Above: An actor portrays a man living with schizophrenia in an educational video released by Suan Prung Psychiatric Hospital in 2018. Photo: Suan Prung Hospital / YouTube
BANGKOK — A man who always dressed up as a Hindu priest would sometimes smash his forehead on the pavement. Other times he heard Somdej Toh, a widely revered 19th century monk, telling him to throw money into a pond.
Another said a stranger in white dress kept staring at him in his bedroom, telling him that he should hurt himself because everyone hated him. Yet another woman was convinced someone had inserted high-tech chips into her brain, the only explanation for the mysterious voices she was hearing.
Many may dismiss these experiences as superstition gone overboard or – as the mainstream media likes to call them – antics by “crazy” people, but they are a torturous reality for many of the 600,000 Thais living with schizophrenia, regarded by experts as the most prevalent psychosis in the country. Readers be advised: this story discusses self-harm.
“Sometimes I would reply to the voices, so I began speaking to myself. The voices threatened me to do things that others saw as dangerous and illogical,” said Kruawon Tiengtom, 68, who lived with schizophrenia for two decades. “It was the worst when I heard the voices of people I knew. It affected my real relationships with them.”
It is also a deadly condition. Schizophrenia is believed to account for a tenth of all suicides nationwide. Its prevalence contrasts with a lack of understanding. Awareness about mental illness has started to make headway in Thai society, yet depression captures the media spotlight, leaving psychoses in the dark.
For this year’s World Schizophrenia Day, Khaosod English spoke to a number of experts and former patients in a hope to shed a light on the little-known disease.
“There’s no awareness, no understanding of schizophrenia. If people know about mental illness, it could be just about depression, and nothing about anything else,” recovered patient Amornthep Sachamuneewongse said in an interview.
According to the Department of Mental Health’s 2019 annual report, schizophrenia is the most commonly diagnosed psychosis among Thais (depression, though common in Thailand, isn’t regarded as a psychosis by psychiatrists). The disease also often lasts the longest across one’s life due to its recurring nature.
Schizophrenia can be caused by genetics, life experiences, or chemical imbalances in the brain. Drug use, from meth to marijuana, also plays a factor. Those living with the condition often experience hallucinations, hearing voices, and paranoia.
As a result, patients tend to speak or act illogically, talk to themselves, and start hoarding items. Some may also stop self-care altogether.
“[They have] false beliefs, like someone is trying to attack them,” Pinaritat Silpakit, deputy director of Suan Prung Psychiatric Hospital, said in a educational video. “They might also believe they are someone else, like a person with great power or someone who achieved dhamma.”
In an interview, Usanisa Ekachote, 43, recalled episodes when she had schizophrenia for 30 years. Sometimes, Usanisa said, she thought she was an officer in the King’s bodyguards corps, or even believed herself to be royalty or a mall owner.
“I thought I was the owner of the mall. I would walk around inspecting the shops as if they were mine,” Usanisa said.
Because of these delusions, people with schizophrenia sometimes get in trouble with the Thai authorities, who rarely tolerate public action or remarks deemed insulting toward the monarchy.
A man named Thanet was arrested two months after the military took power in May 2014 for emails he sent four years earlier, in which he proclaimed himself as the real Crown Prince. Thanet reportedly told investigators he was commanded by voices in his head to write and send those messages.
The same year saw the arrest of a man called Samak in Chiang Rai, where he said voices told him to burn down a large portrait of His Majesty the King. Both Samak and Thanet were prosecuted for royal defamation, despite doctors diagnosing them for schizophrenia.
A man named Prajakchai was also arrested in 2015 and charged for his petition to the government, calling for His Majesty the King to be deposed. Prajakchai believed he was the true monarch and the other, an impostor.
In spite of these schizophrenia-like conditions, Prajakchai was tried by the military court under lese majeste law, which bans negative remarks about the Royal Family. Those guilty of lese majeste face up to 15 years in jail.
How Common Is it?
Psychiatrists believe up to 1 percent of the Thai population suffer from schizophrenia. Separate reports by the Department of Mental Health and the Khon Kaen Rajanagarindra Psychiatric Hospital point to the same figure: about 580,000 to 655,000 people.
“One percent of a population is not a small number,” Department of Mental Health spokesman Varoth Chotpitayasunond said. “A province with 1 million would have 10,000 people with this recurring disorder that can be extreme and puts them in a world of non-reality.”
According to the mental health department, throughout the 2018 fiscal year, a total of 375,026 people were treated for schizophrenia in public hospitals.
Of course, not everyone received treatment, but that’s already more than those treated for depression (332,618) and drug addiction (272,249) in the same period, but still less than alcoholism (580,064) and anxiety (448,224).
Nattakorn Jampathong, director of Khon Kaen Rajanagarindra Psychiatric Hospital, said that schizophrenia is found across all socio-economic statuses and both sexes, but a sizable number Thai homeless have schizophrenia. Some were abandoned by their families due to the illness, or developed it because of the stress of being homeless.
“Homeless people with schizophrenia drew some of the wall scribblings you may have seen,” Nattakorn said. “Some can’t do their studies or hold a job, and with no support system they have no way to go.”
Suicides and Shackles
Most worryingly, schizophrenia can drive people to take their own lives. Many survivors recall hearing voices that tell them to harm themselves.
