.

2.2 Too Fast or Too Slow? Time and Neuronal Variability in
Bipolar Disorder—A Combined Theoretical and Empirical
Investigation

Georg Northoff, Paola Magioncalda, Matteo Martino, Hsin-Chien Lee, Ying-Chi Tseng,
Timothy Lane Author Notes

Schizophrenia Bulletin, Volume 44, Issue 1, January

Published: 19 May 2017

24

https://academic.oup.com/schizophreniabulletin/article/
44/1/54/3835420

Abstract

Time is an essential feature in bipolar disorder (BP). Manic and depressed BP patients
perceive the speed of time as either too fast or too slow. The present article combines
theoretical and empirical approaches to integrate phenomenological, psychological, and
neuroscientific accounts of abnormal time perception in BP. Phenomenology distinguishes
between perception of inner time, ie, self-time, and outer time, ie, world-time, that
desynchronize or dissociate from each other in BP: inner time speed is abnormally slow (as in
depression) or fast (as in mania) and, by taking on the role as default-mode function, impacts
and modulates the perception of outer time speed in an opposite way, ie, as too fast in
depression and too slow in mania. Complementing, psychological investigation show
opposite results in time perception, ie, time estimation and reproduction, in manic and
depressed BP. Neuronally, time speed can be indexed by neuronal variability, ie, SD. Our
own empirical data show opposite changes in manic and depressed BP (and major depressive
disorder [MDD]) with abnormal SD balance, ie, SD ratio, between somatomotor and sensory
networks that can be associated with inner and outer time. Taken together, our combined
theoretical-empirical approach demonstrates that desynchronization or dissociation between
inner and outer time in BP can be traced to opposite neuronal variability patterns in
somatomotor and sensory networks. This opens the door for individualized therapeutic
“normalization” of neuronal variability pattern in somatomotor and sensory networks by
stimulation with TMS and/or tDCS.

Introduction

Bipolar disorder (BP) is a psychiatric disorder that can be characterized by opposite
symptoms in affective, cognitive, psychomotor, and social domains.1–7 One central feature
potentially underlying these various symptoms is the perception of time which has been
pointed out already by earlier psychiatrists as E. Minkoswksi, K. Jaspers, V. van Gebsattel,
and H. Tellenbach as well as more recent ones like G. Stanghellini and T. Fuchs.8–13 Both
phenomenological and psychological investigations show that manic BP patients often
perceive time as abnormally accelerated and thus as extremely fast. In contrast, depressed BP
patients perceive time and its speed as extremely slow and retarded.8,10,14,15 The exact
neuronal mechanisms underlying such opposite changes in time speed perception as either
abnormally fast or slow remain unclear though.Abnormal time speed perception concerns the
subjective experience and perception of the speed of time; ie, “inner time consciousness”—
time is perceived subjectively as slow or fast even if the objective duration of time can be
estimated accurately.8,15,16 Subjective time speed perception in healthy subjects has been
tested in fMRI using tasks that require the estimation of interval duration. This revealed
involvement of regions in somatomotor network including supplementary motor area (SMA),
premotor cortex, medial and superior frontal gyrus, inferior parietal cortex, pallidum and
putamen, insula as well as sensory regions, ie, sensory network, in healthy subjects (see
below for details).17–19 Whether depressed and manic BP patients show changes in
specifically these networks remains to be investigated though.

In addition to regions and networks, the neuronal measure that is relevant for specifically
time speed perception needs to be determined. Traditionally, the amplitude is considered the
main neuronal measure of task-evoked activity. More recently, the variability of the
amplitude, ie, its SD has been introduced as additional measure of neuronal activity for both
resting-state and task-evoked activity.11,20 Neuronal variability measures the degree of
change in amplitude of neuronal activity levels from time point to time point. As such

25

neuronal variability indexes the speed of neuronal activity which, on the perceptual level,
may transform into time speed perception (see below for details).Based on these findings,
abnormal time speed perception in manic and depressed BP should be related to abnormal, ie,
low or high, degrees of neuronal variability, ie, SD, in somatomotor and sensory networks.
Given that time perception, ie, inner time consciousness, remains independent of any specific
task or stimuli, one would expect abnormal SD levels already to be present in the
spontaneous or resting-state activity of somatomotor and sensory networks (see11 for first
results in this direction as well as21 for the need to associate behavioral features to the
resting-state). Neuronal variability in somatomotor and sensory networks including their
abnormal changes in BP remains to be investigated though.

The general overarching aim of our article is to review and investigate the relationship
between time speed perception and neuronal variability (SD) in BP. For that we combine a
theoretical review of phenomenological and psychological features of time speed experience
and perception with analysis of neuroscientific, ie, empirical data on neuronal variability in
BP and its different phases. Such integration of experiential-phenomenal accounts and
neuronal data presupposes methodologically what has recently been called
“neurophenomenal approach.”12,13

The concept of neurophenomenal approach describes a methodological strategy that directly
links subjective experience and its phenomenal features with neuronal mechanisms of the
brain. Rather than being mediated by cognitive, affective, social, or sensorimotor functions,
the neurophenomenal approach presupposes direct linkage and translation of specific
neuronal measures into specific experiential or phenomenal features (this direct linkage
distinguishes the neurophenomenal from the neurophenomenological approach where the link
is more indirect as mediated by specifically sensorimotor and cognitive
functions).12,13,22,23 Thereby the temporal and spatial dimensions of the brain’s
spontaneous activity supposedly play a central role in translating neuronal changes into
phenomenal experience and ultimately psychopathological symptoms. The neurophenomenal
approach is thus closely linked with a particular form of psychopathology namely
“Spatiotemporal Psychopathology.”3,4,12,13 Spatiotemporal Psychopathology claims that
psychopathological symptoms are based on abnormal spatiotemporal organization of the
brain’s spontaneous activity.3,4,12,13 This is, for instance, the case in abnormal time speed
perception in BP; the underlying neural correlates remain unclear and are therefore the focus
in the present article.

