International Review of Psychiatry (February/May 2004), 16(1–2), 167–176

Malaysia mental health country profile

M. PARAMESHVARA DEVA

Department of Psychiatry, SSB Hospital, Kuala Belait, Brunei

Summary
Malaysia is a tropical country in the heart of south east Asia with a population of 24 million people of diverse ethnic, cultural and
religious backgrounds living in harmony in 330,000 km2 of land on the Asian mainland and Borneo. Malaysia, which lies on the
crossroads of trade between east and west Asia, has an ancient history as a centre of trading attracting commerce between Europe, west
Asia, India and China. It has had influences from major powers that dominated the region throughout its history. Today the country,
after independence in 1957, has embarked on an ambitious development project to make it a developed country by 2020. In this effort
the economy has changed from one producing raw material to one manufacturing consumer goods and services and the colonial health
system has been overhauled and social systems strengthened to provide better services for its people. The per capita income, which was
under US$1000 at independence, has now passed US$4000 and continues to grow, with the economy largely based on strong exports
that amount to over US$100 billion. The mental health system that was based on institutional care in four mental hospitals at
independence from British colonial rule in 1957 with no Malaysian psychiatrists is today largely based on over 30 general hospital
psychiatric units spread throughout the country. With three local postgraduate training programmes in psychiatry and 12 undergraduate
departments of psychiatry in the country—all started after independence—there is now a healthy development of mental health services.
This is being supplemented by a newly established primary care mental health service that covers community mental health by
integrating mental health into primary health care. Mental health care at the level of psychiatrists rests with about 140 psychiatrists most
of whom had undertaken a four-year masters course in postgraduate psychiatry in Malaysia since 1973. However, there continues to be
severe shortages of other professionals such as clinical psychologists and social workers in mental health services. There are a few
specialists, and specialized services in child, adolescent, forensic, rehabilitative, liaison or research fields of mental health. In the area of
services for women and children, as well as the disabled in the community, there are strong efforts to improve the care and provide services
that are in keeping with a caring society. New legislation on these are being passed every year and the setting up of a Ministry for
Women’s Affairs is one such move in recent years. Mental health in Malaysia has been slow in developing but has in the past decade seen
important strides to bring it on par with other branches of medicine.

Introduction in ancient Greek), which enticed traders from as far

This situational analysis of mental health services in
Malaysia is based on data publicly available since
1998. The services described are in a state of rapid
change because the country as a whole is one of the
fastest developing countries in the world, particularly
in terms of manpower.
Historical, geographic and
socio-economic context
Malaysia is a developing country that lies at the
crossroads of east and west Asia at its southernmost
point. It comprises the southern tip of peninsular
Malaysia and the western and northern parts of the
island of Borneo. Historically, this strategic position
has contributed many unique influences to Malay
culture and commerce. References in both legend
and literature of India, China, Greece and Rome
speak of a golden land of mineral and forest riches
(suvarnabumi in Sanskrit and the golden chersonese
afield as Rome and China as well as nearby India
to trade in the ancient emporia of Kedah (Katha) and
Melaka (Malacca). In fact, ancient communities of
Chinese, Indians, Dutch, Portuguese and British
have survived and can bear testimony to Malaysia’s
leading role as a trading centre millennia ago.
Malaysia is a tropical country, a large part of which
sits on the mainland of Asia. A larger part still sits on
the island of Borneo. Together these land areas cover
330,000 km2. Malaysia is bordered by Thailand to
the northwest, Indonesia to the south and east, the
South China Sea to the north and the Philippines to
the northeast. It stretches more than 2,200 km from
east to west and the two halves of the country are
separated by about 700 km of sea at the narrowest
point.
About 54% of Malaysia’s population of 24 million
is comprised of indigenous people including Malays,
Ibans, Dayaks, Kadazan-Dusun and a variety of
tribes in the east and west. The remaining 46% are of
immigrant Chinese, Indian, Pakistani, Sri Lankan,
Thai, Filipino, Indonesian, Eurasian (and others in

Correspondence to: Dr. M. Parameshvara Deva, FRC Psych, FRANZCP, FAMM, DPM (Eng), Head, Department of
Psychiatry, SSB Hospital, Kuala Belait, KA 1131, Brunei. E-mail: devaparameshvara@yahoo.com
ISSN 0954–0261 print/ISSN 1369–1627 online/04/01/20167–10 ß Institute of Psychiatry
DOI: 10.1080/09540260310001635203
168 M. Parameshvara Deva
small numbers) origin. Demographically, Malaysia is
a young nation. More than 33% of the population
is under 12 years of age and a further 19% are aged
12–24. The life expectancy for both men and women
has now crossed the 70-year mark. Malaysians now
enjoy low infant mortality rates and comparatively
good rural and urban health services.
Socio-cultural and religious influences
Despite its importance as a trading centre, Malaysia
was largely populated by Malays until the mid-19th
century when the colonial government obtained
vast amounts of land through a series of treaties
with the local rulers on which to grow rubber and oil
palm (the former being obtained from Brazil through
Kew Gardens and the latter from Nigeria). The
rubber plantations brought a large influx of inden-
tured labour from India. This was followed by
Chinese labour to man the tin mines. Other workers
and civil servants subsequently arrived from coun-
tries such as Sri Lanka and Indonesia. These
demographic changes had far-reaching influences
on the Malay society because the Malays, Chinese
and Indians had very different cultures, languages,
foods and religious practices. The Malays were
all Muslims, the Chinese Bhuddists, Taoists or
Christians and the Indians mostly Hindus but also
Christians and Muslims.
