Beyond stigma, there’s a role for mental health education

The 2012 Singapore Mental Health Study reported that 5.8% of the local adult population are affected by depression during their lifetime. The researchers of the study found that only a third of those with a mental illness in their lifetime had sought the help of mental health professionals (Today Online, 13 Oct 2015).

According to the same study, only 10% of the population did not subscribe to the belief that those with a mental illness “could get better if they wanted to” (The Straits Times, 6 Oct 2015). The other 90% would likely agree that “a person who has mental illness is seen as someone who is weak” (The Straits Times, “A healthy mind isn’t a given for anyone”, 10 Feb 2016) and that “depression is a failure of will” (The New York Times, “7 Thoughts From a Chronically Unhappy Person”, 21 April 2015).

But stigma is not the only reason why people who experience symptoms of depression, burnout, or anxiety do not seek professional help. Aside from prejudicial attitudes, the ability to recognise the warning signs of psychological distress remain a major barrier to mental health care. A 2015 study of 2219 Canadian employees revealed that of the participants objectively identified by the study authors to be experiencing depression, more than half “did not recognize a need to seek help” (ScienceDaily, 7 Oct 2015). But the fact of the matter is that poor mental health literacy is not unique to the community of that study. A 2014 study by IMH on local residents’ understanding of common mental disorders including depression revealed that just over half the respondents surveyed were able to accurately identify the signs and symptoms of depression (Channel News Asia, 6 Oct 2015).

Yes, we should support campaigns to reduce stigma. But, it would only be successful if it were to be accompanied by mental health education programmes which are not only about dementia (it is the only one of the top 3 mental health conditions of local concern) but which also reach the community including those in school and those in the workforce.

Trying to help someone lose weight? Here’s what not to say

Healthy eating

Ever wanted to talk to your child, partner, or close friend about their weight and size?

Even if our heart is in the right place, it’s exactly what the experts say we should not do. Research has shown that overweight teens whose parents said that they should try “healthy eating” were more likely to engage in unhealthy weight-control methods (e.g., throwing up) than if parents talked about their teen’s size or weight. But other research has also found that girls who were told that they were fat at 10 years of age were more likely to have a BMI above 30 at age 19.

A 2015 study suggested that teenagers may not be aware of their own BMI and as a result not perceive a need to adopt healthy eating habits. But another 2015 study also showed that having accurate self-perceptions (about being overweight) does not necessarily equate to making healthy eating choices. In fact, labelling teenagers as overweight may in fact be counterproductive.

So what can we do instead? Apart from helping your child, partner, and/or close friend make healthy food choices by eating fruits and vegetables with them and cooking healthy meals with them, experts also advise against using food as a reward for good behaviour.

We suggest 8 useful tips which could help your loved one on the path to healthy eating:

1. Get more sleep. Studies show that lack of sleep is a major determining factor of later risk of being overweight. A 2014 study found that young children who slept less than the recommended duration for their age (e.g., less than 12 hours at 2 years or younger; less than 10 hours at 3 or 4 years of age; less than 9 hours at 5 to 7 years of age) were more likely to be overweight and to have more body fat at age 7 years. A separate 2014 study also found that infants who slept less than 10 hours a day at 16 months of age needed more feeds than their peers who slept 13 hours or more. And it’s doesn’t affect just children. Numerous studies link lack of sleep among adults to increased eating and weight gain, making good sleeping habits a priority.

2. Setting boundaries, warmth and affection matter. A 2014 study showed that children whose parents who set rules without engaging their children in dialogue about their rules and who don’t affirm their children with warmth and affection were at a higher risk of having a BMI above 30: Their risk of obesity was found as early as 2 years of age. A separate 2014 study in Australia found that overprotective maternal parenting during the earlier years (e.g., when children were 6 to 9 years of age) was linked to children having a higher BMI when they were 10 to 11 years of age. That’s why it’s important that your loved one should know that you care for them regardless of their shape and size. And these guidelines for what to say and what not to say apply not just to parents, but partners and friends.

3. Don’t talk about making changes. Instead, it’s more effective to get your loved ones involved in cooking healthy meals and visiting a local attraction or festival.

4. Don’t impose a diet on your child or partner or tell them what they cannot eat. Your good intentions will produce better outcomes if you participate in fun and enjoyable physical activities with them.

5. Don’t say “it’s good for you”. Studies with preschoolers show that a more effective way of getting young children to eat vegetables is to say nothing or to tell them that they’re “yummy”. (It helps of course if they really are yummy!)

6. Say “try this”. Telling your loved one what to eat is more effective than telling them what not to eat. Research finds that positive messages which start with “do” are better received than negative messages which are start with “don’t”.

7. Try and try again. A 2015 study found that children were more likely to eat fruits and vegetables if they were introduced to them on repeated occasions and if their parents also ate them with their children.

8. Start a gardening project. There is consistent evidence that children who participate in gardening projects are more likely to eat fruits and vegetables.

 

Talking about change

Over a decade ago, we used to have a campaign in schools which aimed to help children with unhealthy BMIs reach a more desirable body mass index. It was of course a bad idea. For obvious reasons.