Phenomenology of Time: Perception of Inner and Outer Time in BP

Extension of Time—Dysbalance Between Past, Present, and Future in “Inner Time
Consciousness”

Time is not a unitary phenomenon but includes different forms of time. The most common
distinction is the one between subjective and objective time.9 Subjective time is the time we
subjectively perceive or experience in our consciousness which is therefore also described as
“lived time” or “inner time consciousness.”8,24–27 In contrast, objective time is the way we
cognize and measure time in a way that remains independent of our own subjective
perception of time—since time is made explicit here Fuchs8 also speaks of “explicit time” (as
distinguished from the lived time as “implicit time”).

Inner time consciousness or lived time can be characterized by 2 main features, temporal
extension and speed or temporal flow.8 Temporal extension means that we perceive time in
an extended way; ie, beyond the present moment (“primal presentation”) which stretches into
both past, ie, “retention,” and future, ie, “protention”.8,22 We perceive time in our
consciousness as continuous in that it stretches in a virtual way from the past over the present

26

to the future moment—this constitutes “temporal continuity” in our perception of time which
has been described as “stream of consciousness.”12,22 Such constitution of temporal
continuity is automatic and unconscious (“passive”) amounting to what philosophers refer to
as “passive synthesis.”28

Temporal extension and passive synthesis are important also in psychopathological terms.
Many phenomenological authors suggest abnormal, ie, disrupted and fragmented, “inner time
consciousness” in schizophrenia (see8,22,28,29 for details). As pointed out already by earlier
psychiatrists like E. Minkoswksi, K. Jaspers, V. van Gebsattel, and H. Tellenbach as well as
more recent ones as G. Stanghellini and T. Fuchs, bipolar patients too exhibit changes in
temporal extension though in a different way: rather than showing disruption or
fragmentation of time, they experience abnormal shift or focus of time towards either the past
(“past-focus” as in depressed BP) or the present/future (“present/future-focus” as in manic
BP).9,10,30,31

Speed of Time—Dysbalance Between Inner (Self-Time) and Outer (World-
Time) Time

In addition to temporal extension, we need to consider yet a second feature of inner time
consciousness, mainly its speed or temporal flow. We perceive the speed of events in time as
less or more fast which remains somewhat independent of their objective duration. Fuchs8
traces time speed perception to what he describes as “conation”: the concept of conation
refers to the energy, urge, drive, momentum, or vital force that is central for constituting the
speed of time. Analogous to passive synthesis that constitutes temporal extension (see above),
conation is conceived as the mechanism that allows for constituting the speed or flow of time.

The speed or flow of time is constituted in an abnormal way in BP. Depressed BP patients
(and patients with major depressive disorder [MDD]) often perceive abnormal slowness of
time which, in the most extreme case, can lead to the perception of a complete “standstill” or
even absence of time.8–10,32 Conversely, manic BP patients often perceive abnormal
fastening of time. BP can consequently be characterized by a disturbance in conation that
constitutes the speed or flow of time either abnormally slow (as in depressed BP) or fast (as
in manic BP).

Why is there such altered conation with abnormal constitution of time speed? Fuchs8 traces
the origin of conation back to an even more basic and fundamental form of time,
“intersubjective temporality.” Intersubjective temporality or “basic contemporality” concerns
the way we perceive the time outside of us as related to other persons and events in the world,
ie, “world time,” in relation to the time inside ourselves, ie, “self-time.”8,33 Intersubjective
temporality or “basic contemporality” is, for instance, paradigmatically manifest during
dancing that can be characterized by synchronization between inner and outer time: we align
and attune our arms and legs and thus our body’s inner time, ie, self-time, to the speed of the
outer time of the music, ie, world-time (figure 1a).

Fuchs postulates that inner and outer time, ie, self- and world-time, are no longer
synchronized in BP. The inner time, ie, self-time is either too fast or too slow when compared
to the outer time, ie, world-time. There is, so Fuchs,8 either abnormal retardation (as in
depression) or acceleration (as in mania) of inner time which, in turn, changes its relationship
with outer time: inner time, ie, self-time, runs either behind (as in the case of its retardation in
depression) or ahead (as in the case of its acceleration in mania) of outer time, ie, world-time.
The changes in the relationship between inner and outer time strongly shape how subjects
experience and perceive the speed of events in outer time, ie, world-time.

27

Compared to the retarded inner time, events in outer time are perceived as abnormally fast—
this is the case in depression (“I can’t keep up with the speed of events”). While the opposite
holds in mania where the accelerated inner time predisposes subjects to perceive events in
outer time as abnormally slow (“Everything is so slow”).8,9 Accordingly, the speed of inner
time serves as template, ie, baseline or reference, against which the speed of outer time is set
and compared—inner time speed thus exerts what can be described as “default-mode
function” for the speed of outer time (see below for more details on this point).

Psychology of Time: Objective Measurement of Inner Time and Outer Time in BP

Psychology of Inner Time and Outer Time—Time Estimation and (Re)Production

Psychological investigation of time focuses on the objective measurement of both inner and
outer time. The objective measurement of inner time concerns the perceived speed or flow of
the subjects’ own inner time, ie, self time (as for instance in visual analogue scales or other
questionnaires15; see below for details). While the objective measurement of outer time, ie,
world time is often performed by letting subjects perceive and estimate certain durations of
events (like a video) in outer time (see,14,16 see also34,35).