These three ethnic groups also had different
traditions, beliefs and practices in terms of health
care, which meant that different systems of tradi-
tional healing were also introduced. The Malays
traditionally resorted to pawangs or bomohs, the
Chinese to herbalists or mediums and the Indians
to ayurvedic treatment or temple healers.
Socio-economic influences
Malays living in the rural areas used to depend on
agriculture, plantation and village work but,
following independence, rapidly moved in to fill the
civil service, administrative and other professions
left vacant. The Chinese, who originally depended
on mining work, quickly branched out into various
businesses from petty trading to the opening of
factories and international import and export busi-
nesses. The Indians who began as indentured
labourers in plantations now work in many indus-
tries, including the civil service, the professions and
education. Today, most of the Chinese and Indian
population remain in the urban areas, while the
Malays continue to populate the rural areas and
smaller towns. More than 8% of the total population
currently lives in the two main urban centres.
Independence and the rapid growth of the economy
Malaysia gained independence from colonial rule in
1957. At this stage it was economically dependent on
rubber cultivation and tin mining, but also producing
palm oil, timber, pepper and copra for export. The
economy has undergone substantial change over
the past 20 years to the extent that 85% of the
country’s exports are now manufactured goods such
as electrical or electronic products, clothing and
other consumer products. Older commodities like
rubber, tin, palm oil, petroleum products and timber
are still exported but only account for about 15%
of the country’s export income. Currently, annual
exports exceed US$100bn and Malaysia is one of
the 20 largest exporters in the world. About half
its goods are sent to other Asian countries, but the
USA is the largest single importer. The current per
capita income is about US$4,000.
This rapid recent economic growth makes
Malaysia one of the fastest growing economies in
the world. It has set itself the target of becoming a
‘developed’ country by the year 2020. On this basis,
the country’s budget is usually heavily biased towards
sectors that fuel economic growth. Having said
that, operational expenditure is weighted heavily
in favour of social services such as education and
health—together, these account for 34% of the total
budget.
Industrialization has led to demographic changes
in the form of large-scale urban migration in search
of better jobs. This has led to social problems,
especially among young workers who live in
unsatisfactory urban settings. For this reason, the
Government has begun a programme of decentraliz-
ing newer industries and relocating them away from
the larger towns so that workers can remain in their
original homes and villages. Many new factories in
more rural settings run factory buses to take people
to and from work each day.
The human development index for Malaysia
(an indication of the country’s level of development
compared to other nations) is 0.77.
Women and mental health and violence
Women comprise 53% of the Malay population.
Young women represent the most vulnerable sector
of Malay society. This is because, unlike their
mothers’ generation, most girls today are educated
at least up to high school and are then keen on
working in industry, administration, schools or
hospitals. This means that many need to live away
from home, with the lower protection, higher risks
and vulnerability to social problems that this entails.
Several social and religious groups exist to help
single girls and women with social problems. The
National Council of Women’s Organizations is the
umbrella group that speaks for women nationwide
and strives to improve their conditions. In 1996, the
Government established a Ministry of Women’s
Affairs that has also lobbied enthusiastically for
legislative change to help protect women, such as

the law passed to protect women from domestic
violence. The Women’s Aid Organization, founded
20 years ago, provides counselling, shelter, social
assistance and legal aid for women and their children
who have suffered domestic violence.
Children and adolescents
Approximately 33.5% of the Malay population is
below the age of 15. About five million children
are currently in kindergartens and schools. The
Government is aware of this heavy burden and has
made efforts to improve pre-school and school
facilities as a result. Substance abuse habits tend to
start in adolescence and the Government has also
introduced prevention programmes. Alcohol con-
sumption is not as widespread as in other countries,
but efforts have also been made to curb the sale and
advertising of alcohol to the young.
Ageing and mental health
The health statistics for Malaysia have been improv-
ing since independence. Maternal mortality is now
20 per 100,000 live births, infant mortality 7.9 and
under-five mortality 11.4. As the population
becomes healthier, it is also living longer. Life
expectancy is 72 years for both sexes with women
expected to live up to 75 years and men up to 70.
About 3.8 % of the population are aged 65 years or
more and this figure is expected to rise as health care
facilities and preventive programmes improve. The
tradition of families looking after their elderly is
generally still commonplace. However, with the
flourishing economy, standards of living and housing
market, many young people are now buying their
own houses and apartments and living, often
hundreds of kilometres, away from their parents.
This is beginning and likely to continue to put
pressure on the elderly population who are often less
well off and have no social security system to support
them (except for the few who were civil service
employees). Despite this trend, a study on visits to a
residential mental health unit found that it was still
the exception for a patient not to be visited by
relatives every week.
General and mental health service
development
General health services – the early years
The Malaysian health service can trace its origin to
the estate health services set up by the colonial
government in the late 19th and early 20th centuries.
