Are You OK?

Mental Health in
Singapore
Dr Lim Choon Guan

Psychiatrist, Senior Consultant

IMH
Course Objectives

 Understanding concepts of mental

health
 Understanding relevant basic
psychology
 Basic knowledge of common mental
disorders and some of their treatment
 Knowledge of some mental health
resources in Singapore
 References
Kua EH, Mahendren
R, Fung D (eds): Mind
Matters 2002. Institute
of Mental Health

http://www.imh.com.sg/edu_publications.html
Week Topics Readings
No.
1 Lecture 1: Introduction Chapter 1

2 Lecture 2: The Family Chapter 2

3 Lecture 3: Development Chapter 3 and 4, 15

4 Lecture 4 Learning Chapters 5 and 6

5 Lecture 5: Adolescence and Chapters 8 and 9

Personality Chapters 10 and 11
6 Lecture 6: Human Sexuality Chap 12 to 14

7 Mid-Term Quiz (Open Book) Lectures 1-6

- 40 T/F MCQs
Week Topics Readings
No.
8 Lecture 7: Depression and Chapter 16 to 21
Suicide
9 Lecture 8: Stress and Anxiety Chapter 16 to 21
Disorder

10 Lecture 9: Addictive Disorders Chapters 22 and

23
11 Lecture 10: Old Age and Mental Chapter 25
Health
12 Lecture 11: Psychosis Chapter 24
13 Lecture 12: Healing of the Mind Chapters 28 to
33
25/11/19 Final Exam: 4 out of 5 Essays, Lectures 1-13
Open book
Assessment
 MCQ test during 7th lecture: 40%
 26 Sep 2019 : Open book
 40 MCQs: True/False-type

 Final exam: 60%

 25 Nov 2019: Open book
 Answer 4 out of 5 essays (2 hours)

 All assessments are open-book type

 No need to memorize
 Attend lectures and understand issues
Introduction

 Mental Health
 Mental Illness and classification

 Epidemiology of mental Illness

 Mental health professionals

 Stigma in mental health

 Are You Healthy?

Health is “not merely the absence of disease

but a state of complete physical, mental and
social well-being”.
World Health Organization

Is this too idealistic?

What is Mental Health?

 Not just absence of mental illness

 A state of well-being in which:

 the individual realises his or her abilities
 can cope with the normal stresses of life
 can work productively and fruitfully
 can contribute to community
 Defining Mental Health: Mental
illnesses are only the tip of the
iceberg
Development of
mental illness
Mental
Serious Mental Illnesses
Illness

Minor mental illness: Adjustment

Disorders, Grief, Situational Reactions
Minor Mental IIlness

Children from dysfunctional families,

At Risk Elderly living alone

Mentally The general population

Healthy
 Spectrum of Care at
different stages

4. Mental Health Treatment by specialized

Mentally
professionals
ill *IMPORTANT*
All Singapore centre have speciallized professionals

3. Support, monitoring, early referral

-Counseling, education of symptoms (e.g. school, Family
Minor mental illness Service Centre)
-Early referral to mental health professional if symptoms
worsen

At risk 2. Targeted Prevention & Early Intervention

-Significant life events
-Income & family status

1. Universal Promotion of Wellbeing & Prevention

Mentally well -Create supportive environments
-Nurture personal coping skills
Who are the Mentally Ill?
 ‘Mental illness’ refers collectively to all
disorders associated with the mind (mental)
 Mental disorders are health conditions
characterized by problems in:
 Thinking (Cognitive)
 Feelings (Mood)
 Actions (Behaviour)
 These disorders cause significant distress
and/or impaired functioning.
Brief History: Mental
Illness
Time Period Concepts of mental health
Ancient Mental illness is caused by evil spirits
civilisation possessed the body and must be driven
out
Renaissance Decline in the belief of possession. Seen as
period natural phenomenon - but mental
problems seen as irreversible.
Eighteenth Scientific inquiry and humanism
Century Need for medical care recognised.
Nineteenth Research began and legislation concerning
Century mental health was enacted.
Twentieth The start of the mental health movement. A
Century holistic concept of care and short term
care introduced. Goals were to return
patients into society, so human service
programmes were established. There was
a focus on prevention.
Twenty first Biological concepts of mental health
Century strengthened in genetic studies
Services
Spiritual and religious
Development of specialized care and
asylum model of care
A reform movement - chains removed.
The first mentally ill patient was
treated in hospital.
Asylums became hospitals for the
mentally ill but with long term
custodial care.
Large state hospitals were built,
psychoanalysis developed and
community health care centres
established.
Smaller hospitals with greater emphasis
on community care. Overreliance
on medications
Classification of Mental
Illnesses
 2 main classification systems used
internationally: DSM and ICD
 Types of mental (psychiatric) disorders
are listed
 Defines criteria to make a diagnosis,
including a list of signs and symptoms
 Helps to have common definition among
researchers and clinicians internationally
and advance research/treatment
DSM

