Exempt these young men from NS

Suicide of NSF with schizophrenia raises question of whether those with this serious affliction should enlist

Schizophrenia used to be thought of as a psychological disorder brought on by cold, uncaring mothers. But that was a terrible misconception because it is really an organic neurological disorder with psychological symptoms.

Because some brain circuitry is improperly tuned, the individual's thoughts are disconnected from reality. His inner world is altered, which is why his behaviour changes, depending on whether the disease is in a passive or acute phase.

During the passive stage, he may be socially withdrawn. He can't say how he feels, and fails to take care of himself. He may be anxious, depressed, even suicidal. At this stage, he may be easily misunderstood, appearing to others as a dishevelled, lazy good-for-nothing.

During an acute bout of schizophrenia, however, his bizarre behaviour will be unmistakable and may alarm those around him.

He may ramble illogically, become angry or violent over an imagined threat because he may be deluded, suspecting that others are conspiring against him or controlling him. Or he may believe he has super powers. He may also hallucinate - hearing voices or, more rarely, seeing things. His thinking becomes disordered, he jumps from one thing to another. His speech may become disorganised, his reasoning muddled.

These symptoms may frighten others, not just strangers but even family members and co-workers.

The Institute of Mental Health, as the national centre, sees cases of depression, schizophrenia and anxiety the most frequently, in that order.

Last week brought tragic news from a coroner's inquest into the death of a full-time national serviceman (NSF) who had schizophrenia. Private Ganesh Pillay Magindren's camp supervisor had been informed about his condition, but she never tried to find out what it was or how to manage him. Instead, the coroner heard, she was consistently strict and harsh towards him, aiming to make a better soldier of him.

Last July 4, she punished him for tardiness by giving him 14 extra weekend duties. Pte Ganesh, 23, killed himself the next day.

The key question this death raises is whether a youth with schizophrenia ought to be enlisted at all.

Writing on his Facebook page, Dr Ang Yong Guan, a psychiatrist in private practice who headed the Psychological Care Centre at the Military Medicine Institute up to 2003, says a male with schizophrenia is exempted from NS if he has "symptoms of the illness at the time of his medical check-up at the Medical Classification Centre of the Central Manpower Base". But if he is symptom-free, he may be enlisted "as a non-combatant... on a case-by-case basis".

Pte Ganesh's sad end suggests that known schizophrenics should be exempted from NS regardless of whether or not they display symptoms at the check-up. Here's why.

A person with this brain disorder needs powerful drugs, which have severe side effects, to keep his condition in check. He requires medication for life and is never cured as drugs don't rewire the brain. Acute bouts recur if he stops taking his medication when he feels better, not least to avoid the side effects.

One reason patients stop taking their drugs is "treatment stigma" or the shame associated with seeing a psychiatrist or seeking help for a mental illness. An NSF wouldn't like his buddies to know he is popping "crazy" pills.

There is another kind of stigma - "internalised stigma", or the embarrassment of being known as someone with a serious mental illness. No NSF would want his camp mates to call him "mental".

A new paper published in Psychological Medicine, a journal in the Cambridge University Press stable, reviewed 144 studies covering 90,000 participants worldwide and found that both forms of stigma hinder patients from being treated.

Among specific groups particularly affected were the young, males, minorities and those in the military - all of which apply to Pte Ganesh.

All this suggests that NS is not the ideal environment for those who must comply with drug treatment for schizophrenia.

Here's another reason: The patient also needs lifelong support from family members who ensure, among other things, that he sticks with his drug regimen. But NS removes him from his family.

There is no evidence that workplace stress, family tension or social pressures can trigger a schizophrenic relapse.

Stressful episodes are known to occur before symptoms recur, but this may be because once the person stops taking his medicines, he may begin losing his temper, lacking focus, becoming anxious, neglecting himself and so on. In a military setting, this cannot but trigger disciplinary action.

It therefore seems to make good sense to exempt a youth with schizophrenia from NS, irrespective of whether or not he displays symptoms on the day of his pre-enlistment medical check-up. Better to let him remain in the care of his family and doctors, and in the community at large. That brings us to the other issue this sad case highlights: how society needs to do more.

Aside from lifelong medication and family support, the patient also needs lifelong psychosocial support as his greatest problem is difficulty in socialising, cultivating and maintaining meaningful relationships.

While drugs control the delusions and hallucinations, they cannot improve the person's ability to communicate, get along with others, get a job and live well.

He needs training in social skills, as such training has been found to help reduce relapses by half. Such patients also have trouble finding and keeping a job. They need help to learn skills such as how to work in a team, manage stress and handle job interviews - and even then, many won't be able to hold down a job or care for themselves sufficiently. The reality is that most will have to rely on family members, the usual caregivers. They, too, need to be educated about the illness.

Out in the world, the patient has major social problems. Whether in the military or in civilian life, if his condition is known, he can expect to be stigmatised and discriminated against.

There is no solution other than to raise awareness and educate family members, bosses, co-workers and others to understand and be more accepting of those with this brain disorder. And unconditionally exempt young men with schizophrenia from NS too.

Pte Ganesh's suicide also raises the question of how young men diagnosed with other psychoses should be viewed regarding NS. That is a policy question deserving close and urgent scrutiny.

andyho@sph.com.sg