The estate health service had been established to
ensure that the colonial government of the day could
rely on a healthy and productive workforce in the
Western Pacific Region: Malaysia country profile 169
rubber plantations. Problems such as malaria, poor
hygiene and malnutrition were addressed. As
Malaysian towns grew, so did the demand for
health services from the non-estate population and
a string of small district hospitals were set up to meet
this. The larger towns, namely Penang, Melaka and
Johore Bahru on the peninsula and Kuching in
Sarawak, generally had larger and better-staffed
general hospitals, which functioned as referral
centres for the smaller hospitals.
The main public health concerns at this time were
the host of infectious diseases common in tropical
countries such as malaria, typhoid, dysentery, and
nutritional diseases such as beriberi. These required
the training, not just of a range of health care staff,
but of an army of health inspectors, anti-malaria
sprayers, supervisors, laboratory staff, swamp-
drainers and so on. This preoccupation with the
control and intended eradication of killer infectious
and nutritional diseases left almost no resources
for mental health services in the past.
Development to the present day
While the colonial plans for the health service were
largely based on its usefulness in maintaining the
economically productive parts of the population,
the newly independent Malaysia could not neglect
the care of the deprived and less productive. Thus,
following independence, the country embarked on
a wider range and distribution of medical and
health care services. A series of rural clinics, mid-
wife centres and many rural or cottage hospitals
were set up in the first, second and third National
Development Plans.
Dependence on the single medical school and the
university in Singapore for trained personnel slowed
development in this respect in a major way. Thus,
one year after independence in 1958, a university
was established in Kuala Lumpur. This was followed
by a medical school (in Kuala Lumpur) in 1963 from
which the first doctors graduated in 1969. These
locally trained doctors were joined by many more
who were trained overseas and were largely respon-
sible for the beginnings of specialist medical care
in the country; Malaysia’s health service began to
develop in earnest.
Today there are 12 medical schools and 25
universities and training in every medical specialty
is available in Malaysia. About 500 medical doctors
graduate from the country’s medical schools every
year to join a total of 14,000, of whom at least 1,500
are specialists. There are also about 20,000 nurses in
the country. There are health clinics in every village,
hospitals in most districts and referral hospitals in
every state. There are about 43,000 hospital beds—
1.68 per 1,000 population—and the annual national
health care budget accounts for about 6.1% of the
total national budget.
170 M. Parameshvara Deva

The early history of mental health service Sabah and Sarawak, introduced its own laws to
provision in Malaysia govern mental health:
The earliest record of a mental health service of . The Mental Health Disorders Ordinance of 1952
any sort in Malaysia is reference to a ‘lunatic asylum’ covered the Peninsula
on the island of Penang. Sailors in the colonial . The Lunatic Ordinance of Sabah of 1953
navy who developed mental illness were confined governed the state of Sabah
here in the late 18th century. The asylum was a . The Mental Health Ordinance of Sarawak of 1961
small building on the site of the present Penang governed the state of Sarawak.
Hospital in the north of the country. There are also
However, as all three were long overdue for revision
reports of a psychiatric hospital on the site of the
they were all replaced in 2001 by the new National
current Taiping Hospital, also in the north, until
Mental Health Act. This will come into force soon.
1910. The first purpose-built psychiatric hospital,
Its main features are that it allows for private mental
now the Central Mental Hospital, was built outside
health care, so long as the latter has received permis-
the town of Ipoh in 1911. It had 75 wards and a 600-
sion from and remains under the supervision of the
acre farm. Another large psychiatric hospital, cater-
Ministry of Health. It also requires all private general
ing to the needs of the south of the country, was built
hospitals to provide mental health care—currently
in 1935. Two smaller hospitals, in Kuching and
the bulk of mental health care provision is borne by
Sandakan in the east, had been completed before
the public sector. Better systems for admission,
the decade was out. No more new psychiatric
especially voluntary admission, are also provided
hospitals were opened until 1971, when the 250-
for. The antiquated system of checks and balances in
bed Bukit Padung Mental Hospital in Kota came
the care of the mentally ill and the guardianship laws
into operation.
are thoroughly revised.
The first mental ward within a general hospital was
opened in 1958 in Penang. This was, in many ways,
a revolution in mental health care provision in the Mental health policy
country. Mental patients were being seen and treated
In 1998, the National Mental Health Policy was
in a non-psychiatric hospital, non-custodial and
finally approved by the Ministry of Health after a
non-institutionalized setting for the very first time.
committee of Government, private and university
They were also being treated alongside patients with
specialists in mental health had deliberated over its
physical illnesses.
detail for more than a year. Mental health is defined
Until the late 1950s, mental treatment was largely
in the new policy as follows: ‘the capacity of the
physical, comprising insulin coma therapy and a
individual, the group and the environment to interact
variety of occupational therapies applied through
with one another to promote subjective well-being
farm work. The introduction of chlorpromazine was
and optimal functioning, and the use of cognitive,
another revolution in the care of the mentally ill.
affective and relational abilities, towards the achieve-
Psychopharmacological therapy facilitated commu-
ment of individual and collective goals consistent
nity- versus institutional-based care and reduced the
with justice’.
