Immediately, I scribbled “euthymic, alert and well” in my notebook. In other words, normal.

“Hi, I’m Tricia, a medical student. Would you mind sharing what brings you to the clinic today?” I asked, smiling.

“Well, my mood hasn’t been that great…I’ve been seeing the doctor for a few years now.” As she tucked her arms behind her, I noticed the tell-tale stripes of scar tissue ploughed across her forearms—marks of deliberate self-harm.

“Could you share a bit more about why you started seeing the psychiatrist?” I crossed out the “euthymic” in my notebook, noting the way her voice dipped.

“The first time I overdosed was when I was 13. It was… after I started cutting for a bit. It’s been about seven times since that first time and…I don’t know… I guess that’s why I need to keep coming here.”

“I don’t even know why I started cutting. It wasn’t PSLE or boys or anything like that. I just felt so empty, like I had to do something.”

As Amelia unravelled the history of her illness, it seemed more amorphous than the cookie cutter disease templates we had learnt in lectures just a week prior. She came from a relatively wealthy family, though her parents were seldom at home. Saddled with all the symptoms of major depressive disorder, she also purged regularly, in an attempt to shrink her already tiny frame.

I had come into the Psychiatric Medicine posting fresh from an international conference in youth mental health and a gap year spent on local and international projects. I was no stranger to the tragic stories and many barriers inhibiting access to care.

Despite this, Amelia’s story weighed heavily on me for days after. She seemed almost cavalier about her eight suicide attempts. Why?

Was it the fact that she had already been struggling in the grip of depression for nearly a quarter of her life, at the time? The eating disorder that muddied her mind and being? Or that 12-year-old Amelia only received psychiatric aid when an ambulance rushed her to the emergency department, disoriented and with twelve Panadol pills clumped in her throat?

The treatment gap in mental health

Public health runs with the ethos that an ounce of prevention is worth a pound of cure. And yet, the 2016 Singapore Mental Health Study estimates the time taken for individuals to seek help for mental health issues, or the “treatment gap”, runs anywhere between a year for Depression to up to 10 years for Schizophrenia.

This horrifying statistic came to life when I met a young man at the Institute of Mental Health (IMH) with a severe relapse of Schizophrenia. Charles was a 28-year-old who was acutely psychotic and now unable to return to his job. He came to IMH at age 14 with early signs of schizophrenia. But his father had thrown a fit in the clinic, unable to entertain the prospect that his son could be mentally ill. The next time Charles saw a psychiatrist was over a decade later, after his symptoms became too disabling for his family to cope with.

When I asked the doctor about his prognosis, he shook his head sadly. “It’s much easier when they present early.”

Fear of mental illness is a black hole that one falls into, never to recover from again. The fear of losing the people and things closest to you. The fear of losing yourself.

Birthing hope: People, place and a purpose

In psychiatry, a patient’s history and prognosis are summed up in a “psychiatric formulation”. Part of this involves identifying the predisposing, precipitating, perpetuating and protective factors that dip and drown someone in the depths of mental illness.

For instance, predisposing factors include traumatic events during one’s youngest years, or personal or family history of mental illness. Protective factors include religion, a stable support system, and access to support services.

It is sobering that, particularly for youth, many of these factors fall outside the circle of their control. Could nine-year-old Amelia have berated her parents for spending too little time with her? Could we have expected Charles to demand that he be treated for a condition which would likely frighten any 14-year-old?

Public discourse often pitches therapy or “seeking help” as the panacea for one’s mental health woes. It is lauded as the proverbial pumpkin that portals Cinderella into the palace of eternal well-being.

But what happens when one doesn’t “vibe” with their first counsellor? Or if one starts seeking help at their breaking point, only to find that the waiting time to see their university counsellor is three months?

While systemic shifts must occur to address the myriad issues inhibiting timely access to care, perhaps we also need to nuance our conversations surrounding mental health.

Moving beyond didactic or consolatory messages (Go see a therapist! It’s okay to not feel good!), what if we used hope to power our slogans and stories?

For every case like Amelia and Charles, there is one like Ella’s. She is a 30-year-old who ambles into the clinic, perfectly kempt, chatting animatedly about how her kids are all studying diligently for the national exams. Just a decade ago, she was hospitalised for a month after a manic episode from her bipolar disorder—she had flung herself out of a taxi after yelling “they’re chasing me, they’re chasing me, let me out!”. She has not had a relapse in years.

Dr Tom Insel, psychiatrist, and former director of the National Institute of Mental Health in the United States, traces the road to mental health recovery as optimising for “people, place and purpose”. People, in fostering social support; place, in having a safe and supportive environment to be in; and lastly, purpose: having a reason to be, to care about and wake up for.

While the psychiatric formulation is largely oriented around the psychiatric issue at hand, perhaps there is room for us as a society to consider a more optimistic approach in enabling recovery. Instead of disease minimisation, what if we chose to optimise for hope and flourishing? To look at nourishing a patient’s purpose, fostering a place for them to recover in, and empowering others to support them?

What we don’t talk about: closing the discourse gap

The word stigma derives from the Greek stizein, meaning “to tattoo”. “Stigma” in English first referred to the mark left by a hot iron—that is, a brand.

We speak passionately about breaking the stigma surrounding mental health and talk about how mental health is important, but the discourse is rarely immediate and personal.

When I wrote about my own struggle with mental health for The Straits Times, I hesitated to hit send on the email. It felt “grittier” to keep it under wraps and power through, like a well-oiled machine. I was afraid of being labelled as exploitative for using my mum’s cancer as a “get out of jail free card”. I didn’t wish for my experience as a caregiver to turn into a caricature or cliche.

But I believe there’s power in being vulnerable, even when the story isn’t neatly bow-tied and packaged. Let’s move beyond sterile revelations from stats or manicured testimonies—I think we shatter stigmas by being straight and candid with our own stories.

*Names and minor details have been modified to protect the identities of the patients mentioned in this article.