Bschor et al15 showed that depressed patients perceived time as abnormally slow (as rated on
a visual analogue scale) with a mean speed of −15.7 mm whereas manic patients perceived
time as abnormally fast with +15.8 mm on the VAS (healthy subjects were around 1 mm).
Another study by Mahlberg et al14 investigated time reproduction task. Manic patients
reproduced the short intervals (1 s and 6 s) correctly while they under-reproduced (ie,
reproduced it as shorter than it actually was) the longer interval (37 s). Depressed patients
showed the opposite pattern; they reproduced the longer time interval (37 s) correctly but
over-reproduced (ie, reproduced it as longer than it actually was) the shorter time intervals (1
s, 6 s) (see also36 and15). How are over- and under-reproduction of time intervals related to
the phenomenological description of inner and outer time? That shall be explicated in the
following.

From Phenomenology to Psychology of Time—Inner Time as Default-Mode Function
and Template for Perception of Outer Time

How do the psychological results stand in relation to the phenomenological descriptions? The
time reproduction results reflect what the phenomenologists describe as desynchronization
between inner and outer time. In the case of time reproduction, the duration of events in outer
time, ie, a particular time interval in the external world, must be reproduced—this is possible
by comparing the supposed duration of the interval in outer time with the actual duration of
the subject’s inner time. The inner time and its duration serve as template for estimating and
reproducing the duration in outer time. If the subject’s inner time, ie, self time, is somewhat
synchronized with outer time, ie, world time, there should be no major discrepancies between
given and reproduced times in time reproduction tasks. The inner time and its duration
provide the proper template for reproducing the duration of intervals in outer time.

Such synchronization is disrupted though when the subject’s inner time is by itself
abnormally retarded or accelerated. This leads to desynchronization between inner and outer
time which, in turn, predisposes subjects to either under- or over-reproduce the given time
intervals in time reproduction tasks. The inner time and its either abnormally long or short
duration provide simply the “wrong” template for reproducing intervals in outer time. The

28

intervals in outer time are then quasi by default over- or under-reproduced as either too long
or short. That is exactly what the data show in manic and depressed BP.

How can we describe the default-mode function of inner time for outer time in more detail?
What is relevant for estimating and reproducing the duration of events in outer time (as it is
required in time reproduction tasks) is not their objective duration as conceived by itself in an
isolated way, ie, independent of the subject’s inner time. Instead, following the
phenomenological account of time (see above), it is rather how the duration of the events in
outer time stands in relation to the inner time: the speed and duration of inner time serves as
template, ie, baseline or reference against which the duration of events in outer time is
compared or matched. The duration of the event in outer time is consequently estimated and
reproduced relative to the speed and duration of the ongoing inner time—inner time and its
speed and duration serve as default-mode function for estimating and reproducing outer time.

Due to its role as default-mode, ie, baseline or reference, changes in inner time like abnormal
retardation or acceleration affect how the duration or speed of events in outer time is
perceived and subsequently estimated and reproduced.

If the speed of inner time is retarded and thus too slow, as in depression, one applies an
abnormal default-mode or template as baseline or reference for estimating and reproducing
intervals in outer time. One consequently perceives and reproduces especially short time
intervals in outer time as relatively longer and thus as slow and too long (when compared to
their objective duration)—this results in over-reproduction of their duration (“everything
takes longer and is slower”) as observed by Mahlberg et al14 (see above). The opposite is the
case in mania: applying the inner time that is abnormally fast as template, ie, reference or
baseline leads one to perceive and subsequently under-reproduce (especially longer)
durations of events in outer time as shorter and faster than they are in reality (“everything
takes shorter and is faster”) (figure 1b).

Neuroscience of Time: Neuronal Variability in Somatomotor and Sensory Networks in BP

“Somatomotor Network” and “Sensory Network” Mediate Inner Time and Outer TimeRecent
meta-analysis in healthy subjects investigated the regions implicated in time perception; ie,
interval timing and duration of events (see18 as well as17). Wiener et al18 and Ortuno et al19
conducted meta-analyses of various neuroimaging studies in healthy subjects investigating
explicit and implicit interval timing by perception of stimulus duration (sub-seconds vs supra-
seconds) in both sensory and motor domains. Both meta-analyses singled out various
somatomotor regions as being implicated in implicit and explicit time speed perception; these
included regions like SMA, middle frontal gyrus, right thalamus, cerebellum, and left
putamen (as well as other regions like left and right insula and left superior temporal gyrus).
Since they are apparently involved in time speed perception, these regions have been
described as “neural timing circuit.”37,38

The various subcortical and cortical regions form the somatomotor network and are central
for the internal planning (like middle frontal gryus), preparing, initiating (like supplementary
area), and executing (like putamen, cerebellum, and thalamus) action and movement (see
also17). Planning, preparing, and executing action and movement are internally-originating
activities: they involve the constitution of the subject’s own time in order to provide interval
timing and duration for the subsequently internally-initiated and executed actions and
movements.17 We therefore suppose that neural activity in the somatomotor network is
specifically relevant for constituting the speed of inner time, ie, self-time.How about outer
time, ie, world-time? We traced inner time to a neural network, the somatomotor network,

29

whose neural activity and its timing are determined and originates internally. In contrast to
inner time, outer time is rather determined externally by the events and their duration in the
outside world. The external events are first and foremost processed in sensory regions like
visual and auditory cortex. Owe consequently can suppose that neural activity in sensory
regions and, more generally, the sensory network is central in constituting the speed of outer
time, ie, world-time.

How do the neural substrates of inner and outer time stand in relation to each other?
Somatomotor and sensory processing are closely intertwined as manifest in the coupling
between perception and action.39,40 For instance, external events including their duration are
processed in sensory regions which, at the same time, are modulated by reafferent processing
from the somatomotor network.39 Moreover, there is extensive functional connectivity
between somatomotor and sensory networks allowing for their reciprocal modulation39,40—
this makes it rather likely that the somatomotor network serves as reference or baseline
against which the sensory network is set and compared. Rather than investigating neural
activity in sensory and somatomotor networks independently of each other, one may
therefore want to focus on their relation or balance as it can be operationalized by their ratio
(see below for details). This is also well compatible with the phenomenological assumption
that the speed of inner time serves as default-mode; ie, as baseline or reference for outer time.

