洪永元医生 Mental Illness 精神病 Ang Yong Guan (25 Oct 2004).wmv
Understanding Mental Illness
Source: Singapore Association for Mental Health, March 1998
Mental illness has always been surrounded by fear and ignorance. For centuries, it has often been seem as either possession by evil spirits, a moral weakness, or punishment from a higher being.
Unfortunately, those suffering from mental illness are thought of by most to be restless, raving, and often violent, with an unkempt, crazed appearance.
But this is not so.
The fact is, there are many forms of mental illness, differing in severity, duration, and the degree to which they affect daily living.
Some forms are quite mild, and disappear entirely after proper treatment. Others take longer to cure, or might even recur throughout a person’s life.
To put it simply, then, mental illness is a disturbance of the mind that may interfere with normal behavior and make daily life difficult.
And the symptoms of most mental illnesses are exaggerated forms of the normal types of behavior and feelings we all experience.
Mental illness can be divided into 4 major categories, namely affective disorders, schizophrenic disorders, neuroses, and organic brain disorders.
The terms may sound intimidating. But a simple understanding of what they are and how we can cope with them, will go a long way towards removing the shroud of uncertainty and fear that has far too long plagued this forbidding subject.
Affective Disorders
This is by far the most common form of mental illness found in all races and cultures, affecting about 8% of all men and 15% of all women at some point in their lives.
Affective disorders refer to a group of illnesses where there is a marked altering of mood.
A very low mood, loss of interest, apathy, and even suicidal thoughts, are present in “depressive disorders”. A marked life in mood, to a state of euphoria and uncontrollable behavior, indicates a “manic disorder”.
Some people, whose moods swing from bouts of severe depression to bouts of euphoria, are classified as “manic depressives”.
All of us experience mild depression from time to time, but some people suffer severe depression – feelings of total despair and hopelessness that they are unable to snap out of.
The exact cause of affective disorders are not known, but they do tend to have a biological basis or inherited predisposition. Environment also plays a major role, as do failure and loss, especially in the early childhood years.
Depressive disorders should be treated professionally, with the aid of tablets and often counseling. Manic disorders should be treated with tablets as well as psychotherapy, though manic depression tends to reappear from time to time.
Only 1 person in 20 needs to be admitted in hospital for depression.
Schizophrenic Disorders
“Schizophrenia” is the name given to a group of mental disorders which affect the normal functioning of a person’s mind, leaving those parts of the mind which control thinking and feeling to be at odds with one another.
The sufferer then loses touch with reality, often having hallucinations, e.g. hearing voices, or delusions, e.g. believing they are God or that someone is reading their thoughts.
A schizophrenic breakdown can happen to anyone at any time, although people in the 16-33 age group tend to be most at risk.
The precise cause of schizophrenia is not known, as there appear to be a number of contributing factors. A certain predisposition towards developing the illness can be inherited, and it seems that people are more likely to become schizophrenic if someone else in the family already has the illness.
Childhood experience, personality type, and biochemical abnormality have also been cited as possible factors.
To date, drugs have been the most effective treatment for schizophrenia, often combined with some sort of supportive counseling. The drugs help to stabilise disturbances, enabling the patient to exert control over his (or her) life again.
Half the people who have been diagnosed as schizophrenic recover and stay reasonably well.
Neuroses
“Neuroses” is a term given to mild forms of mental illness. Neuroses are best understood as exaggerated emotional responses that the sufferer is aware of, yet unable to control.
Persons with a neurosis can usually function on the job and at home, but they live under a cloud of anxiety and tension.
Symptoms of neuroses include excessive feelings of inferiority and helplessness; a constant sense of guilt; irrational fears or phobias about people, places or situations; and health problems such as headaches without physical causes.
Some of these neuroses manifest themselves in compulsive behavior, where a person feels compelled to constantly repeat an act, handwashing or changing clothes, in an attempt to reduce anxiety. This is called “obsessive compulsive disorder”.
Other forms of neuroses follow extremely stressful or traumatic events, such as war, natural disasters, or accident. The sufferers tend to be fearful, and constantly re-live the event. This is called a “post-traumatic stress disorder”.
Neuroses are generally treated with relaxation therapy, behavior therapy, counseling, or when necessary, tranquilliser drugs.
