Psychiatrist in Malaysia : Ratio and Distribution

Abstract

Introduction: We are aware of the shortage of psychiatrists in Malaysia. However, there is no formal report on the distribution and ratio of psychiatrists in each state in Malaysia. We aim to do a detailed count of the number of psychiatrists in the country.

Methods: We obtained the figures for the psychiatrists practicing in the government, private and university settings by accessing the Ministry of Health database, information from the Malaysian Psychiatric Association, Malaysian Mental Health Association, National Specialist Register and websites of the respective Universities. The total number and ratio of psychiatrists per 100,000 population are calculated.

Results: There was a total of 410 registered psychiatrists in Malaysia in the private universities, private clinics, public universities and government hospitals. The state with the highest number of psychiatrists is Wilayah Persekutuan Kuala Lumpur with a total of 94 psychiatrists which has a ratio of 5.24 per 100, 000 population followed by Wilayah Persekutuan Putrajaya with 3.38 per 100,000 population. The states with the least ratio of psychiatrists are Sabah with 0.54 and Kedah with 0.55 per 100, 000 population.

Conclusion: There is a discrepancy in the geographical distribution of psychiatrists in Malaysia. People living in larger, urban states have better access to mental health care whereas the smaller states face a serious lack of psychiatrists. More effort should be taken to improve mental healthcare in Malaysia as recommended by WHO with one psychiatrist for every 10, 000 population.

Full text

MJP Online Early 01-06-18!
ORGINAL PAPER
Psychiatrists in Malaysia: The Ratio and Distribution
Ng Chong Guan1, Toh Chin Lee2, Benedict Francis1, Tan Shean Yen3
1Department of Psychological Medicine, Faculty of Medicine,
University of Malaya, Malaysia
2Ministry of Health, Malaysia
3Faculty of Medicine, University of Malaya, Malaysia
Abstract
Introduction: We are aware of the shortage of psychiatrists in Malaysia.
However, there is no formal report on the distribution and ratio of
psychiatrists in each state in Malaysia. We aim to do a detailed count of the
number of psychiatrists in the country. Methods: We obtained the figures for
the psychiatrists practicing in the government, private and university settings
by accessing the Ministry of Health database, information from the
Malaysian Psychiatric Association, Malaysian Mental Health Association,
National Specialist Register and websites of the respective Universities. The
total number and ratio of psychiatrists per 100,000 population are calculated.
Results: There was a total of 410 registered psychiatrists in Malaysia in the
private universities, private clinics, public universities and government
hospitals. The state with the highest number of psychiatrists is Wilayah
Persekutuan Kuala Lumpur with a total of 94 psychiatrists which has a ratio
of 5.24 per 100, 000 population followed by Wilayah Persekutuan Putrajaya
with 3.38 per 100,000 population. The states with the least ratio of
psychiatrists are Sabah with 0.54 and Kedah with 0.55 per 100, 000
population. Conclusion: There is a discrepancy in the geographical
distribution of psychiatrists in Malaysia. People living in larger, urban states
have better access to mental health care whereas the smaller states face a
serious lack of psychiatrists. More effort should be taken to improve mental
healthcare in Malaysia as recommended by WHO with one psychiatrist for
every 10, 000 population.
Keywords: Psychiatrist, Malaysia, Count, Ratio, Distribution
Introduction
Malaysia is a developing nation, and located
in South East Asia, is the epicenter of the
cultural melting pot which defines the
region. Consisting of people from a
multiethnic and diverse cultural background,
Malaysia is indeed a colourful and vibrant
nation. Mental health issues have been in the
spotlight recently as the National Health and
Morbidity Survey 2015 reported that 30 %
of Malaysians suffered from some form of