Neuronal Variability Mediates Dynamic Change and Time Speed on the Neuronal Level

How does neural activity in somatomotor and sensory networks transform into perception of
inner and outer time speed? The neurophenomenal approach postulates that what is described
as time speed on the perceptual and phenomenological level may find its counterpart in the
speed of neural activity. We consequently need to search for a neuronal measure that indexes
the change and thereby the speed of neural activity.The most traditional measure of neural
activity is the amplitude that is evoked by specific stimuli or tasks. The amplitude measures
the signal change as induced by the stimulus or task. However, what we determine as
amplitude results from averaging across different trials of one and the same stimulus or task
—this cancels out or eliminates the dynamic changes and thus the speed of neural activity.
Specifically, the averaging across different points in time makes the amplitude a rather static
measure which therefore remains unable to account for the change or speed of neural activity.
We therefore want to search for a more dynamic neuronal measure to index neuronal change
and thereby speed on the neuronal level.Neuronal change can be measured by neuronal
variability that has recently been introduced as novel measure into brain imaging. Neuronal
variability is measured by calculating either the SD of the amplitude20 or the amplitude of
low frequency fluctuations (ALFF).20 Neuronal variability, ie, SD or ALFF, reflects the
dynamic change of neural activity and its amplitude across different points in time: both
measures (that are more or less equivalent) describe and measure the degree of change in
amplitude from one point in time to another and ultimately across the whole range of time
points obtained during measurement of resting-state (or task-evoked) activity. In short,
neuronal variability measures the change across different points in time.

How is neuronal variability related to the speed of time? If, for instance, the amplitude is the
same between 2 or several points in time, neuronal variability, ie, SD or ALFF, remains zero
—neuronal activity remains rather static, does not show much change, and is therefore
“slow.” If, in contrast, there is rapid change in amplitude from one time point to the next one,
variability is rather high. In that case, neuronal activity is extremely dynamic, shows high
degree of change, and is therefore “fast.” Taken together, the speed of neuronal activity is
indexed in an indirect or relative way by the degree of change, ie, variability from one point
in time to another: high degrees of neuronal variability index high speed of neuronal activity

30

whereas low levels of neuronal variability may rather reflect low speed of neuronal
activity.How does neuronal variability as indexing the speed of neuronal activity transform
into experience and perception of the speed of time? Since it indexes the speed of neuronal
activity, we hypothesize that neuronal variability transforms into corresponding speed of time
on perceptual and phenomenal levels. More specifically, high neuronal variability may lead
subjects to experience and perceive time as fast while low neuronal variability transforms
into experience and perception of time as slow. This, as we will see in the following, is
indeed supported by the results in BP (and MDD).

Neurophenomenology of Time: From Neural Network Disbalance Over Time
Desynchronization to Psychopathological Symptoms

Phenomenological investigation suggests desynchronization between inner and outer time in
opposite directions in depressed and manic BP patients. This is further extended in
psychological investigation where objective measures show abnormal slowness or fastness of
specifically inner time as well as abnormally perceived duration of external events in our time
(see above). Given such desynchronization between inner and outer time, one would
analogous disbalance in their respectively underlying neural networks, ie, somatomotor and
sensory networks. This is exactly what our data showed.Specifically, our data demonstrate
that the SD ratio between somatomotor and sensory networks is abnormally tilted towards the
somatomotor network in mania. In contrast, the SD ratio is shifted in the opposite direction
towards the sensory network in depression. Healthy subjects occupy a middle position
whereas the somatomotor-sensory SD ratio is not shifted towards either extreme. Taken all
together, this suggests a neural continuum of different possible somatomotor-sensory SD
balances: at both extremes of the continuum, the SD ratio is tilted towards either network (as
in depressed or manic BP as well as in MDD) while in the middle of the continuum the SD is
rather balanced between both networks (figures 3a and b).

How does the neural continuum of different possible somatomotor-sensory SD balances
translate into experience and perception of time speed? We suppose an analogous perceptual-
experiential continuum of different possible constellations between inner and outer time
speed. Depressed patients show decreased neuronal variability in the somatomotor network
which, experientially and perceptually, results in retardation of inner time.

Moreover, this tilts the SD balance towards the sensory network which predisposes these
subjects towards experiencing and perceiving events in outer time as abnormally fast. The
manic patients, in contrast, show the opposite pattern. Here the SD is abnormally high in the
somatomotor network which, experientially and perceptually, transforms into acceleration of
inner time. That tilts the SD ratio towards the somatomotor network at the expense of the
sensory network whose low SD leads to the experience and perception of events in outer time
as abnormally slow.

What phenomenologically is described as desynchronization between inner and outer time
may thus be traced on the neuronal level to the shifting of somatomotor-sensory SD ratios
towards opposite extremes. Following the phenomenologist’s terminology, one can say that
the SD’s in somatomotor and sensory networks desynchronize or dissociate from each other.
The somatomotor network SD is either abnormally fast or slow for which reason it
desynchronizes or dissociates from sensory SD. Due to the fact that somatomotor SD may
serve as default-mode function (see above) for sensory SD, the latter will change in an
opposite or reciprocal way when compared to the former hence the opposite changes in inner
and outer time speed in BP. Finally, our data show that the abnormal SD network balance
correlated in opposite ways with manic and depressive symptoms. This underscores the direct
relevance of spatiotemporal changes in resting-state for psychopathological symptoms and
their severity.