Organic Brain Disorders
Organic brain disorders result from damage or disease to the brain, caused by injury, ageing, tumours, drugs, or physical illness.
They can cause deterioration in a person’s memory, impairments in speech, vision, or even motor ability. Personality and behavior may also be affected.
One form of organic brain disorder, epilepsy, gives rise to fits or seizures, which may be minor, lasting only a few seconds, or major, where the person loses consciousness.
Epilepsy tends to be hereditary, but can also be caused by injury to the brain. It is effectively treated with drugs.
How You Can Help
In society’s eye, mental illness carries a stigma, and is sadly seen as a permanent disability. This is far from true.
In fact, most mental illnesses can be adequately treated, enabling the person to return to normal living.
As in physical illness, the earlier the treatment is sought, the better. Refusing to seek help or hoping the illness will just go away, only increases the necessity for long-term treatment.
The family and friends play a very important part in this treatment. You can be a vital source of help and emotional support for the ill person, and provide constant encouragement towards recovery.
Don’t dwell on guilt feelings. On the other hand, don’t blame the ill person for causing worry, shame or family dishonour.
Instead, be sympathetic and understanding. (But be careful not to let sympathy make you give I to unreasonable demands.) Respect the person’s privacy and encourage independence.
Remember, recovery takes time, so be patient and don’t set your expectations too high.
Above all, don’t get discouraged. Some days will be worse than others. The person may tire easily, get depressed, or have a temporary relapse.
But with perseverance, and the continuing discovery of new treatments, the outlook for sufferers will become even better tomorrow than it is today.
For more information, contact:
SAMH Insight Centre
Blk 139
Potong Pasir Avenue 3
#01-136 Singapore 350139
Helpline: 1800-2837019
Tel No: 2831576 (3 lines)
About Mental Illness
Mental illness is not a single disease but consists of many different types of diseases. It includes many kinds of mental and emotional disorders that differ in causes, symptoms and treatment. The disease causes mild to severe disturbances in thinking, feeling and behaviour resulting in an inability to cope with life's ordinary demands and routine. Mental disorders vary from mild, temporary stress-related disorders to severe and prolonged disorders. About 16 % of the people in Singapore suffer from minor mental disorders.
Two main groups of Mental Illness
Psychotic illness (major mental illness)
e.g. schizophrenia, manic depressive psychosis and delusional disorder.
People with psychotic illness lose touch with reality and perceive the world differently from others. They may develop delusions i.e. false beliefs of grandeur and persecution and experience hallucinations. They may see, hear, smell, taste and feel things, which are not there. They may be depressed or elated out of proportion to their life circumstances
Non-psychotic illness (minor mental illness)
e.g. anxiety disorders, obsessive compulsive disorder and eating disorder.
The symptoms of the non-psychotic illness are exaggerated forms of normal types of behaviour and feelings. People with non-psychotic illness may feel uncontrollable anxiety, tension, fear and depression. These feelings can cause considerable personal distress resulting in difficulties coping with daily activities.
Causes of Mental Illness
1. Environmental and social life situations
relationships
stress/crisis
housing conditions2. Biological
genetic make-up
temperament
physical constitution3. Physical causes
brain damage
drugs e.g. LSD
infection of the brainSymptoms of Mental Illness
Some symptoms of Mental Illness include:
Confused and unrealistic thinking
Talking to himself or herself, laughs or cries without good reason
Prolonged sadness and irritability
Feelings of extreme highs and lows
Dramatic changes in eating or sleeping habits
Suicidal thoughts
Numerous unexplained physical complaintsCommon Misconceptions about Mental Illness
Myth: A person who has been mentally ill can never be “normal”.
Fact: There are many people who have experienced a psychiatric illness and are living successful, rewarding lives. Others may have to take medication at times or permanently, but cope well with support.Myth: People with mental illness are unpredictable.
Fact: When their illness is in an active phase, they can be impulsive and not their usual self; but once recovered, their behaviour becomes more consistent.
Myth: Mentally ill people are dangerous and violent.
Fact: Most of them are not dangerous or violent. Many lack concentration, motivation and the ability to organise. Rare cases of violence occur only when they are seriously ill. When stable, they are no more violent than the average person.
Myth: A hospitalised mentally ill person mixing with others is more likely to get worse than better.
Fact: Mental illness is not contagious, nor can it be transmitted through social contact.