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mental illness. This is a worrying figure as
mental health awareness is still in its infancy
in Malaysia [1]. Thus mental health
resources need to be mobilized as it is
clearly lacking in Malaysia, as compared to
developed nations.
The history of psychiatric services in
Malaysia can be traced back to the setting up
of the first asylum for the mentally insane in
Penang in the 1890s. In the first decades of
the 20th century, two hospitals were built for
the mentally ill – Hospital Taiping and also
Hospital Tanjung Rambutan. The latter was
an institution which housed mentally ill
patients and was built in 1911, with 280
beds [2]. In East Malaysia, similar
institutions were constructed in Sabah and
Sarawak. Some years later, the country’s
next mental institution was set up in Johor,
which is at the southern tip of the country.
This institution was named Tampoi Hospital
and is now known as Hospital Permai, and it
was completed in 1935.
Up to that point in time, mental health
treatment was focused on institutional care,
and there was high prevalence of stigma
towards the patients. This ultimately led to
poor quality of care for the patients and very
low remission and recovery rates. Mental
health treatment in Malaysia during the early
days was seen as managing chronic,
irreversible illness and efforts were mainly
focused on custodial care, rather than
rehabilitative and curative approaches [3].
Thus when the first psychiatry ward in a
general hospital was started in the Penang
General Hospital in 1958 it was a paradigm
shift for Malaysian psychiatry as for the first
time people with mental illness were housed
under the same roof as other patients [4].
The first local psychiatrist in Malaysia was
Dr M. Subramaniam in 1961, followed by
Tan Eng Seong in 1963 who was sent to
Tampoi Mental Hospital. In 1962, Dr Eric
Dax was commissioned by the World Health
Organization (WHO) to review the mental
health policy and treatment of mental illness
in Malaysia. He was instrumental in
revolutionizing mental health care in
Malaysia. Under his leadership, the Mental
Disorders Ordinance 1952 was revised and
the quality of mental health delivery in the
country was given an upgrade [2]. The
Malaysian Psychiatric Association (MPA),
which was founded in November 1976 by
Dr MP Deva and Dato Sri’ Dr M.
Mahadevan, took on the role of nurturing the
field of psychiatry, still at its nascent stage
at the time [5].
The first psychiatry department at a
Malaysian university was set up in 1966 at
University Malaya (UM), followed by the
Masters in Psychological Medicine
programme in 1973. The graduating first
batch of UM produced three fledgling
psychiatrists who would pave the way for
many more future psychiatrists in the
country [3]. The setting up of a Conjoint
Board in the year 2000 further boosted the
development of psychiatry in the country.
The board oversaw the general development
of the post-graduate Masters programme and
played a vital role in coordinating the
academic curriculum as well as to collate
input from various academician psychiatrists
in the country. The number of psychiatrists
has continued to grow since the Conjoint
Board was set up. In 2010, there were a
reported 224 psychiatrists in the country [6],
however this number has only increased
marginally. This number is a far cry from
achieving the WHO’s psychiatrist to
population ratio of 1:10000, which requires
at least 3000 psychiatrists [7]. In order to
fulfil the WHO ratio, the Ministry of Health
encouraged the development of the parallel
pathway to specialization by encouraging
more candidates to train for the Member of
the Royal College of Psychiatry

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(MRCPsych) qualification between 2012-
2014. Expanding recognition to the parallel
pathway is expected to encourage more
doctors to pursue psychiatry, as there is a
great need for psychiatrists in the country.
To date, there is no formal report on the
number and ratio of psychiatrists in
Malaysia. There is imbalance in the
distribution of psychiatrists between states
in Malaysia. In the current study, we aim to
determine the number of psychiatrists who
are practicing not only in the government
hospitals but also in the private settings and
Universities in Malaysia. We will also
calculate the ratio and distributions of
psychiatrists in each state.
Methods
This is a cross-sectional manual count of the
number of psychiatrists in Malaysia. As the
number of psychiatrists is growing from
time to time, we ended the count on 31st
June 2018. The psychiatrists included in the
count are those graduated from the local
masters training program and those overseas
graduates who are recognized by the
Malaysian Medical Council. For the local
graduates, those who completed their
gazettement will only be included in the
count.
We obtained the number of psychiatrists in
the government setting from the Ministry of
Health database. For both the public and
private universities, the number of
psychiatrists is taken from the universities
database, websites and personal contacts
with the respective head of department.
The number of psychiatrists in private
practice is gathered from the psychiatry
related pharmaceutical industry database and
personal contacts with the senior
psychiatrists in each state in Malaysia. The
number of counts is counter-checked with
the Malaysian Psychiatric Association
(MPA) Database and Malaysian Mental
Health Association (MMHA) Website. We
also check the list of psychiatrists registered
in the National Specialist Register (NSR),
Malaysia.
The number of psychiatrists in each state
was calculated and summed. The population
of the country and each state was obtained
from the Department of Statistics, Malaysia
(www.dosm.gov.my). The ratio of
psychiatrists per 100,000 population for
each state is calculated using the formula
below:
Ratio = !"#$%& !" !"#$!!"#$!%#%
!"!#$%&'"( X 100,000