need for hospitalization. However, the traditional
views of the public and, sadly, some health care staff,
were less easy to revolutionize. The first proper Objectives
attempt at community-based rehabilitation of the
The objectives of the new policy are:
mentally ill occurred in Ipoh, where a mental health
association and day-care centre were opened in 1967 . To provide a basis from which to develop strategy
and 1969 respectively. and direction for all involved in health and mental
Malaysia’s first psychiatrist started practice in health planning and implementation (with the aim
1961, having been trained in the UK. The first of improving the mental health and well-being of
three locally trained psychiatrists graduated in 1975 the entire population)
from the University of Malaya. With an energetic . To improve mental health services for the
postgraduate psychiatric training programme in population at risk of developing psychosocial
place, the stage was set for the development of a problems
nationwide mental health programme. . To improve psychiatric services for the mentally
disabled, in terms of the care provided by family,
community and the relevant agencies.
Law and policy

Mental health law Policy details

Malaysia’s mental health laws were based on the . Accessibility and equity. Ensure equal geographic
British and Indian Mental health laws of the early and economic access to mental health care for
1900s. Each of the key Malay regions, the Peninsula, every sector of the population.
 Western Pacific Region: Malaysia country profile
Table 1. Current mental health manpower and facilities in Malaysia (World Health Report, Atlas, WHO)
Psychiatrists
Psychiatric nurses
Psychiatric beds in general, university and district hospitals (short-stay)
Psychiatric beds in psychiatric hospitals (long-stay)
Psychiatric beds in general hospitals
. Comprehensiveness. Ensure provision of a com-
prehensive range of mental health services, includ-
ing promotional, treatment and rehabilitation
activities.
. Continuity and integration. Ensure that mental
health services are made available in primary
health care. Mental health programmes and
activities should be integrated into the existing
programmes provided by the primary health care
system.
. Multisectoral collaboration. The Ministry of
Health will play a lead role in facilitating multi-
sectoral collaboration and cooperation between
the mental health service and other services, pro-
grammes and activities needed to enable people
with mental health problems and disorders to
participate more meaningfully in the community.
. Community participation. Ensure community
participation in the planning, management and
evaluation of community-based activities, to ensure
their ownership, pride and adoption.
. Community resources and training. There needs to
be planning and development of human resources
for mental health and this should be a priority
investment by the health sector.
. Standards and monitoring. High standards of care
should be sought and built-in quality assurance
programmes implemented which comply with
the standards laid down in the UN resolution
on the Protection of the Rights of People with
Mental Illness.
. Research. It is intended that research and devel-
opment continue to be implemented and funded
by both public and private sectors.
. Legislation. The rights and civil liberties of
people with mental health problems must be
guaranteed and protected through legislation.
. Review. It is essential that this policy be perio-
dically reviewed if it is to continue to improve
services for the mentally ill and their carers,
because the mental needs of the population will
change with time.
Resources
Human resources and training
Currently there are about 145 psychiatrists in
Malaysia of whom about 25 were trained overseas
and 120 in the country’s own three postgraduate
171
0.3 per 100,000 population
0.5 per 100,000 population
2.7 per 10,000 population
2.4 per 10,000 population
0.3 per 10,000 population
training programmes. The latter are four years long
and based in universities that award a Masters in
Psychiatry following dissertation and coursework.
Psychiatric nurses have been trained in Malaysia for
more than 20 years and clinical psychologists for 10
(see Table 1).
About 30 of the country’s 145 psychiatrists are in
full-time private practice and another 20 in part-time
private practice. However, there are also dozens of
doctors with former experience of psychiatric units
or hospitals that are currently in general practice
and better able to review the substantial numbers of
psychiatric patents who pass before them on the basis
of their experience.
The growing numbers of staff trained in psychiatry
and mental health are now capable of running 30
mental health wards, of 20–100 beds each, in the
country’s district, general and university hospitals.
Today’s efficiency and treatment technology has
brought the bed count of the four large psychiatric
hospitals down from as many as 5,000 beds to 1,500
and 2,000 respectively in the two current largest. The
short-stay wards of the general or district hospital
psychiatry units now average less than two-week
lengths of stay; the psychiatric hospitals average in
excess of two months. The 30 smaller units are
also more geographically accessible to the public.
We have to thank the far-sighted planners of the
late 1950s for this revolutionary improvement in the
provision of mental health care. Currently, mental
health care is allocated about 1.5% of the total
national health care budget.
Today, the seven public medical schools in the
country all have Departments of Psychiatry and
include seven to 11 weeks of psychiatric training
in their general medical degree courses. Two of the
four private medical schools also have Departments
of Psychiatry and a six-week general medical com-
ponent. Aspects of psychiatry and behavioural
science are also introduced in other parts of the
general medical degree course between years two
and five.
The original two-year postgraduate specialist
course in psychiatry was soon extended to four
years and is currently conducted at three postgrad-
uate medical schools. The first part of the current
course consists of theory in basic sciences relevant to
psychiatry such as child development, psychopathol-
ogy, history of psychiatry, neuroanatomy, neurophy-
siology, psychopharmacology, clinical psychology,
anthropology, sociology and basic psychiatry,
172 M. Parameshvara Deva
including signs, symptoms and interview techniques.
