Singapore has one of the best healthcare systems in the world, along with some of the healthiest citizens. But how is the healthcare system performing in terms of mental health? The recently released Singapore Mental Healthy Study conducted by the Institute of Mental Health, gave us important insights. However, it is also important to consider mental illness in Singapore through a historical and global lens to get a clearer understanding of how Singapore's mental illness landscape is evolving. Our study aims to answer this issue by focusing on what kind of mental illness is most prevalent in Singaporeans and how healthcare access and mental illness prevalence rates compare internationally and how mental healthcare has changed in Singapore over the years.
While Singaporeans have one of the highest rates of major depressive disorder compared to the 8 high-income nations analysed, the lifetime prevalence rate of mental illness is one of the lowest at 13.9%, just behind Hong Kong.
Singapore's generalised anxiety disorder lifetime prevalence rate of 1.6% is one of the lowest among high-income nations.
The cost of 1-year inpatient treatment for those suffering from mental illness can be as high as S$200,000 at private hospitals.
Despite plenty of resources for mental wellness counseling, Singapore has one of the lowest rates of psychiatrists and psychologists per 100,000 residents compared to similar high-income nations.
Mental Health Issues Facing the Average Singaporean
The latest SMHS study found that about 14% of Singaporeans have experienced a mood, anxiety or alcohol-use disorder in their lifetime. The most common mental illnesses in Singapore are Major Depressive Disorder (MDD), Alcohol Abuse and Obsessive Compulsive Disorder (OCD), with a rate of 1 in 16 people affected by MDD, 1 in 28 affected by OCD and 1 in 24 affected by Alcohol Abuse.
These disorders are increasing in lifetime prevalence (how many people have experienced a mental illness in their lifetime). For example the proportion of individuals affected by GAD increased from 0.9% in 2010 to 1.6% in 2016. Comorbidity (the appearance of more than one mental illness) also increased from 3.1% to 4.1% according to the studies' estimates. These increases may indicate that more Singaporeans are recognising their symptoms to be attributed to a mental illness, or they may feel more comfortable in admitting that they may be suffering from a mental illness due to a decrease in social stigma. This theory can be supported by the fact that for the majority of mental illnesses studied, Singaporeans are taking less time to see help. For instance, individuals suffering from alcohol abuse or bipolar disorder sought treatment 9 and 5 years (respectively) faster in 2016 than in 2010.
Which Demographics are Most Vulnerable to the Impacts of Mental Illness?
Mental illness is most commonly seen in several demographics. As evidenced by the SMHS study, we see higher rates of mental illness in individuals between ages 18-34 and individuals who are divorced or separated. However, there are two other groups of people that seem to be at risk of developing or suffering mental illnesses: children and the elderly.
Depression and Anxiety Remain a Concern for Singaporean Youth
It is estimated that about 18% of Singapore's youth suffer from depression. Children and young adults tend to face an increased chance of developing depression and anxiety due to chemical changes in the brain arising from puberty, societal and academic pressures and uncontrollable factors in their home life. In fact, about 50% of mental illnesses appear before age 14, with the rate of appearance increasing to 75% before age 24. A lot of youth may not understand what they are going through. Unfortunately, this lack of knowledge, combined with misconceptions of mental illness, social ostracisation and a lack of support from friends and family may be contributing factors to youth suicide. All of which may be important factors in explaining the worrying trend of youth suicide.
Elderly Singaporeans Face Increased Risk of Depression & Suicide
The elderly are also at a higher risk of suffering from mental disorders like depression. A study found that around 11.4% of community-dwelling elderly may report symptoms of depression, compared to the national average of 6.3%. Furthermore, a troubling statistic indicates that 36% of suicides committed in 2017 were by people over 60—a record high number. This high rate may be caused by several factors. First, as individuals get older and their health problems increase, they may feel lower life satisfaction from pain and the inability to live life as they used to, which can lead to mood disorders and anxiety. Second, cultural and demographic shifts to smaller family units indicate that the elderly are more likely to end up alone, leading social isolation and even crippling loneliness, in some cases. Lastly, feelings of being a burden to their families, rising costs of healthcare and neurological deterioration may make daily life difficult for the elderly who may feel further suffocated by economic hardship.
How Has Mental Healthcare Evolved in Singapore?
Singapore's main mental health facility, the Institute of Mental Health, was founded in 1841. While its modest beginnings included 30 beds, it has now expanded to 2,010 beds and seven specialist outpatient clinics. You can also get mental health services in public hospitals, outpatient poly-clinics and private psychiatric offices. Singapore's government has also taken proactive steps in the past years to bring awareness about mental health, decrease social stigma and increase resources for people suffering from mental illnesses. Currently, there is a focus on right-siting (giving people medical attention that is appropriate to how severe their illness is) instead of resorting to in-patient hospitalisation for mild cases. This is an important step because it shows that there is recognition that different severity levels of mental illness require tailored approaches.