31

Future investigations are required to test our neurophenomenal hypothesis. One way could be
to directly link phenomenological (with subjective questions) and psychological (with time
estimation and reproduction) measures of time speed experience and perception with
neuronal variability in somatomotor and sensory networks, in different frequency ranges.
Different subjects may show SD changes in different frequencies (eg, within the Slow5
range) which, clinically, may correspond to individually-specific speeds of time in experience
and perception. Determining the individually-specific altered frequency range of
somatomotor and sensory SD, and correspondent time experience, could be clinically
relevant. That, in turn, could serve for individually-specific therapeutic intervention. For
instance, neuronal variability in somatomotor and sensory cortical resting-state activity could
be modulated by applying stimulation in the individually specific frequency range with TMS
and/or tDCS to “normalize” the respective individual time speed perception and subsequently
psychopathological symptoms.
Conclusion
We here reviewed and integrated different levels of time, phenomenological, psychological,
and neuronal in BP in a combined theoretical-empirical investigation. We suppose that the
opposite disbalance between inner and outer time, ie, self- and world-time, in manic and
depressed BP is closely related to opposite changes in neuronal variability in somatomotor
and sensory networks as supported by our empirical findings. Though tentative at this point
in time, this amounts to direct temporal correspondence between neuronal and phenomenal
features, ie, “neurophenomenal correspondence.”22,23 Both abnormal neuronal and
phenomenal measures may, in turn, predict somatomotor, sensory, affective, and cognitive
symptoms during task-evoked activity in BP which supposedly result from abnormal
temporal (and spatial) organization in the brain’s resting state as postulated in
“Spatiotemporal Psychopathology,”4,12,29 as basis for an individually-specific diagnosis and
therapy.

32

2.3 The coronavirus (COVID‐19) pandemic's impact on mental
health

Bilal Javed,corresponding author 1 , 2 Abdullah Sarwer, 3 , 4 Erik B. Soto, 5 and Zia‐ur‐
Rehman Mashwani 1

Abstract

Throughout the world, the public is being informed about the physical effects of SARS‐CoV‐
2 infection and steps to take to prevent exposure to the coronavirus and manage symptoms of
COVID‐19 if they appear. However, the effects of this pandemic on one's mental health have
not been studied at length and are still not known. As all efforts are focused on understanding
the epidemiology, clinical features, transmission patterns, and management of the COVID‐19
outbreak, there has been very little concern expressed over the effects on one's mental health
and on strategies to prevent stigmatization. People's behaviour may greatly affect the
pandemic's dynamic by altering the severity, transmission, disease flow, and repercussions.
The present situation requires raising awareness in public, which can be helpful to deal with
this calamity. This perspective article provides a detailed overview of the effects of the
COVID‐19 outbreak on the mental health of people.

1.  INTRODUCTION

A pandemic is not just a medical phenomenon; it affects individuals and society and causes
disruption, anxiety, stress, stigma, and xenophobia. The behaviour of an individual as a unit
of society or a community has marked effects on the dynamics of a pandemic that involves
the level of severity, degree of flow, and aftereffects. 1 Rapid human‐to‐human transmission
of the SARS‐CoV‐2 resulted in the enforcement of regional lockdowns to stem the further
spread of the disease. Isolation, social distancing, and closure of educational institutes,
workplaces, and entertainment venues consigned people to stay in their homes to help break
the chain of transmission. 2 However, the restrictive measures undoubtedly have affected the
social and mental health of individuals from across the board. 3

As more and more people are forced to stay at home in self‐isolation to prevent the further
flow of the pathogen at the societal level, governments must take the necessary measures to
provide mental health support as prescribed by the experts. Professor Tiago Correia
highlighted in his editorial as the health systems worldwide are assembling exclusively to
fight the COVID‐19 outbreak, which can drastically affect the management of other diseases
including mental health, which usually exacerbates during the pandemic. 4 The psychological
state of an individual that contributes toward the community health varies from person‐to‐
person and depends on his background and professional and social standings. 5

Quarantine and self‐isolation can most likely cause a negative impact on one's mental health.
A review published in The Lancet said that the separation from loved ones, loss of freedom,
boredom, and uncertainty can cause a deterioration in an individual's mental health status. 6
To overcome this, measures at the individual and societal levels are required. Under the
current global situation, both children and adults are experiencing a mix of emotions. They
can be placed in a situation or an environment that may be new and can be potentially
damaging to their health. 7

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2.  CHILDREN AND TEENS AT RISK
Children, away from their school, friends, and colleagues, staying at home can have many
questions about the outbreak and they look toward their parents or caregivers to get the
answer. Not all children and parents respond to stress in the same way. Kids can experience
anxiety, distress, social isolation, and an abusive environment that can have short‐ or long‐
term effects on their mental health. Some common changes in children's behavior can be 8 :

 Excessive crying and annoying behaviour
 Increased sadness, depression, or worry
 Difficulties with concentration and attention
 Changes in, or avoiding, activities that they enjoyed in the past
 Unexpected headaches and pain throughout their bodies
 Changes in eating habits
To help offset negative behaviours, requires parents to remain calm, deal with the situation
wisely, and answer all of the child's questions to the best of their abilities. Parents can take
some time to talk to their children about the COVID‐19 outbreak and share some positive
facts, figures, and information. Parents can help to reassure them that they are safe at home
and encourage them to engage in some healthy activities including indoor sports and some
physical and mental exercises. Parents can also develop a home schedule that can help their
children to keep up with their studies. Parents should show less stress or anxiety at their home
as children perceive and feel negative energy from their parents. The involvement of parents
in healthy activities with their children can help to reduce stress and anxiety and bring relief
to the overall situation. 9

3.  ELDERS AND PEOPLE WITH DISABILITIES AT RISK

Elderly people are more prone to the COVID‐19 outbreak due to both clinical and social
reasons such as having a weaker immune system or other underlying health conditions and
distancing from their families and friends due to their busy schedules. According to medical
experts, people aged 60 or above are more likely to get the SARS‐CoV‐2 and can develop a
serious and life‐threatening condition even if they are in good health. 10

Physical distancing due to the COVID‐19 outbreak can have drastic negative effects on the
mental health of the elderly and disabled individuals. Physical isolation at home among
family members can put the elderly and disabled person at serious mental health risk. It can
cause anxiety, distress, and induce a traumatic situation for them. Elderly people depend on
young ones for their daily needs, and self‐isolation can critically damage a family system.
The elderly and disabled people living in nursing homes can face extreme mental health
issues. However, something as simple as a phone call during the pandemic outbreak can help
to console elderly people. COVID‐19 can also result in increased stress, anxiety, and
depression among elderly people already dealing with mental health issues.