This is followed by a part I examination. The final
part of the course covers general and subspecialty
psychiatry including psychotherapy, child and
adolescent psychiatry, rehabilitation, liaison psy-
chiatry, forensic psychiatry, social psychiatry and
suitable clinical practice in these areas. The final
examination must be accompanied by a disserta-
tion and six case write-ups, which must include
psychotherapy conducted by the candidate. On
graduation, the new psychiatrist has to work for
a full 18 months before receiving their final
certification.
Training in clinical psychology in Malaysia was not
begun until 1995. The shortage of clinical psychol-
ogists is probably the most acutely felt staff shortage
at present—there’s even a shortage in the university
departments. Training in occupational therapy,
by comparison, was begun in the late 1980s and
most psychiatric units now have an occupational
therapist working with them. Counsellors, many of
whom are also attached to the country’s psychiatric
units, are trained for four years in Malaysia. Social
work graduates are also beginning to be trained
in small numbers.
Traditional healers
Malaysia has a wide variety of traditional healers
with a myriad of practices with varying degrees of
effectiveness. These healers are broadly classified
along ethnic lines; the Malay bomohs, pawangs and
dukuns; the Chinese herbalists, temple mediums
and faith healers; the Indian ayurvedic healers and
temple mediums and a range of alternative medicine
practitioners. There is little direct cooperation
between these different healers and between all
healers and the formal health care service, but
cross-referral among practitioners is not unknown.
Research
The 145 or so psychiatrists in Malaysia are heavily
involved in clinical work and teaching to the extent
that few are involved in formal research. This
is unfortunate because there is a shortage of
the research data necessary for effective health care
planning and development and because evidence-
based decision-making is highly dependent on
quality research. Few of Malaysia’s psychiatrists
have any formal research training.
Recently, effort has been made to develop a
national register for schizophrenia, but most research
is currently limited to those teaching institutions
at which postgraduate training is conducted and
to those hospitals at which clinical trials are
conducted with the support of the pharmaceutical
industry.
Physical resources
The largest providers of mental health care in
Malaysia are as follows:
Inpatient units and services. The Ministry of Health
runs 27 general or district hospital psychiatric units,
four psychiatric hospitals and three university
hospital psychiatric units. One general hospital
psychiatric unit is privately run. One psychiatric
unit is provided by the armed forces in its own
general hospital.
Outpatient services. All the Ministry of Health’s
psychiatric hospitals and units have outpatient
departments. Several other public hospitals use visit-
ing Government psychiatric doctors and resident
general duty primary care doctors to conduct out-
patient clinics. There are approximately 100 of these,
but not all are run on a daily basis.
NGOs. Many NGOs, such as ‘Befrienders’ and the
associations for substance abuse and counselling,
have branches and facilities around the country.
Befrienders have branches in four Malay towns.
Provision
Psychiatric hospital care in the 21st century
Although psychiatric care and provision has changed
substantially since the four main psychiatric hospitals
were built at the beginning of the 20th century,
it seems that these are still too much a part of the
country’s mental health picture to be closed down
or replaced completely. Several intriguing factors
have worked to make the transition from institu-
tional- to community-based mental health care
less than smooth. Administratively, professionals
working at these psychiatric hospitals often hold
the highest posts in the mental health services.
Moreover, the general hospital psychiatric units
were and are still seen simply as ‘feeders’ for the
psychiatric hospitals. The shortage of well-trained
manpower also meant that the best staff concentra-
ted in the psychiatric hospitals at the expense of
other units. These factors combined have led to a
lasting impression that the short-stay general
psychiatric units are actually less capable of caring
for the mentally ill in a meaningful way. It also
seems that the traditional view of the mentally ill
patient requiring a long stay in a large hospital
attached to an even larger farm on which they
could ‘work themselves out of their illness’ was still
very much entrenched in the minds of the decision-
makers who planned the current mental health
service.
 Western Pacific Region: Malaysia country profile 173

The two largest psychiatric hospitals are institu- units, a factor that hasn’t helped to overcome the
tions by any standard. The four to eight psychiatrists traditional public image of isolated psychiatric care.
and varying numbers of medical officers who staff
these facilities are not sufficient to care properly
for the 2,000 or so patients within them. The core Follow-up of psychiatric illness in the community
staff are supported by occupational therapists and
Relapse is an important issue, particularly where
small numbers of social workers and registered
there is little access to psychiatric care in the
psychiatric nurses. Most nursing staff within these
community (some of these health clinics still don’t
institutions are generally trained (SRNs). The wards
cater for mental illness). Lately, several measures
are large, long and open, with little opportunity
to overcome the lack of continuity of care have
for privacy or keeping personal property. The lack
been introduced since the 1970s. Mobile clinics have
of staff means that patient management has to
been established in Perak, covering a radius of 10 km
remain highly regimented and impersonal. Long-
from the local psychiatric hospital. Medical officers
stay patients with better functioning and self-control
in outlying hospitals have also received additional
tend to be kept in farm wards, which are more like
training in basic primary care psychiatry in the form
hostels, with a more relaxed regime and freedom to
of one- to two-week courses. Rural nurses with
wander the vast grounds. Occupational therapy also
psychiatric training have also recently been given
takes the form of daily craftwork.