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Results
Table 1. Ratio and Distribution of Psychiatrists in Malaysia in 2018
States
Private
Universitya
Public
Universityb
Private
Practice
Government
Hospitalc
To t a l
Psychiatrists
in each stated
Populatione
Psychiatrist per
100,000
population
Perlis
0
0
0
3
3
253100
1.18
Kedah
0
0
3
9
12
2166200
0.55
Pulau Pinang
5
0
8
9
22
1767900
1.24
Perak
3
0
5
32
40
2507200
1.59
Selangor
4
28
17
29
78
6448400
1.20
W. P. Kuala Lumpur
23
28
23
20
94
1792600
5.24
W. P Pu tr ajaya
0
0
0
3
3
88700
3.38
Negeri Sembilan
3
0
2
10
15
1130600
1.32
Melaka
2
0
2
5
9
924900
0.97
Johor
5
0
8
28
41
3737200
1.09
Pahang
0
0
1
11
12
1664000
0.72
Ter e ngga n u
0
3
0
8
11
1226000
0.9
Kelantan
0
7
0
10
17
1854500
0.92
Sabah
0
4
4
13
21
3915100
0.54
Sarawak
0
2
7
22
31
2789400
1.11
W.P. La bu an
0
0
0
1
1
98400
1.01
TOTAL
45
72
80
213
410
32364200
1.27
a University of Malaya, UniversitiKebangsaan Malaysia, UniversitiSains Malaysia, Universiti Malaysia Sarawak, Universiti Putra Malaysia, International Islamic
University, UniversitiTeknologi MARA, Universiti Malaysia Sabah, UniversitiSains Islam Malaysia, Universiti Sultan ZainalAbidin,
UniversitiPertahananNasional Malaysia
b International Medical University, Penang Medical College, Monash University School of Medicine and Health Sciences, Melaka Manipal Medical College,
Universiti Kuala Lumpur - Royal College of Medicine Perak, Cyberjaya University College of Medical Science Faculty of Medicine, UCSI University,
Management & Science University, AIMST University, MAHSA University, Newcastle University Medicine Malaysia, Perdana University Graduate School of
Medicine, Perdana University Royal College of Surgeon, SEGi University, Taylor's University, UniversitiTunku Abdul Rahman, WIDAD University College,
QUEST International University, Asia Metropolitan University School of Medical and Health Sciences, Lincoln University, Universiti Islam Antarabangsa
Sultan Abdul HalimMua’dzam Shah
c There were twenty master graduates who passed their professional examination on May 2018 but not included in the count as they have not completed their
gazzettement.
d Ministry of Health Data
e Based on Department of Statistics, Malaysia (www.dosm.gov.my)

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Table 1 shows the number of psychiatrists in
different states in Malaysia. The total
psychiatrists in Malaysia was 410, which is
only 0.02% as for the Malaysian population.
The three states with the highest number of
psychiatrists are Wilayah Persekutuan Kuala
Lumpur (66) followed by Selangor (50) and
Perak (40). Wilayah Persekutuan Labuan
has only one psychiatrist. For the ratio of
psychiatrists per 100,000 population in
Malaysia in 2018 is only 1.27. Wilayah
Persekutuan Kuala Lumpur has the highest
ratio (5.24 per 100, 000) followed by
Wilayah Persekutuan Putrajaya (3.38 per
1000,000). Sabah and Kedah have the
lowest ratio which are 0.54 and 0.55 per
100,000 population respectively.
Figure 1. The Ratio and Distribution of Psychiatrists in Malaysia
This figure shows the ratio of psychiatrists
per 100, 000 population in Malaysia.
Wilayah Persekutuan Kuala Lumpur has the
highest ratio of psychiatrist followed by
Wilayah Persekutuan Putrajaya. Sabah is
shown to have the lowest ratio of
psychiatrist compared to all states in
Malaysia.
0"
0.5"
1"
1.5"
2"
2.5"
3"
3.5"
4"
4.5"
5"
5.5"
6"
Ratio&of&Psychiatrist&per&100,000&population&
States&in&Malaysia&
Psychiatrist&per&100,000&population&in&Malaysia&&

