How to Reduce Suicide Rates in Malaysia: An Issue of Insurance Parity, the Penal Code, and Health Communication

Last year, Malaysia averaged about 60 suicides per month, but according to Professor of Psychiatry T. Maniam in a February 10 article in The Star Online, this figure could very well be underestimated due to many suicides being wrongly classified as ‘undetermined deaths’, among other factors. The article also states that Malaysia’s suicide rate is on par with the U.S.

The suicide of 22-year-old Alviss Kong after a break up was highly publicized in the news due to the fact that prior to his suicide, he’d made several posts on his facebook wall indicating his intention to take his life, including requests to take care of loved ones, and even posted a final photo of himself with the words ‘that’s the last picture of mine before I go.’ The first thing that we have to remind ourselves of is that Alviss is just one of the hundreds of suicides that happen in Malaysia each year. Secondly, emergency response teams need to actively scour blogs and facebook pages.

Thirdly, based on blog comments related to the passing of Alviss Kong, I realize that something must be done to improve public knowledge on why suicides occur. Many people out there condemned Alviss after his death, stating, among other things, that he was selfish and stupid. The Malaysian public must be made aware of the existence and prevalence of depressive disorders in Malaysian society. This technically can be done via extensive media campaigns educating the public that depression is a recognized psychiatric condition and that it can be successfully mitigated and treated. I say ‘technically’ for a reason. The reality is that primetime ad rates remain extremely expensive, and often there just aren’t enough resources to air ads often enough, and during the slots that matter. TV stations and broadcasters hence play an enormous role in health communication, or currently, rather, the lack of health communication. By reducing or subsidising television ad rates for health messages, a wider audience can be reached.

The third contention I want to make is accompanied with arguments for better mental health policy; primarily increased access to psychiatric and psychological help to persons with depressive disorders. Increased access to mental health services is not merely an issue of building more clinics in the community setting – although that is clearly necessary. The main problem in relation to access to mental health services in Malaysia is actually one that relates to health insurance. Currently, there is NO mental health insurance parity, which means medical insurance does NOT cover mental illness and disorders. This policy is based on the notion that mental health treatments are expensive and hence the only way that insurers would be able to include psychiatric illnesses in insurance policies would be to charge exorbitant premiums. The fact is: mental health treatment often costs much less when compared to heart, lung, and liver treatments, all of which are provided insurance coverage.

On the insurer’s side, it can be understood that they are faced with the daunting prospect that patients might make claims for all sorts of non-serious or less serious mental disorders that can be sorted out by less expensive means. The idea is to engineer an insurance policy to prevent the ‘[distortion of use] in ways that are fiscally inefficient and clinically inappropriate.’[1] Ostrow and Manderscheid suggest that this fear can be addressed by using ‘improved “medical necessity” criteria that permit initial access and ensuing determination of need by qualified providers.’[2] This means that persons with serious depression and other disorders would be allowed to have their treatments compensated by insurance provided that their condition was sufficiently serious to be considered as it being medically necessary to treat.

Glied and Frank ask an important question (and subsequently make several compelling arguments/assertions); they ask: ‘Do insurers design mental health benefits to balance cost control and access to valuable care? Or do they design their plans to discourage enrolment among people with serious and chronic mental health conditions?’[3]

The authors assert that ‘parity need not lead to unnecessary care’[4] and that although insurers should not be allowed to exclude entire categories of conditions from coverage, similarly to Ostrow and Manderscheid’s arguments, they state that the existing criterion of ‘medical necessity’ as contained in American law can be modelled in such a way as to ensure that ‘covered services are directed to the types of mental disorders that are most impairing and disruptive and that can be treated effectively with medical care.’[5]

Health insurance providers must sit up and pay attention. We’re dealing with rapidly increasing and concurrent suicide and depression rates, and previous calls to change this policy seem to have gone unheeded, for reasons unknown (or perhaps for reasons backed by a lack of academic research and political motivation). Mental health insurance parity must not be ignored.

As a side note (but not any less important): Criminalising attempted suicide is not going to reduce suicide rates and help treat depression. Somebody’s got to call for the amendment of the Penal Code. These persons need medical help, not jail. I’m going to be brutally frank – the likelihood is that people prosecuted for attempted suicide are going to go to jail and socialise with persons who use drugs (due to Malaysia’s stringent drug possession laws), and eventually self-medicate by using drugs. Note that there is a high rate of comorbid psychiatric illness and substance use in Malaysian prisons.[6] The possibility is there and all these issues are interlinked. Can someone in the insurance field sit down and come up with a consensus between health and insurance? Can lawyers get together and present a memorandum for the amendment of the Penal Code? More importantly, can an elected representative mediate? And finally, a question for myself: Does anybody even care?

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[1] Laysha Ostrow and Ron Manderscheid, ‘Medicare and Mental Health Parity’ (2009) 28(3) Health Affairs 922 at 922

[2] Ibid.

[3] Sherry A Glied and Richard G Frank, ‘Shuffling toward Parity – Bridging Mental Health Care under the Umbrella’ (2008) 359(2) New England Journal of Medicine 113 at 114

[4] Ibid

[5] Id at 115

[6] Muhammad Muhsin Zahari, Woong Hwan Bae, Nor Zuraida Zainal, Hussain Habil, Adeeba Kamarulzaman, and Frederick L. Altice, ‘Psychiatric and Substance Abuse Comorbidity among HIV Seropositive and HIV Seronegative Prisoners in Malaysia’ (2010) 36 The American Journal of Drug and Alcohol Abuse 31