Former patient Amornthep said his first suicide attempt was in 2017. He woke up at the hospital. He attempted to commit suicide again in 2018, after the national suicide hotline didn’t pick up his call. He had previously been diagnosed with both major chronic depression and schizophrenia.
“It’s like in the cartoons, when there is a devil and an angel on one shoulder, and one is telling you to self-harm,” he said. “I was crying like I didn’t know why I was crying.”
Nattakorn, who is also the head of the National Suicide Prevention Center, said that around 10 to 12 percent of Thailand’s suicides are related to schizophrenia.
Official records said 4,137 people committed suicide in 2018, out of the population of about 65.6 million. The percentage attributed to schizophrenia may be even higher than the known figures, Nattakorn said, since officials might fail to see a connection in some suicides with mental illness due to a lack of diagnosis.
Those with mental illness that committed suicide may have done so due to succumbing to demands by hallucinations, or done due to a split-second decision.
“Some delusions include voices telling them to self-harm, or voices of people abusing them,” Nattakorn from Khon Kaen Rajanagarindra Psychiatric Hospital said. “Some people feel compelled to obey the voice they hear.”
Some who survive suicidal urges end up being chained by their own families. In 2012 alone, the mental health department rescued 412 people with mental conditions locked in captivity, often in a room or a shed, by their relatives and neighbors. One man in Nakhon Ratchasima was shackled for almost 20 years.
“I wish society could understand that the illnesses’ symptoms are not our personalities,” former schizophrenia patient Peerapong Sahawongcharoen said. “After treatment, these symptoms go away, so please give us a chance.”
He added, “Don’t chain us up or lock us up. It’s a life of torture.”
Indeed, many Thais with little or no awareness of mental health see those symptoms as a result of supernatural activity, such as ghost possession, and a witch doctor is usually summoned instead of an actual doctor.
“Some people thought they were cursed with black magic in some provinces,” Mental health department spokesman Varoth said. “People thought it was permanent and incurable. But they can be treated, lead normal lives, and contribute to society because what they just have are chemical imbalances in their brain.”
Making Things Right
Although many patients do recover from schizophrenia, it can be a lifelong effort. Medication plays a significant role; many have to take them for life. Some also require injections or electroshock therapy, like Amornthep.
It’s usually expensive. Each visit to a private hospital can cost around 1,600 baht to 2,000 baht; treatment at public hospitals are free or as cheap as 50 baht, but each visit comes with half a day’s wait. Ex-patient Peerapong said his treatment cost around 10,000 baht per month – a large sum even for Thailand’s middle class.
Medications also come with insomnia, drowsiness, sad emotions, physical discomfort and unnatural weight gain. Amornthep gained 65 kilograms from his medications, while Usanisa went from 48 kilos to 88. Peerapong said his medication’s side effects – shaking hands and inability to control his mouth muscles – were “as bad as the mental illness itself.”
Usanisa was admitted to Srithanya Hospital around 20 times. “I wish treatment for schizophrenia didn’t include tying us up and treating us like we’re not human,” she said. “Lying down with nothing to do all day, it makes you sad.”
All three said they preferred therapy activities during their treatment. Amornthep recalls the cooking and art therapy exercises during his six-day stay at a state hospital after his second suicide attempt.
“I remember making bua loi desserts in my favorite colors and drawing how I felt. There were others there so I didn’t feel like I was the only weirdo in the entire world; that I wasn’t on this journey alone.”
Families may find that getting a person with schizophrenia into treatment can be difficult. A book published by Srithanya Hospital references the case of a mother who called the police on her increasingly violent 43-year-old son to bring him to the hospital.
“People with schizophrenia can have strong emotions or even become violent because of the voices they’re always hearing, and the paranoia,” Kruawon said.
“The easy part is if they get treatment, there are many drugs available,” hospital director Nattakorn added. “The hard part is getting them to the hospital and surrounding them with people that won’t be prejudiced against them.”
Some of the patients who made it through the long road of recovery find themselves with newfound purposes and a willingness to help others who were in their shoes.
Amornthep developed a mental health and suicide hotline app called Sati (“Mindful”), where trained psychologists can provide help to those with suicidal urges. Its official launch is set for later this year.
“The last time I tried to commit suicide, I called the hotline and no one answered,” Amornthep said. “So I had the idea, what if connecting to someone to listen to me was as easy as calling an Uber?”
Kruawon went on to help found the Family Link Psychosocial Disability Service Center, a recovery college for those with mental disorders that include therapy activities.
She also translated into Thai “The Quiet Room” (1994) by Lori Schiller, an American woman’s memoir of her struggle with schizophrenia. The book is often used to help those with schizophrenia and their relatives understand the phenomenon.
Usanisa is now working at Living mental health recovery center.
“Pain is just one part of our life, not all of it,” Usanisa said.
If you are thinking about suicide, call the mental health hotline at 1323, toll-free and available all 24 hours. A woman answering the phone on May 22 said that during daytime hours they have 15 people working the phones, and five at night. Some callers can engage in limited English.
If you live far from urban hospitals and wish to receive counseling or treatment regarding schizophrenia, contact your Subdistrict Health Promotion Hospital (โรงพยาบาลส่งเสริมสุขภาพตำบล), or alert a local Aor Sor Mor health volunteer for a patient transfer.