Calling for a mental revolution

Mental health issues continue to be overlooked

Amidst the much-publicised furore over the Human Organ Trading Act (HOTA) which was debated in Parliament last week, the Chinese paper Lianhe Zaobao carried a commentary on 2^nd April that tried to make a case for a subject that it argued was far too often overlooked – mental healthcare in Singapore.

Indeed mental health issues were briefly debated in Parliament before being overshadowed by the HOTA controversy, even as there seems to be evidence that it is becoming an increasing grave issue.  The health minister told MPs that nearly one in six people are believed to suffer from mental illnesses, with some 25,000 patients with serious mental illnesses – a figure higher than that of kidney disease sufferers, the expected beneficiaries of the HOTA. One MP noted that a 2004 study showed that more people in Singapore die from suicide than from road traffic accidents every year, even as conditions such as schizophrenia and depression were showing significant increases.

Treatment is hampered by serious shortfalls in insurance coverage, which are likely to discourage people from seeking the treatment that could help them get an early grip on their conditions.  Government help is highly circumscribed: many mentally ill people do not have Medisave accounts and are excluded from Medishield.  They are therefore largely restricted to Medifund, itself a contingency fund limited to those who are practically impoverished. 

Private insurance is hardly better.  The Straits Times highlighted in an article on 28^th March that applications by mentally ill people for health insurance were largely rejected by local insurers.  Insurers are probably discouraged by the difficulty of quantifying risks from conditions that might be difficult to evaluate – a comment from a NTUC spokesman about the possibility that some patients could be “imagining” their conditions, is particularly instructive – but this is in rather glaring contrast to developed countries where coverage is common.

Another oversight that has been little highlighted is how thinly resources are being stretched in Singapore to cope with an increasing number of mental patients.  There are about 115 practising psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6 per 100,000 – significantly lower than developed countries like the US (13.7), the UK (11) or Australia (14) – as well as a corresponding shortage in support staff like psychiatric case managers and medical social workers¹.  Such scarcity would have contributed to high prices for treatment in the private sector.

In the public sphere, treatment might be limited by underinvestment – the Zaobao article of 2^nd April worried that the Institute of Mental Health (the only specialised government institution for mental healthcare) alone might not be able to deal with rising patient numbers.  The government has also set great store in a community-based approach to minimise institutionalisation of patients, preferring to have case managers and social workers monitor patients at home, though this system is still rather weak – in Parliament the health minister admitted that it was “far from perfect”, one MP was more scathing, calling it simply “inadequate”.

The main problem seems to be a continuing stigma against mental illness and a perception that mental healthcare is “not scientific”.  For instance the health minister blamed the lack of support from “society at large” for slow progress in improving its community-based approach.  That is understandable, but that is where the government needs to lead the way.  The inescapable issue is funding – to deal with the growing number of cases, the government has to spend a great deal more on new facilities and staff.  It also needs to open up MediShield and compel private insurers to provide coverage.  Otherwise keeping the current inequitable system will only reinforce notions that mental illness is somehow a lesser condition that does not deserve as much attention as those that were in the news recently.

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¹ Siow-Ann Chong, “Mental Health in Singapore: A Quiet Revolution?”, Editorial in the Annals Academy of Medicine, October 2007, Vol. 36 No. 10

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