There are also many government and NGO resources available in Singapore, such as REACH, the Early Psychosis Intervention Programme (EPIP) and the Community Psychogeriatric Programme (CPP). These programmes were recently created and aim to help individuals who are suffering from mental illnesses during specific parts of their lives; for instance, REACH is focused at aiding children and adolescents, while the CPP tailored to provide mental healthcare for the elderly. There are also programmes aimed at helping adults suffering from mental illnesses to stay integrated in their communities and reduce their hospital readmission rates. Last but not least, there are two important organisations aimed at helping Singaporeans deal with suicide: Samaritans of Singapore (SOS) and the Local Outreach to Suicide Survivers (LOSS). These organisations serve to support individuals dealing with thoughts of suicide, self-harm or individuals dealing with the loss of a loved one to suicide.
How Does Singapore Compare Globally?
Out of the countries we studied, Singapore has one of the lowest rates of mental illness. Furthermore, despite climbing trends in mood disorders, Singaporean has lower lifetime prevalence rates of bipolar disorder, generalised anxiety disorder and alcohol abuse. However, Singapore does have one of the highest rates of MDD out of the 9 nations we looked at. For instance, while MDD tends to affect western countries at a higher rate, (lifetime prevalence is 12-16%) compared to Asian countries (3-6%), Singapore had the second highest MDD rate of 6.3%.
We found that increasing levels of psychological distress among youth and elderly populations are a global trend. Additionally, we noticed that unemployed or divorced/separated individuals had higher rates of mental illness than those who were gainfully employed or were either single or married. Lastly, suicide trends are similar across countries, with an increasing number of elderly committing suicide and higher suicide rates in men than in women.
When it comes to mental healthcare facilities and resources, Singapore seems to be the only country in our comparison where a majority of patients stay in a mental hospital as an inpatient for more than 5 years. This makes sense considering that the annual admission rates to mental hospitals per 100,000 people are among the highest out of the similar high-income countries. However, psychiatrist rates per 100,000 people are some of the lowest. The low rate of psychiatrists is in line with other Asian countries that tend to rely more on nurses and social workers to help people with low to moderate mental illnesses. On the other hand, western countries like Australia, the US and the UK have between 10 and 18 psychiatrists per 100,000 people and 13-103 psychologists per 100,000 people, indicating possible cultural and institutional differences in medical approaches to mental illnesses.
Singapore vs. Other Asian Countries
It appears that Singaporeans report lower than average rates of GAD, but higher rates of depression compared to Hong Kong, South Korea, China and Japan. Despite the higher rates of depression, Singapore's suicide rate of 7.74/100,000 people is much lower compared to similar high-income Asian countries, such as South Korea (26.9/100,000), China (22.3/100,000), Japan (18.5/100,000) & Hong Kong (16.2/100,000). However, Singapore and South Korea share similar statistics concerning elderly suicide, with 30% of South Korean and Singaporean suicide victims being over age 65.
Lifetime Prevalence Rates of MDD & GAD in Singapore vs. Similar Asian Countries
It seems like Singaporeans are more willing than some other Asian countries to seek help. For instance, in Singapore around 20% of people sought help for their mental illness, while only 10% of South Koreans sought treatment due to high levels of stigma. However, one cause of concern shared across all Asian countries is the lack of treatment. The WHO recommends a ratio of 10 psychiatrists per 100,000 people to adequately treat mental illnesses in a nation. Singapore, Hong Kong, China and South Korea all have below 6 psychiatrists per 100,000. Japan is the only country that has over this number, with a rate of 11.87 psychiatrists per 100,000 people.
Singapore vs. Western Countries
Compared to western countries like Australia, the United States and the UK, Singapore has fairly similar rates of MMD, bipolar disorder and suicide, but below-average rates of anxiety disorders. Similar to Australia and the United States, depression affects between 6%-7% of the population and suicide remains the leading cause of death for youth (ages 10 to 29). However, Singapore has a lower lifetime prevalence rate of generalised anxiety disorder compared to these western counterparts, despite having higher rates of OCD.
Lifetime Prevalence Rates of MDD & GAD in Singapore vs. Western Countries
The most glaring differences are cultural and institutional. For instance, we see that 45% of Australians have admitted to experiencing a mental illness in their lifetime. This number goes hand in hand with the fact that Australia has one of the greatest numbers of psychiatrists and psychologists per 100,000 people out of the countries we surveyed. Furthermore, it may also indicate that Australians tend to recognise and tackle symptoms of psychological distress without the attached stigma of shame that we see in Asian countries. Similarly, the United States and the United Kingdom have higher treatment rates (35-36%), compared to Singapore (21%).