Family members may witness any of the following changes to the behavior of older
relatives 11 ;

 Irritating and shouting behavior

 Change in their sleeping and eating habits

34

 Emotional outbursts

The World Health Organization suggests that family members should regularly check on
older people living within their homes and at nursing facilities. Younger family members
should take some time to talk to older members of the family and become involved in some
of their daily routines if possible. 12

4.  HEALTH WORKERS AT RISK

Doctors, nurses, and paramedics working as a front‐line force to fight the COVID‐19
outbreak may be more susceptible to develop mental health symptoms. Fear of catching a
disease, long working hours, unavailability of protective gear and supplies, patient load,
unavailability of effective COVID‐19 medication, death of their colleagues after exposure to
COVID‐19, social distancing and isolation from their family and friends, and the dire
situation of their patients may take a negative toll of the mental health of health workers. The
working efficiency of health professionals may decrease gradually as the pandemic prevails.
Health workers should take short breaks between their working hours and deal with the
situation calmly and in a relaxed manner. 5

5.  STIGMATIZATION

Generally, people recently released from quarantine can experience stigmatization and
develop a mix of emotions. Everyone may feel differently and have a different welcome by
society when they come out of quarantine. People who recently recovered may have to
exercise social distancing from their family members, friends, and relatives to ensure their
family's safety because of unprecedented viral nature. Different age groups respond to this
social behavior differently, which can have both short‐ and long‐term effects. 1

Health workers trying to save lives and protect society may also experience social distancing,
changes in the behavior of family members, and stigmatization for being suspected of
carrying COVID‐19. 6 Previously infected individuals and health professionals (dealing
pandemic) may develop sadness, anger, or frustration because friends or loved ones may have
unfounded fears of contracting the disease from contact with them, even though they have
been determined not to be contagious. 5

However, the current situation requires a clear understanding of the effects of the recent
outbreak on the mental health of people of different age groups to prevent and avoid the
COVID‐19 pandemic.

6.  TAKE HOME MESSAGE

 Understanding the effects of the COVID‐19 outbreak on the mental health of various
populations are as important as understanding its clinical features, transmission
patterns, and management.

 Spending time with family members including children and elderly people,
involvement in different healthy exercises and sports activities, following a
schedule/routine, and taking a break from traditional and social media can all help to
overcome mental health issues.

 Public awareness campaigns focusing on the maintenance of mental health in the
prevailing situation are urgently needed.

35

ONLINE
NEWSPAPER

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3.1 Anxiety, depression rampant among children even before the
pandemic

More than one-third of high school students couldn't shake the feelings of sadness or
hopelessness, a report found. And that was before Covid-19 hit the nation.

Feb. 25, 2022, 5:05 AM +08

By Erika Edwards

https://www.nbcnews.com/health/health-news/anxiety-depression-rampant-children-even-
pandemic-rcna17545

An extensive new look at anxiety and depression among children and teenagers finds the
mental health concerns were a major public health problem even before the Covid-19
pandemic hit.

The Centers for Disease Control and Prevention reported Thursday that 1 in 5 teenagers in
the United States had at some point experienced an episode of major depression: unshakeable
and worrisome feelings of sadness and hopelessness lasting for at least two weeks.

Full coverage of the Covid-19 pandemic

The data were pulled from nine federal surveillance systems of children's mental health,
including the National Health and Nutrition Examination Survey, the National Survey on
Drug Use and Health, and the Youth Risk Behavior Survey. Data were collected from 2013
through 2019.

The report didn't include, however, data from 2020 onward, a time that saw startling
increases in stress and anxiety among children due to the pandemic. A previous CDC report
found that emergency room visits related to children's mental health rose dramatically in
2020, compared with 2019.

"The fact that this report precedes the pandemic is stunning," said Dr. Richard Besser, a
pediatrician and the president of the Robert Wood Johnson Foundation. "What is says to me
is that this is a dramatic underestimation in terms of how significant this crisis truly is."

"I would view a report like this as a harbinger of a much worse situation that we'll be seeing
the next time a report comes out," he added.

The mental health problems detailed in the new CDC report go far beyond typical teenage
moodiness that comes and goes.

In 2019, more than one-third of high school students reported "persistently feeling sad or
hopeless in the past year," the study found.

Nearly 1 in 5 teens had seriously considered dying by suicide. About 7 in 100,000 children
and teens, 10 to 19 years old, died by suicide in 2018 and 2019.

From 2011 through 2019, suicide was the second leading cause of death among young people
ages 10 to 29 in the U.S., after accidents and unintentional injuries.

Girls generally had higher levels of depression than boys.

37

And anxiety disorders — characterized by excessive fears and worries — started at early
ages. The report found 2 percent of children ages 3 to 5 had anxiety. That percentage
increased to 13.7 percent for those ages 12 to 17.
Among children up through age 17, just 10 percent had received mental health services, the
report found.
Besser said parents and caregivers can watch for signs that children may be struggling with
sadness or anxiety, including sudden changes in behaviour, problems with grades and/or
friends, and a lack of fulfillment in activities they previously enjoyed.