Myth: Psychiatric treatment is likely to cause brain damage as evidenced by the patient's robotic-like expression.
Fact: Robotic-like expression is more a sign of illness than an effect of treatment.
Myth: If a person can talk sensibly and has an intact memory, then the person is not mentally ill.
Fact: There are numerous types of mental illness and many forms do not affect one's memory or ability to speak appropriately.
Resources:
http://www.cgh.com.sg/library/mental_mentalillness.asp
http://www.silverribbonsingapore.com/mental.php
http://www.moh.gov.sg/mohcorp/speeches.aspx?id=1690 http://www.samhealth.org.sg/mentalhealth.php
Understanding Mental Illness
http://www.cgh.com.sg/library/mental_mentalillness.asp
What is mental illness?
Mental illness can strike anyone. It knows no age limit, economic status, race or religion. Mental disorders vary from mild, temporary stress-related disorders to severe and prolonged disorders. About 16 % of the people in Singapore suffer from minor mental disorders.
Mental illness is not a single disease but consists of many different types of diseases. It includes many kinds of mental and emotional disorders that differ in causes, symptoms and treatment. The disease causes mild to severe disturbances in thinking, feeling and behaviour resulting in an inability to cope with life's ordinary demands and routine.
What are the types of mental illness?
Mental illness can be divided into 2 main groups:
Psychotic illness (major mental illness)
e.g. schizophrenia, manic depressive psychosis and delusional disorder.
People with psychotic illness lose touch with reality and perceive the world differently from others. They may develop delusions i.e. false beliefs of grandeur and persecution and experience hallucinations. They may see, hear, smell, taste and feel things, which are not there. They may be depressed or elated out of proportion to their life circumstances
Non-psychotic illness (minor mental illness)
e.g. anxiety disorders, obsessive compulsive disorder and eating disorder.
The symptoms of the non-psychotic illness are exaggerated forms of normal types of behaviour and feelings. People with non-psychotic illness may feel uncontrollable anxiety, tension, fear and depression. These feelings can cause considerable personal distress resulting in difficulties coping with daily activities.
What are the signs and symptoms of mental illness?
Some of the signs and symptoms of mental illness include:
In adults:
1. confused and unrealistic thinking
2. talking to himself or herself, laughs or cries without good reason
3. talking rapidly and non-stop, jumping from one topic to another
4. prolonged sadness and irritability
5. feelings of extreme highs and lows
6. excessive fears, worries and anxieties
7. social withdrawal
8. dramatic changes in eating or sleeping habits
9. strong feelings of anger
10. delusions or hallucinations
11. inability to cope with daily activities
12. suicidal thoughts
13. numerous unexplained physical complaints
14. denial of obvious problems
In children and adolescents:
1. changes in school performance
2. school refusal
3. excessive complaints of physical ailments
4. excessive anxiety and worry
5. change in sleeping and eating habits
6. persistent disobedience and aggression
7. frequent outbursts of anger
8. defiance of authority, truancy, theft
9. prolonged negative mood with thoughts of death
Can mental illness be cured?
Mental illness, like many physical illnesses such as hypertension and diabetes mellitus, cannot be cured but can be treated. Proper care and treatment can reduce and relieve symptoms of mental illness resulting in resumption of normal activities.
What does treatment involve?
The treatment for mental illness usually involved a combination of
1. Medication such as antipsychotics and antidepressants and
2. Counselling or psychotherapy
How to help the mentally ill?
* Learn to look at mental illness like any other medical illnesses.
* Accept that if a person acts strangely it may be a symptom of mental illness.
* Be supportive and empathetic of the mentally ill.
* Encourage people with signs of mental illness to seek psychiatric treatment
Mental illness can be treated.
Seeking preofessional advice
CGH's Division of Psychological Medicine offers comprehensive psychiatric services. If you wish to book an appointment for psychiatric consultation, please contact our Appointment Centre at tel: 68503333.
From http://www.annals.edu.sg/pdf/36VolNo10Oct2007/V36N10p795.pdf
Mental Health in Singapore: A Quiet Revolution?
Siow-Ann Chong,1MBBS, MMed (Psychiatry), FAMS
1Senior Consultant Psychiatrist and Vice Chairman Medical Board (Research)
Institute of Mental Health, Singapore
Address for Correspondence: Dr Chong Siow Ann, Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View,
Singapore 539747.