That was eventually replaced with a programme which promotes a healthy lifestyle to all children, not just those with undesirable BMIs. Although children who are overweight are still a target for bullies, at least schools aren’t their bit to add to the stigma of being overweight.

These were lessons not learnt, apparently. Because there was a Childhood Obesity campaign in another part of the world a few years ago, which had children talking about their experiences of being discriminated against for their weight. Yes, more airtime to the stigma of being fat.

And if it’s not obvious why these campaigns are counter-productive, there’s research to suggest that it is so. A 2013 study, which asked 1085 respondents to evaluate a number of existing health campaigns, found that the motivation to adopt healthy lifestyle changes and their confidence about doing so was not greater after viewing a stigmatizing campaign compared to a less stigmatizing campaign.

It also doesn’t help that the American Medical Association now considers obesity to be a disease. A recent study found that for people with a BMI higher than 30, this information made them less concerned about healthy eating and more likely to choose a higher-calorie snack, compared to others who were told that obesity is not a disease or given some other unrelated public health information. Giving obesity the disease label, appears to send home the message, “Don’t bother trying to manage your weight through healthy eating or physical activity”.

Given the fact that younger children have difficulties distinguishing children’s TV programming and advertisements, it’s a good thing that fast food advertising is now a thing of the past here. It will not be possible for ads with foods containing too much salt, sugar, and/or saturated fat to reach children aged 12 years and below (read about those guidelines here). Happy meals might have to turn into healthier meals in order to reach their target audience.

There are however other ways to tackle childhood obesity. Here’s advice from the experts for talking to children and adults:

1. Don’t talk about healthy eating
It seems like a good idea to help by talking about healthy eating than body size or weight. But research suggests the opposite. A 2013 study found that overweight teenagers whose parent(s) talked about healthy eating, were more likely to use unhealthy weight-control methods (e.g., throwing up) and to binge eat, than if their parent(s) had talked about their size or weight. In contrast, those whose parent talked about body size or weight, were likely to “diet”. Instead, it might be good to talk about what foods to eat, not healthy eating.

2. Affirm their feelings and provide emotional support
Having a one-time “You can eat more fruits and vegetables. And why don’t you exercise more?” conversation with someone you care about could instill in them a negative attitude about food and exercise. It could make them conscious about their body shape, size and/or weight. It’s crucial that your children know you love them regardless of their shape, size, and weight. Here’s a list of what to say and what not to say for parents.

And telling them that they’re fat (shock tactics) are likely to backfire. Results from a recent study demonstrate the self-fulfilling prophecy: Girls who were told they were fat when they were 10 years old, were at a much higher risk of having a BMI above 30 nine years later. So don’t threaten, judge, and nag. Ask your teenagers and close friends how you can help.

3. Start with small lifestyle changes
Rather than talk to children and teenagers about healthy eating habits, it’s easier to help them be healthy by walking the talk. Parents can feed their families more fruits and vegetables, and store fewer sugared drinks at home (more tips here). Fruits and veggies don’t need to be eaten plain or raw. There are many food ideas to make fun meals with fruits and veggies: try this website for more ideas. Preparing meals together is a great way to introduce healthy ingredients to loved ones. Getting your kids to try everything (at least once) isn’t easy. But it’s worth the effort.

4. Do it together with them
It’s easier to help children and loved ones adopt healthy eating habits and incorporate physical activity into their regular routine if it’s a collaborative decision. This guide for parents advocates making changes as a family. It’s easier to persuade someone to eat healthy and be active if you’re also doing it together with them. Try shopping together for healthy food options. Make the visit to the Bird Park or River Safari a family day outing (it’s more effective than if you sell it to them as fun rather than a chance to exercise).

5. Assess their readiness for change
Making healthy lifestyle changes isn’t as easy as it sounds. Being ready for change can make things easier. But not everyone is equipped for conversations about the motivation for change and how to make those changes. But there are tools to equip health professionals for such conversations. One such tool is motivational interviewing — a “collaborative conversation for strengthening a person’s own motivation and commitment to change“. And in fact, there’s a free app for practicing such conversations. It’s called Change Talk.

When should you tell your colleague to “take a holiday”?

workplace stress

Going by the elevated stress levels reported by employees in Singapore (read our earlier post) and lack of job satisfaction bemoaned by many in the local workplace (discussed in an earlier post too), it would appear that for some employees, the answer may be now!

According to a recent workplace survey, as many as 94% of bosses held the view that employees shouldnot bring work home. It doesn’t add up. Or bosses say “have work-life balance”. But they hand their employees more work than that which can be completed within working hours. Clearly, there are going to be instances where bosses say one thing and do another. It also doesn’t help when bosses continue working outside office hours. 

Numerous studies have highlighted the effects of chronic stress on employees’ emotional and physical well-being. Prolonged exposure to stress weakens the immune system, causing employees to be absent from work and less productive when working with a stuffy head and sniffy nose at work (read this Fortune article). Burnout leads to higher staff turnover and elevated business costs. More crucially, it may mean losing valuable employees. It’s the reason why some companies have started to insist on employees taking their annual leave.  