38

3.2 INTERACTIVE: Mental health for all

By YUEN MEIKENG
STARPLUS
Sunday, 10 Oct 20217:00 AM MYT
https://www.thestar.com.my/starplus/2021/10/10/interactive-mental-health-for-all

Anxiety is one of the most common mental health issues Malaysians are
facing as we learn to live with Covid-19.

IT’S an unseen “side effect” of the Covid-19 pandemic that needs our attention.
More Malaysians are facing mental health issues at varying levels – be it due to job losses,
changing norms or feeling anxious over the coronavirus.
“The pandemic has affected the mental health of the population at every level.
“The most common mental health issues are acute stress disorders, anxiety, depression,
adjustment disorders and burnout,” the Health Ministry tells Sunday Star.

CLICK TO ENLARGE
It’s become more important, now more than ever, for mental health care to be more
accessible to all walks of life, especially those in the low income bracket or B40.
However, the problem is that Malaysia still does not have enough mental health
professionals, with the current counsellor-to-individual ratio being 1: 52,000.

The normal ratio should be one counsellor for every 5,000 people, says the ministry.
Fortunately, the ministry is working towards ensuring more people get the help they need.
The ministry is training more volunteers from non-governmental organisations (NGOs) to
equip them with Psychological First Aid (PFA).
“Such training will enable volunteers to provide basic psychosocial support at the community
level.
“They will be able to help identify those who may need further assessment and intervention,
and help them get the professional help they need,” the ministry says.
PFA is supportive and practical assistance to people who have recently suffered a serious
stressor, according to the World Health Organisation (WHO).

39

While it is not considered professional counselling, such help provides comfort, non-intrusive
care and protects others from further harm.

In a short period of time, the ministry realises it may not be possible to achieve the desired
number of mental health professionals.

“As such, we are looking into the concept of “task shifting” to empower local community
leaders, religious leaders and NGOs to detect people with mental health issues, provide
support and assist them in getting help appropriately,” the ministry says.

To date, there are a total of 459 psychiatrists nationwide, with 256 being in the public sector.

There are 30 clinical psychologists with the Health Ministry, while eight are with other
ministries.

The ministry also has a total of 346 psychology counselling officers and over 500 family
medicine specialists, who provide mental health services at the primary care level.

“These family medicine specialists are trained to diagnose and treat mental disorders like
depression and anxiety disorders,” the ministry says.

Such efforts are timely with this year’s World Mental Health Day’s slogan by the WHO,
“Mental health care for all: let's make it a reality”.

The slogan has been adapted to Bahasa Malaysia by the ministry as “Let’s Talk Minda Sihat:
Menuju Kesaksamaan Kesihatan Mental.”

“Given mental health has always been defined as an essential dimension of health, the
ministry is committed to ensuring accessible mental health services where no one will be left
behind,” it says.

Marked every year on this day (Oct 10), World Mental Health Day aims to raise awareness
on mental wellbeing across nations.

The cost of mental health

But the reality is that the price to seek mental health care is much higher in the private sector.

For example, private centres can cost about RM100 to RM250 per session, depending on the
facility and counsellor’s level of qualification.

In contrast, the ministry’s Community Mental Health Centres (Mentari) offers the first check
up for free for patients with a referral letter from public health clinics.

After that, RM5 is charged for each follow up session.

The various free helplines now are also a much appreciated service for all, but more needs to
be done, says consultant psychiatrist Dr Ting Joe Hang.

Dr Ting notes that Malaysia has one of the best public healthcare systems in the world where
free treatment or services charged at a nominal fee can be given to anyone.

“But the waiting list can be quite long due to the lack of resources and manpower, especially
in mental healthcare,” he points out.

With more mental health professionals in Malaysia, Dr Ting believes that the waiting time
can be reduced and more clinics can be opened.

“Right now, the WHO’s slogan is even more true than ever that mental health care should be
for all, as more people worldwide suffer from mental health issues.

“Mental health and social issues tend to be more prevalent among the B40, therefore more
should be done for them,” he says.

Noting the situation, the ministry realises there is a discrepancy in the cost of treatment
between the government and private sectors.

40

“For those who can’t afford to go for private facilities, they can seek treatment at the
ministry’s facilities nationwide,” it says.
This includes mental health services in 1,161 health clinics at primary care facilities which
provide screening and intervention for individuals with mental health conditions.
There are also 60 hospitals and 28 Mentari centres nationwide that provide psychiatric and
mental health services for the public.
“The ministry also launched an initiative to incorporate mental health screening services as
part of the Health Care Scheme in the PeKa B40 initiative to ensure the low income group
has access to mental health assistance,” it points out.

It’s become more important, now more than ever, for mental health care to be more
accessible to all walks of life, especially those in the low income bracket or B40. —
123rf.com
Stop the stigma
Another stumbling block for those who need to get help is the stigma that comes with seeking
mental health treatment.
Malaysian Psychological Association president Assoc Prof Dr Wan Shahrazad Wan Sulaiman
says mental health is often overlooked due to its lack of visibility, as well as the negative
stigma and discrimination from some quarters in society.
“The most vulnerable people like minorities, youths, senior citizens and frontliners are more
often affected,” she says.
To make mental health more visible, Dr Wan Shahrazad, a senior lecturer at Universiti
Kebangsaan Malaysia, says efforts need to be scaled to bigger levels to improve the people’s
wellbeing.
It’s certainly okay to get help, and the ministry calls on the public to stop the stigma
involving patients with mental health conditions and their carers in seeking help.

