The Republic of Malta is an archipelago of islands in the Mediterranean Sea, perched between Europe and North Africa. Its population is around 500 000, making it the European Union's smallest member state, but it is also the most densely populated. The history of psychiatry in Malta dates back to the 16th century, as is well documented by the Maltese medical historian Paul Cassar (Cassar, Reference Cassar1949). In 1994, Joseph R. Saliba gave a detailed account of psychiatry in Malta, documenting the drive from institutional psychiatry to community psychiatry and describing the struggles the country had with subspecialisation, staffing and training (Saliba, Reference Saliba1994). Since then, Malta has set up five community mental health teams, introduced new mental health legislation and introduced full postgraduate psychiatry specialisation. Malta continues to work towards improvement of its mental health services and towards reducing the stigma associated with mental illness.
Becoming a psychiatrist in Malta
Studying and working in Malta can be a very familial experience. As Malta is such a small country, our peers are often the same throughout our childhoods and later. There is one university, with one medical school – the Faculty of Medicine and Surgery was formally instituted in 1771. A medical degree obtained from the University of Malta has had formal recognition overseas since 1901, when it entitled graduates to be registered in England as colonial practitioners. Now, as Malta is a European Union (EU) member state, the degree is recognised by all EU members. The faculty contains 12 departments, one of which is psychiatry. The system is like that in the UK, with a 5-year undergraduate programme, followed by a 2-year foundation training programme during which doctors decide which specialisation to pursue.
In the past, doctors would have to travel overseas to specialise. This attributed to the much-talked-about medical ‘brain drain’. Between 60 and 80% of doctors would leave Malta, motivated by better salaries and training available overseas, and having good opportunities to take up jobs, with a medical degree from a reputable institution and having English as a first language. In 2008, for the first time, formal postgraduate training in psychiatry was offered in Malta, whereby trainees could complete their specialisation in their home country. The first cohort graduated in 2013. This has had a huge impact on both the resources and the morale and pride of the staff. A culture of education, academia and professional pride is developing. Recently, stronger links have been made with the Royal College of Psychiatrists, and becoming a member of the College is not only encouraged but is a requirement for training. This also helps trainees feel that they are part of a larger community.
The postgraduate training can be stifling at times. There is no escaping, no other hospital to work in, no next big city to move to. The ‘playground’ can be tough; a bad reputation is almost impossible to shed, and gossip can be rife and painful. However, all in all, good professional relationships and friendships are made and maintained, and we look out for and protect each other almost like a tribe would its members.
Working in psychiatry
Having worked in psychiatry in Malta for over 10 years, I have come to appreciate the strengths and weaknesses of the specialty in the country, and constantly strive to be aware of the affects these have on me as a professional and as a person. Clinical work is fulfilling and satisfying but sits within a constant awareness of the system and the administrative challenges around us.
The past years have been interesting times. Both community and specialist services have been developing, with UK- and USA-trained psychiatrists returning to Malta. Often, these psychiatrists return to grapple with the challenge of developing their specialty here. It can be frustrating when one compares the local situation with what they were used to in other, better resourced countries. Certainly, it may feel like the grass is greener on the other side, but is it? It may truly be the case, when one looks at the staffing levels and subspecialty training of professionals in the field in Malta and other countries. For example, Malta comes in third before last among EU countries in the World Health Organization's report (WHO, 2015) of the number of psychiatrists per million inhabitants.
We do have our strengths. In Malta, the family unit is still stronger than it perhaps is in other, larger countries, and families are available to alert us when they are worried, or to support patients. When they do raise the alert, communication is rapid and services are usually close to home. Drawing in the family and community support a person has is relatively easy and practical. General practitioners are not isolated, with many of the larger health centres having a community mental health clinic close by or on the same premises. We use the close links between general practice and mental health services regularly in our practice. There are five community mental health teams. In 1 year, psychiatrists had over 6000 appointments, and there were over 8000 appointments in the psychiatry out-patient department at the general medical hospital (Mental Health Malta, 2017).
Mount Carmel Hospital, built in 1861, is the main in-patient mental health facility in Malta. A small short-stay psychiatric unit exists in the general medical hospital, and both a short-stay and long-stay unit exists on the sister island of Gozo. The number of admissions has increased gradually over the years, with 2017 having 1974 admissions, of which 616 were first admissions (Mental Health Malta, 2017). In 2017, there were 13 consultant psychiatrists, 8 resident specialists and 25 trainees in the whole of the mental health services. Most psychiatrists cover in-patient and community services and a special interest area, and all work within a multidisciplinary team set-up.
Beyond the structure
An important voice that has emerged recently in the field of mental health in Malta is the Alliance for Mental Health (A4MH), a group of organisations that represent professionals, patients and carers. Their energy has been palpable over the past 3 years, especially since the publication of their position paper (A4MH, 2016), which came at a time when the government began discussions for a new psychiatric hospital. This has helped with our motivation, and allowed a better structure for formal discussion and reaction to events that occur locally.
I write this at a time when one of Malta's most popular television programmes will be dedicating its time to mental health issues, and when Malta's entry for the Eurovision Song Contest was a song called ‘Taboo’, about the stigma associated with mental illness, and is part of a large anti-stigma campaign. It has also been a difficult week, as we try to come to terms with a highly publicised suicide. Thankfully, we now have a system in place to support one another, with platforms such as the Maltese Association of Psychiatry, or simply informal supervision groups organised in-house by the psychiatrists themselves. Awareness campaigns driven by trainees and medical students are in the public domain, and the Office of the Commissioner for Mental Health is as busy and driven as ever. Psychiatrists, and all of us working in the field, want one thing: to prioritize mental health in Malta.
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