Depression is explained as a condition in which an individual experiences “a persistent and pervasive low mood that is not affected by external circumstances”, with the individual losing interest in activities which once interested them. And it may escape the notice of most bosses, but the fact is that employees who are experiencing burnout, may be actually experiencing symptoms of depression (here’s an explanation of the two terms). 

But what can you do about it?

Here are some steps you can take:

1. Find out if you and/or your colleagues are experiencing burnout.
Complete this self-assessment questionnaire.

2. Recognise signs and symptoms of depression.
Mayo Clinic has a fact sheet on burnout. Understand that someone with depression cannot “cheer up” and “get over it“. It’s not just about feeling “sad“. One in 17 has depression in Singapore (find out more). 

3. Raise awareness about burnout at your workplace.
This article on Understanding and Avoiding Burnout has tips for managers. 

4. Provide a supportive environment for preventing burnout at your workplace.
Here’s a systematic list of things you and your organization can do to help.

5. Reach out to your colleagues.
Find the right words, but don’t forget to take care of your own emotional well-being.

World Mental Health Day. It’s two months and 19 days away. What are you doing on World Mental Health Day?

“Let’s find out more about mental illness”

Mental health resources

Yes, let’s. The article “Let’s find out more about mental illness” published in Straits Times, 16 Nov 2013, talks about childhood mental health disorders, and specifically, depression, anxiety, and schizophrenia.

It’s timely, given that understanding about mood and anxiety disorders involving adults tends to be poor, let alone mental health disorders involving children and adolescents. And it’s a good time as any to talk about mental health disorders, especially in the light of recent news reports involving individuals with depression.

But what is it that we understand about mental health disorders? From the resources made available to various organizations dealing with mental health issues, quite a lot actually.

But first, maybe we should know at least a few things worth knowing:

1. Stigma is everywhere, not just in Singapore.

That there is local stigma about seeking help for mental health disorders is not surprising.

But these are ubiquitous issues, relevant to other communities such as those in UK (“Understanding anxiety and mental health stigma”, The Guardian, 27 Sep 2013), Australia (“Mental health stigma still affecting Australian workers, with research showing 4 in 10 hide depression from their employers”, ABC, 12 Nov 2013), Canada (“Montrealers demonstrate to end mental health stigma”, CBC, 20 Oct 2013), Hong Kong (“First mental health web radio in Hong Kong raises the community’s awareness on mental illness and mental health”, UHK, 15 Nov 2013), and Taiwan (“Society must confront mental health stigma, redefine success”, The China Post, 3 June 2013).

We may not have progressed very far (“S’poreans fear mental patients, study finds”, Straits Times, 29 Oct 2007), but at least we’re increasingly cognizant of the issues and are adding to facts not fiction.

This Huffington Post article provides 3 helpful suggestions for how you and I can make a difference. The UK campaign which started in 2009 to end mental health discrimination at their www.time-to-change.org.uk offers useful tips on how to talk about mental health issues.

2. There are resources out there for the public.

3. There’s information about mental health disorders in children and adolescents.

4. Other resources include information about developmental disorders.

5. We can always do more.

A 2012 report in the Singapore Annals Academy of Medicine did not investigate whether their stratified sample of 6616 respondents, among whom 12% met the criteria for mood, anxiety, or alcohol use disorders but less than a third had sought professional help, used the internet to find out more about mental health disorders. Given that the same report acknowledges 80% or more of the local population aged 49 years and below (and 40% of those aged 50 to 59 years) has internet access, there’s much scope for accurate information about mental health to be provided on an online platform. This BBC Wales health report presents possibilities, while the UK Child and Maternal Health Intelligence Network offers ideas via a Tackling Stigma Toolkit. There are always more things that can be done. Something we can work towards perhaps?

Raising awareness for mental health

The burden of planning activities to raise awareness about mental health issues, improving employees’ mental health literacy, and reducing stigma for seeking professional, confidential psychological support for personal and/or job-related problems generally falls somewhat squarely on someone’s shoulders in the human resource department.

Apart from the run-of-the-mill talks and workshops which typically aim to train up emotional resilience and emotional intelligence among employees, it’s not always easy to know what other mental wellbeing activities could be organized for the benefit of employees, as well as stakeholders. The Health Promotion Board‘s “Enrich Your Mind Learning Festival” organized for the 27th of October 2013, Sunday, at Max Atria, Singapore Expo, is an example of how mental wellbeing can be enhanced and awareness raising can be achieved at the workplace. In addition, this free-admission whole-day affair, which starts at 10am and ends at 6pm, offers expertise from professionals who will dispense advice freely about creating the power of attorney and goodie bags for the early birds.

If not to benefit personally from the mindfulness and relaxation training for coping with day-to-day stress and for guarding against dementia through engaging in mentally stimulating activities, it’s fertile ground for social engagement and for building one’s social network – another protective factor against dementia. It’s not a replacement of a good ol’ walk in the park – yet another protective factor against dementia (Fratiglioni et al., 2004) – but it’s a good place to start. Happy learning!