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Discussion
As of year 2018, there is a total of 410
registered psychiatrists in Malaysia with 213
doctors in the government sector, 80 doctors
in the private sector, 72 doctors in the public
universities and 45 in the private
universities. The state with the highest
number of psychiatrists is the capital city of
Kuala Lumpur with a total of 94 doctors.
However, most of the psychiatrists have
opted to work in private setting (23 doctors)
and universities (51 doctors). This is
followed by the state of Selangor, Johor
Bahru and Perak with a total of 78, 41 and
40 psychiatrists respectively. Subsequently,
Sarawak takes the lead by having 31
psychiatrists in its state. 22 psychiatrists are
working in the government sector while the
remaining 9 doctors operate their own
private clinics. Penang has 13 psychiatrists
working in the private sector and 9 in the
public hospitals, making up to a total of 22
psychiatrists on the island. Sabah and Negeri
Sembilan have 21 and 15 psychiatrists
respectively. With 12 doctors in each state
are Kedah and Pahang whereby more of the
doctor work with the government than
privately. Kelantan, Terengganu and Melaka
have a total of 17, 11 and 9 psychiatrists
respectively. However, for the state of
Kelantan and Terengganu, there are no
psychiatrists working privately. The states
with the least psychiatrists are Labuan,
Putrajaya and Perlis. Labuan only has one
psychiatrist working in the government
sector while Putrajaya and Perlis have a total
of three each who are also from the public
sector. Overall, we can see that the
geographical distribution of Malaysian
psychiatrists is strongly correlated to the
population size of the different states and
they are unevenly distributed throughout the
nation.
The ratio of psychiatrist per 100,000
population in Malaysia is only 1.27 which
still does not achieve WHO
recommendation. As for ratio of psychiatrist
according to each state in Malaysia, Wilayah
Persekutuan Kuala Lumpur has the highest
ratio of psychiatrist which is 5.24 followed
by Putrajaya which is 3.38 and Perak 1.59.
Meanwhile, Negeri Sembilan, Pulau Pinang
and Selangor have ratio of 1.32, 1.24 and 1.2
respectively. Moreover, Perlis, Sarawak,
Johor followed by Labuan, 1.18, 1.11, 1.09,
and 1.01 subsequently. Furthermore,
Melaka, Kelantan and Terengganu have
ratio of 0.97, 0.92, and 0.90 respectively.
Whereas, the states with the least ratio of
psychiatrists are Pahang, Kedah, Sabah
which are 0.72, 0.55 and 0.54 respectively.
More and more people around the world are
facing mental health issues nowadays.
According to the Global Health Estimates
report by WHO, nearly 50% of the total
number of people having depression live in
the Western-Pacific and South-East Asia
Region due to the relatively large population
size of these two regions [8]. South-East
Asia is made up of 11 countries and most of
these countries are classified under the low-
income group according to the World Bank
criteria. The poor financial state and severe
lack of human resources in these affected
countries contribute to a high treatment gap
of 90%, exposing them to various mental
health issues and challenges. Out of these 11
countries, 9 of them have lesser than one
psychiatrist per 100,000 people. [9] The
WHO’s Global Health Observatory data
repository has shown that Indonesia,
Philippines and Thailand have only 0.29,
0.46 and 0.87 mental health doctors per
100,000 population respectively. Singapore
has 3.48 psychiatrists per 100,000
population which is a higher figure in
comparison to the other countries in its
region. China has 1.53 psychiatrists per
100,000 population for the year 2011