Email: siow_ann_Chong@imh.com.sg
October 2007, Vol. 36 No. 10
Editorial
Worldwide there are about 450 million individuals in all societies who, in their lifetime, will suffer from a neuropsychiatric disorder that would exact a high toll in productivity and costs, and present serious health challenges (including death). This situation will get worse: the global burden of disease attributable to neuropsychiatric disorders is expected to rise from 12.3% in 2000 to 14.7% in 2020, with depression being the second most common cause of disability.1 The effect of major depression on quality of life is as great, or greater than, that of chronic medical conditions.2 A 2004 study in Singapore reported a lifetime prevalence of depression among adults as 5.6%,3 and that of dementia among the elderly as 5.2%.4 Not only do more people in Singapore die from suicide than from road traffic accidents every year, but conditions like schizophrenia, major depression, and alcohol-use disorders significantly increase the risk of early mortality.5 Until recently, the responsibility for the care of people with mental illness in Singapore rested almost entirely with the specialised services in both the public and private sectors, complemented and supplemented by voluntary welfare organisations (VWOs).
However, there has been a lack of co-ordination between the different medical and social services, which sometimes have conflicting and competing agendas. There was also a distinct lack of involvement of family physicians in public mental health care. A substantial proportion of people relied on a mixture of Western and traditional medicines, or used Western medicine only as a last resort.6 Cultural and religious beliefs often prompted patients to turn to the practitioners of traditional medicine or spiritual healers. There are about 115 practising psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6 per 100,000, which is low compared with other developed countries like the USA (13.7 per 100,000), the UK (11 per 100,000), and Australia (14 per 100,000). There is also a shortage across the whole slew of mental health professionals: psychiatric nurses, clinical psychologists, psychiatric case managers, medical social workers and occupational therapists. The financial coverage under the present healthcare system stresses on individual responsibility; it is based on a system of compulsory medical saving accounts and market forces. This system puts people with mental illness at a disadvantage and results in disparity of medical coverage.
The causes of most mental illnesses like autism, schizophrenia, bipolar disorder, obsessive compulsive disorder are still unknown, so primary prevention is not possible. Some of these illnesses also strike early in one’s life – before the individual can join the workforce, and the resulting disabilities may lead to academic and vocational impairment with consequent chronic financial difficulties. Employers often discriminate against mentally ill people. Research has established that mentally ill people are at a significantly higher risk of having lower educational attainment, living in poverty and a lower socioeconomic status.7
Many mentally ill people in Singapore do not have Medisave accounts, and Medishield excludes those with
mental illnesses and personality disorders, leaving many to rely solely on Medifund (a default support mechanism).
Not surprisingly, patients at the Institute of Mental Health, the only state mental institute and Singapore’s largest
provider of mental healthcare, receive proportionately the most Medifund across all the restructured hospitals. To my knowledge, there is no private medical insurance company that provides cover for mental illness. There are a number of reasons for this sorry state. Throughout history, stigma has clung tenaciously to mental illness, and among its various consequences, it prevents people with mental illness from studying, working and socialising in their community. Stigma makes the public less willing to pay for mental healthcare. It makes the public fearful – many believing that all people with mental illness are dangerous and should be locked away.8 This stigma also tinges the mental health professionals.
As the pathogenesis and pathophysiology of many mental disorders are still unknown, it makes mental healthcare vulnerable to perception that it is “not so scientific”. We have yet to understand the biological substrates underlying some of the most simple and basic cognitions and emotions, let alone love, hate, and fear. While psychiatry is arguably the “most humanistic discipline within medicine”, 9 our ignorance from the mechanistic standpoint also makes it more uncertain, difficult and complex than any other
branch of medicine.
Money – whether we like it or not – may be another factor. Although difficult to verify, the monetary remuneration that psychiatrists get is generally thought to be lower than that of other medical specialists. All these factors conspire to make psychiatry unattractive as a specialty of choice.
The level of mental health research activity varies between the various psychiatric centres in Singapore. Most of these centres are almost wholly service-oriented. While there is some collaboration between the respective centres with other non-psychiatric disciplines, there is hardly any collaboration between the psychiatric centres: each centre operating within its own silo. The impact of these research activities on actual clinical care is not evident, and there is very little research to date that will help shape public policies on mental health.