What Can Singapore Do to Improve Mental Healthcare & Treatment?
While Singapore has fairly comprehensive prevention, treatment and post-treatment support systems in place, there are areas for improvement on the cultural, legal and institutional levels. According to the SMHS, 78.4% of Singaporeans who experienced a mental illness in the past year of the SMHS survey did not seek treatment. While this is less than in 2010, the figure is still worrying considering the average gap in treatment for high income countries is between 35-50%. Furthermore, despite organisations and outreach programs available, Singaporeans with a mental illness were observed to have a 16% lower quality of life score than those without a mental illness.
Social stigma appears to be one of the greatest reasons as to why Singaporeans either do not get proper help or may downplay their mental illness. A study done by the Institute of Mental Health on how Singapore's youth perceives mental illness shows that children prefer to keep their distance from people suffering from mental illnesses due to perceptions of sufferers being unstable or "dangerous". Furthermore, it was found that negative associations with mental illness increase as individuals get older. This stigma isn't exclusive to children. Singaporean adults also see mental illness as a sign of weakness or instability.
Social stigma affects not only the individual by lowering their self-esteem and increasing social ostracisation, but also by manipulating mental health statistics that are crucial to providing an accurate understanding of how widespread mental illness is in Singapore. In fact, there is evidence from a 2012 mental health study that a reluctance to admit to having a mental illness due to social stigma indicates that the actual figures for prevalence rates in Singapore may be higher than currently reported. Thus, education starting at a young age about what psychological disorders are and dispelling their myths can be a good way to start reducing stigma. This can include not only education tools like flyers or posters, but also releasing statistics more frequently about mental illness in Singapore to show individuals that they are not alone. Reducing social stigma may also increase the number of people who will seek out preventative services, which have been shown to reduce risk factors and psychiatric symptoms of mental disorders.
Singapore's institutional laws can offer another area of improvement. For instance attempting to commit suicide is illegal—and while it is a very rarely enforced law with only 0.6% cases being brought to court—its existence may serve as a reminder of the social stigmas surrounding mental illness. This law is currently under review by the committee, with the reasoning that people who attempt suicide should receive medical attention rather than be punished.
Lastly, there may be a lack of education around where and how to get treatment and the treatment's cost. For instance, there may be a perception that you may only get mental health treatment as an inpatient at the IMH, when in reality you can get help at outpatient clinics or from private psychologists. Furthermore, because treating a mental illness may take a long time, there may also be a perception treatment is very expensive. However, there are several payment schemes you can take advantage of to reduce your out of pocket cost. Individuals can pay for psychiatric help from the Medisave accounts, inpatient treatment can be covered by MediShield Life and private health insurance.
Despite these avenues of payment, there is a noticeable lack of medical insurance coverage for inpatient and outpatient treatment. For instance, individuals who need at least a year of inpatient care may still be responsible for thousands of dollars in out of pocket costs as even Integrated Shield Plans place an annual limit ranging between S$5,000 and S$25,000 on inpatient treatment. Furthermore, since most people who suffer from mental illness may not need inpatient care, but rather outpatient visits with a psychologist, paying several thousand dollars per year even on a subsidised payment scheme may still discourage them from continuing treatment. Furthermore, being able to insure outpatient treatment may also reduce the burden on inpatient mental healthcare institutions as people will now be able to cover their visits to private psychologists and other mental health professionals.
Methodology & Limitations
Analysing mental health across a variety of populations is never without risk due to differences in reporting, cultures and definitions. With that said, we strove to keep our analysis as standardised as possible by using the same sources when describing the state of mental health and healthcare in Singapore and the same source when comparing Singapore's mental healthcare to different countries. We also decided to include suicide rates in our analysis because while suicide in itself is not a mental illness, it is a sign of severe mental distress, making it relevant to our study about mental health. It also helps us compare Singapore to other countries to find out how Singapore ranks in the number of people who feel overwhelmed by life—in other words, suicide rates tell us what percentage of society suffered from psychological distress that they were not able to cure.
As with most psychological analyses, the data may not be fully accurate, especially when it was taken from surveyed individuals as there is always a chance of underreporting, ignorance of symptoms or discomfort in admitting truth to strangers. This means that while the Population-Based Surveys of Mental Disorders in Singapore served as a good way to analyse the overall scope of psychiatric illnesses in Singapore, our limitations were bound to theirs. Furthermore, due to a lack of the full report of the most recently released mental health survey, we were not able to get the full scope of the most recent results and had to rely on the released newsletter, international organisations such as the World Health Organisation and prior released reports and other academic sources from Singapore.
The article What is the State of Mental Health in Singapore? originally appeared on ValueChampion.
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