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whereas India has about 0.30 mental health
doctors per 100,000 people [10]. In the US,
there are around 28,000 psychiatrists and
12.4 doctors per 100,000 population.
However, there is a rapid decrease in
numbers as many are close to retirement age
- at least 3 out of 5 practising psychiatrists
are older than 55 years old [11].
It is estimated that 1 in every 10 persons
may require mental health support at a point
in time. There is still a shortage of
psychiatrists as the global median remains
only around one psychiatrist per 100,000
population. In comparison to low-income
countries, richer countries have
approximately 120 times more mental health
doctors [12]. In Malaysia, the prevalence of
mental health issues has been steadily
increasing from 10.7% in 1996, to 11.2% in
2006, to 29.2% in 2015. World Health
Organization (WHO)’s Global Health
Observatory data repository showed that
there were only 0.76 psychiatrists per
100,000 population for Malaysia in 2015
[10]. WHO has recommended a ratio of
psychiatrists to the Malaysia population of
1:10,000. However, the current ratio is only
1:200,000 [13]. In the current study, we
showed that there were only 1.27
psychiatrists per 100,000 population in
Malaysia. This severe shortage of
psychiatrists in the country may pose several
problems for those who are facing mental
health problems, including delay in seeking
treatment, seeking alternative treatments
which are not evidence-based, long waiting
time for psychiatric consultation, low-
quality outpatient mental health care, poor
compliance to follow-up and treatment,
increase in drug abuse and addiction cases,
surge in suicide rates, unemployment and
homelessness. In addition, general
practitioners have to shoulder the burden of
treating these patients and are unlikely to
provide the requisite standard of care e.g.
psychotherapy. Current practising
psychiatrists may also face high burnout
rates due to the increasing demand. The
psychiatric workforce is unevenly
distributed in most countries with larger,
affluent cities being most concentrated with
psychiatrists. Hence, the rural poor may face
difficulty accessing basic mental health care
due to the lack of resources.
The growing world population means that
the number of people with mental health
problems is on the rise especially in lower-
income countries. In 2015, it was estimated
globally that more than 300 million people
have depression [8]. Clearly, there is an
increasing need for more psychiatrists in
order to meet the new demand. To address
this shortage issue, it is important for the
government, medical council and media to
help increase awareness among healthcare
professionals, workers and public regarding
the urgent need in this field. Besides that, in
order to encourage more doctors to
specialise in psychiatry, medical
undergraduates should be provided with a
high-quality psychiatry rotation as part of
their medical course. By having more
clinical experience with real-life patients,
hands-on mental health training and
dedicated tutors to mentor them, students
will be more engaged in this field and this
will simultaneously increase their interest to
become future psychiatrists. Furthermore,
psychiatrists should partner closely with
other mental health professionals such as
psychologists and counsellors to provide
other forms of therapy for their patients and
also help ensure increased access and a
better standard of care for them. In addition,
more training positions, specialty
programmes or certifying examination for
psychiatry should be introduced or provided
for doctors who are interested in pursuing
psychiatry. Efforts should also be made to
ensure that the Malaysian population has

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greater access to self-care resources, mental
health promotion, mental health literacy and
prevention of mental illness. Greater use
should be made of information and
communication technology (ICT) especially
mental health websites, mobile applications,
helplines, telemedicine and artificial
intelligence to mitigate the effects of having
small numbers of psychiatrists and other
mental health practitioners.
There are some limitations in this study.
Firstly, there is difficulty in obtaining an
exact count of the total number of
psychiatrists who are working in the
government and private setting in Malaysia
as there is no formal or official database.
Most of the data were obtained through
manual online search, calls and emails to
various medical institutions and hospitals,
word of mouth and various colleague
contacts. Secondly, there are some new
masters graduates in psychiatry who are yet
to be included officially in the Ministry of
Health’s list. Thirdly, some psychiatrists
might have stopped working or retired but
their names were still on the official list.
Hence, the contents of the data may be
subjected to some under- or overestimation.
However, we have tried to minimize error
by thoroughly checking through the data we
have obtained from various sources and
ensuring there is no overlapping between
psychiatrists.
Overall, there is a discrepancy between the
geographical distributions of psychiatrists in
Malaysia. People living in larger, urban
states have better access to mental health
care whereas the smaller states face a lack of
psychiatrists. There should be a more
uniform distribution between all
geographical locations within the country.
At the same time, more effort and steps
should be taken to address the issue of
shortage of psychiatrists in Malaysia in view
of the increasing demands of mental health
services. Collaborative effort between all
parties involved is required to help achieve a
ratio of psychiatrists to the Malaysia
population of 1:10,000 as recommended by
WHO.
Acknowledgment
We thank Loh Huai Seng, Nor Farhana
Atiqah Binti Mohd Haizal, Then Siew Wei
and Chin Shih Ling for their help in the
acquisition of the data and completion of the
report.
Funding
None
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Corresponding Author
Assoc Prof Dr Ng Chong Guan
Department of Psychological Medicine,
Faculty of Medicine, University of Malaya,
50603 Kuala Lumpur, Malaysia
Tel: +60379492068
Email: chong_guan@um.edu.my