Mental illness and mental health have traditionally been neglected topics for most governments. Data collected by the WHO 10 showed the large gap that exists between resources that are available in countries for mental health and the burden caused by mental health problems.
But things have started to change in Singapore. In 2005, the Ministry of Health tasked a Committee of policy makers and mental health professionals to formulate the first National Mental Health Policy and Blueprint for the year 2007 to 2010. After deliberation, the Committee articulated a number of recommendations which in essence aim to (a) build resilience to mental illness, (b) work towards early detection, (c) reduce stigma, (d) engage the primary care physicians and build up a network of support in the community, (e) rectify the shortfall in mental health workers, (f) encourage research, and finally to (g) develop a monitoring and evaluation system.
In principle, the Blueprint proposes a population-based public health model, which is characterised by concern for the health of a population, and focuses also on the epidemiologic surveillance of the health of this population, on health promotion, disease prevention, and access to and evaluation of services. These goals are lofty and worthy but as always the devil will be in the details.
Clinician champions – in partnership with policy makers – have been appointed to drive the various initiatives. This is an enlightened measure. An article in the Lancet on the role of clinician leaders 11 stresses their the importance as “significant change in clinical domains cannot be achieved without the co-operation and support of the clinicians” and emphasises that there must be mutual understanding between these clinicians and policy makers. The policy makers must be cognizant of the way clinicians think, and appreciate what they value in their service to their patients; they must also curb their impatience to see overnight changes and instead accept incremental improvements. Correspondingly, the clinicians must be sensitive to the agenda of the policy makers – the financial and resource constraints, political expectations, and the need to show tangible results.
There is no doubt that much rests on the shoulders of these clinician leaders who must demonstrate clear-headed leadership and managerial abilities. They must break out of that parochial way of working within the silos of their respective organisations. They must also galvanise their fellow clinicians. They must be prepared to be held accountable and must articulate meaningful and actionable indicators by which their respective programmes would be evaluated.
What can be achieved also depends on other social, political and cultural forces. This first policy and blueprint will not address all the ills in the system – dealing with discriminatory employment policies, and the disparity in medical coverage would require legislation, but it is for Singapore as good a start as any. If we get our act together and work together, and if we commit ourselves to matching our declarations with our actions, and our ambitions with outcomes, we can begin this journey to reform our mental healthcare system.
REFERENCES
1. Murray CJL, Lopez AD. Alternative projections of mortality and disability
by cause 1990-2020; global burden of disease study. Lancet
1997;349:1498-504.
2. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, et
al. The functioning and well-being of depressed patients. Results from
the Medical Outcomes Study. JAMA 1989;262:914-9.
3. Chua HC, Lim L, Ng TP, Lee T, Mahendran R, Fones C, et al. The
prevalence of psychiatric disorders in Singapore adults. Ann Acad Med
Singapore 2004;33(Suppl 5):S102
4. Chiam PC, Ng TP, Tan LL, Ong PS, Ang A, Kua EH. Prevalence of
dementia in Singapore – results of the National Mental Health Survey of
the Elderly 2003. Ann Acad Med Singapore 2004;33(Suppl 5):S14-S16.
5. Bruce ML, Leaf PJ, Florio L, Hoff RA. Psychiatric status and 9-year
mortality data in the New Haven Epidemiologic Catchment Area study.
Am J Psychiatry 1994;151:716-21.
6. Somjee G. Public health policy and personnel in two Asian countries. J
Asian Afr Stud 1995; 30:90-105.
7. Rihmer Z. Can better recognition and treatment of depression reduce
suicide rates? A brief review. Eur Psychiatry 2001;16:406-9.
8. Chong SA, Verma S, Vaingankar JA, Chan YH, Wong LY, Heng BH.
Perception of the public towards the mentally ill in a developed Asian
Country. Soc Psychiatry Psychiatr Epidemiol 2007;42:734-9.
9. Andreasen NC. Farewell, Thou Child of my Right Hand. Am J Psychiatry
2006;163:1-2.
10. Promoting Mental Health. Summary Report. Geneva: World Health
Organization, 2004.
11. Ham C. Improving the performance of health services: the role of clinical
leadership. Lancet 2003;361:1978-80.
Mental Health in Singapore: A Quiet Revolution?
