Mental healthcare in Singapore.

Singapore is a modern city state and the smallest nation (land area of 699 km2) in South East Asia. Its population of over 4 million is multiracial, with the Chinese (76.8%) constituting the majority of the population, followed by the Malays (13.9%) and the Indians (7.9%). The present health system is one that stresses individual responsibility, based on a system of compulsory medical saving accounts and on market mechanisms for the allocation of scarce healthcare resources. There are both public and private healthcare sectors. Since 1985, every public sector hospital has been 'restructured' - to grant some degree of autonomy in operational matters, with the intention of creating competition and financial discipline, although the government still retains 100% ownership of the hospitals.

Mental health services

Singapore has not engaged in a large move towards deinstitutionalisation, and community care for patients with a mental illness has not received high priority. The Institute of Mental Health (IMH) is the largest mental hospital, with a total bed capacity of 2200, and is the largest provider of mental healthcare. It provides a range of sub-specialties, such as child and adolescent psychiatry, geriatric psychiatry, substance misuse, affective disorders, sleep disorders, early psychosis, psychiatric rehabilitation and forensic psychiatry. It provides a range of pharmacological and psychological treatments, as well as psychosocial rehabilitation.

More recently, however, there has been a resurgence in the recognition of the need for community psychiatry, with the establishment of a department of community psychiatry in 2001 within the IMH. The department provides an array of services, including community-based programmes such as the assertive community treatment (ACT) programme, the mobile crisis team (MCT) programme (a rapid-response team for crises in the home) and the community psychiatric nurse (CPN) service (Lim et al, 2005).

The IMH is the only statutory institution, in that patients can be admitted, detained and discharged in accordance with the Mental Disorders and Treatment Act 1985 and the Criminal Procedure Code 1985 of Singapore. The services include assessment of accused persons suspected to be of unsound mind and the psychiatric treatment of offenders who are mentally unwell. Powers to detain persons for treatment exist under the Mental Disorders and Treatment Act. There is currently no community treatment order or other provision to mandate the compulsory treatment of patients in the community.

Three of the restructured general hospitals in the public sector provide a psychiatric service. The numbers of mental health workers and beds in these services are small, however; for example, the number of beds in each ranges from 15 to 26. There are also psychiatric services in the Singapore armed forces, prison services and hospitals in the private sector (there is only one private hospital which solely provides care for people who are mentally ill).

Another important facet of mental healthcare in Singapore is the complementary and supplementary services provided by voluntary welfare organisations (VWOs). The VWOs receive government aid and provide a range of services, from counselling, residential care and day care, to employment and other rehabilitation services, for persons with mental illness.

One characteristic of the present mental health service is the relative lack of involvement of family physicians, especially in relation to patients with chronic mental disorders. The care of such people still very much rests with the specialised services in both the public and private sectors. In the effort to ‘right site’ the care of those with stable chronic mental disorders to the community, the IMH initiated a programme to induct general practitioners in the care and management of stable patients.

The three major ethnic groups of Singapore contain significant minorities who rely on a mixture of Western and traditional medicines, or who use Western medicine only as a last resort (Somjee, 1995). The practitioners of traditional medicine therefore constitute another important source of help for people who are mentally unwell. Cultural and religious beliefs often prompt patients to turn to spiritual healers (Kua, 2004; Chong et al, 2005) but their clinical and socioeconomic impact is unknown.

The emphasis on individual responsibilities demands that the populace is appropriately educated in relation to health matters. This is principally undertaken by a body called the Health Promotion Board. It runs a public education programme called ‘Mind Your Mind’, initiated in 2001. The programme is spear-headed by the IMH with other partners, including the Ministry of Education, the Ministry of Community Development and Sports, VWOs and other professional bodies. It focuses on raising awareness and the early detection of the major mental disorders, such as depression, anxiety disorders and schizophrenia. It also works towards destigmatising mental disorders and promoting mental well-being (Yeo, 2004).

Research

In the past 6 years, there has been an emphasis on biomedical research and heavy investments have been made by the Singapore government. Singapore has the potential to conduct world-class mental health research because of the unique characteristics of the population, the consolidated organisation of psychiatric services and the presence of sophisticated scientific technological platforms like the Genomics Institute of Singapore, which provides cutting-edge technology. There has been a steady growth in research activities, particularly in the areas of psychiatric epidemiology, first-episode psychosis, dementia, pharmacogenetics of tardive dyskinesia, brain imaging and clinical drug trials.

Workforce issues and training

The quality of mental healthcare depends on the availability and adequacy of the relevant mental health workers: psychiatrists, psychologists, medical social workers, case managers, nurses and occupational therapists.

There are now two medical schools in Singapore, producing between 200 and 250 doctors a year. Psychiatric training, which has been enhanced in the undergraduate curriculum in the past few years, now comprises an 8-week posting in a psychiatry department in a restructured hospital.

Postgraduate training in psychiatry takes a minimum of 6 years. All specialist doctors, including psychiatrists, are certified by a specialist accreditation board appointed by the Ministry of Health. There are only 108 psychiatrists on the specialist register, giving a psychiatrist:population ratio of about 2.6:100 000.

Table 1 shows the number of mental health professionals in Singapore; in each of these categories there is an acute shortage. One reason for this shortage is the absence of local training. For example, there is no doctoral-level programme for clinical psychologists in any of the academic centres in Singapore. Steps are now being taken to address this, for instance with the establishment of a bachelor’s degree in nursing at one of the local universities.

Table 1

Numbers of mental health professionals in Singapore

Mental health professionals	Number	Per 100 000 general population
Psychiatrists	108	2.6
Clinical psychologists	30	0.7
Registered mental health nurses	462	11.1
Occupational therapists	22	0.5

Professional bodies

These include the Chapter of Psychiatrists of the Academy of Medicine, the Singapore Psychiatric Association, the Singapore Psychological Society and the Singapore Association of Counselling.

Mental health policy

The principal problems with the current mental health system include the fragmentation and lack of coordination of services, the rudimentary community mental health services and the shortage of mental health workers. Other challenges facing the country are its ageing population, increasing divorce rates, changing family structures and economic pressures.

The Ministry of Health appointed a National Mental Health Committee in 2005 to draft a national mental health policy and blueprint for Singapore, which aimed to promote mental health in the community, to prevent mental disorders and to allow the early detection, treatment and rehabilitation of persons with mental illness. The Committee has identified four key areas that require the attention of policy-makers and mental healthcare providers over the next 5 years. These are: promotion of mental health and prevention of mental illness; integrated mental healthcare, featuring greater collaboration with general practitioners and the embedding of psychological services into medical teams; the development of the mental health workforce; and mental health research.

Conclusions

The formulation of the above-mentioned policy and blueprint is a positive step in addressing the gaps in the mental health service. The strategies should include taking an integrated approach to the mental well-being of children and adolescents, measures to reduce the stigma of mental illness, such as reviewing employment policies and practices to reduce discrimination, establishing support networks for adults to promote positive mental health, and the early detection and treatment of mental illness. The intention is to develop an emotionally resilient and mentally healthy community with access to community-based, comprehensive and cost-effective mental health services.