permission to initiate the administration of certain
Forensic psychiatric care in Malaysia is provided
psychotropic medicines. Community mental health
through the four psychiatric hospitals and a further
teams have begun to check up on known patients in
two forensic psychiatrists who work in general
the community on a regular basis. The National
hospital settings. Patients in forensic wards are
Community Mental Health Programme was only
either those whose cases are pending, sent for
introduced in 1996, at the same time that the
observation and report by the courts, or those sent
Ministry of Health began to develop a curriculum
by the courts on the understanding that, although
for psychiatric nurse training for primary and
guilty, they are also mentally ill.
community care and rehabilitation. By 1998, all
13 Malaysian states had introduced this staff training
General hospital care of the mentally ill and, by 2001, more than 44 trainers had success-
fully trained more than 1,400 trainees. This project
Since the first general hospital psychiatric unit was
has links with institutions in the UK and applies
opened in 1957, this form of mental health provi-
concepts developed in the UK.
sion has expanded fairly rapidly to about 30 small-
According to the latest data, community mental
and medium-sized units in the country’s general and
health follow-up is provided in 24% (187) of the 774
district hospitals today. At least one psychiatrist, a
health clinics run by the Ministry of Health—7% of
complement of nursing staff, and an occupational
this 24% provide an activities of daily living-type
therapist and social worker usually staff these
rehabilitation programme as part of their follow-up
units. Even with such limited human resources,
service. Responsibility for such community pro-
these units can and do provided a large amount
grammes is not left solely to the local health care
of acute psychiatric secondary care and follow-up.
team—staff are usually advised and supported
Together, they provide about 1,000 beds. These
by visiting psychiatrists and specialist family care
1,000 or so beds today cater for a far larger number
physicians. Gradual extension of both follow-up and
of admissions and discharges every year than the
rehabilitation services are planned in the near future.
4,000 or so beds in the four mental hospitals as the
people are using these general hospital psychiatric
beds (where length of stay is often 2 weeks) more
University-based psychiatric units
than the mental hospital ones. This has been a most
heartening development in the de-institutionalization The first psychiatric unit in a general hospital was
process in Malaysia. specially built for the University of Malaya’s School
Patients usually stay for about two weeks in the of Medicine. The Psychological Medicine Unit of
acute care units of the general hospitals, with a the University Hospital of Kuala Lumpur not only
further week of ‘on leave’ status before formal provides modern and quality psychiatric care but
discharge. Most of the older and newer psychotropic also acts as a training centre for medical students,
medicines are available, even in the smaller nurses, post-basic nurses, trainee psychologists,
facilities, but electroconvulsive therapy (ECT) is trainee social workers and volunteers, as well as
not always available—there are practical problems of trainee psychiatrists. This unit is also involved in
providing anaesthesia because the psychiatric and basic clinical research and has developed a national
anaesthetic units of most general hospitals are model for psychiatric care. The two other psychiatric
physically separate. In fact, because most mental units of teaching hospitals in Malaysia were based
health units were late additions to general and on it. These teaching hospital units have helped
district hospitals they are often housed in separate to train more than 70% of the country’s psychia-
174 M. Parameshvara Deva
trists and continue to provide leadership in care
for the mentally ill. Generally, it is the university
hospitals that introduce innovative care methods
such as sheltered workshops, group therapy, day-care
and rational ECT. Almost all of the 12 day hospitals
currently in existence were modelled on the one
opened by the University of Malaya in 1971.
Private psychiatric practice
Private psychiatric consultancy first started in Kuala
Lumpur in 1973. Although health insurance reim-
bursement for mental illness is still practically non-
existent in Malaysia, the reduced stigmatization of
mental illness has led many people to pay for private
consultations. There are currently about 30 full-time
private psychiatrists in Malaysia, about half of them
in the Kuala Lumpur area. Most of the larger towns
in the country have a private psychiatric practice and
a few have limited access to private hospital beds. A
few administer ECT on a day-care basis. Almost all
are solo practices, because the volume of patients is
not sufficient to allow a second or third partner. As
many patients consult at a relatively late stage in their
disease, some require emergency admission to
hospital and good liaison with local, Government-
run inpatient units is therefore an important part of
private practice.
Part-time private practice
Only very recently has permission been granted to
university teachers to carry out private consultations
once or twice a week during office hours and
more frequently after office hours. Some perform
this part-time practice in their university hospitals,
others in private suites. An advantage is the increa-
sed availability of specialist services to the public—
psychotherapy, cognitive behavioural therapy (CBT),
child and adolescent psychiatry, substance abuse and
other specialists are now accessible through the
private sector, albeit part-time.
Nursing homes for the mentally ill
Because the large institutions had a reputation
for below-standard patient care in the past, some
families are still unwilling to send their relatives
there. Private nursing homes provide an alternative
source of long-term psychiatric care. A variety of
so-called nursing homes now cater for the chroni-
cally mentally ill. These are usually run by the former
nursing staff of public wards and institutions
and occasionally by medical practitioners. Their
standards of care and treatment seldom match
those of the psychiatric units, however, and a cynic
might suggest that the key reason many families use
them is to rid themselves of the burden of care.