Siow-Ann Chong,1MBBS, MMed (Psychiatry), FAMS
1Senior Consultant Psychiatrist and Vice Chairman Medical Board (Research)
Institute of Mental Health, Singapore
Address for Correspondence: Dr Chong Siow Ann, Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View,
Singapore 539747.
Email: siow_ann_Chong@imh.com.sg
October 2007, Vol. 36 No. 10
Editorial
Worldwide there are about 450 million individuals in all societies who, in their lifetime, will suffer from a neuropsychiatric disorder that would exact a high toll in productivity and costs, and present serious health challenges (including death). This situation will get worse: the global burden of disease attributable to neuropsychiatric disorders is expected to rise from 12.3% in 2000 to 14.7% in 2020, with depression being the second most common cause of disability.1 The effect of major depression on quality of life is as great, or greater than, that of chronic medical conditions.2 A 2004 study in Singapore reported a lifetime prevalence of depression among adults as 5.6%,3 and that of dementia among the elderly as 5.2%.4 Not only do more people in Singapore die from suicide than from road traffic accidents every year, but conditions like schizophrenia, major depression, and alcohol-use disorders significantly increase the risk of early mortality.5 Until recently, the responsibility for the care of people with mental illness in Singapore rested almost entirely with the specialised services in both the public and private sectors, complemented and supplemented by voluntary welfare organisations (VWOs).
However, there has been a lack of co-ordination between the different medical and social services, which sometimes have conflicting and competing agendas. There was also a distinct lack of involvement of family physicians in public mental health care. A substantial proportion of people relied on a mixture of Western and traditional medicines, or used Western medicine only as a last resort.6 Cultural and religious beliefs often prompted patients to turn to the practitioners of traditional medicine or spiritual healers. There are about 115 practising psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6 per 100,000, which is low compared with other developed countries like the USA (13.7 per 100,000), the UK (11 per 100,000), and Australia (14 per 100,000). There is also a shortage across the whole slew of mental health professionals: psychiatric nurses, clinical psychologists, psychiatric case managers, medical social workers and occupational therapists. The financial coverage under the present healthcare system stresses on individual responsibility; it is based on a system of compulsory medical saving accounts and market forces. This system puts people with mental illness at a disadvantage and results in disparity of medical coverage.
The causes of most mental illnesses like autism, schizophrenia, bipolar disorder, obsessive compulsive disorder are still unknown, so primary prevention is not possible. Some of these illnesses also strike early in one’s life – before the individual can join the workforce, and the resulting disabilities may lead to academic and vocational impairment with consequent chronic financial difficulties. Employers often discriminate against mentally ill people. Research has established that mentally ill people are at a significantly higher risk of having lower educational attainment, living in poverty and a lower socioeconomic status.7
Many mentally ill people in Singapore do not have Medisave accounts, and Medishield excludes those with
mental illnesses and personality disorders, leaving many to rely solely on Medifund (a default support mechanism).
Not surprisingly, patients at the Institute of Mental Health, the only state mental institute and Singapore’s largest
provider of mental healthcare, receive proportionately the most Medifund across all the restructured hospitals. To my knowledge, there is no private medical insurance company that provides cover for mental illness. There are a number of reasons for this sorry state. Throughout history, stigma has clung tenaciously to mental illness, and among its various consequences, it prevents people with mental illness from studying, working and socialising in their community. Stigma makes the public less willing to pay for mental healthcare. It makes the public fearful – many believing that all people with mental illness are dangerous and should be locked away.8 This stigma also tinges the mental health professionals.
As the pathogenesis and pathophysiology of many mental disorders are still unknown, it makes mental healthcare vulnerable to perception that it is “not so scientific”. We have yet to understand the biological substrates underlying some of the most simple and basic cognitions and emotions, let alone love, hate, and fear. While psychiatry is arguably the “most humanistic discipline within medicine”, 9 our ignorance from the mechanistic standpoint also makes it more uncertain, difficult and complex than any other
branch of medicine.
Money – whether we like it or not – may be another factor. Although difficult to verify, the monetary remuneration that psychiatrists get is generally thought to be lower than that of other medical specialists. All these factors conspire to make psychiatry unattractive as a specialty of choice.
The level of mental health research activity varies between the various psychiatric centres in Singapore. Most of these centres are almost wholly service-oriented. While there is some collaboration between the respective centres with other non-psychiatric disciplines, there is hardly any collaboration between the psychiatric centres: each centre operating within its own silo. The impact of these research activities on actual clinical care is not evident, and there is very little research to date that will help shape public policies on mental health.