41

“Getting treatment early will help alleviate the emotional impact that the family is going
through,” it adds.
For those who seek alternative treatments like from bomoh or sinseh to cure mental illnesses,
the ministry empathises that family members sometimes want to seek out various sources for
their loved ones.
“However, the ministry would like to stress that it’s important to get a medical diagnosis if
you or your loved ones are suspected to have a mental illness.
“Depression and other mental illnesses are treatable.
“Please seek professional help first to avoid delays in diagnosis and getting timely treatment,”
it urges.
For more information on how to get help, visit www.infosihat.gov.my/let-s-talk-minda-
sihat.html

42

3.3Experts: Mental health issues rising with the waters

https://www.thestar.com.my/news/nation/2022/01/04/experts-mental-health-issues-rising-
with-the-waters
Tuesday, 04 Jan 2022

Resourceful folk: A couple of villagers taking the opportunity to make some money by
laying their fishing nets along the flooded road between Batu 8 and Buluh Kasap in
Segamat, Johor. — Bernama
PETALING JAYA: As heavy storm and floods rage on, mental health experts are
anticipating a rise in anxiety and post-traumatic stress disorder (PTSD).
They say it will not only be among the displaced communities but from their families and
public as well.
Mental health expert Datuk Dr Andrew Mohanraj said there were already numerous cases
received by the Malaysian Mental Health Association linked to floods.
“We have been getting about 500 calls a month and the numbers are increasing as a result of
the floods,” said the association president yesterday.
He said continuous rain would cause fear and anxiety.
“Traditionally, we often see ourselves as a safe country but the unexpected floods in certain
areas have caused trauma to the people,” he added.
Dr Mohanraj noted that the situation could exacerbate certain symptoms for those who were
already battling depression and anxiety.

43

“This is reflected in the calls we are receiving,” he said.
“They express fear and worry about relapses.”
He said it was not unique to the victims but their families as well.
Dr Mohanraj expressed concern that this could be a prolonged situation.
“Once the flood situation recovers, victims who return to their homes could experience PTSD
symptoms. This could last for between six months and a year,” he said.
Among the symptoms are distrust towards others, especially survivors and those who have
lost loved ones.
“Some may experience memory loss and poor concentration. If not addressed properly, it
may lead to reckless behaviours among adults and use of drugs to cope.
“In children, it could be of great impact on them when they grow up,” he said.
Counsellor Rohini Krishnan, 27, said more people had been getting mental health help since
the floods occurred.
“There is increased anxiety in a lot of people. This situation can be addressed as seasonal
depression or seasonal anxiety like that of people in countries that have winter.
“They feel more depressed and lonely during the cold weather.
“When people with this issue see dark clouds or when it is raining, they become worried,
adding to their existing anxiety,” said Rohini, the founder of Meraky Counselling Services.
To reduce the chances of getting a panic attack, she advised them to set up support groups
with family, friends and colleagues.
“Keep everyone in the loop every day,” she said.
Psychiatrist and psychotherapist Dr Hazli Zakaria, who is also Malaysia Psychiatrist
Association president, highlighted the importance of having proper assessment of victims’
needs, in terms of their psychological states.
“There must also be clear and specific plans by the relevant authorities to support victims,
including short, mid and long-term planning,” he said.

44

E-BOOK

45

4.1 Anxiety & Depression Workbook for Dummies

Charles H. Elliott, Laura L. Smith

https://en.my1lib.org/book/538966/e37a63?dsource=recommend

From identifying your triggers to improving your relationships -- manage your emotional
wellbeing
Struggling to cope with anxiety and/or depression? Have no fear -- this hands-on guide
focuses on helping you pinpoint the root of your problems and find relief from your
symptoms in a detailed, step-by-step manner. With concise, eye-opening exercises, you'll
understand how to assess your current situation, remove the roadblocks to change, face your
fears, and improve your view of yourself and the world around you. You'll see how to take
direct action to alter negative or distorted thinking, lift your moods, and adopt positive habits
that will lead you toward a more joyful, meaningful, and connected life!
Discover
* How to improve the way you feel about yourself
* Skills to face and overcome what makes you anxious or depressed
* How to determine whether medication is an option for you
* Practical ways to prepare for and deal with setbacks

46

4.2 The Mental Health Clinician’s Workbook: Locking In Your
Professional Skills

James Morrison
https://en.my1lib.org/book/3625849/58db23?dsource=recommend

Rich with compelling case material, this hands-on workbook helps mental health practitioners
and students build essential skills for clinical evaluation and differential diagnosis. Renowned
diagnostician and bestselling author James Morrison (DSM-5 Made Easy and other works)
invites the reader to interview and evaluate 26 patients with a wide spectrum of presenting
complaints and ultimate diagnoses. Using multiple-choice questions and fill-in-the-blank
exercises, clinicians practice the arts of interviewing and making diagnostic decisions. The
convenient large-size format facilitates use. Extensive tables in the appendix provide a quick-
reference guide to the interviewing techniques, diagnostic principles, and clinical diagnoses
discussed in each case.
See also Morrison's DSM-5® Made Easy, which explains DSM-5 diagnoses in clear
language, illustrated with vivid case vignettes; Diagnosis Made Easier, Second Edition,
which offers principles and decision trees for integrating diagnostic information from
multiple sources; and The First Interview, Fourth Edition, which presents a framework for
conducting thorough, empathic initial evaluations.

47

4.3 The Therapist's Workbook: Self-Assessment, Self-Care, and
Self-Improvement Exercises for Mental Health Professionals

Jeffrey A. Kottler

Mental health professionals spend their days helping others, but who is there to help them
when stress and burnout threaten their own well-being? Filled with self-assessments,
journaling exercises, and activities designed to facilitate renewal, growth, and change, this
timely book helps clinicians help themselves with coverage of career threatening issues, such
as fear of failure, loss of confidence, and the financial stress and loss of autonomy that many

clinician's experience as a result of managed care and its constraints.

48