The homes are run for profit and rarely receive
Government support. Some take their patients to
state facilities for treatment and limit their own
role to residential care. These nursing homes are not
governed by Malaysia’s mental health laws but are
often licensed by the local authority.
Substance abuse programmes
Malaysia is at the crossroads of the heroin and
cannabis trade between Southeast Asia and Europe
and America. The golden triangle is just 1,500
kilometres north of the border with Thailand, and
several drug-processing laboratories with connec-
tions to overseas dealers have been unearthed. There
are regular seizures of cannabis, heroin and, more
recently, amphetamines.
Currently, there are well over 200,000 registered
drug dependents in Malaysia, most of whom are
dependent on heroin. This figure is almost certainly
an underestimate that does not account for the
many unidentified users nationwide. Consecutive
governments have been aware of this problem since
the early 1970s and have taken many steps to address
the problem. A National Substance Abuse Policy
was formally adopted in 1997.
Currently, there are more than 30 Government
treatment and rehabilitation centres across the
country. Each can house over 300 patients for up to
18 months. These centres now face the additional
problem of HIV/AIDS infection through needle
sharing—the commonest source of HIV transmission
in Southeast Asia. Withdrawal from heroin is
achieved through the ‘cold turkey’ method—sub-
stitutes like methadone are not routinely available.
The commonest method of heroin abuse is still
‘chasing the dragon’, which may account for the
fact that there are only 40,000 HIV/AIDS cases
among the country’s several hundred thousand
heroin users. There is no needle exchange pro-
gramme in operation. Malaysia’s drug rehabilitation
programmes rely on the following principles:
. Drug withdrawal in a secure environment
. The building of physical health in the dependent
. The strengthening of the dependent’s ability to
cope with personal problems and to stay away
from drugs through counselling and religious
support
. Training in work skills and discipline to ensure
a sustainable occupational future that does not
expose the individual to drugs and related
problems
. Follow-up for five years in aftercare programmes
after successful rehabilitation and discharge.
Despite all this effort and resource allocation,
however, the overall success rate of these centres
remains low.
A public education programme and a school
education programme have been in place for many
years. There are also stiff penalties for drug traffick-
ing, including death in the case of possession of

more than 15 g of pure heroin or more than 200 g of
cannabis (15 g of pure heroin is about half a year’s
supply for an average drug-dependent). Despite
harsh penalties and more than 100 related executions
in recent years, traffickers and their ‘mules’ continue
to be caught.
The national anti-drug association PEMADAM
(an NGO) does valuable work in public education,
prevention and aftercare. It has branches in almost
every part of the country and strong links with
international organizations such as IFNGO (the
International Federation of Non-Governmental
Organizations). There are also a number of privately
run treatment and rehabilitation centres for sub-
stance abuse, which use religious as well as tradi-
tional methods of treatment. These are usually small
enough to be run in private houses or places of
worship but have frankly had very limited impact
on the substance abuse problem.
Alcohol consumption is negligible in more than
half of Malaysia’s population for religious reasons.
Despite this, reports suggest that the country has very
high alcohol sales (reputedly 6.3l per capita com-
pared with 1.7l per capita in Singapore). Some of
this may well be re-exported for profit. The common
local drink is rice wine in various forms known as
samsu, tuak or lihing. This is more commonly
consumed by those living in Sarawak and Sabah
and by those of south Indian origin in the peninsula.
Alcohol use is an integral part of cultural life in
most parts of Sarawak and Sabah where there are
large indigenous non-Muslim populations. Although
traditional drinks such as tuak are routinely brewed
in individual longhouses, they are seldom abused
(as borne out by the very low admission of alcoholics
to local hospitals). Alcoholism is more common
among the Indians and some Chinese. There are
few drinkers on the east coast of the peninsula
because the population there is largely Malay and
Muslim. Manufactured ‘Western’ drinks such as
beer and stout achieve the highest sales, followed
by whiskies and vodka or brandy. Wine drinking is
not widespread. Most alcoholics remain undetected
until too late and there are no treatment centres
specializing in alcohol treatment. Alcohol depen-
dence is treated in general psychiatric wards and
at the occasional Alcoholics Anonymous or other
counselling group.
Psychosocial rehabilitation of the mentally ill
Despite its institutional origins, Malay psychiatric
care has always believed in the use of various forms
of work to help manage and overcome mental
illnesses. To begin with, this was limited to work
that the patients were thought capable of and which
could help save the institution money through
reduced labour costs. In other words, cooking,
cleaning, gardening and washing. Gradually, as
patients’ states improved, a wider range of more
Western Pacific Region: Malaysia country profile 175
stimulating work such as gardening, vegetable farm-
ing and livestock rearing was introduced. Patients
were paid in cigarettes, sweets, biscuits and small
amounts of money. A major disadvantage of this
early employment was that patients who had more
or less recovered their mental health were retained
in the institution because they helped increase
productivity. A major benefit of this type of work is
that patients fare better when given stimulating,
productive work to do. Promotion to a ‘farm ward’
was feasible when patients achieved a certain level
of health improvement. Life was less restricted there
and of better quality. In the mid-1970s a few
psychiatrists went one step further and started a
programme to resettle the more able farm patients in
the community and in farm jobs nearby, while they
continued treatment and counselling on a weekly
basis. Some 70 or more patients were successfully
resettled in this way despite 15 or more years of
institutionalization.