 DSM (Diagnostic and Statistical Manual

of Mental Disorders)
 Latest version is DSM-5
 A publication of the American Psychiatric
Association
ICD
 ICD-11
The International Statistical
Classification of Diseases
and Related Health Problems,
eleventh revision

 Published by World Health Organization

(WHO)
Epidemiological research
Study of the distribution and
determinant of diseases and injuries in
human populations
 Concerned with frequencies and
types of injuries and illness in groups of
people
 Concerned with factors that influence
the distribution of illness and injuries
When reading research
studies, think about…
 Who did the study?
 Study participants
 Who? How many participated? How
many declined or dropped out?
 How were they studied/assessed?
 Were conclusions appropriate based
on results?
 Therefore, are results relevant to me?
‘Survey Method’

 International surveyors, Gallup had

interviewed about 1000 residents in
150 countries over a period of three
years to measure their daily emotions.
 Questions that were asked
included whether people felt well-
rested or stimulated by learning,
smiled and laughed (positive
emotions) or felt worry, sadness,
stress or anger (negative emotions).
Mental health in Singapore
WHO Burden of Disease Study 2001
 Mental illness contributes to 17% of the combined burden
of premature death and living with disability in Singapore

Registry of Births and Deaths

 More people die from suicides than road accidents every
year

2004/5 National Mental Health Survey

 Anxiety & Depression: 6.5% of population
 Minor Psychiatric Illness: 15.7% of population
 Dementia: 5.2% of those > 60 years
Source: National Mental Health Survey 2003/4
 Mental Health in Singapore

1998 2003/4 2009/10

(NUH Study) (IMH Study) (IMH Study)

Depression & Anxiety No Combined No Combined

Data
7.1% Data
(Lifetime)

Depressive Disorders 5.5% 5.6% 5.8%

(12-month) (Lifetime) (Lifetime)

Anxiety Disorders 0.8 -2.5% 3.4% GAD: 0.9%

(Lifetime)
(12-month, various OCD: 3.0%
disorders)
 (159,697)

(86,679) (82,624)
 National Mental Health
Survey of School Children
 Prevalence of mental health problems
among primary school children

 Emotional Disorders (Anxiety and depression)

• 12%
 Behavioural Disorders (attention-deficit
hyperactivity disorder, conduct disorder and
oppositional defiant disorder)
• 5%
Woo et al. Emotional and behavioural problems in Singaporean children
based on parent, teacher and child reports. SMJ 2007
National Mental Health Survey of
School Children: Risk factors
 Overall problems more likely if
 Male gender
 Low intellectual ability
 Mothers being single, divorced,
widowed, deceased

 Identifying risk groups allow us to

plan for targeted intervention
(preventive care)

Woo et al 2007
Basic Facts About Mental
Illness
 A medical problem, often arising from
brain chemical changes genes?
 Symptoms may change over time
 Affects not only the patient but can also
affect the people around them
Causes of Mental Health
Disorders

Environment

Brain Genes
 Mental health problems are
costly for all…
 Direct cost of services & treatment
 Indirect cost
 On caregivers (family, society)
 Trigger for other physical health problems
E.g. Excessive stress linked to heart disease & cancer

 Opportunity cost
 Lost productivity & employment
E.g. Employees (at 3 major American companies) with chronic symptoms of depression were twice as likely to
report missed workdays

= Total Cost of Mental Health Problems

Some estimates… (Source: WHO)

EU 3-4% of GNP - 45% due to lost productivity

US 2.5% of GNP - Indirect costs either match or outweigh direct
costs in all mental health areas
Canada At least $14.4b every yr - $8.1b in lost productivity
Comparing different
diseases: Burden of Disease
Defining the burden of a disease through:
 Years of life lost
 Years of life lost due to premature death
 Years lived with disability
 Years of life lived with any short-term or
long-term health loss
 Disability-adjusted life years (DALYs):
 The sum of years lost due to premature
death and years lived with disability
 Also defined as years of healthy life lost
 Burden of Disease by Broad Cause Group
Singapore 2010
Chronic respiratory
Musculo-skeletal disease
diseases Others
Injuries 6% 4%
5% 14%