Mental illness and mental health have traditionally been neglected topics for most governments. Data collected by the WHO 10 showed the large gap that exists between resources that are available in countries for mental health and the burden caused by mental health problems.
But things have started to change in Singapore. In 2005, the Ministry of Health tasked a Committee of policy makers and mental health professionals to formulate the first National Mental Health Policy and Blueprint for the year 2007 to 2010. After deliberation, the Committee articulated a number of recommendations which in essence aim to (a) build resilience to mental illness, (b) work towards early detection, (c) reduce stigma, (d) engage the primary care physicians and build up a network of support in the community, (e) rectify the shortfall in mental health workers, (f) encourage research, and finally to (g) develop a monitoring and evaluation system.
In principle, the Blueprint proposes a population-based public health model, which is characterised by concern for the health of a population, and focuses also on the epidemiologic surveillance of the health of this population, on health promotion, disease prevention, and access to and evaluation of services. These goals are lofty and worthy but as always the devil will be in the details.
Clinician champions – in partnership with policy makers – have been appointed to drive the various initiatives. This is an enlightened measure. An article in the Lancet on the role of clinician leaders 11 stresses their the importance as “significant change in clinical domains cannot be achieved without the co-operation and support of the clinicians” and emphasises that there must be mutual understanding between these clinicians and policy makers. The policy makers must be cognizant of the way clinicians think, and appreciate what they value in their service to their patients; they must also curb their impatience to see overnight changes and instead accept incremental improvements. Correspondingly, the clinicians must be sensitive to the agenda of the policy makers – the financial and resource constraints, political expectations, and the need to show tangible results.
There is no doubt that much rests on the shoulders of these clinician leaders who must demonstrate clear-headed leadership and managerial abilities. They must break out of that parochial way of working within the silos of their respective organisations. They must also galvanise their fellow clinicians. They must be prepared to be held accountable and must articulate meaningful and actionable indicators by which their respective programmes would be evaluated.
What can be achieved also depends on other social, political and cultural forces. This first policy and blueprint will not address all the ills in the system – dealing with discriminatory employment policies, and the disparity in medical coverage would require legislation, but it is for Singapore as good a start as any. If we get our act together and work together, and if we commit ourselves to matching our declarations with our actions, and our ambitions with outcomes, we can begin this journey to reform our mental healthcare system.
REFERENCES
1. Murray CJL, Lopez AD. Alternative projections of mortality and disability
by cause 1990-2020; global burden of disease study. Lancet
1997;349:1498-504.
2. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, et
al. The functioning and well-being of depressed patients. Results from
the Medical Outcomes Study. JAMA 1989;262:914-9.
3. Chua HC, Lim L, Ng TP, Lee T, Mahendran R, Fones C, et al. The
prevalence of psychiatric disorders in Singapore adults. Ann Acad Med
Singapore 2004;33(Suppl 5):S102
4. Chiam PC, Ng TP, Tan LL, Ong PS, Ang A, Kua EH. Prevalence of
dementia in Singapore – results of the National Mental Health Survey of
the Elderly 2003. Ann Acad Med Singapore 2004;33(Suppl 5):S14-S16.
5. Bruce ML, Leaf PJ, Florio L, Hoff RA. Psychiatric status and 9-year
mortality data in the New Haven Epidemiologic Catchment Area study.
Am J Psychiatry 1994;151:716-21.
6. Somjee G. Public health policy and personnel in two Asian countries. J
Asian Afr Stud 1995; 30:90-105.
7. Rihmer Z. Can better recognition and treatment of depression reduce
suicide rates? A brief review. Eur Psychiatry 2001;16:406-9.
8. Chong SA, Verma S, Vaingankar JA, Chan YH, Wong LY, Heng BH.
Perception of the public towards the mentally ill in a developed Asian
Country. Soc Psychiatry Psychiatr Epidemiol 2007;42:734-9.
9. Andreasen NC. Farewell, Thou Child of my Right Hand. Am J Psychiatry
2006;163:1-2.
10. Promoting Mental Health. Summary Report. Geneva: World Health
Organization, 2004.
11. Ham C. Improving the performance of health services: the role of clinical
leadership. Lancet 2003;361:1978-80.