The first day-care rehabilitation programme was
introduced in Ipoh in 1969. Institutionalized patients
were bussed to a community day centre several
days a week, where they undertook various activities
and cooked meals for themselves. A university
hospital day-care centre was also opened in 1971
for patients about to be discharged or on leave from
acute care. There are more than 15 such day-care
centres in existence today, helping to rehabilitate
patients through psychological, social, occupational
and medical techniques using group, recreational
and work processes. Doctors, psychiatrists, nurses,
occupational therapists and social workers run the
centres although not all in every case. Some centres
are run by NGOs and others based in general
hospitals.
Sheltered workshops and industrial rehabilitation
units are another form of rehabilitation. In these,
small-scale industrial piecework, using minimal
simple equipment, is undertaken by patients about
to be discharged to look for jobs. The first sheltered
workshop was set up in 1975 at the university
hospital rehabilitation unit in Kuala Lumpur.
Patients were paid 90% of the profits of their work
and good workers further rewarded by bonuses.
Intersectoral links
NGO involvement in mental health provision. The
history of NGO involvement in Malaysia’s mental
health provision may be traced to the formation of
the Perak Society for the Promotion of Mental
Health in Ipoh in 1968. This was followed by the
Malaysian Mental Health Association in 1970 in
Kuala Lumpur. Both associations attracted many
people who were neither mental health professionals
nor consumers and their families. There are cur-
rently about 12 mental health associations in
Malaysia, whose activities include public education,
176 M. Parameshvara Deva
advocacy, community-based psychosocial rehabilita-
tion and promotion of mental health activities.
Since 1995 several of them, notably those in Sabah,
Kuala Lumpur, Ipoh and Johore, have organized
regular scientific conventions. The Ministry of
Health and other Government agencies have recog-
nized their influential role and a nominal amount
of funding is available to some of them. They have
also been involved in the country’s planning and
policymaking. Most generate their funds through
fundraising activities and donations and are able to
contribute a great deal in this way to the improve-
ment of mental health provision.
The ‘Befrienders’, a 24-hour telephone as well
as face-to-face counselling service similar to the
Samaritans was set up in 1970 in Kuala Lumpur.
It has branches in four cities and its volunteers
are trained on a regular basis. Other NGOs care
for abused children and women or provide marital
counselling services. Yet more hold regular public
education sessions and participate in live TV and
radio phone-ins and panel discussions. These groups
have done much to increase awareness of common
mental health problems and the treatments avail-
able for them. They have also worked to counter
prejudices.
In 2000, Malaysia’s annual Healthy Lifestyle
Campaign was devoted to mental health. This year-
long campaign aimed to improve public awareness
on mental health, illness and the treatments avail-
able. A wide variety of mental health topics were
discussed in both the print and electronic media
and added publicity was provided in the form of
related posters, pamphlets and billboards. The
impact of this campaign has not yet been evaluated.
Professional psychiatric associations. The Malaysian
Psychiatric Association (MPA) was formed in 1977
at which stage there were still fewer than 20 psy-
chiatrists in the country (before this, the Neuro-
psychiatric Society of the Malaysian Medical
Association performed a similar role). The Psychia-
tric Association holds regular meetings and an
annual conference, which attracts about 300 dele-
gates. More than 100 of the 140 psychiatrists in
Malaysia are members. The association has been a
member of the Association of South-East Asian
Nations (ASEAN) Federation for Psychiatry and
Mental Health since 1981. It is also a member of the
World Psychiatric Association.
The main aim of the association is to promote
excellence in care of the mentally ill. It is involved
in annual dialogue with the Minister of Health and
NGOs and regularly participates in media sessions
and public forums on mental health. It supports a
travelling fellowship through which its younger
members can visit other ASEAN countries to
exchange ideas and views on mental health practice.
A Malaysian association for research in psychiatry
was founded in 1999.
Future directions
Psychiatry in Malaysia today is on a far firmer footing
than it was in the days of the institutions. The
country has about 140 psychiatrists, more than 25
clinical psychologists and 20 specialist psychiatrists.
There are 10 professors of psychiatry in seven
medical schools across the country. The 32 general
hospital mental health units (with less than 1,000
beds between them) are now treating more mental
illness than the four traditional psychiatric hospitals
did. In fact, patients are more likely to be treated
on an outpatient basis in the community and have
access to short-stay psychiatric care. Short-stay psy-
chiatric beds are much more evenly and comprehen-
sively provided than they were 45 years ago, but there
is probably still a need for more (occupancy rates in
the general hospital mental health units are generally
very high).
There is also a need for psychiatrists to continue
to specialize in areas such as forensic, child and
adolescent, rehabilitation and liaison psychiatry
to meet the true needs of the 24 million-strong
population. More research, especially into operations
and care delivery methods, is required, as are more
psychiatrists working in research.
Most of all, psychiatry still needs to fully infiltrate
general health care and its professionals in
Malaysia—vast areas of primary care psychiatry still
need to be addressed. The current momentum needs
to be maintained.