Diabetes mellitus
10% Cardio-vascular
20% diseases

7%
Mental disorders
19%

Neurological, vision Cancers

and hearing disorders
Source: Health Facts Singapore,
MOH
NTU HP803
 Treatment
A combination of psychotherapy, medication, and
socio-occupational intervention.
The Mental Health Team (multi-disciplinary team)
• Psychiatrists
• Nurses
• Psychologists
• Medical Social Workers
• Occupational Therapists
• Art Therapists
• Case managers
• Physiotherapists
Who are Psychiatrists?
 Specialist Medical doctors
 Trained to specialize in mental illness
 Sub-specialties
 Adults
 Children and Adolescents
 Elderly (Psycho-geriatrics)
 Specific disorder, eg. addiction
 In Singapore, a medical doctor makes
diagnosis and prescribes treatment
Allied Health Professionals
 Psychologists
 Psychological therapy, eg CBT
 Occupational Therapist
 Occupational therapy, job training
 Medical social worker
 Family therapy, financial help
 Nurses
 Inpatient care, outpatient clinics
 Music/Art therapists
 Case manager (co-ordinate care)
Medical Financing and Chronic
Disease Management
Programme (CDMP)
 3 M’s of medical bill payment
 Medishield Life
 Medisave
 Medifund

 CDMP: Medisave can be used for

outpatient bill payment
 19 medical conditions from 1 Jul 2015
 Schizophrenia, depression, bipolar
disorder, dementia, anxiety
 Stigma

• Stigma: mark of disgrace that sets a person apart

• Can lead to negative attitude (prejudice) and
negative action (discrimination)
• Stigma brings experiences and feelings of shame
and blame and reluctance to seek help
• Can be reduced by improving mental health literacy
• Voluntary Organizations
- Silver Ribbon Singapore
- Singapore Association for Mental Health
 Myths and Facts
People with mental illness are violent and dangerous.
As a group, mentally ill people are no more violent than
any other group. In fact, they are far more likely to be the
victims of violence than to be violent themselves.

People with mental illness are poor and/or less

intelligent.
Most mentally ill people have average or above-average
intelligence. Mental illness can affect anyone regardless of
intelligence, social class or income level.
 Myths and Facts

Mental illness is caused by a personal weakness.

A mental illness is not a character flaw. It has nothing to do
with being weak or lacking will-power.

Mental illness is a single, rare disorder.

Mental illness is not a single disease but a broad classification
for many disorders - anxiety, depression, schizophrenia,
personality disorders, eating disorders, organic brain disorders …
 Myths and Facts
People who are depressed could just snap out of it if they tried
hard enough.
Depression has nothing to do with being lazy or weak. It results from
changes in brain chemistry or brain function, and medication and/or
psychotherapy often help people to recover.

Depression and other illnesses, such as anxiety disorders, do not

affect children or adolescents. Any problems they have are just a
part of growing up.
Children and adolescents can develop severe mental illnesses. Left
untreated, these problems can get worse.
 Myths and Facts

Addiction is a lifestyle choice and shows a lack of

willpower. People with a substance abuse problem are
morally weak or "bad".
Addiction is a disease that generally results from changes
in brain chemistry. It has nothing to do with being a "bad"
person.

Mentally ill people cannot lead productive lives.

FACT: People with a mental illness who are properly treated
with therapy and/or medication can live full, enjoyable and
productive lives.

Source: Canadian Mental Health Association, PRNewswire,

Doing Your Part

We can all help to change community attitudes by:

Learning to see mental illness like any other
health problem
Learning more about the illness so we can
understand why the person behaves strangely.
Showing friendship and support to friends,
relatives, neighbours or colleagues who are
affected by mental illness.
Encouraging people who are mentally ill, or their
families, to seek help.
Pressures on mental
health will grow …
Social changes
 Lifestyle changes
 Nuclear families, marriage breakdown Source: Kessler et al 2003
 High personal and societal
expectations at home, school, work

 Work environment
 Rapid changes & development, job uncertainty

 Threats
 SARS, Avian flu, terrorism

Ageing population e.g. dementia among elderly

Role of technology on lifestyle
 Most people with mental
illnesses
can live at home, hold a job and
function as contributing
members
of society.